1. Gestational diabetes (GDM) is defined as glucose intolerance that begins or is first recognized during pregnancy and accounts for 1-14% of all pregnancies. 2. Risk factors for GDM include age over 35, BMI over 30, history of GDM, family history of diabetes, and certain ethnic backgrounds. 3. Screening involves a glucose challenge test at 24-28 weeks followed by an oral glucose tolerance test if thresholds are met, with diagnosis made if two out of four glucose levels are met. 4. GDM can lead to complications for both mother and baby such as preeclampsia, preterm birth, and fetal macrosomia. Treatment involves medical nutrition therapy

1. Dr. Rumella Afroze
Registrar (Obst. & Gynae)
M Abdur Rahim Medical College Hospital
Dinajpur
1

2. Definition
GDM has traditionally defined as any degree of glucose
intolerance with onset or first recognition during
pregnancy

3. Incidence
•About 1-14% of all pregnancies are complicated
by DM
•90% of them are GDM

4. Pathogenesis
• Insulin Resistance
• Increased lipolysis
• Changes in gluconeogenesis

5. Low risk
-Age < 25 years
- Members of Ethnic group with low prevalence of GDM
- No history of DM in first degree relative
- No history of abnormal glucose metabolism
- BMI ≤ 25
- No history of adverse obstetric outcome

6. High risk
-age > 35-40 years
- BMI > 30
- History of GDM
-Heavy glycosuria
-History of unexplained stillbirth
-Strong family history of DM

7. Screening for Diagnosis of GDM
• One step strategy:
75g OGTT at 24-28 weeks of gestation
GDM is diagnosed if:
FBS ≥92 mg/dl (5.1mmol/L)
Post 1 hour ≥180 mg/dl ( 10.0 mmol/L)
Post 2 hour ≥153 mg/dl ( 8.5 mmol/L)

8. Two Step strategy
• Step 1:
50g GLT at 24-28 weeks of gestation
plasma glucose level after 1 hour 130mg/dl,135mg/dl or 140
mg/dl then proceed to next step.

9. • Step 2: 100g OGTT
GDM is at least two of the following plasma glucose level are met
Glucose
Measured
Level of glucose
Carpenter & Coustan Criteria NDDG criteria
FBS 95 mg/dl ( 5.3 mmol/L) 105 mg/dl ( 5.8 mmol/L)
1 hour 180 mg/dl ( 10.0 mmol/L) 190 mg/dl ( 10.6 mmol/L)
2 Hour 155 mg/dl ( 8.6 mmol/L) 165 mg/dl ( 9.2 mmol/L)
3 Hour 140 mg/dl ( 7.8 mmol/L) 145 mg/dl ( 8.0 mmol/L)

10. WHO Recommendation
Glucose measured Level Of glucose
Fasting Blood glucose > 6.9 mmol/L
2 hours after 75g glucose > 7.7 mmol/L

11. Effects Of DM on Pregnancy
• Preeclampsia
• Preterm labour
• Polyhydramnios
• UTI
• Maternal distress
• ketoacidosis

12. • Prolonged labour
• Shoulder dystocia
• Perineal injuries
• PPH
• Operative interference

13. • Puerperal sepsis
• Lactation failure

14. • Fetal macrosomia, growth restriction, malformations
• Hypoglycemia
• Hyperbilirubinemia
• Hypocalcemia
• RDS

15. • Medical Nutrition Therapy
Total calorie intake varies according to BMI of Women
BMI < 25kg/sqm – 3000kcal/day
Overweight (BMI 25-30kg/sqm) -2500kcal/day
Morbid obesity (BMI >40 kg/sqm) -1200kcal/day

16. • Total calorie requirement
Carbohydrate <45%
Protein 30%
Fat 25%
Carbohydr
ate
45%
Protein
30%
Fat
25%
Nutritional Requirements
GDM
Carbohydrate
Protein
Fat

17. Excercise
According to NICE guideline:
Around 30 minutes of mild to moderate
exercise daily

18. Pharmacotherapy
• Oral hypoglycemic agents:
Metformin
Glyburide

19. Insulin
• Gold standard
 Short acting Regular Insulin
 Rapid acting analogue-Aspart, lyspro
 Intermediate acting-NPH Insulin
 Long acting- Detemir

20. When to Start Insulin?
• Insulin should be started
-FBG exceeds 90mg/dl
- 2 hour PPG more than 120mg/dl

21. Insulin Dosing
• Dose varies fromm 0.6-1 U/kg/day
• Total daily requirement=2/3 in morning + 1/3 at night
• Morning dose=2/3 NPH +1/3 Short acting
• Predinner dose= ½ NPH + ½ short acting

22. Antenatal Care
• If Excellent control by diet alone
-Fetal surveillance with nonstress testing or biological profile
may be initiated at 40 weeks
• If uncontrolled
-Fetal surveillance & USG should be advised

23. Timing & Mode Of Delivery
• Spontaneous delivery up to 40 weeks in uncomplicated case
• Elecive delivery at around 38 weeks
-Complicated cases
-Who require insulin

24. • Usual bed time insulin prior to the day of induction
• No breakfast and morning insulin
• Blood glucose measured by glucometer
• Normal saline infusion begun and induction done by LRM
• If no contraindication then oxytocin drip started

25. • An IV drip of 1 L 5% DA is set up with 10 units of soluble insulin
• Blood glucose level monitored hourly
• Epidural analgesia is ideal for pain relief
• If labor fails starting within 6-8 hours or progress un satisfactorily
then CS

26. • Continuous monitoring of FHR
• Partograph must be charted
• Care during second stage
• Both traumatic and atonic PPH must be maintained
• Baby should be evaluated by a neonatologist

27. Precaution during Caesarean Section
• Anesthetist must be consulted
• Consent & blood availability
• Light meal & night dose of insulin are given morning dose is omitted
• FBS level should be done

28. • Normal saline Infusion should be started
• 5% DA 1 L + 10 Units insulin Drip
• Performed as first case in morning
• Adequate incision size
• Post operative glucose monitoring

29. Postpartum Management
• Insulin requirement reduces
• It can be stopped if glucose level become normal
• Wound care is important
• Prolonged antibiotic therapy

30. Prognosis
50% risk of developing DM within 10-15 years

31. Follow-Up
• All patient with GDM should have 2 hour 75g OGTT approximately 6
weeks postpartum
• If normal glucose tolerance reassess every 3 years
• If IGT or IFG then re-evaluate annually