4. PRE EXISTING DIABETES
• Diagnosed Before the start of preg.
• Hyperglycemia diagnosed for the first time in pregnancy. Meets WHO
criterion for diabetes mellitus in non pregnant state.
• May occur any time during pregnancy including first trimester.
5. Prevalence
• 2010 data...22million women between 20-39 yrs have diabetes.
• Expected to rise by 20% in next 10yrs.
• 54 million women with IGT or prediabetes potential to develop GDM
during pregnancy.
• Prevalence in India varies from 3.8% to 21% in different parts of
country.
• GDM has been found to be more prevalent in urban areas than rural.
7. Definition
• GDM defined as any degree of glucose intolerance which is diagnosed
for the first time in pregnancy. Irrespective of treatment whether with
diet or insulin.
8. Pathophysiology of GDM
• Maternal hepatic glucose production
• increase by 15% to 30% to meet fetal demand in late pregnancy
• . |
• Insulin resistance due to |. Pancreatic beta dysfunction
• Placental secretion of. Due to genetics,autoimmune
• anti insulin hormones disorders,ch.insulin resistance
• /
• GESTATIONAL DIABETES
9. Whom to Screen.
• Universal screening appears to be optimum approach as the Indian
women have 11 fold increased risk of developing glucose intolerance
during pregnancy compared to caucasian women.
10. Which Screening Method
Diabetes in pregnancy study gp.of India(DIPSI)
Criterias
• One step approach proposed by DIPSI & Endorsed by GOI
• On 14 th March 2007 Govt.of India issued instruction that Universal
Screening of Glucose Intolerance during pregnancy is mandatory.
• The order recommends that all women should be screened between
24 to 28 weeks of gestation with 2hours 75 gm oral glucose.
11. How To Do It
•
• 75 gm Glucose with 300ml water
• Irrespective of last meal
• Ingestion to be completed within 5-10 min.
• Measure Blood Sugar after 2hours.
• If vomitting within 30 min.of test repeat test next day.
12. Interpretation of DIPSI Test
• With 75gm oral glucose tolerance test (WHO criterias)
• Plasma Glucose. In Pregnancy. Outside Pregnancy
• 2hrs≥200mg/dl. Diabetes Diabetes
• 2hrs≥140mg/dl. Gestational Diabetes Impaired glucos tolerance
• &≤199mg/dl.
• 2hrs ≥120mg/dl Gestational glucose
• &≤139mg/dl intolerance
• 2hrs ≤120mg/dl. Normal. Normal.
13. Take Care
• 1. PG BSL (DIPSI) ≥200 mg% at first visit------OVERT DM.
• . Look for Hypertension
• . Retinopathy.....Fundus Examination
• . Nephropathy...Serum creatinine
14. Advantages of DIPSI criterion
• 1. Simple, Feasible, Convenient, Economical and acceptable in Indian
scenario.
• Indian population is diverse and variable, International criterion may
not be practical and feasible.
16. ADA and WHO and IADPSG
• ÀDA… .American diabetic association 2 step approach for diagnosis of
GDM
• 1st step screening of all women with an initial glucose challenge test
with 50 gm glucose Load followed by a diagnostic OGTT With 75 gm
glucose Load .
• WHO .. Criteria….GDM diagnosed Using 75gm glucose.
• 1. If fasting glucose levels more than 126mg/dl.
• 2. After are values more than 140mg/dl.
17. IADPSG Criterias.
• 1… recommended 75gm OGTT for all pregnant women.
• Diagnosed GDM if one or more values exceeded
• 1. Fasting values more than 92
• 2. One hour value 180 or more
• 3. 2 hour value 153 or more.
18. Why Diagnose and Treat GDM
• Identification of women with GDM is imp. Because appropriate
therapy can decrease maternal and fetal morbidity and mortality.
• Can prevent two generations from developing diabetes in future.
19. Maternal Problems
• Early Pregnancy... Spontaneous miscarriage
• Pregnancy.... PRE ecclampsia, Gestational Hypertension,
Macrosomia,Hydramnios.
• Delivery.....Pre term birth, Instrumental delivery, Traumatic Delivery,
Cessarian, Post partum infections, PPH , Increased mortality and
morbidity.
• Post partum infections, Lactation failure
• Long term Post partum.. Obesity , GDM in subsequent preg,DM,CVD.
22. Outline for GDM management
• Primary management strategy for GDM....... Dietary Changes and
Exercise .
• If uncontrolled hyperglycemia with lifestyle change
• INSULIN should be first line therapy.
• Use METFORMIN if Insulin can not be used.
23. GDM management During pregnancy
• 1. Nutrition counseling by dietician to achieve Nutrition, weight and
blood glucose goals.
• Healthy Diet, replacement of High glycaemic index food with low
glycaemic index foods to reduce need for insulin initiation.
• Measures for appropriate weight gain and healthy lifestyle through
out pregnancy.
24. Medical Nutrition Therapy
• Therapeutic Goals
• 1. Adequate Nutrition
• 2. Adequate weight gain
• 3. Prevention of Ketosis
• 4. Prevention of postprandial Hypeglycaemia.
25. GDM DIET
• Diet....30kcl/kg... Normal wt. Women, 24kcl/kg.....overwt.wt. Women
and 12 kcl/kg for morbidly obese women.
• Diet should contain carbohydrates 50%, , proteins 20%, and fat 25
to30%.
• Usually three meal regimen with breakfast 25% of the total intake,
lunch30%, dinner 30%.
26. Physical Activity
• Unless contraindicated, physical Activity should be included pregnant
women daily routine.
• Regular moderate intensity physical activity like walking can help to
reduce Glucose levels.
• Cardiovascular training with wt.bearing limited to upper body to
avoid mechanical stress on abdominal region.
27. Target Weight Gain in GDM
• PRE pregnancy BMI. Category. Total wt. Gain
• ≤18.5. Underweight. 12.5-18kg.
• 18.5 to24.9. Normal weight. 11.5 to16 kg.
• 25-29.9. Overweight. 7-11.5 kg.
• ≥30. Obese. 5-9kg
28. Insulin initiation during pregnancy
• About 50% of women treated with diet alone will require additional
therapy and insulin therapy recommended.
• Therapy with insulin individualized but most pregnant women
require0.7units per kg daily.
• 2/3rd of the insulin administered in morning and 1/3rd in evening with
1:2 ratio of short to intermediate or long acting isuli.
29. Insulin Dosing guidelines During pregnancy
• Weeks Gestation. Total daily dose of Insulin
• 1-13 weeks. 0.7x weight in kg.
• 14-26 weeks. 0.8x wt.in kg
• 27-37 wks. 0.9x wt.in kg
• 38 wks to delivery. 1.0 xwt.in kg.
• Post partum & in Lactation. 0.55x wt.in kg.
30. The total Daily dose Of Insulin shud be split so that 50% used for basal
insulin and 50% used premeal rapid acting insulin boluses
Night time Insulin Dose decreased by 50% in lactating mother to
reduce hypoglycemia.
31. Status of Oral Hypoglycaemic Agents in
pregnancy
• METFORMIN and sulfonylurea glyburide are the two most common
OHA during pregnancy.
• METFORMIN crosses Placental, category B.
• Glyburide minimal transfer some formulation category B, others
category C
• Both may not be sufficient to maintain normoglycaemia all times
during postprandial period.
32. • Due to efficacy and safety concern sada And DIPSI DOES NOT
RECOMMEND ORAL ANTI HYPERGLYCEMIC AGENTS FOR GDM OR PRE
EXISTING T2DM.
33. METFORMIN
• Insulin sensitizer
• Given with meal.
• 500mg.once or twice started daily with food.
• Dose increased gradually weekly 2000mg per day.
• No teratogenic effect.
• Category B
• But not approved by FDA.
34. Monitoring Blood Glucose
• At least 4 times self monitoring.
• Fasting and 3 one and hour postprandial
• After achieving Target level lab monitoring till 28 wks once in a
month.
• 28-32 weeks once in 2weeks.
• More than 32 wks once a week.
• Other parameters,Fundus,microalbuminurea to be monitored.
35. Glycaemic Targets
• Mean plasma glucose..105mg/dl
• Maintain FPG at 90 &PP at 120.
• Mean plasma glucose should never go below 86
36. Fetal monitoring
• Baseline ultrasound
• At 18-22 wks ..Level II for major mal formations.
• 26wks onward growth and liquor volume
• III trimester frequent ultrasound for accelerated growth abdominal
and head circumference weight gain AFI.
37. Monitoring During Pregnancy
•
• FIRST TRIMESTER
• Clinical exam
• Dating scan
• Nuchal translucency
• Biochemical Screening l
• Uterine artery,MCA for monitoring IUGR
38. III RD Trimester
• Clinical exam – fundal height, abdominal girth
• Growth scans 28wks, 32wks,36wks, colour Doppler as indicated.
• AFI, non stress test 32 wks onward if on INSULIN.
40. When to Deliver
1..38 to 39 wks
2.Fetal wt ≤ 3.8kg appropriate for Gestational age continue to 40
wks.But if poor compliance,poor control induce labour.
3. Fetal 3.8 kg to 4kg or large for Gestational age..induce labour.
4. Fetal wt.more than 4kg. Elective Cessarian delivery.
41. Care in Labour and Delivery
• AHyperglycemia in pregnancy controlled on diet and spontaneous
labour...... Admission CTG,Partograph, Blood Sugar 2hrly, Target level
80-120mg%.Continuous fetal monitoring.
• Spontaneous labour in pts on insulin or oral antidiabetic drugs....same
as above. I/V fluids as per blood glucose levels.
42. Labour management 2nd& 3rd stage.
• 2nd stage
• Controlled ARM, vigilant for fetaldistress.
• Anticipate shoulder dystocia.
• Assisted vaginal delivery
• Neonatologist presence
• 3rd stage.....
• 1.Active management of 3rd stage
• 2. Management of atonic or traumatic PPH
43. Insulin Management During Labour
• Usual dose of Intermediate acting Insulin at bedtime.
• Morning dose is with held.
• I/v infusion of normal saline.
• During Active labour,if glucose levels fall below 70 mg/dl infusion
changed from normal saline to 5% dextrose.
• If Glucose levels exceed140mg/dl short acting insulin given by iv
infusion.
44. Immidiate Post Partum Care..GDM on MNT
• No need of glucose monitoring immidiately after delivery
• Regular Post natal care
• OGTT 6 wks post partum.
45. GDM on OHAs
• Stop drugs immidiately after delivery.
• Continue preprandial BGL monitoring QID for 24 hrs.
• If preprandial BGL 72-126mg/dl .. Discontinue monitoring
• If BGL ≤72 or more than 126 mg/dl seek medical review.
• 1-8% may continue to be Glucose intolerant and may need therapy.
46. On Insulin
• Preprandial BGL monitoring QID for 24 hrs
• If BGL morethan 126 mg/dl medical review.
• Insulin therapy generally not indicated unless marked fasting
hyperglycemia.. Fasting glucose 200-250mg/dl.
47. For Persisting Diabetes
• Recommend OGTT at 6wks postpartum to screen persistent diabetes
• Lifelong screening for diabetes every 3 years
• Early Glucose monitoring in future pregnancy.
48. Breast Feeding
• Should be initiated immidiately after delivery.
• Early breast feeding prevents childhood obesity
• To reduce risk of type 2 diabetes and Hypertension in mother.
50. Summary
• Universal testing of all pregnant women for GDM.
• Recommended twice in pregnancy at first antenatal visit and again at
24 to28 wks.
• DIPSI recommends again at 34 wks.
• Single step 75gm 2hrs OGTT performed
• Women testing positive with 2hr OGTT ≥140mg/dl should be started
with Nutritional therapy and walking for 2wks.
• If 2hour PPBS more after MNT and physical exercise medical
management
51. • Early delivery with antinatal steroid to be planned if lady with
uncontrolled blood sugar or any other obstetric indication.
• Vaginal delivery preferred.
• LSCS for obstetric indication or Macrosomia.
• Neonatal monitoring for hypoglycemia and other complications.
• Postpartum evaluation of glycaemic status by 75 gm OGTT at6wks
after delivery.
