1. Gestational DM

2. Diabetes Mellitus
 Diabetes mellitus is an endocrine disorder of
carbohydrate metabolism.
 It is characterized by hyperglycemia resulting
from the inadequate production or ineffective
use of insulin.

3. Classification

5.  Pregestational DM: type 1 or 2 DM that
existed before pregnancy occurred.
 Gestational DM (GDM): glucose intolerance
with onset during pregnancy.

6. Effect of pregnancy on Diabetes
 Pregnancy has been called a diabetogenic state in
which the need for glucose is increased, creating a
resistance to insulin.
 Maternal insulin dose not cross placenta.
 By the 10th
weeks of gestation the fetus must secrete
his own insulin.
 During the first trimester maternal glucose levels
decrease as result of fetal demand for rapid cell
division, N&V.

7.  During the 2nd
and the 3rd
trimester rising levels of
hormones ( estrogen, progesterone, human
placental lactogen, cortisol, and insulinase) increase
insulin resistance through their action as insulin
antagonists.
 Maternal insulin demands increases 3 folds.
 During labor, with increased energy needs, the DM
mother may require more insulin.
 Pp decrease in insulin requirements.
 Maternal tissues quickly regain their nonpregnant
sensitivity to insulin.

8. Pregestational DM
 Pregnancy will affect glycemic control.
 Pregnancy may accelerate the progress of vascular
complications.
 OHA cannot be taken during pregnancy.
 During the 1st
trimester, the mother’s blood glucose
levels are usually reduced and she may need less
insulin.
 Insulin resistance continues to rise until the last few
weeks of pregnancy.

9. Risks and complications
 Fetal complications
1. Maternal hyperglycemia may cause fetal
anomalies.
2. Macrosomia and impaired fetal lung functions
( RDS) can occur.
3. At birth hypoglycemia may occur in the neonate.
4. Polycythemia, hypocalcaemia, hyperbilirubinemia,
thrombocytopenia.

10. Two babies born to
diabetic mothers in the
Rijks hospital 1956.
One mother attended the
center throughout
pregnancy, the other
didn’t.

11.  Maternal complications
1. Spontaneous abortion.
2. Infections ( UTI, vaginal infections).
3. Polyhydrominios.
4. Gestational hypertension.
5. Hypoglycemia.

12. Assessment and management
 The advised care plan:
1. Monitoring diet.
2. Exercise.
3. Insulin administration.
 Assess the emotional status.
 Her knowledge of DM to determine her educational
needs.
 Physical examination include ECG to assess her
cardiovascular status.

13. Diet
 The recommended diet is based on blood glucose
levels.
 Average diet may be 30-35 kcal/kg of body weight in
the 1st
trimester, and 35kcal/kg in the 2nd
and 3rd
trimester with carefully planned snacks.
 About all women 1500-2000 kcal.
 A large bed time snack is recommended to prevent
overnight hypoglycemia.
 40-50% of calories should be complex, high fiber
carbohydrates, 20% protein, 30-40% from fats

14.  The woman is taught signs of hypoglycemia and hyperglycemia
and home care of such events.
 Vitamins and folic acid in the form of prenatal vitamins is
recommended.
 Exercise: individually prescribed exercise according to the
prepregnant life style is recommended. Proper exercise
enables muscle activity to help normalize glucose levels.
 15-30 minutes of walking 4-6 time per week .avoid vigorous
exercise ,must performed after meal ,if uterine contraction was
felt, the exercise should be stopped immediately .

15. Insulin therapy : In 1st
trimester the insulin
dosage reduce to avoid hypoglycemia.
0.7units /kg
In 2nd
&3rd
trimester the insulin dosage
0.8units /kg in 18-26 week
0.9units /kg in 27-36 week
1unit /kg in 37 week

16. Gestational DM
 GDM is diabetes mellitus defined as carbohydrate
intolerance of variable severity, with the first
recognition during pregnancy.
 Some women with GDM exhibit the classical S&S of
diabetes, including excessive thirst, hunger,
urination, and weakness.
 The routine urine analysis showing glucoseuria.
 The risk of congenital malformation and
spontaneous abortion is less than pregestational
DM.
 GDM is usually diagnosed in the 2nd
half of
pregnancy.

17.  Diet often controls gestational diabetes, however 10-
15% of women with GDM will require insulin to
maintain glycemic control.
 S&S of GDM may disappear a few weeks after the
birth of the newborn. However 35-50% of women will
show deterioration of CHO metabolism in the next 15
years of life.

18. Screening During Pregnancy
 The usual time to screen is between 24-28 weeks gestation.
 Glucose challenge test commonly given for GDM is the 50-g, 1-
hour diabetes challenge test.
 If the plasma glucose 1 hour after ingestion 50 g glucose is
greater than 140 mg/dl, a follow up oral glucose tolerance testis
performed for more accurate evaluation.
 Oral glucose tolerance Test ( OGTT) gold standard test.
 Fasting BS before test, give100g glucose (3 hr) 1,2,3 hr BS
sample.

19. )OGTT)
Positive for GDM two or more levels are met or
exceeded
Fasting Less than 95 mg/dl
1-hr Less than 180 mg/dl
2-hr Less than 155 mg/dl
3-hr Less than 140 mg/dl

20. Glucose monitoring
 Aim of therapy strict BS control.
 Fasting BS  65-105mg/dl ( Euoglucemia)
 The goal of glucose monitoring is to maintain a level
between 80-120 mg/dl postprandial level.
 The evaluation of glycemic control is based a
glycosylated hemoglobin( HbA1c) level. Measuring
the amount of glucose attached to HbA determine
the glycemic control for the preceding 2-3 months.
 Monitor daily blood glucose at home.
 Fasting + postprandial glucose weekly.

21. 1. Adult Without Diabetes :- 2.2%- 4.8%
2. Good Diabetic Control:- 2.5%- 5.9%
3. Fair Diabetic Control:- 6% - 8 %
4. Poor Diabetic Control:- > 8%
HbA1c level

22.  Insulin therapy:
 Pregestational DM and GDM could be
managed by diet and exercise.
 Up to 20% need insulin.
 FBS more than 105 insulin should be started.

23.  Elective induction of labor may be planned between
38-40 weeks in well controlled diabetic woman.
 Intrapartum care: during labor and birth monitor BS
every 2 hrs, range between 80-120, glucose IVF not
commonly used.
 C/s birth is common because of CPD.
 PP care: most GDM return to normal BS levels after
birth. ( 50% next pregnancy may develop GDM).

24. Fetal surveillance
 Prenatal fetal assessment is essential during
pregnancy and labor.
 Tests include a biophysical profile, kick
count, nonstress test.