Gestational Diabetes mellitus(GDM)

by professor Miami Abdul Hassan

Ali
17.5.2020
Definition: carbohydrate intolerance of
variable severity first diagnosed during
pregnancy.
The definition is applicable regardless of
whether insulin is used for treatment or
the condition persists after pregnancy.
Occurs in 10-15 % of all pregnancy
10–15% percent
Screenings for GDM
1.FBS, RBS, glycoseurea,.HbA1c
are not recommended by the nice
guideline 2015 during pregnancy.
3.OGTT .The ‘gold standard’
diagnostic test for gestational diabetes
is the 75 g 2hours oral glucose
tolerance test (OGTT) conducted at
24–28 weeks of gestation.
Test done after overnight fasting. with
the patient sitting quietly and not
smoking;
it is also important that the patient
should have normal meals for the
previous three days and should not
have been dieting.
1. FBS is checked.
2. Ask to take 75 g glucose
dissolved in 300 ml water.
3. Blood glucose is checked
after 2 hours.
oral GTT
 Diabetes is diagnosed
• The UK National Institute The WHO guidelines (2013)
for Health and Care recommend a diagnosis with :
Excellence •a fasting glucose of 5.1
• (NICE) guidelines (2015) mmol/l
recommend a diagnosis of •and/or a 1 hour (post 75 g
GDM with:
glucose load) of 10.0
• a fasting glucose ≥5.6
mmol/l
mmol/l
•or 2 hour of 8.5 mmol/l.
• and/or a 2 hour (post-75 g
glucose load) of 7.8 mmol/l.
INDICATIONS FOR WHO AND WHEN TO SCREEN

• Early screening
• Offer women who had gestational diabetes in
a previous pregnancy:
• Early self-monitoring of blood glucose or
75 g 2-hr OGTT as soon as possible after •
booking (whether in first/second trimester),
and further 75 g 2-hr OGTT at 24–28 weeks if
results of first OGTT are normal
 OGTT:At 24–28 weeks in the presence
of the following risk factors
• BMI >30 kg/m2 (
• Previous macrosomic baby ≥4.5 kg
• Previous gestational diabetes
• First degree relative with type 1 or
type 2 diabetes
• Women on long-term antipsychotic
medications
• Family origin with a high prevalence
of diabetes – south Asian
(specifically country of family origin:
India, Pakistan middle Eastern :Saudi
Arabia, United Arab Emirates, Iraq,
Jordan, Syria, Oman, Qatar, Kuwait,
Lebanon or Egypt)
 OGTT
• Previous unexplained stillbirth
• Glycosuria ( 1 episode of 2+ , 2
episodes of 1+)
• Polyhydramnios in the current
pregnancy.
• Macrosomia in the current
pregnancy.
• Age > 35years.
• >3 spontaneous abortions in
the 1st or 2nd trimester.
 Management of woman diagnosed
GDM
Explain to women with gestational diabetes:
• about the implications (both short and long
term) of the diagnosis for her and her baby
• that good blood glucose control throughout
pregnancy will reduce the risk of fetal
&maternal Complications.
 Risks of GDM to women and babies include:
• Birth trauma (to mother and baby)
• Induction of labour or caesarean section
• Pre-eclampsia,
• In addition, there are long-term effects associated
with GDM pregnancies such as an increased
maternal risk of developing metabolic syndrome
and Type 2 diabetes later in life.
• Of the women who develop GDM, 20% to 50%
will develop overt diabetes in the next 5 to 10
years.
 Risks of GDM to women and babies include:

• The infants of GDM

women are at an
increased risk for stillbirth
• Fetal macrosomia
• Transient neonatal
respiratory complications.
• Neonatal metabolic( e.g
hypoglycaemia and
hypocalcemia),
 Risks of GDM to women and babies include:
• Neonatal hematological (e.g.
Bilirubinemia and
polycythemia)
• Increased perinatal mortality.
• There is adverse neurological
and cognitive outcomes in
addition to the possibility of
early development of
metabolic syndrome in the
offspring (hypertension,
obesity and diabetes) when
gestational diabetes is not
treated or poorly managed
Congenital
anomalies and
spontaneous
abortions are not as
serious
complications in
GDM as they are
in pre-gestational
diabetes.
Glucose monitoring is carried out using a
glucometer. The patient should record
fasting glucose values and 1-hour (or 2-
hour) postprandial glucose values with
each meal to determine the adequacy of
diabetic control.
Target for control:

Preprandial glucose≤ 5.3

mmol/L (95 mg/dL)
• 1 h Postprandial
glucose≤ 7.8 mmol/L (140
mg/dL)
or
• 2 h Postprandial glucose
≤ 6.7 mmol/L (120 mg/dL)
21
• GDM is divided into two categories:
• A1 (euglycemia achieved by diet
alone)
• A2 (glycemic status inadequately
controlled by diet alone).
gestational diabetes will respond
to changes in diet and exercise in
most women
. Patients should be encouraged to
maintain a healthy, consistent
level of activity throughout
pregnancy, provided that no
complicating factors (i.e., preterm
labor, pre-eclampsia
 Control of blood glucose
• Offer metformin to women with
gestational diabetes if blood glucose
targets are not met using changes in
diet and exercise within 1–2 weeks.
• Offer insulin instead of metformin to
women with gestational diabetes if
metformin is contraindicated or
unacceptable to the woman.

24
 Control of blood glucose
• Offer addition of insulin to the
treatments of changes in diet, exercise
and metformin for women with
gestational diabetes if blood glucose
targets are not met.
• Offer immediate treatment with
insulin, with or without metformin, as
well as changes in diet and exercise, to
women with gestational diabetes who
have a fasting plasma glucose level of
7.0mmol/litre or above at diagnosis.
25
Consider immediate treatment
with insulin, with or without
metformin, as well as changes in
diet and exercise, for women with
gestational diabetes who have a
fasting plasma glucose level of
between 6.0 and 6.9 mmol/litre if
there are complications such as
macrosomia or hydramnios
Consider glibenclamide for women
with gestational diabetes:
in whom blood glucose targets are
not achieved with metformin but
who decline
insulin therapy or who cannot
tolerate metformin. [new 2015]
 Oral Hypoglycemic Agents
• The American College of Obstetricians and
Gynecologists (2013) acknowledges that
• both glyburide and metformin are
appropriate, as is insulin, for first-line glycemic
control in women with gestational diabetes.
• Because long-term outcomes have not
been studied, the committee
recommends appropriate counseling
when hypoglycemic agents are used.
Insulin Management

• Depending on the maternal weight

and recorded glucose levels, the
insulin dosage should be initiated as
follows:
• 0.7 units/kg for gestational age of 6 to
18 weeks;
• 0.8 units/kg for gestational age of 18
to 26 weeks;
• 0.9 to 1.1 units/kg for gestational age
of 26 to 40 weeks
 Dietary management
• Do not skip meals!-should be eating about 3
main meals a day with 2-3 snacks.
• Limit fruit intake- Fruits are healthy, but also
high in sugar. So it’s all about moderation.
Instruct to ovoid eat those fruits which are
canned in syrup water.
• Food portion control- half a plate of veggies, 1
quarter protein and another quarter carbs.
• If you think fruit juices are healthy… think again!- It
takes a few fruits to make up a glass of juice, which
makes it a concentrated source of carbohydrate. And
because it’s so easy to just gulp it all down, it can raise
your blood sugar level quickly!
• Strictly limit sweets and desserts- Cookies, cakes,
pastries all have large amount of carbs and sugar and
offer very little in nutrition. It’s all also important to
stay away from added sugars in your food like honey
and syrup and avoid all sodas and sweet beverages!
 Obstetrical
Management
• GDM-A1 diabetic
patients are not at
increased risk
for fetal demise
before 40 weeks'
gestation. Therefore,
no antepartum
testing is required
beyond that
recommended for a
normal pregnancy..
 Obstetrical
Management
• Women with GDM-A2 require antenatal testing similar
to that recommended for pre-gestational DM (twice
weekly NSTs/BPP from 32 to 34 weeks until delivery).
• A 34- to 36-week fetal growth ultrasonographic
examination is recommended to assess fetal size.
• Insulin-treated women are offered inpatient admission
after 34 weeks’ gestation, and fetal heart rate
monitoring is performed three times each week
 Delivery
• Women with GDM-A2.
• If good glycemic control scheduled delivery at 39 weeks
• The prolongation of the gestation beyond 39 weeks
increases the risk of fetal macrosomia without reducing
Cesarean section rates.
• GDM is not an indication for delivery by Cesarean.
• However if estimated fetal weight>4.5kg for CS
• If poor glycemic control scheduled delivery at 37-39
weeks
For women who were diagnosed with gestational
diabetes whose blood levels returned to normal after
the births should be offered lifestyle advice (including
weight control, diet and exercise)
Screening with a fasting glucose or HbA1c should be
offered 6–13 weeks after childbirth.
Screening for type 2 DM yearly.
 Contraception

• Low-dose hormonal contraceptives may be used safely

by women with recent gestational diabetes .The rate of
subsequent diabetes in oral contraceptive users is not
significantly different from that in those who did not
use hormonal contraception .
• Importantly, comorbid obesity, hypertension, or
dyslipidemia should direct the choice for contraception
toward a method without potential cardiovascular
consequences. In these instances, the intrauterine
• device is a good alternative.
Thank you for listening

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