It is an emerging health problem with a higher feto-maternal morbidity.

1. PANEL MODERATOR – DR. KIRAN PANDEY
CO-MODERATOR - DR. PAVIKA LAL
GDM

2. MBBS, MS, FICOG, FIMSA, FICMCH, MAMS
HEAD OF DEPARTMENT , DEPT OF OBG,
GSVM MEDICAL COLLEGE, KANPUR.
PRESIDENT 2016-18, KANPUR OBS & GYNAE SOCIETY
SECRETARY UPSC AGOI 2017-2019
VICE-PRESIDENT STATE CHAPTER (UPCOG) 2018-U.P.
 Organizing chairperson : National Adolescent Conference Youth Summit
And C.M.E 2017
 Organising Secretary ,National Conf of Obs &Gynae &UPCOG 2015.
 Organising Chairperson, Urogynaecology, NDVH, Pelvic Floor Repair
Workshop, National Conference 2015
 Contributed chapters in various books- Fetus in-utero, Abnormal Uterine
Bleeding, Amniotic fluid embolism, Gestational diabetes in “Current
trends” , epilepsy in pregnancy.
 11 National, 8 State level & 8 District level Awards & >30 awards at IMA.
 Received DR VC RASTOGI AWARD for Best women doctor in IMA UP State.
 Received WOMEN OF SUBSTANCE award on international women’s day 2009-10.
 Published > 100 research Papers in National & International Journals.
 Doing original research (8yrs) for early Dx of Carcinoma Cx with IIT
Kanpur.
 Interest-Oncology, Infertility, Adol. health, Urogynaecology, High risk
pregnancy
DR KIRAN PANDEY

3. Any degree of glucose intolerance
that either commences or is first
diagnosed in pregnancy
Prevalence - 18%
Increase in prevalence due to life
style, dietary habits, older age @ first
conception, PCOD, obesity etc.,
INTRODUCTION

5. CASE 1
A 29 years old female, G2P1+0(1 alive and
healthy) came for her first antenatal visit at
22weeks gestation.
• Weight-81kg
• BP- 130/90 mm of hg.
• Fundal ht- appropriate for GA.
• Obs. history- FTNVD of alive male baby (wt
3.8 kg)
How do we proceed?

6. SHOULD
SHE BE
SCREENED
FOR GDM??

7. LOW RISK
AGE<25YRS
LOW RISK ETHINICITY
NO DM IN FIRST DEGREE RELATIVE
NO ABNORMAL GLUCOSE
METABOLISM
NORMAL PREGNANCY WEIGHT
NORMAL BIRTH WEIGHT
NO
ROUTENE
SCREENING

8. MODERATE RISK
AGE >25YRS
HIGH RISK ETHINICITY
PRE PREGNANCY OVER WT
HIGH BIRTH WT
SCREEN
@ 24 -28
WKS

9. High risk
Over wt/obesity
first degree relative with DM2
High risk ethinicity
Prev h/o of GDM/ macrosomic
baby
Testing
ASAP

10. TO CLASSIFY, We elicit more history
• Family history-mother -DM2.
• Patient had been over weight since
her childhood
She is in high risk category – screening
ASAP

11. Is there a term as
EARLY GDM?
• ACOG introduced a new term called early
gestational diabetes mellitus in 2017.
• This classifies the patients who are high risk for
developing gestational diabetes.
• These patients are screened early leading to early
and effective treatment
• This also reduces maternal and fetal complications
to a great extent.
ACOG practice bulletin number 180, july 2017

12. • Controlled without
meds
• Diet & exercise
A1GDM
• Requires medications
A2GDM
ACOG practice bulletin number 180, july 2017

13. ACOG recommendation
Screening strategy to
detect pre-gestational
diabetes and early
gestational diabetes
mellites
 Test all women who are
over weight or obese
(BMI>23 in indians) +
one or more of the
following risk factors
Physical inactivity
First degree relative with
DM2
High risk ethnicity
Prev H/O GDM or macrosomic
baby
Hypertension / Dyslipidemia /
PCOD
HbA1c < 5.7% / impaired gluc.
tolerance

14. HOW TO
SCREEN??

15. 2008 NICE
– one step
2011-One step-
IADPSG,WHO
&ADA
Changes in policy regarding
how to screen GDM
2001 –
ACOG –
two step

16. 1 STEP vs 2 STEP APPROACH
1 step 2 step

17. ACOG still recommends(2017) the
two step approach
Step 1: 50g Glucose Challenge
Test- 50g anhyd. Gluc orally f/b
venous blood sugar after 1 hr
If it is > 130mg/dl go for step 2
Step 2: 3 hours diagnostic OGTT
ACOG practice bulletin number 180, july 2017

18. OGTT
STATUS CARPENTER &
COUSTON CRITERIA
NATIONAL DIABETIC
DATA GROUP
FASTING 95mg/dL 105mg/dL
1 HOUR 180mg/dL 190mg/dL
2 HOURS 155mg/dL 165mg/dL
3 HOURS 140mg/dL 145mg/dL
75g anhyd.
glucose
3 samples @
hrly intervals
>= 2 abnormal
values is positive

19. High risk women found to have normal glucose
tolerance [NGT], in the first trimester, should
be tested for GDM again around 24th – 28th
week and finally around 32nd – 34th week.
WHEN SHOULD YOU REPEAT THE
TEST?
Low risk women – repeat testing if
recurrent UTI/ polyhydramnios/ fetal
macrosomia or any other complications

20. High risk for GDM Moderate risk Low risk for GDM
Screen
immediately
Screen @ 24-
28wks+
32-34wks
Screen??
OGTT
Diagnosis of GDM
Monitor pregnancy closely
negative
positive positive
positive
negative
negative no
yes*

21. What is the
SCENARIO IN INDIA??
 HAPO study says – Asians have higher insulin
resistance
 Indian women belong to high risk ethinicity group
 This validates universal screening in Indian set-up
 Most woman don’t come fasting for ante natal check
up
 Drop-out Rate increases when they are asked to
come back for an OGTT
 So single step procedure is best in India

22. DIPSI recommendations
 Universal screening – single step diagnostic
procedure for all patients
Pregnant women given 75g
glucose load orally
Irrespective of fasting status/
time of previous meal
GDM diagnosed if @2hrs bld
glucose>=140mg/dL

23. ADVANTAGES OF DIPSI PROCEDURE
Pregnant women need not be fasting
Can be performed @ first visit itself
Hardly affects the daily routene of the woman
Screening as well as diagnostic procedure
Reduces the drop-out rate in Indian setting

24. The patient was screened for GDM
through the one step process and she
was found to have gestational diabetes
mellitus.
What are the possible maternal & fetal
complications?

25. WHAT ARE THE EXPECTED
MATERNAL
COMPLICATIONS?
GDM
Pre
eclamp
sia
nephro
pathy
retino
pathy
Neuro
pathy
RPL
Poly
hydra
mnios
Pre-
term
labour

26. WHAT ARE THE FETAL
COMPLICATIONS?
Growth
abnormalitie
s
Chemical
imbalance
Fetal
oxygenation
problems
Long term
sequelae

27. MALFORMATIONS
 Exposure to high glucose levels during organogenesis
results in malformations
• Neural tube defectsCNS
• TGA, VSD, ASD
• Hypoplastic left heart synd
CVS
• Caudal regression syndrome
• Spina bifida
SKELETAL
OTHERS • Renal agnesis, duodenal
atresia

28. Maternal glycosylated haemoglobin
levels in the first trimester may help to
predict the risk of occurrence of
congenital anomalies in the fetus
WHAT IS THE IMPORTANCE
OF HbA1c LEVELS??
HbA1c RISK
< 7 no greater risk than non diabetic mother
7 – 8.5 5%
>10 22%

29. CHEMICAL IMBALANCES
Neonatal hypo-glysemia
Hypocalcemia & hypomagnesemia
Surfactant deficiency
Abnormalities of iron metsbolism
hyperbilirubinemia

30. FETAL HYPOXIA
Fetal hyperglycemia & hyperinsulinemia
Oxygen consumption increases
Fetal hypoxia
Increased erythropoietin
Neonatal stroke/ seizures/ NEC/
sudden death

31. FOAD hypothesis
CAN GDM CAUSE LONG TERM
PROBLEMS IN THE BABY’S
FUTURE LIFE??
Fetal origin of adult diseases – developed by David Barker in mid 1980s

32. WHAT IS THE ROLE OF PRE-
CONCEPTIONAL COUNSELLING ??
Women with previous h/o GDM or k/c/o DM
should undergo pre- conceptional counselling.
Start appropriate dietary modification,
exercise.
Optimal pre pregnancy weight
Optimal glycemic control - Pre-pregnancy
HbA1c levels < 5.7
All OHAs except metformin stopped &
substituted with insulin
Renal, cardio vascular & retinal
assessment

33. she was put on medical nutritional
therapy. She was taught to self-monitor
her blood sugar levels and asked to come
for a weekly review for 2 weeks to
confirm that glycemic control is
established.

34. WHAT IS MEDICAL
NUTRITION THERAPY?
 First line therapy for GDM patients
 Individualized diet plan (according to BMI) by an
experienced dietician
 Caloric allotment – CHO 33-40%, protein 20% & fat
40%
 3 meals & 2-3 snacks/ day – distribute CHO intake-
reduce blood glucose fluctuations.
 Avoid canned foods, carbonated drinks. Take high
fibre diet
 Avoid atarvation

35. 3000 cal/day 2500cal/day 1250cal/day
NUTRITIONAL THERAPY
IDEAL Caloric intake
BASED ON BMI
BMI(<25 kg/m²) BMI(25-30 kg/m²) BMI(>40kg/m²)

36. 20% protein
Total calories
40-50%
carbohydrate
Better blood glucose &
lipid control
20-35% fat

37. IS EXERCISE RECOMMENDED?
 30 min of moderate
intensity aerobic exercise
for atleast 5 days/ week
 10 to 15 min of Brisk
walking after each meal is
commonly recommended
 Easier to control weight
gain
 Important to maintain
balance and avoid falls in
glucose levels

38. How to monitor?
 There is insufficient evidence to define
optimal frequency of glucose testing
 Current recommendations – FBS f/b
once after each meal – 4 times / day
 Once the glucose levels are well controlled ,
the frequency can be adjusted
 It should be kept in mind that the degree of
glucose intolerance increases with gestational
age

39. One day our patient arrives in the
emergency department with pain
in the abdomen since 2 hours,
her POG was – 38 weeks 4 days
She was found to be in latent
phase of labour, her labour was
progressed, she delivered a healthy
female baby. 

40. Case 2

41. A 34 years old female, came to our OPD for her
routene antenatal visit,
she was G5P1+3(1 alive & healthy)
POG- 8 weeks 2 days gestation.
Obs history –
• 1 term delivery of an alive female baby
weighing 4kg by lscs 12 years back
• following which she had 3 first trimester
pregnancy losses.
When she was evaluated for the same, she was
found to have abnormal glucose tolerance.

42. after 1 week, her sugar charting was,
How to proceed now?
Day BBF ABF AL AD
Mon 115 146 184 148
Tue 120 158 172 159
Wed 113 156 175 162
Thu 112 142 169 149
Fri 110 150 170 170
Sat 114 148 181 154
Sun 120 153 190 169

43. We have to start the patient on
Insulin therapy
Diet
Exercise

44. HOW TO START INSULIN
THERAPY??
 Gold standard in GDM treatment
 Diabetologist opinion to be taken
 Rapid acting , short and intermediate acting insulins
can be used
 Long acting – mitogenic effect – high affinity to IGF
RECEPTOR – macrosomia.
 Dose of insulin – 0.6 – 1 U/kg/day
Total insulin required= 2/3rd in morning +
1/3rd in night
Morning dose = 2/3rd NPH + 1/3rd short acting
Pre dinner = ½ NPH + ½ short acting

45. Time of pregnancy Dose
Pre-pregnancy 0.6 U/kg/day
I trimester 0.7 U/kg/day
II trimester 0.8 U/kg/day
III trimester(upto
34 wks)
0.9 U/kg/day
Term (35 to 39
weeks)
1.0 U/kg/day
STARTING DOSE CALCULATION

46. Is there a role for oral
hypoglycemic agents in
GDM??

47. METFORMIN
 Metformin is a reasonable second line drug in GDM
treatment
 It reduces the insulin requirement & total wt gain.
 Absence of long term neonatal follow up after in
utero exposure to metformin – ADA still
recommends insulin as first line therapy
 It should be started at 500mg HS, dose is slowly
increased as needed to a maximum of 2.5g – 3g/day
in divided doses
Rowan JA et al metformin versus insulin in treatment of gestational
diabetes published in NEJM 2008 ; 359:106

48. GLYBURIDE
Several studies also indicate that
 use of glyburide doesn’t yield glycemic
control equavalent to insulin
 it has worse fetal outcomes
so it is not recommended for GDM patients
Langer O et al A comparison of glyburide and insulin in women with
gestational diabetes mellitus NEJM 2000; 343:1134-8

49. How to do Fetal surveillance
in GDM?
I trimester
• PAPP-A
• Beta HCG
• NT
II trimester
• Anomaly
scan
• Fetal ECHO
• Umbilical art
doppler
III
trimester
• USG for
macrosomia
• BPP
• DFMC

50. The patient’s blood sugar levels were well
controlled with insulin therapy. She came for
regular antenatal check ups. Her ANC period
was uneventful.
Now the patient ’s POG is 37 weeks 2 days.
How will you plan her mode and timing of
delivery??

51. WHAT ABOUT TIMING AND
MODE OF DELIVERY?
• Not before 39 wks, unless
obstetrically indicated
• ACOG recommends expectant
management upto 40 6/7 wks
GDM well
controlled
with diet only
• From 39 0/7 to 39 6/7 weeks
GDM well
controlled
with meds

52. UNCONTROLLED GDM – EARLIER DELIVERY??
 There is no clear recommendations regarding
the degree of glycemic control that necessitates
early delivery.
 Considering all the pros & cons, delivery b/w 37
0/7 and 38 6/7 can be justified.
 Delivery b/w 34 0/7 and 36 6/7 – reserved for
women with failed in-hospital attempts of
glycemic control or abnormal fetal testing

53. IS LSCS MORE SAFE IN
GDM??

54. Vaginal delivery is not contra indicated for suspected
macrosomia unless EFW > 4.5kg
Recent study says among cases of ultrasonographically
detected LGA only 22% turned out to be actually LGA @
birth
Data are insufficient to determine if cesarean should be
performed in suspected macrosomia to reduce the risk
of birth trauma

55. WHAT ARE THE PRECAUTIONS TO BE
TAKEN DURING LABOUR?
 Consent to be taken regarding the need for
instrumentation and emergency section if needed
 Monitor vitals , fluid intake & output, urine ketones
and blood sugar levels 1-2 hrly
 Fetal heart should be monitored and partograph is
charted
 Instrumental delivery, if needed, should be under
taken with care
 Traumatic & atonic PPH should be watched for.

56. BLOOD GLUCOSE
LEVELS
INSULIN INFUSION RATE
Up to 100 mg/dl
101-140 mg/dl 1.0 U/h 1.0ml/h
141-180mg/dl 1.5 U/h 1.5 ml/h
181-220 mg/dl 2.0 U/h 2.0 ml/h
INSULIN INFUSION RATE & BLOOD SUGAR LEVELS

57. HOW TO DO INTRA PARTUM
MONITORING?
 High risk Consent taken
 Aim is to keep glucose level b/w 72 and 126 mg/dL
 Two I.V lines to be secured
 If glucose level is not maintained then dextrose-
insulin neutralizing drip is started.
 50 units of regular insulin in 50ml of normal saline
in one line
 10% dextrose drip @ 125mL/hr is given through
other line
 Attempts for instrumentation should be
undertaken with care
 Prepare for both traumatic & atonic PPH

58. Elective LSCS in case the
patient does not consent for
NVD or if LSCS is done for any
other obstetric indications,
what are the precautions to be
taken??

59. What Precautions will you take
during LSCS?
 Night dose of insulin should be given
 Usually take up as the first case in the morning
 Morning insulin dose is omitted
 Sliding scale of insulin can be started and continued
in post-op period
 Adequate incision size to allow delivery of big baby
 Early mobilization
 Severely obese patients - thromboprophylaxis

60. In GDM
Need for
insulin
reduces
STOPPED if
glucose
levels are
normal
In pre-
gestational
diabetes
insulin
continued
for ---- wks
Pre-
conceptio
nal meds
resumed
ACOG RECOMMENDS 75g OGTT in all GDM
patients @ 4 to 12 weeks postpartum. If results
are normal, test is repeated every 1-3 years
HOW DO WE DO POSTPARTUM
FOLLOW UP??

61. All GDM patients- FBS + 75g 2hr OGTT @ 4-12wks pp
FBS>125md/dL ;
@2hr> 199mg/dL
Diabetes mellitus
Manage accordingly
FBS 100-125mg/dL
&/or @2hr 140-
199mg/dL
Impaired fasting
glucose / IGT/ both
Life style changes/MNT/
metformin & yearly
assessment
FBS<100mg/dL;
@2hr<140mg/dL
normal
Yearly re-
assessment

62. CONTRACEPTIVE
ADVICE
Method of choice – barrier
Progesterone only pills can also be used
Combined oral pills should be
avoided
IUCDs can predispose to infections
Diabetic patients may undergo tubal
sterilization with precaution

63. IN PCOS WITH GDM CAN METFORMIN BE
CONTINUED THROUGH OUT PREGNANCY?
The MIG (metformin in GDM) trial- 2011 results
show that there is no significant short term/ long
term adverse outcomes in neonates of mothers
treated with metformin throughout the pregnancy
But ADA and ACOG continue to recommend that
metformin should be replaced with insulin therapy
during second trimester due to insufficient data
regarding fetal outcomes

64. WHAT IS THE SIGNIFICANCE OF THYROID
SCREENING IN DIABETIC MOTHERS??
ADA states that in type 1 diabetes
mellitus patients screening for
hypothyroidism is important as both
the diseases have an underlying
auto-immune etiology
As per Present studies there is no role
in GDM

65. Thank you!!