1. Gestational Diabetes
Mellitus
Screening
Diagnosis
Challenges in management
Dr Hema Divakar

2. GDM
 GDM refers to women who are
shown to be diabetic for the first
time during pregnancy
 regardless of whether diabetes
persists after pregnancy

3. Screening for GDM

4. Story of failure to screen
 Society of obstetricians – Canada
 Recommend universal screening
 Doctor failed to implement this policy
 Missed the diagnosis
 Did not request ultrasound
 Baby – macrosomic / erbs / 4.4 kg/shoulder dystocia
 Court found that his care was negligent
 He failed to follow guideline recommendations

5. Universal screening for GDM is essential
 The prevalence of GDM in India varied from 15 to 21% in
different parts of the country compared to 3.8 % in the
west
It is generally accepted that women of
Asian origin and especially ethnic
Indians, are at a higher risk of
developing GDM
(and subsequent type 2 diabetes)

6. Screening for GDM
 Indians fall into the high-risk category for
developing GDM
 therefore universal screening is
recommended in pregnancy

7. When ??
 offer universal screening – to ALL antenatal
 women at 24 – 28 wks of gestation
 and an early screening at booking if there
 are additional risk factors identified by history
o Previous unexplained loss at term
o Previous baby weight > 4 kg
o Previous Pregnancy with GDM
o Strong F/H

8.  Patients who had GDM in a previous
pregnancy have a 33–50% likelihood of
recurrence in a subsequent pregnancy.
 Therefore women who have had GDM in
a previous pregnancy must be screened
at first booking and then at regular
intervals.

9. Screening
- HOW ???
 50 gm GCT for screening
 Ref : Sacks DA. et al. How reliable is the fifty-gram, one-hour glucose screening test?
AM J OBSTET GYNECOL 1989; 161(3):642-645
 Glucose screening and testing-American Pregnancy Association (Aug 2007)
 ADA/NDDG and Medical Journal of Australia 2005, 183(6):288-289
 No short cuts
 Venous sample more reliable in correctly diagnosing
GDM
 Glucometer vs Venous Sample
 Reference : Journal of Obs & Gynae of India. Glucometer screening of
Gestational Diabetes, Vinita Das. et al. KGMC, Lucknow (INDIA)
November/December 2006, 499-501

10. Screen Positive
 GCT >140 mg/dl
subjected to OGTT with 100
gms Glucose.

11.  100 gm OGTT according to Carpenter & Coustan
criteria
 Fasting <95 mg/dl
 1 hours <180 mg/dl
 2 hours <155 mg/dl
 3 hours <140mg/dl
 Gestational Diabetes Mellitus (GDM) is diagnosed
Diagnosis

12. One step test – screening and diagnosis
 75g oral glucose load*,
 without regard to the time of the last meal.
 2 hours later
 A venous blood sample
 GDM is diagnosed if 2 hr plasma glucose is ≥ 140 mg/dl.
 Avoids – multiple visits/multiple samples
 Validated by dr Seshiah and team – Chennai
 Published in ACTA – 2009

13.  Once diagnosed as Gestational diabetes the
patients are under the care of a team for
monitoring of maternal sugar and fetal well
being. The team -
Endocrinologist
Dietician
Obstetrician
Pediatrician
Sonologist
Management Approach
Multi-Disciplinary

14. Maternal Risks
 Hypoglycaemia
 Diabetic Ketoacidosis
 Retinopathy
 Nephropathy
 Hypertension
 Atherosclerosis
 Neuropathy
 Infection
 Operative Delivery

15. Fetal Risks
 Congenital Anomalies
 Early pregnancy losses
 Preterm labor
 Fetal Growth - macrosomia
 Shoulder Dystocia & birth trauma

16. Neonatal Complications
 Hypoglycaemia
 Hyperbilirubinemia
 Hypocalcaemia
 Polycythemia
 Cardiomyopathy
 RDS

17. Diet
 Dietician charts a diet plan according to
patients
 Body Weight
 Obese women : 25-30 kcal / kg
 Non-obese : 35 –40 kcal /kg
 Dietary compliance is evaluated and reinforced
during weekly hospital visits
 Targeted values are
 Fasting < 95 mg/dl
 1 hour post meal < 140 mg/dl

18. Glucose Monitoring
 For further quality control, blood glucose is
measured in the laboratory at weekly visit
 Patients on insulin therapy are instructed to use
Glucometer and self monitor blood glucose at
home

19. Patient Education
The compliance with the treatment plan
depends on the patient’s understanding of:
 The implications of GDM for her baby and
herself

 The dietary and exercise recommendations

 Self monitoring of blood glucose
 Self administration of insulin and adjustment of
insulin doses

20. The role of oral antidiabetic agents in
the treatment of GDM
 Oral antidiabetic agents have, till now, been
contraindicated in pregnancy.
 Glyburide, a secondgeneration sulfonylurea, was compared with
insulin in a randomized trial among patients with GDM who failed to
achieve adequate glycemic control with diet alone Glucose control
was similar, and the glyburide group had pregnancy outcomes
similar to those of the insulin group,including rates of cesarean
delivery, preeclampsia, macrosomia (>4 kg), and neonatal
hypoglycemia.
 Further study is recommended before the use of newer
oral
 hypoglycemic agents can be supported for use in
pregnancy

21.  At 28 weeks – Inj Betnesol 12 mg 2
doses
 All patients on diet therapy before 32
weeks are followed by fortnight visit and
weekly visits thereafter
 Patients on insulin therapy are always
monitored by weekly visit
Antepartum Management

22. Antepartum Management(contd)
…
 As per ACOG recommendations for GDM
patients weekly fetal surveillance was
started from 32nd
week of gestation for
Clinical Examination
Growth profile
Biophysical profile
Non stress test

23.  The decision for intervention
depends on the maternal
outcome variables such as
 Poor glycemic control
 on diet / insulin or
Macrosomia
 Surveillance test showing
non-assuring / omnious NST
– flat NST
Decision for Intervention
Liq

24. Timing of delivery
  Good glucose control with diet and exercise
 and no complications: expectant management till 40
weeks of gestation
  GDM on insulin: induction of labour at 38 weeks
because the incidence of shoulder dystocia
  GDM with HTN or previous stillbirth: induction
of labour at 37-38 weeks depending on the condition of
the fetus

25. Post Partum Management
 Maternal sugars are monitored
 Every 6-8 hours for the first post operative
day
 Every 12 hours in the 2nd
POD
 4th
POD Fasting / 1 hour post meal
 Patients were reviewed after 6 weeks with
 Fasting / 2 hour post OGTT with 75 gms glucose
 Advise on contraception and weight reduction
and long term risk of Diabetes and risk of GDM
in subsequent pregnancy is given

26.  With good obstetric care, theWith good obstetric care, the
perinatal mortality rate for a GDMperinatal mortality rate for a GDM
pregnancy is similar to that in thepregnancy is similar to that in the
non-diabetic populationnon-diabetic population

27. The future …..The future …..
 women who exhibit glucose
intolerance during pregnancy have
an increased risk of developing type
2 diabetes within 15 years .
Children born out of these –
childhood obesity / adult onset
diabetes

28.  Timely action taken now in screening all
pregnant women for glucose intolerance
achieving euglycemia in them and ensuring
adequate nutrition may prevent in all probability
the vicious cycle of transmitting glucose
intolerance from one generation to another

29.  More to understandMore to understand
 More to doMore to do

30. Thank YouThank You
Dr Hema DivakarDr Hema Divakar