Please find the power point on Gestational Diabetes Mellitus (GDM) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you

1. Gestational Diabetes Mellitus
Sunil Kumar Daha

2. Introduction
“Carbohydrate intolerance of variable severity with onset or
first recognition during the present pregnancy”
• Usually presents in late 2nd or during 3rd trimester.
• >50% GDM ultimately develops to overt diabetes by next
15-20 yrs

3. Carbohydrate intolerance. WHY ?
• Normal pregnancy - mild fasting hypoglycemia,
postprandial hyperglycemia, and hyperinsulinemia
Pregnancy
Elevated
CRP
IL-6
GH
CTRH
HPL
Progesterone
FFA
Placenta
Insulin antagonism
and resistance
• Metabolic Changes Necessary ?? WHY ??

4. • Positive family history of diabetes
• Previous birth of an overweight baby of ≥4 kg
• Previous stillbirth with pancreatic islet hyperplasia
• Unexplained perinatal loss
• Polyhydramnios or recurrent vaginal candidiasis in present
pregnancy
• Age over 30 years
• Obesity - Diabesity
• Persistent glycosuria
• Ethnic group (East Asian, Pacific island ancestry)

5. Screening: 50g, 1hr oral glucose challenge test
• 1 hr glucose measured
• Cutoff 140 mg/dL
• Time of day, Last meal do not count.
If sensitive consider 100gm (WHO-75 gm) oral glucose
tolerance test.
Low risk group
Average risk group
High risk group

6. • Oral glucose load= 100gm (WHO- 75 gm)
Time Venous Plasma (mg/dl)
Fasting ≥ 95 but <126 at any
Gestational age
1 hour >180
2 hours >155
3 hours >145
O’Sullivan and Mahan modified by Carpenter and Coustan

7. • Symptoms of diabetes or Random Plasma
Glucose concentration of 200 mg/dl or more
According to American Diabetic Association
Time Venous Plasma (mg/dl)
Fasting ≥126 mg/dl
2 hr postprandial ≥200 mg/dl
HbA1C ≥6.5%

8. • Explains how pregnancy makes complication even worst
compared to nonpregnant state.
• Insulin antagonism  increased insulin demand.
• “Accelerated Starvation” : pregnancy-induced switch in
fuels from glucose to lipids.
• Hyperemesis + Sympathomimetics + corticosteroids 
Ketoacidosis
• More complicated vasculopathy.

9. • Explains simply the complication of diabetes
(Hyperglycemia and adverse pregnancy
outcome)
1) Maternal
2) Fetal and Neonatal

10. During pregnancy
• Abortion
• Preterm labor (20%)
• Infection (UTI and Vulvo-vaginitis)
• Increased incidence of preeclampsia (25%)
• Polyhydramnios (25-50%)
• Maternal distress
• Ketoacidosis and vascular changes
3
Ps

11. During labour:
• Prolongation of labor due to big baby
• Shoulder dystocia
• Perineal injuries
• Post partum haemorrhage
• Operative interference
During puerpurium:
• Puerperal sepsis
• Lactation failure

12. • Congenital malformations (6-10%)
• Fetal macrosomia (40-50%)
• Birth injury (brachial plexus)
• Intrauterine fetal death (IUFD)
• Growth restriction
• Hypoglycemia
• Respiratory distress syndrome
• Hyperbilirubinemia (25-50%)

13. • Polycythemia
• Hypocalcemia (<7 mg/dl)
• Hypomagnesemia (<7 mg/dl)
• Cardiomyopathy
• Long term effects: childhood obesity, neuropsychological
effects and diabetes

14. CNS & Skeletal CVS Renal GI Others
Neural tube
defects
VSD, ASD Renal agenesis Duodenal atresia Single
umbilical
artery
Anencephaly Coarctation of
Aorta
Hydronephrosis Anorectal atresia
Microcephaly Transposition
of great
vesssels
Double ureter Omphalocele
Caudal
Regression
syndrome
Situs inversus Polycystic kidneys Tracheoesophageal
fistula
Sacral agenesis Fallots
tetralogy

15. Preconceptional counselling
• To achieve tight control of diabetes
• Regular monitoring of HbA1C
• Folic acid supplementation
• Appropriate advice on diet and insulin
Principles in the managements are:
• Careful antenatal supervision & glycemic control
• To find out optimum time and method of delivery
• Arrangement for care of the newborn

16. 1. Exercise
 Improves cardiorespiratory fitness
 Improves physiological and psychological well being
of the patient
2. Glucose monitoring
 Routine check up of blood glucose level
 HbA1C at end of 1st trimester and trimonthly
thereafter (<6% is desirable)

17. 3. Diet
 Caloric consumption should be
 30 Kcal/kg for normal weight
 24 Kcal/kg for overweight
 12 Kcal/kg for morbidly obese women
 The constituents of diet may be:
 Carbohydrates:40-50%
 Proteins: 20%
 Fat: 30-40%
 Saturated fat<10%,

18. 3. Diet
 ↑ Complex carbohydrate (Fiber rich diet)
 Restricted cholesterol
 Avoid sugar
 Avoid hematinic and calcium supplements
4. Obstetric management:
If good glycemic control or no need of insulin,
• Women can wait for spontaneous onset of labor
• But, not to excede expected date of delivery
• Elective delivery by induction or CS if requiring insulin
or with complication

19. If diet modification not consistently maintain the
fasting plsma glucose levels <95 mg/dL or the 2 hour
postprandial plasma glucose <120 mg/dL
pharmacological method is recommended. (ACOG,
2013)

20. Insulin therapy
 Does not cross placenta.
 Starting dose is typically 0.7-1.0 units/kg/day
 Given in divided doses
 Combination of intermediate acting (isophane) and short
acting insulin.
 Subcutaneous insulin infusion by insulin pump preferred
(more physiological)
Oral hypoglycemic agents:
 Glibenclamide and metformin (biguanide) used
 Both cross placenta but no teratogenic effects
 ACOG acknowledges both drugs for first line use.

21. In uncomplicated cases, patient admitted at 34-36 wks
Early hospitalization facilities:
1. Stabilization of diabetes
2. Minimizes the incidence of preeclampsia,
polyhydramnios, preterm labor.
3. Good monitoring fetal wellbeing.
4. Select appropriate time & method of delivery

22. Induction of labor
Indications
1. Diabetic women on insulin after 38 wks
2. Women with vascular complications (Preeclampsia, IUGR) after 37
wks

23. Induction of labor
Methods:
1. Usual insulin dose prior the day to induction
2. No breakfast & no morning dose given on the day
3. Normal saline infused
4. Induction done by low rupture of membrane
5. Oxytocin drip
6. IV drip of 1 lt of 5% dextrose with 10 units of soluble insulin
7. Infusion rate 100-125 ml/hr (1-1.25 units/hr)
8. Blood glucose level estimated hourly
9. Epidural analgesia ideal for pain relief
10. CS if no labor within 6-8 hours or unsatisfactory progression

24. Cesarean section
Indications:
1. Fetal Macrosomia
2. Diabetes with complications
3. Elderly Primigravidae
4. Multigravidae with bad obstetric history
5. Preeclampsia, Polyhydramnios, Malpresentation

25. Procedure
• Scheduled for early morning
• Breakfast and insulin dose omitted
• Capillary blood glucose checked
• NS infusion started
• Dextrose and insulin dose as in induction method
• Prepregnant dose started after the delivery
• Epidural or spinal anesthesia better than general anesthesia
• oral feeding can be started soon after delivery
Cesarean section

26. Puerperium
 Antibiotics prophylactically
 Breastfeeding encouraged
 In lactating women insulin dose is lower
Care of the baby
 Kept in NICU for at least 48 hours
 Treat complications effectively if arises
 Look for congenital malformations
 Check blood glucose within 2 hours (hypoglycemia<35mg/dl)
 Should be given Vit K 1 mg IM
 Breastfeeding within 1/2 - 1 hr and repeat at 3-4 hourly to
minimize hypoglycemia

27. Postpartum Evaluation
• Women diagnosed with GDM should undergo evaluation with a 75g
–OGTT at 6 to 12 weeks postpartum and other intervals thereafter
(Metzger, 2007)
• Women with a history of gestational diabetes are also at risk for
cardiovascular complications associated with dyslipidemia,
hypertension, and abdominal obesity. So must be concerned and
need proper counselling for best health outcome.

28. Contraception
• Low-dose hormonal contraceptives may be used safely.
• Comorbid obesity, hypertension, or dyslipidemia should direct
the choice for contraception toward a method without
potential cardiovascular consequences.
• So what is the alternative ??

29. 1. Williams Obstetrics 24th edition
2. DC Dutta’s textbook of Obstetrics, 8th edition