powerpoint on GDM for undergraduates & Postgraduates

1. GESTATIONAL
DIABETES MELLITUS
DR ANITA RAMESH

2. OVERVIEW
• DEFINITION
• PREVALENCE
• RISK FACTORS
• MATERNAL COMPLICATIONS
• FETAL COMPLICATIONS
• SCREENING
• DIAGNOSIS
• ANTENATAL MANAGEMENT
• INTRANATAL MANAGEMENT
• POSTNATAL MANAGEMENT
• PREVENTION

3. DEFINITION of GDM
• Any amount of carbohydrate intolerance diagnosed for the
first time during pregnancy
• It can be a PRE EXISTING DM or GESTATIONAL DM
• How to differentiate?
Do HbA1C….If > or equal to 6.5% it is pre existing
DM,FBS>126mg%,RBS>200mg%............OVERT
DIABETES
90% GDM & 10%PREXISTING DM

4. GESTATIONAL DIABETES MELLITUS
• Hyperglycemia during pregnancy that is not chronic
diabetes
• Hyperglycemia diagnosed for the first time during
pregnancy
• May occur anytime during pregnancy but most likely after
24 weeks

5. PREVALENCE
• 22 million women between 20 to 39 yrs have diabetes-
2010 data
• Expected to rise by 20 percent in next 10 years
• Women with IGT or pre diabetes have the potential to
develop GDM if they become pregnant
• In India prevalence is 1% to 14%percent
• GDM is more prevalent in urban areas compared to rural
areas
• Almost 50%will develop OVERT DM in next 10-15 years
• GDM leads to diabetes & obesity in the offspring

6. EFFECT OF PREGNANCY ON
GLUCOSE METABOLISM
• PREGNANCY IS A DIABETOGENIC STATE
• HPL,E,P,CORTISOL & ENZYME INSULINASE
• HPL,E,P & Cortisol cause insulin resistance
Increased insulinase activity destroys insulin
Pregnancy unmasks DM in latent diabetic subjects.
90% of women show increased insulin secretion to counter
this insulin resistance.
Those 10% show insulin resistance.
Basically GDM unmasks chronic beta cell function of
pancreas.

8. CLASSIFICATION

11. RISK FACTORS FOR GDM
• Age >30yrs
• BMI >25kg/m2.Obese patients
• Family history of DM in first degree relatives
• Ethnicity:Prevalent in South Asians
• Previous OH:H/O GDM in prev pregnancies,Stillbirth,Repeated
miscarriages,Macrosomic baby,Unexplained perinatal loss
• Recurrent vaginal candiasis or polyhydramnios in present
pregnancy

12. MATERNAL COMPLICATIONS
• Early pregnancy:Spontaneous miscarriages
• Late pregnancy:PE 25%,UTI,Macrosomia,hydramnios
25%-50%
• Delivery:Preterm labour 26%, Instrumental delivery,
Traumatic delivery, CS, PPH, Maternal morbidity/mortality
• Puerperium:Infections,Lactation failure
• Long term complications:GDM in subsequent
pregnancy,DM,CVD

13. FETAL COMPLICATIONS
• DIABETIC EMBRYOPATHY:Congenital
malformations(increasing sugar levels r not favourable for
organogenesis).Risk is5% if HbA1C <8% & 25% if
HbA1C>10%
• FETAL MACROSOMIA:Shoulder dystocia,Traumatic
delivery,CS
• NEONATAL
COMPLICATIONS:Hypoglycemia,Hypocalcemia,Hypomagnese
mia,Hyperbilirubinemia,RDS,Cardiomyopathy
• Unexplained IUD:Risk is more in the last 4 to 6 weeks of
pregnancy

16. CAUSE OF IUD
• Uncontrolled diabetes…mat hyperglycemia….fetal
hyperinsulinemia….fetal hypoglycemia….hypoxia
• Fetal hyperinsulinemia….increased oxygen demand of
fetus
• HbA1C binds oxygen more but releases less
oxygen…fetal hypoxia
• Overt diabetes…vasculopathy…placental
insufficiency…FGR

17. HOW TO DIAGNOSE GDM.Screening
versus Diagnostic Test
• Purpose is to identify asymptomatic individuals with a high
probability of having or developing a specific disease
• UNIVERSAL SCREENING IS ADVISED FOR
DIAGNOSING GDM

18. WHOM TO SCREEN?
UNIVERSAL SCREENING IS THE OPTIMUM
APPROACH AS INDIAN WOMEN HAVE 11 FOLD RISK
OF DEVELOPING GLUCOSE INTOLERANCE DURING
PREGNANCY COMPARED TO CAUCASIAN WOMEN

19. HOW TO SCREEN?DIPSI CRITERIA
Diabetes in Pregnancy Study Group of
India
• ONE STEP APPROACH
• On 14th mar 2017,GOI asked for universal screening
• All women have to be screened at 24 to 28weeks of
gestation with 2 hrs 75 gms oral glucose

20. HOW DIPSI TEST IS PERFORMED?
• SINGLE STEP TEST
• No need to keep the patient fasting
• 75g glucose is orally administered by diluting in 300ml
water.
• Blood glucose levels are monitored after 2hrs
• If vomiting occurs within 30 minutes,the test has to be
repeated
• The threshold level of equal to or > than 140 is the cut off
for diagnosis of GDM

21. ADVANTAGES OF DIPSI
• SIMPLE,ECONOMICAL,ACCEPTABLE
• PATIENT DOES NOT NOT HAVE TO FAST
• DIPSI has got more sensitivity & negative predictive value

22. DIPSI CRITERIA

23. WHEN TO DO DIPSI?
• First booking visit
• 24-28 weeks[GOI/DIPSI}
• 32-34weeks{dipsi}

24. Why to do DIPSI?
• Identify & treat the patients
• Prevent diabetes in the 2 generations

26. MANAGEMENT OF GDM
• Educate the patient
• Tight glycemic control.Target FBS 90mg%,1 hr PPBS
140mg% & 2nd hour PPBS 140mg%
• Monitoring the patient and the fetus
• Labour management
• Multidisciplanary
approach:obstretician,diabetologist,dietician,neonatologist

27. EDUCATING A GDM PATIENT
• DIETARY CHANGES:replace with low glycemic foods
• Discuss appropriate weight gain during pregnancy
• EXERCISE :Daily 30mins to I hour of moderate exercise
• Start with MNT
• IF UNCONTROLLED:INSULIN THERAPHY Or
METFORMIN THERAPHY(OHAs)
• Self monitoring of glucose
• Self administration of insulin

28. MNT(MEDICAL NUTRITION
THERAPHY)
• Adequate nutrition.Well balanced diet
• Adequate weight gain
• Prevention of ketosis(overt diabetes)
• Prevention of postprandial hyperglycemia
• If within 2 weeks glucose levels r not under control ..switch to
drugs
• GDM DIET-30kcal/kg/d in normal weight women,24kcal/kg/d for
overweight women & 12kcal/kg/d for morbidly obese patients
Diet should have 40%carb,30%protein & 30% fat
Usually 3 meal & 3 snacks with breakfast 10%,lunch30% &
dinner 30%,30% snacks

30. TARGET WEIGHT GAIN IN GDM
• BMI<18.5kg/m29(underweight)----12.5kg-18kgs
• BMI18.5-24.9kg/m2(ideal)---11.5-16kgs
• BMI25-29.9kg/m2(overweight)--------7-11.5kgs
• BMI>30kg/m2(obese)--------5-9kgs

31. Insulin Initiation During Pregnancy
• About 50% women treated with diet alone will require additional
theraphy with insulin
• GDM patients require low doses of insulin compared to pre
existing DM patients
• Insulin is given subcutaneously
• Recombinant human insulin is most preferred
• Start with 4 units of premixed(30/70)insulin BB.Give 30mins
BB.If not controlled increase every 4th day by 2 U till 10
units.Usually they don’t need >20units
• Insulin dose has to be individualised………0.7units/kg daily
• Two thirds of insulin is administered in the morning & 1/3rd in
the evening with 1:2 ratio of short to intermediate or long acting
insulin

33. Insulin options safe in pregnancy
name type onset peak duration dosage
Aspart Rapid
acting
15min 60min 2hrs Start of
each meal
Lispro Rapid
acting
15min 60min 2hrs Start of
each meal
Reg insulin Intermediat
e acting
60mins 2-4hrs 6hrs 60-90mins
before
meal
NPH Intermed
acting
2hrs 4-6hrs 8hrs Every 8 hrs
Detemir Long acting 2hrs 12hrs Every
12hrs

35. OHA /INSULIN IN GDM
• Metformin or insulin can be started if MNT fails.Insulin is
the first choice & metformin can be given after 20 WOG
• Insulin can be started anytime during pregnancy
• Metformin max dose is 2g/day

36. MONITORING BLOOD
GLUCOSE(SMBG)
• Atleast 4 times self monitoring
• Fasting & three 2hrs postprandial
• If target levels r achieved,lab monitoring to be done once a
month till 28 weeks
• 28-32 weeks,lab monitoring of plasma glucose done every 2
weeks
• >32 weeks…once a week
• Do FUNDOSCOPY,MONITORING MICROALBUMINURIA

37. GLYCAEMIC TARGETS
• Mean plasma glucose of 105mg/dl
• Fasting plasma glucose at 90mg/dl & PP at 120mg/dl
• Mean plasma glucose not to go below 86

38. MONITORING DURING PREGNANCY
• FIRST TRIMESTER
• Clinical exam,Dating scan,NT scan,Double marker
test,Color doppler for prediction of PIH
• SECOND TRIMESTER
• Clinical exam,Anomaly scan,fetal 2D echo at 24 weeks
• THIRD TRIMESTER
• Clinical exam,DFKC,Growth scans at 28,32,36
weeks,Color doppler if indicated,AFI,NST(32 weeks
onward)

39. WHEN TO DELIVER?
• Deliver in a tertiary care hospital
• Timing & mode of delivery
GDM controlled on diet alone & no complications:deliver
at 40 weeks
GDM on insulin theraphy:induction at 38 weeks
Vaginal delivery is allowed if macrosomia is ruled out
Morning dose of insulin is omitted
Glucose levels r checked hourly with glucometer
IV infusion of NS started
If glucose levels <70mg%,D5 is started
If glucose levels>140mg% regular insulin is
administered in IV infusion

40. INSULIN DOSAGE IN LABOUR ACC TO
BG LEVELS
Blood glucose mg/dl Insulin dosage Iv fluids at 125ml/hr
<100 0 D5
100-140 1 D5
141-180 1.5 NS
181-220 2 NS
>220 2.5 NS

41. • If baby weight >4kgs deliver by CS
• If uncontrolled sugar levels or any other complicating
factor,deliver the fetus
• If preterm…steroids r to be given with strict monitoring of
BG levels

42. INTRAPARTUM CARE
• FIRST STAGE
• If hyperglycemia controlled on diet & spont labour…admission
CTG,PARTOGRAM,GLUCOMETER MONITORING 2
HRLY[Sugars 80 to 120}
• If hyperglycemia controlled by insulin/metformin,spont
labour…….same as above & IV fluid as per blood sugar levels
• INSTITUTIONAL DELIVERY
• EXPERT OBST
• CONTINUOUS CTG

43. • SECOND STAGE
1. Controlled ARM
2. Anticipate shoulder dystocia
3. Neonatologist
• THIRD STAGE
1. AMTSL
2. Prevent traumatic or atonic PPH

44. POSTPATUM CARE
• Careful glucose monitoring for 2 hrs postdelivery & for 48
hrs
• Regular postnatal care
• OGTT at 6 weeks postpartum
• Note:maternal insulin requirements fall significantly
immediately after delivery and continue to decline(insulin
drip can be reduced or stopped after delivery)

45. IMMEDIATE POSTPARTUM CARE
• STOP insulin AS GLUCOSE CONTROL WILL BE
ACHIEVED IN MOST WOMEN IMMEDIATELY AFTER
DELIVERY
• CONTINUE PREPRANDIAL BGL FOR 24 HRS
• IF preprandial BG 72-126…discontinue monitoring
• If BG <72 OR >126…MED OPINION
• 1-8% may be glucose intolerant & need OHAs
• Metformin,glibenclamide,glyburide r safe during lactation

46. RISK FACTORS FOR PERSISTENT
DIABETES
• Pregnant FBS >126
• Diagnosis of GDM during first trimester
• A prior history of GDM

47. MONITOR FOR PERSISTENT
DIABETES(longterm consequences)
• OGTT to be done at 6 weeks postpartum to screen for
persistent diabetes
• 50%o f GDM will develop type 2 DM within 15 yrs of
delivery
• If GDM on insulin,50% will develop type 2 DM in 5 years
• Recommended lifelong screening for diabetes every 3 yrs
• Early glucose monitoring in future pregnancy(risk of
recurrence is 30% -50%)

48. CONTRACEPTIVE ADVICE
• Barrier methods
• POP/DMPA
• COC/Implants are contraindicated with macrovascular
disease

49. FETAL LONGTERM CONSEQUENCES
• Increased risk of developing OBESITY,DIABETES
• FETAL ONSET OF ADULT DISEASE
• GESTATIONAL PROGRAMMING:process whereby
stresses or stimuli that occur at sensitive periods of fetal
dev permanently change structure,physiology and
metabolism that predisposes individuals to diseases in
adult life.intrauterine exposure to diabetogenic
environment is risk factor fpr dev of DM in adult life.

50. CONCLUSION(KEY POINTS)
Universal testing of all pregnant women
Testing to be done twice in pregnancy..once at 1st visit &
second at 24-28 weeks
Single step test recommended
Start on MNT for patients with positive OGTT test>140mg/dl
If not controlled start on OHA or insulin
In uncontrolled diabetes or those with obstetric indication
early delivery recommended after steroid theraphy
Vaginal delivery preferred but LSCS for
macrosomia/obstetric indication
Neonatal monitoring for hypoglycemia & other
complications
Postpartum evaluation of glycemic status at 6 weeks to be
done postdelivery

51. •THANK YOU ALL FOR
PATIENT HEARING