This document discusses gestational diabetes mellitus (GDM). It begins by defining GDM as glucose intolerance that begins during pregnancy. The prevalence of GDM is approximately 18% globally and is increasing due to lifestyle factors. The document then discusses the classification, epidemiology, pathophysiology, screening, and management of GDM. Key points include that GDM occurs in approximately 7% of pregnancies, is associated with increased insulin resistance during pregnancy, and screening and treatment can help reduce maternal and fetal complications. Management involves medical nutrition therapy, exercise, insulin therapy if needed, and monitoring during labor and delivery.

1. By: DR. LATA CHANDRA
JUNIOR RESIDENT
ANMMCH GAYA
GESTATIONAL DIABETES
MELLITUS

2. INTRODUCTION
• 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 at first conception, PCOD,
obesity etc.,

4. WHITE CLASSIFICATION

5. 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.

6. EPIDEMIOLOGY
• GDM happens in about 7 of every 100
pregnancies.
• The recent data on the prevalence of GDM in
India was 16.55% by WHO criteria of 2 hr PG ≥
140 mg/dl .
• Significant disturbances in carbohydrate
metabolism occur in about 1 % pregnancies .
• The incidence of GDM increases by approximately
8 times for pregnant women aged 35 years and
over compared with women aged 25 years or
under.

7. PATHOPHYSIOLOGY
 The maternal metabolic adaptation is to maintain the
mean fasting plasma glucose of 74.5 ± 11 mg/dl and
the post prandial peak of 108.7 ± 16.9mg/dl.
 This fine tuning of glycemic level during pregnancy is
possible due to the compensatory hyperinsulinaemia,
as the normal pregnancy is characterized by:-
 Increased insulin resistance and
 Decreased insulin sensitivity.
 A pregnant woman who is not able to increase her
insulin secretion to overcome the insulin resistance
that occurs even during normal pregnancy develops
gestational diabetes.

8. INCREASED INSULIN RESISTANCE
 Due to hormones secreted by the placenta
that are “diabetogenic”: -
 Growth hormone
 Human placental lactogen
 Progesterone
 Corticotropin releasing hormone
Transient maternal hyperglycemia occurs after meals
because of increased insulin resistance.

9. RELATIVE BASELINE HYPOGLYCAEMIA
 Proliferation of pancreatic beta cells (insulin-
secreting cells) leads to increased insulin
secretion.
 Insulin levels are higher than in pregnant than
nonpregnant women in fasting and postprandial
states.
 Hypoglycemia between meals and at night
because of continuous fetal draw
Blood glucose levels are 10-20% lower.

10.  24-hour insulin requirement before conception is
approximately 0.6 units / kg.
 In the first trimester, the insulin requirement rises to
0.7units / kg of the pregnant weight – more unstable
glycemia with a tendency to low fasting plasma glucose
and high postprandial excursions and the occurrence of
nocturnal hypoglycemia.
 By the second trimester, the insulin requirement is 0.8
units per kilogram. From 24th wk onwards steady
increase in insulin requirement and glycemia stabilizes.
 By third trimester the insulin requirement is 0.9 - 1.0
unit /kg pregnant weight per day.
 Last month – may be a decrease in insulin and
hypoglycemia especially nocturnal.

12. SCREENING OF GDM

22. 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.

25. GDM GUIDLINES FEB 2018 GOI INTRODUCES IN RCH AND NPCDCS
Recommonded by FOGSI and WHO
GDM screening done-same as DIPSI….Screening done ASAP at 1st visit
• IF2hr BI.SUGAR<140mg/dl
REPEAT TESTINNG AT 24-28 WK
IF BL.SUGAR<140-GDM –VE
IF BL.SUGAR>140-GDM+VE
v
n
m
m
e
m
IF BL.SUGAR >140mg/dl
MNT+EXERCISE+LIFE
STYLE MODIFICATION
(FOR 2WK)
IF BL.GLUCOSE<120-GDM-VE
IF BL.GLUCOSE>120-GDM+VE
(START NSULINE/METFORMIN)

26. INSULIN THERAPY A/C TO BLOOD
SUGAR
BLOO GLUCOSE INSULIN
120-160 = 4 UNIT
160-200 = 6 UNIT
>200 = 8 UNIT
On third day again OGTT repeat
1) FBG = <95
PPBG=<120
2) FBG=<95
PPBG>120
ALL
GIVEN
AS
SINGLE
DOSE 30
MIN
BEFORE
BREAKFA
ST
CONTIN
UE
INSULIN
KEEP INSULIN SAME BUT ADD 2 UNIT BEFORE
BREAKFAST

27. • FBG>95
PPBG>120
Only Human insulin premix 30:70 used
40 IU SYRINGE USED;ONLY SC inj. given
KEEP DOSE SAME BUT SPLIT THE DOSE IN
MORNING(+2U) AND EVENING DOSE(+4U)
WE TITRATE IT ON EVERY THIRD DAY
UNTIL WE REACH THE TARGET OF
FBS<95
PPBS<120 ACHIEVED

28. MANAGEMENT

29. 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 carbohydrate
intake and reduces blood glucose fluctuations.
 Avoid canned foods, carbonated drinks. Take high fibre
diet.
 Avoid starvation.

30. MATERNAL COMPLICATION OF GDM
 PREECLAMPSIA
PRE-TERM LABOUR
POLYHYDRAMNIOS
RPL
RETINOPATHY
NEPHROPATHY
NEUROPATHY

32. FETAL COMPLICATIONS OF GDM:-
GROWTH ABNORMALITIES
FETAL OXYGENATIONS PROBLEMS
CHEMICAL IMBALANCES
LONG TERM SEQUELAE

38. Role of Exercise
• 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.

39. 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

41. ROLE OF ORAL HYPOGLYCAEMIC
DRUG IN GDM
1. 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.

42. 2. 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 .

45. TIMING AND MODE OF DELIVERY
GDM well controlled with Diet only:-
 Not before 39 wks, unless obstetrically indicated
 ACOG recommends expectant management upto 40
6/7 wks .
 GDM well controlled with medications:-
 From 39 0/7 to 39 6/7 weeks

47. MODE OF DELIVERY IN GDM

48. PRECAUTION 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.

49. INTRAPARTUM 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.

50. DOSE OF INSULINE A/C TO
BL.GLUCOSE
• BL.GLUCOSE
• <90mg/ml
• 90-120mg/ml
• 120-180mg/ml
• 180-240mg/ml
• >240mg/ml
• INSULINE
• 0.5U/hr
• 1U/hr
• 2U/hr
• 3U/hr
• 4U/hr

51. INTRAPARTUM MONITORING A/C TO
MOHFW
BLOOD SUGAR LEVEL AMOUNT OF INSULIN IN
500 ML NS
RATE OF NS INFUSION
90-120mg/dl 0 100 ml/hr(16 drops/min)
120-140 mg/dl 4u 100ml/hr(16 drops/min)
140-180 mg/dl 6u 100ml/hr(16drops/min)
>180 mg/dl 8u 100ml/hr(16drops/min)

53. PRECAUTION DURING LSCS IN GDM:
• 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.