Gestational diabetes is a condition where women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy, especially in the third trimester. It affects between 2-3% of pregnancies and is associated with complications. It is diagnosed through fasting and post-meal blood glucose tests. Treatment may include medical nutrition therapy, blood glucose monitoring, and potentially insulin therapy if needed to control blood sugar levels and minimize risks. Close monitoring of the mother and baby's health is important throughout the pregnancy.

1. GestationalGestational
diabetesdiabetes
BYBY
Sohaib AhmedSohaib Ahmed
08-18308-183

2. DefinitionDefinition::
It is a condition in which women
without previously diagnosed
diabetes exhibit
high blood glucose levels during
pregnancy (especially during their
third trimester(.

3. Prevalence:Prevalence:
Gestational diabetes and impaired glucoseGestational diabetes and impaired glucose
tolerance (IGT) in pregnancy affectstolerance (IGT) in pregnancy affects
between 2-3% of all pregnanciesbetween 2-3% of all pregnancies
and both have been associated withand both have been associated with
pregnancy complications.pregnancy complications.

4. Fasting and 2 hours postprandialFasting and 2 hours postprandial
venous plasma sugar duringvenous plasma sugar during
pregnancy.pregnancy.
Border lineBorder line
indicates glucoseindicates glucose
tolerance test.tolerance test.
125-200 mg/dl.125-200 mg/dl.100-125 mg/dl100-125 mg/dl
DiabeticDiabetic>200 mg/ dl.>200 mg/ dl.>125 mg/ dl>125 mg/ dl
Not diabeticNot diabetic< 145mg/ dl.< 145mg/ dl.<100 mg/dl<100 mg/dl
ResultResult2h postprandial2h postprandialFastingFasting

6. Low-risk statusLow-risk status requires no glucose testing, but thisrequires no glucose testing, but this
category is limited to those women meetingcategory is limited to those women meeting allall of theof the
following characteristics:following characteristics:
 Age <25 years.Age <25 years.
 Weight normal before pregnancy .Weight normal before pregnancy .
 Member of an ethnic group with a low prevalence ofMember of an ethnic group with a low prevalence of
gestational diabetes mellitus .gestational diabetes mellitus .
 No known diabetes in first-degree relatives .No known diabetes in first-degree relatives .
 No history of abnormal glucose tolerance .No history of abnormal glucose tolerance .
 No history of poor obstetric outcome .No history of poor obstetric outcome .
Risk assessmentRisk assessment

7. Risk assessmentRisk assessment
 marked obesity.marked obesity.
 personal history of gestational diabetespersonal history of gestational diabetes
mellitus.mellitus.
 Glycosuria.Glycosuria.
 a strong family history of diabetes .a strong family history of diabetes .
A high risk of gestational diabetes mellitus:A high risk of gestational diabetes mellitus:

8. high risk patients should undergo glucosehigh risk patients should undergo glucose
testingtesting
A fasting plasma glucoseA fasting plasma glucose
levellevel >125mg/dL>125mg/dL or aor a
casual plasma glucosecasual plasma glucose
>200 mg/dL>200 mg/dL meets themeets the
threshold for thethreshold for the
diagnosis of diabetesdiagnosis of diabetes
In the absence of this
degree of hyperglycemia,
evaluation for gestational
diabetes mellitus in
women with average or
high-risk characteristics is
by glucose tolerance test .
Risk assessmentRisk assessment

9. 5050--g oral glucose challengeg oral glucose challenge
The screening test for GDM, a 50-g oral glucoseThe screening test for GDM, a 50-g oral glucose
challenge, may be performed in the fasting orchallenge, may be performed in the fasting or
fed state. Sensitivity is improved if the test isfed state. Sensitivity is improved if the test is
performed in the fasting state .performed in the fasting state .
A plasma value aboveA plasma value above one hourone hour
afterafter is commonly used as a threshold foris commonly used as a threshold for
performing a 3-hour OGTT.performing a 3-hour OGTT.
If initial screening is negative, repeat testing isIf initial screening is negative, repeat testing is
performed at 24 to 28 weeks.performed at 24 to 28 weeks.
130130--140140mg/dlmg/dl

10. 33hour Oral glucose tolerance testhour Oral glucose tolerance test
Prerequisites:
- Normal diet for 3 days before the test.
- No diuretics 10 days before.
- At least 10 hours fast.
- Test is done in the morning at rest.
Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally
Criteria for glucose tolerance test:
The maximum blood glucose values during pregnancy:
- fasting 90 mg/ dl,
- one hour 165 mg/dl,
- 2 hours 145 mg/dl,
- 3 hours 125 mg/dl.
If any 2 or more of these values are elevated, the patient is considered to
have an impaired glucose tolerance test.

12. MonitoringMonitoring
Urine glucose monitoring is not useful inUrine glucose monitoring is not useful in
gestational diabetes mellitus. Urinegestational diabetes mellitus. Urine
ketone monitoring may be useful inketone monitoring may be useful in
detecting insufficient caloric ordetecting insufficient caloric or
carbohydrate intake in women treatedcarbohydrate intake in women treated
with calorie restriction.with calorie restriction.

13. DailyDaily self-monitoring of bloodself-monitoring of blood
glucose (SMBG) appears to beglucose (SMBG) appears to be
superior tosuperior to intermittentintermittent officeoffice
monitoring of plasma glucose.monitoring of plasma glucose.
MonitoringMonitoring

14. For women treated with insulin,For women treated with insulin, preprandialpreprandial
monitoring ismonitoring is postprandialpostprandial
monitoring. However, the success ofmonitoring. However, the success of
either approach depends on the glycemiceither approach depends on the glycemic
targets that are set and achieved.targets that are set and achieved.
MonitoringMonitoring
superior tosuperior to

15. Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 ((
It is normally accounts forIt is normally accounts for 5-6%5-6% of the total haemoglobinof the total haemoglobin
mass. A valuemass. A value over 10%over 10% indicates poor diabetesindicates poor diabetes
control in the previous 4-8 weeks.control in the previous 4-8 weeks.
If this is detected early in pregnancyIf this is detected early in pregnancy, there is a high risk, there is a high risk
of congenital anomalies .of congenital anomalies .
If this is detected in late pregnancyIf this is detected in late pregnancy it indicates increasedit indicates increased
incidence of macrosomia and neonatal morbidity andincidence of macrosomia and neonatal morbidity and
mortality.mortality.
MonitoringMonitoring

16. The mean glucose represented by the hemoglobinThe mean glucose represented by the hemoglobin
A1c level can be calculated using the "rule ofA1c level can be calculated using the "rule of
8's." A value of 8 percent equals 180 mg/dl, and8's." A value of 8 percent equals 180 mg/dl, and
each 1 percent increase or decrease representseach 1 percent increase or decrease represents
± 30 mg/dl.± 30 mg/dl.
Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 ((
MonitoringMonitoring

17. Assessment for asymmetric fetalAssessment for asymmetric fetal
growth by ultrasonography,growth by ultrasonography,
particularly in early third trimester,particularly in early third trimester,
may aid in identifying fetuses that canmay aid in identifying fetuses that can
benefit from maternal insulin therapybenefit from maternal insulin therapy
MonitoringMonitoring

18. Maternal surveillance should includeMaternal surveillance should include
blood pressure and urine proteinblood pressure and urine protein
monitoring to detect hypertensivemonitoring to detect hypertensive
disorders.disorders.
MonitoringMonitoring

20. There are insufficient data for any reliableThere are insufficient data for any reliable
conclusions about the effects ofconclusions about the effects of
treatments for impaired glucose tolerancetreatments for impaired glucose tolerance
on perinatal outcome.on perinatal outcome.

21. Medical nutrition therapy should include theMedical nutrition therapy should include the
provision of adequate calories andprovision of adequate calories and
nutrients to meet the needs of pregnancynutrients to meet the needs of pregnancy
and should be consistent with theand should be consistent with the
maternal blood glucose goals that havematernal blood glucose goals that have
been established. Noncaloric sweetenersbeen established. Noncaloric sweeteners
may be used in moderation.may be used in moderation.
1-medical nutrition
therapy

22. Diet therapy is critical to successful regulation ofDiet therapy is critical to successful regulation of
maternal diabetes. A program consisting ofmaternal diabetes. A program consisting of
three meals and several snacks is used forthree meals and several snacks is used for
most patients. Dietary composition should be :most patients. Dietary composition should be :
 50 to 60 percent carbohydrate,50 to 60 percent carbohydrate,
 20 percent protein,20 percent protein,
 25 to 30 percent fat with less than 10 percent25 to 30 percent fat with less than 10 percent
saturated fats, up to 10 percentsaturated fats, up to 10 percent
polyunsaturated fatty acids, and the remainderpolyunsaturated fatty acids, and the remainder
derived from monosaturated sourcesderived from monosaturated sources

23. insulin therapy is recommended when medical nutritioninsulin therapy is recommended when medical nutrition
therapy fails to maintain self-monitored glucose at thetherapy fails to maintain self-monitored glucose at the
following levels:following levels:
FastingFasting whole blood glucosewhole blood glucose <<95 mg/dL95 mg/dL
Fasting plasma glucoseFasting plasma glucose <<105 mg/dL105 mg/dL
oror
1-hour postprandial1-hour postprandial whole blood glucosewhole blood glucose <<140 mg/dL140 mg/dL
1-hour postprandial plasma glucose1-hour postprandial plasma glucose <<155 mg/dL155 mg/dL
oror
2-hour postprandial2-hour postprandial whole blood glucosewhole blood glucose <<120 mg/dL120 mg/dL
2-hour postprandial plasma glucose2-hour postprandial plasma glucose <<135 mg/dL135 mg/dL
2-insulin therapy

24. GOALGOAL
Self-blood glucose monitoring combinedSelf-blood glucose monitoring combined
with aggressive insulin therapy haswith aggressive insulin therapy has
made the maintenance of maternalmade the maintenance of maternal
normoglycemianormoglycemia
((fasting and premeal glucose betweenfasting and premeal glucose between
50-80mg/dl and 1 hour postprandial50-80mg/dl and 1 hour postprandial
glucose <140mg/dlglucose <140mg/dl))
Insulin therapyInsulin therapy ……..cont..cont..

25. Insulin therapyInsulin therapy ……..cont..cont..
Twice daily ( before breakfast and beforeTwice daily ( before breakfast and before
dinner) injections of a combination of shortdinner) injections of a combination of short
and intermediate acting insulins areand intermediate acting insulins are
usually sufficient to control most patientsusually sufficient to control most patients
otherwise a subcutaneous insulin pump isotherwise a subcutaneous insulin pump is
used.used.

26. The total first dose of insulin is calculatedThe total first dose of insulin is calculated
according to the patientaccording to the patient’’s weight as follow:s weight as follow:
Insulin therapyInsulin therapy ……..cont..cont..
In the first trimester .......... weight x 0.7In the first trimester .......... weight x 0.7
In the second trimester........ weight x 0.8In the second trimester........ weight x 0.8
In the third trimester........... weight x 0.9In the third trimester........... weight x 0.9

27. If the total dose of insulin is less than 50If the total dose of insulin is less than 50
units/ dayunits/ day,, it is given in a single morning dose withit is given in a single morning dose with
the ratiothe ratio:: Short acting (regular orShort acting (regular or
Actrapid)/Intermediate (NPH or Monotard) = 1 : 2Actrapid)/Intermediate (NPH or Monotard) = 1 : 2
In higher dosesIn higher doses ,, As a general rule, the amount ofAs a general rule, the amount of
intermediate-acting insulin will exceed the short-intermediate-acting insulin will exceed the short-
acting component by a 2:1 ratio. Patients usuallyacting component by a 2:1 ratio. Patients usually
receive two thirds their total dose with breakfast andreceive two thirds their total dose with breakfast and
the remaining third in the evening as a combinedthe remaining third in the evening as a combined
dose with dinnerdose with dinner

28. Insulin Dose adjustmentInsulin Dose adjustment
Home glucose monitoring with a reflectanceHome glucose monitoring with a reflectance
meter by measuring fasting and preprandialmeter by measuring fasting and preprandial
glucose values 4 times a day (30-40 min)beforglucose values 4 times a day (30-40 min)befor
each meal.each meal.
preprandial glucose measuring allows addingpreprandial glucose measuring allows adding
additional regular insulin to compensate anyadditional regular insulin to compensate any
hyperglycemia already present before meals.hyperglycemia already present before meals.
All values are recorded in a daily log.All values are recorded in a daily log.
NEXT

29. Each time the fasting or premealEach time the fasting or premeal
glucose is measured, the patientglucose is measured, the patient
refers to therefers to the supplemental regularsupplemental regular
insulin scaleinsulin scale to determine ifto determine if
additional regular insulin isadditional regular insulin is
neededneeded
NEXT
Insulin Dose adjustmentInsulin Dose adjustment

30. PreprandialPreprandial
glucose mg/dlglucose mg/dl
Additional unitsAdditional units
(regular insulin)(regular insulin)
<100<100 00
100-140100-140 22
140-160140-160 33
160-180160-180 44
180-200180-200 55
200-250200-250 66
250-300250-300 88
>300>300 1010
supplemental regular insulin scalesupplemental regular insulin scale
NEXT

31. When the pattern for additionalWhen the pattern for additional
regular insulin supplementation isregular insulin supplementation is
identified over 2-3 days, thatidentified over 2-3 days, that
amount of insulin can then beamount of insulin can then be
added to the planned daily dose.added to the planned daily dose.
Insulin Dose adjustmentInsulin Dose adjustment

32. In patients who are not well controlled, aIn patients who are not well controlled, a
brief period of hospitalization is oftenbrief period of hospitalization is often
necessary for the initiation of therapy.necessary for the initiation of therapy.
Individual adjustments to the regimensIndividual adjustments to the regimens
implemented can then be made.implemented can then be made.
3-Hospitalisation

33. KETOACIDOSISKETOACIDOSIS

34. KETOACIDOSISKETOACIDOSIS
As pregnancy is a state of relative insulinAs pregnancy is a state of relative insulin
resistance marked by enhanced lipolysis andresistance marked by enhanced lipolysis and
ketogenesis, diabetic ketoacidosis may developketogenesis, diabetic ketoacidosis may develop
in a pregnant woman with glucose levels barelyin a pregnant woman with glucose levels barely
exceeding 200 mg/dl .exceeding 200 mg/dl .
Thus, DKA may be diagnosed during pregnancyThus, DKA may be diagnosed during pregnancy
with minimal hyperglycemia accompanied by awith minimal hyperglycemia accompanied by a
fall in plasma bicarbonate and a pH value lessfall in plasma bicarbonate and a pH value less
than 7.30. Serum acetone is positive at a 1:2than 7.30. Serum acetone is positive at a 1:2
dilution.dilution.

35. clinical signs of volume depletion follow theclinical signs of volume depletion follow the
symptoms of hyperglycemia, whichsymptoms of hyperglycemia, which
includeinclude
 polydipsia and polyuria.polydipsia and polyuria.
 Malaise.Malaise.
 Headache.Headache.
 nausea.nausea.
 Vomiting.Vomiting.
KETOACIDOSISKETOACIDOSIS

36.  Occasionally, diabetic ketoacidosis may presentOccasionally, diabetic ketoacidosis may present
in an undiagnosed diabetic woman receiving β-in an undiagnosed diabetic woman receiving β-
mimetic agents to arrest preterm labor.mimetic agents to arrest preterm labor.
 Because of the risk of hyperglycemia and diabeticBecause of the risk of hyperglycemia and diabetic
ketoacidosis in diabetic women . Terbutaline andketoacidosis in diabetic women . Terbutaline and
magnesium sulfate has become the preferredmagnesium sulfate has become the preferred
tocolytic for cases of preterm labor in thesetocolytic for cases of preterm labor in these
cases.cases.
 Sometimes Administration of antenatalSometimes Administration of antenatal
corticosteroids to accelerate fetal lung maturationcorticosteroids to accelerate fetal lung maturation
can cause significant maternal hyperglycemia andcan cause significant maternal hyperglycemia and
precipitate DKA. In diabetic patients.precipitate DKA. In diabetic patients.
KETOACIDOSISKETOACIDOSIS

37. An intravenous insulin infusion will usually beAn intravenous insulin infusion will usually be
required and is adjusted on the basis of frequentrequired and is adjusted on the basis of frequent
capillary glucose measurements.capillary glucose measurements.
Therapy hinges on the meticulous correction ofTherapy hinges on the meticulous correction of
metabolic and fluid abnormalities.metabolic and fluid abnormalities.
Every effort should therefore be made to correctEvery effort should therefore be made to correct
maternal condition before intervening andmaternal condition before intervening and
delivering a preterm infant.delivering a preterm infant.
KETOACIDOSISKETOACIDOSIS

39. There isThere is very little evidencevery little evidence to supportto support
either elective delivery or expectanteither elective delivery or expectant
management at term in pregnant womenmanagement at term in pregnant women
with insulin-requiring diabetes. Limitedwith insulin-requiring diabetes. Limited
data from a single randomized controlleddata from a single randomized controlled
trial suggest that induction of labour intrial suggest that induction of labour in
women with gestational diabetes treatedwomen with gestational diabetes treated
with insulin reduces the risk of macrosomiwith insulin reduces the risk of macrosomi

40. When antepartumWhen antepartum
testing suggests fetaltesting suggests fetal
compromise, deliverycompromise, delivery
must be considered.must be considered.

41. Delivery by cesarean section usually isDelivery by cesarean section usually is
favored when fetal distress has beenfavored when fetal distress has been
suggested by antepartum heart ratesuggested by antepartum heart rate
monitoring.monitoring.
If a patient reachesIf a patient reaches 38 weeks'38 weeks' gestationgestation
with a mature fetal lung profile and is atwith a mature fetal lung profile and is at
significant risk for intrauterine demisesignificant risk for intrauterine demise
because of poor control or a history ofbecause of poor control or a history of
a prior stillbirth, an elective delivery isa prior stillbirth, an elective delivery is
planned.planned.

42. During labor, continuous fetal heartDuring labor, continuous fetal heart
rate monitoring is mandatory. Laborrate monitoring is mandatory. Labor
is allowed to progress as long asis allowed to progress as long as
normal rates of cervical dilatationnormal rates of cervical dilatation
and descent are documented.and descent are documented.
arrest of dilatation or descent despitearrest of dilatation or descent despite
adequate labor should alert theadequate labor should alert the
physician to the possibility ofphysician to the possibility of
cephalopelvic disproportion.cephalopelvic disproportion.

43. •• Usual dose of intermediate-acting insulin is given atUsual dose of intermediate-acting insulin is given at
bedtime.bedtime.
•• Morning dose of insulin is withheld.Morning dose of insulin is withheld.
•• Intravenous infusion of normal saline is begun.Intravenous infusion of normal saline is begun.
•• Once active labor begins or glucose levels fall belowOnce active labor begins or glucose levels fall below
70 mg/dl, the infusion is changed from saline to 5%70 mg/dl, the infusion is changed from saline to 5%
dextrose and delivered at a rate of 2.5 mg/kg/min.dextrose and delivered at a rate of 2.5 mg/kg/min.
•• Glucose levels are checked hourly using a portableGlucose levels are checked hourly using a portable
meter allowing for adjustment in the infusion rate.meter allowing for adjustment in the infusion rate.
•• Regular (short-acting) insulin in administered byRegular (short-acting) insulin in administered by
intravenous infusion if glucose levels exceed 140intravenous infusion if glucose levels exceed 140
mg/dl.mg/dl.
Insulin Management during Labor and DeliveryInsulin Management during Labor and Delivery