Gestational DM
2020
GESTATIONAL DIABETES
DEFINITIONS:
GDM is diabetes diagnosed in the 2nd or 3rd
trimester of pregnancy that is not clearly overt
diabetes.
Women with diabetes in the 1st trimester would
be classified as having Type 2 DM ( Overt
DM )
Risk Factors for GDM
Overweight / Physically inactive
History of GDM/ or delivering a baby > 9 lbs ( HR )
Should be re- classified 6 wks after delivery ( 4-12 wks)
Has Hypertension
Family history of DM ( 1st degree relative )
Past history : IGT, IFG, HbAIC > 5.7%
HDL –C = < 35 mg%or 0.9 mmol/l
Triglyc = > 250 mg or 2.82 mmol/l.
Diagnosis of OVERT DM
RISK FACTORS ( previous slide) + ANY ONE OF
the Ff. TEST RESULTS :
FBS = 126 MG/L OF 7 MMOL/L
HbA1C = 6.5 % ( UKPDS assay )
RBS = 200 MG % OR 11 MMOL/L.(UKPDS .) +
cardinal symptoms ( 3 P’s )
WHY Screen ?
GDM carries RISKS for Mother/ Fetus /Neonate
Mother : Pre eclampsia, eclampsia, Polyhydramnios, Intra Uterine
Fetal death ( IUFD )
Fetus : spontaneous abortion, diab.embryopathy : anencephaly,
microcephaly, congenital anomalies, caudal regression/
Macrosomia : shoulder dystocia, LGA ( large for gestational age )
Neonate : neonatal hypoglycemia/ hyperbilirubinemia
All the above is directly proportional to elevations of HbAic
during the first 10 wks of pregnancy. Lowest risk at AiC < 6.5%
SCREENING Test for GDM
Ideally at 24-28 wks AOG
Use 75 g OGTT after 8 hrs overnight fasting
Diagnosis :
FBS >_ = 92 mg/dL or 5.1 mmol/L
1 Hr plasma glucose = 180 mg/dL or 10 mmol/L
2 Hr plasma glucose = 153 mg/dL or >_ 8.5
mmol/l
WHO to SCREEN for GDM
1. Recommended to ALL women not known to have DM prior
to pregnancy
2. High Risk Patients :
a. Prior history of GDM/ hx of delivering an LGA infant
b. Family hx of T2DM- up to 1st degree relatives
c. history of glucosuria
d. history of macrosomia ( past and present ) and
history of polyhydramios ( past and present)
e. Overweight/obese/ PCOS/ hx of drugs (eg.steroids)
When to screen for GDM?
First prenatal visit ( 1st,2nd,3rd trimester )
For women WITHOUT risk = 24-28 wks
For women at HIGH RISK :
Early screening at 16-18 weeks is advised
since the fetal beta cells already recognizes and
responds to maternal glycemic levels at this AOG.
Diagnosis of
GDM( care.diab.journals.)
Two Strategies:
1. One- step strategy : one day test ( Fasting )
2. Two – step strategy : two separate days tests
( one day – non fasting )
( one day fasting ): separate
One Step Screening
Perform a 75 g OGTT after an 8h fasting, in a.m.
Test Plasma Glucose at Fasting, 1h and 2 h ( 3 tests)
Who belongs to this? Women at 24-28 wks AOG,
and NOT previously diagnosed with diabetes
DIAGNOSIS: is made when ANY ONE of the ff.are met
or exceeded :
FBS = 92 mg% / 1h = 180mg% / 2h 153 mg%
( 5.1 mmol/l) ( 10.0mmol/l ) ( 8.5 mmol/l )
Two-Step Strategy
Step 1 – ( women at 24-48 wks AOG , (-) DM )
Non-fasting
Perform 50 grm GLT ( Glucose Load Test )
If after 1 h the PG is _> 130,135,140 mg/dl
then proceed to a 100 g OGTT.
Step 2 – Fasting 8h; At least 2 of the 4 PG are met:
Fasting=95mg/dl / 1h= 180mg/dl / 2h=155mg/dl
3h = 140 mg/dl
Case 1
D.R.D., 24 yrs old , G2P1 ( 1-0-0-1 )
- now at 36 wks AOG on first visit
- OB requested a 75 g OGTT; results are
:
FBS = 5.7 mmol/ l or 102 mg/ dl
1st h = 7.8 mmol/ l or 140 mg/ dl
2nd h = 8.0 mmol/ l or 144 mg/ dl
Case 1 ( cont...)
1. Does she have GDM ?
2. Why ?
3. What strategy was used ?
Case 2
R.I.O., 25 yrs old, G2 P1 ( 1-0-0-1 ) NSD 9 lbs
baby
- now24 wks AOG
- referred by OB due to ++++ glucosuria
PPE 162 lbs or 73.6 kg Ht - 5'4" or 1.62 m.
1. Screen ? ______ yes ______ no
2. What strategy ? ______ Step1 ______ Step 2
Hormonal changes in
pregnancy
Human Placental Lactogen ( HPL )
Increases breakdown of Free Faty acids
Leading to Insulin Resistance
Increase insulin secretion ) --- MA -
Decreased uptake of glucose in tissues ) CRO-
Decreased glucagon response ) SOMIA
Hyperglycemia in
PREGNANCY
It affects all normal changes that occur during
pregnancy
1. Placenta – produces hormone that “act
against”
or block insulin --- hyperglycemia beyond
the
target levels of pregnancy.
2. Birth defects is greatest if B.S. is poorly
controlled esp in the 1st week of pregnancy
Hyperglycemia in
Pregnancy
3. Maternal Risks related to diabetes
a. Pre-eclampsia & eclampsia
b. UTI
c. Polyhydramnios ( 25% -- preterm delivery
)
d. Target organs of diabetes should also be
evaluated: retina & kidneys ; Hypertension
,left untreated ,is assoc. with poor fetal growth &
stillbirth , and pre eclampsia and eclampsia.
Hyperglyceia in
pregnancy.:
Higher frequency of delivery via primary CS
Pre eclampsia/ pre term delivery
Shoulder dystocia or any birth injury
Fetal macrosomia ( > 8 lbs baby )
Neonatal hypoglycemia/ hyperbilirubinimia
Intensive/ prolonged neonatal care
MANAGEMENT of GDM
NON- PHARMACOLOGIC :
Diet - Medical Nutrition Therapy ( MNT )
Maternal surveillance
Fetal surveillance
Moderate exercise
PHARMACOLOGIC : insulin ( in certain cases:15
%)
MEDICAL NUTRITION
THERAPY ( MNT )
Cornerstone of GDM management
Dietitian/ HC with experience
Include Calories & Nutrition to meet the needs of
both mother and fetus and to meet glycemic
goals
Avoid weight loss/ ketonuria
Obese : ~25 kcal/kg ABW/day
DIET : Calorie needs:
1st trimester : 28-36 cal/ kgDBW
2nd trimester : 36-38 cal/ kg DBW
Distribution: 50% Carbo high fiber to decrease PPBS
and avoid constipation
20% lean protein ( meat/fish)
30% fats ( MUFA/ PUFA ) 10% of which is from
saturated fats.
Smaller meals; frequent snacks
Maternal surveillance
Goal is to detect & maintain GOOD glycemic
control throughout pregnancy to decrease
adverse maternal and fetal outcomes. HOW ?
SELF – MONITORING BLOOD GLUCOSE
( SMBG )
Target Levels :
Pre prandial: 95 mg/dL
1hr post prandial : 140 mg/dL
2hr post prandial : 120 mg/ dL
Other non DM monitoring
Monitor every Pre Natal Visit :
BP, Body weight
Pedal edema
Urinalysis for proteins ( pre eclampsia ) &
ketones ( to check if diet is adequate )
Starvation ketosis has detrimental effects to the
fetus
Fetal Surveillance
Mother should be taught to monitor fetal
movement in the last 8-12 wks of pregnancy
and to report any reduction in movement.
If GDM is diagnosed in the first trimester,
ultrasound is advised to detect congenital
anomalies.
If GDM is poorly controlled and with co-
morbidities, stress testing and biophysical
profiling is recommended; intensify care beyond
40 wks AOG
INSULIN
If MNT fails to meet glycemic control goals in
1-2 weeks, Insulin administration should be
considered.
HUMAN INSULIN –is the least immunogenic, low
antigenecity thereby minimizing transplacental
transfer of insulin antibodies.
Adverse Reactions to
Insulin
Hypoglycemia – most common; depend on the
type
& preparation
_ usua. due to 1. Hi dose of insulin
2. increased physical acivity
3. ommision of a meal
S/S : hunger, pallor, sweating, palpitation,
anxiety, headache, visual disturbance. If
untreated, may lead to convulsion and coma.
Effects of Insulin, cont… :
GI : weight gain, nausea
CNS : headache, fatigue, transient blurred
vision
CVR : peripheral edema, pallor, tachycardia
Dermatologic :pruritus, rash, urticaria
local effects : lipoatrophy, lipohypertrophy,
hypersensitivity reactions
Glibenclamide
May be used as alternative to insulin who are
unable or unwilling to inject insulin.
It is used as an adjunct to MNT and Phys.
Acitvity .
It is safe and effective in 80% of pts with GDM.
Minimal transplacental transfer.
NOT associated with neonatal hypoglycemia
Moderate Exercise
Unless there are medical or obstetrical
contraindications or glucose control is worsened
by exercise, AEROBIC exercise for 30 min daily
has been shown to lower maternal glucose
levels.
Consider the ff.
GDM is not an indication for for Ceasarian section.
GDM is not a consideration for delivery before 38 wks
unless there is maternal/ fetal compromise.
Gestation past 38 wks increases risk for macrosomia.
All women are encouraged breastfeeding; it prevents
childhood obesity & prevent T2DM
Early feeding is encouraged to prevent hypoglycemia
AFTER PREGNANCY :
SCREEN patient 6- 12 weeks POSTPARTUM
to check for persistent hyperglycemia; then
every 3 Years
Early prevention is better than cure.
THANK YOU FOR YOUR ATTENTION
