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Gestational diabetes mellitus
1.
2. Gestational Diabetes
(GD)
Presented by
DR . HINA KHUDA-I-DAD
Working under supervision of
PROF. DR .TASNEEM ASHRAF
HEAD OF DEPARTMENT GYNAE UNIT IV
3. INTRODUCTION
Gestational diabetes is Any degree of
Glucose intolerance with onset or first
recognition during pregnancy.
It affects 3-5% of all pregnancies.
4. PRENATAL MANAGEMENT
1- Screening and diagnosis
2-PATIENT’S EDUCATION
3-GLYCEMIC TARGETS
4-DIET AND EXERCISE
5-INSULIN AND ORAL HYPO-
GLYCEMIC DRUGS
6-MONITORING FETAL
GROWTH
5. WHO SHOULD BE SCREENED
AND WHY
Risk stratification
Low risk: no screening
Average risk: at 24-28 weeks
High risk: as soon as possible
6. LOW RISK
Age <25 years
Weight normal before pregnancy
Member of an ethnic group with a low
prevalence of GDM
No known diabetes in first-degree relatives
No history of abnormal glucose tolerance
No history of poor obstetric outcome
In the presence of all these factors no screening
is recommended
8. Caution
High risk of gestational diabetes
Marked obesity BMI >30.
Previous history of gestational diabetes mellitus.
Strong family history of diabetes .
Native Americans, Asians, Hispanics, African AND
arabic specially of mid-eastern origin.
Previous macrosomic babies, unexplained stillbirths.
women with risk factors should be screened as
soon as possible
9. Oral glucose tolerance
test
Prerequisites:
Normal diet for 3 days before the test.
At least 10 hours fast ,in morning at rest.
Give 100 gm of glucose in 250 ml water
Criteria for glucose tolerance test:
fasting 5.3 mmol/L
1 hour 10 mmol/L
2 hours 8.6 mmol/L
3 hours 7.8 mmol/L
If any 2 or more of these values are elevated, the patient is DIAGNOSED to
have GDM.ADA CRITERIA
10. Patient education
cornerstone in GDM management
Inform mother about maternal and fetal
complications
Diet therapy
Teach mother about self monitored blood
glucose measurement and glycemic targets
Fetal monitoring: ultrasound
Planning on delivery
11. Potential Risks of
Untreated GDM
IN CHILD
1,Growth abnormalities
-Macrosomia
2,Chemical imbalance
-Hypoglycemia
-Jaundice
-Hypocalcemia
Prone for diabetes in future
12. Potential Risks of Untreated
GDM in mother
PIH and Pre-eclampsia: affects 10-25% of all pregnant
women with GDM
Infections: high incidence of chorioamnionitis and
postpartum endometritis
Postpartum bleeding: caused by exaggerated uterine
distension
Ceasarian section due to fetal macrosmia and cephalo-
pelvic disproportion
Weight gain
Third trimester fetal deaths
Long term risk of type-2 diabetes mellitus
19. INSULIN IN GDM
Insulin used if fasting blood glucose >105
mg/dl or 2 hr postprandial blood glucose >120
mg / dl on a diet
Use intermittent bolus regime of Short
acting insulins to cover each meal.
Insulin requirements increase by 50% from
20-24 weeks to 30-32 weeks, after which
insulin needs often stabilize.
20.
21. ORAL HYPOGLYCEMIC
AGENTS
Glyburide is a clinically effective alternative to
insulin in GDM (Langer et al. 2000)
Metformin may be effective in GDM (Ratner
et al., 2008; Coustan, 2007
22. HYPOGLYCEMIA
During treatment with insulin patient can
have low blood sugar <60mg/dl
Why does low blood sugar occur?
1. Too much exercise
2. Skipping meals or snacks
3. Delaying meals or snacks
4. Not eating enough
5. Too much insulin
23. SYMPTOMS OF
HYPOGLYCEMIA
Very hungry
Very tired
Shaky or trembling
Sweating or clamminess
Nervous
Confused
Like going to pass out or faint
Blurred vision
25. Fetal monitoring
(1) Ultrasound :NICE guideline is to assess
fetal growth on 4 weekly basis from 28-36wks
Fetal growth ,Amniotic fluid volume at
28,32,36 wks polyhydramnios
(2) cardiotocography (C.T.G). after 32 wks
(3) Doppler.
(4) Biophysical profile B.P.P.
26. TIMING OF DELIVERY
In well controlled diabetic mother ,the
pregnancy can be continued till 40 wks in the
absence of any complications .
Indication for induction of labour.
Uncomplicated diabetes at 40 wks
Developing macrosemia at 38 wks
Pre eclampsia
27. MANAGEMENT DURING
LABOUR
Vaginal delivery: preferred
Cesarian section only for routine obstetric
indication
GDM alone is not an indication !
> 4.5 Kg fetus: Cesarean delivery may reduce the
likelihood of brachial plexus injury in the infant
and still birth
Maintain euglycemia during labor 4-7mmol/L
Monitor sugars 1-4 hrly intervals during labour
Give insulin only if blood sugar >120 mg/dl
28. IV INSULIN DURING C-
SECTION
I.V insulin infusion.
50 ml N/S +50 unit regular insulin Aim at 1-2
unit (1ml)/hr.
At the same time 10% of glucose started on
other arm.
BSL b/w 4.0-7.0 mmol/L
29. POST-PARTUM FOLLOW UP
Check blood sugars before discharge
Lifestyle modification: exercise, weight
reduction
Oral glucose tolerance test at 6-12 weeks
postpartum
Counseling for contra-ception, and pre-
conception care for next pregnancy
30. IMMEDIATE MANAGEMENT OF
NEONATE
Hypoglycemia<40 mg/dl : 50 % of
macrosomic infants
Encourage early breast feeding
If symptomatic give a bolus of 2- 4 ml/kg, IV,
10% dextros
Check for calcium, if seizure/irritability/RDS
31. Conclusion
Gestational diabetes is a common problem in
worldwide
Risk stratification and screening is essential
in all pregnant women.
Tight glycemic targets are required for good
maternal and fetal outcome
Patient education and Long term follow up is
essential