CLINICAL CLERKS CASE CONFERENCE

GESTATIONAL
DIABETES
MELLITUS
SUBGROUP A6 | Cabujat to Catral
 OUTLINE
CASE
PRESENTATION Salient Features Gaps in Knowledge Classification

DIAGNOSTICS &
OUTCOMES Screening Tests Diagnostic Work-up Perinatal Outcomes

MANAGEMENT
PLAN Non-Pharmacologic Pharmacologic Obstetric & Discharge

 SUBJECTIVE
SALIENT
FEATURES IDENTIFYING DATA
Z.D., 36 years old, G3P2 (2002), married, Filipino,
Roman Catholic from Cupang Antipolo City, admitted
for the first time at UERMMMC last November 4, 2019.

OBJECTIVE
CHIEF COMPLAINT
Labor pains of 3 hours duration

COURSE

 SUBJECTIVE
SALIENT
FEATURES HISTORY OF PRESENT ILLNESS
3 hours PTA → Mild to moderate uterine
contractions occurring regularly every 2-3 minutes
lasting for 30-40 seconds, (+) spotting, (-) watery

OBJECTIVE
vaginal discharge
Prompted consult at UERM consultation room →
examined and admitted for Emergency Low
Transverse Cesarean Section

COURSE
 SUBJECTIVE
SALIENT
FEATURES Menstrual History
Menarche: 12 years old
Menstrual cycle: Regular 28-30 day cycles lasting 3
days consuming 2-3 pads per day, moderately soaked

OBJECTIVE
(-) Dysmenorrhea

COURSE
 SUBJECTIVE
SALIENT
FEATURES OBSTETRIC HISTORY
G3P2 (2002)
G1 - 2005, delivered a live full term boy via LTCCS I
secondary to cephalopelvic disproportion at Queen Mary

OBJECTIVE
Hospital, BW 3318g.
G2 - 2011, delivered a live full term girl via Elective LTCCS
II for repeat at UERMMMCI, BW 2818g ; GDM on insulin
therapy diagnosed at early pregnancy. Glucose levels
normalized after pregnancy.

COURSE
G3 - present pregnancy, 38 4/7 wks AOG via LMP, EDD
November 14, 2019, poor prenatal check up.
 SUMMARY OF PRENATAL CHECK-UP
DATE & AOG FINDINGS/ ASSESSMENT PLAN

1st PNCU Pregnancy uterine 8 6/7 weeks AOG by LMP

Trans vaginal Ultrasound and urinalysis done;
04/10/19 G3P2 (2002) with 2 previous LTCCS (2005, 2011);
Prescribed with multivitamins and FeSO4
AOG: 8 6/7 Advanced maternal age

For CBC, Blood Typing, Urine CS, HbsAg, VDRL, pap

2nd PNCU Total Weight Gain 11.4 kg
smear, 75g OGTT, TAS for CAS
09/12/19 BP: 90/60

AOG: 31 weeks FH: 31 Normal FHT

Continue Multivitamins and Ferrous Sulfate

Total Weight Gain 18.4 kg

3rd PNCU CBC and Pap smear normal
Scheduled for elective LTCCS III @ 39 4/7 weeks
10/16/19 HbSAg: reactive
For Hepa B panel and co-managed with GIT service
AOG: 35 6/7 75g OGTT: high fasting (105.4 mg/dl)
Appropriate EFBW: 2145 grams (?)
 SUBJECTIVE
SALIENT
FEATURES Menstrual History
2011 - UTI treated with Cefuroxime
No history of:
Abnormal uterine bleeding

OBJECTIVE
Sexually transmitted infections
Pruritus
Abnormal vaginal discharge

COURSE
 SUBJECTIVE
SALIENT
FEATURES SEXUAL HISTORY
Coitarche at 20 years old, 1 sexual partner
No dyspareunia, no post-coital bleeding

OBJECTIVE
CONTRACEPTIVE HISTORY
No history of contraceptives use

past medical history

No hypertension, allergy, cardiovascular or thyroid

COURSE
diseases, or obesity
 SUBJECTIVE
SALIENT
FEATURES family medical HISTORY
Hypertension - paternal side
Diabetes Mellitus - maternal side

OBJECTIVE
SOCIAL History
Occupation: Pharmacy assistant since 4 years ago
Occasional alcoholic beverage drinker
Non-smoker
Diet pre-pregnancy: 1 cup of rice per day

COURSE
Diet during pregnancy: 2-3 cups of rice per day and a viand
No regular exercise
 SUBJECTIVE
SALIENT
FEATURES PHYSICAL EXAM ON ADMISSION

General
Patient is conscious, coherent, not in cardio-respiratory distress
Appearance

OBJECTIVE
Vital Signs BP: 120/60mmHg > HR :90bpm > RR :18cpm > T: 36.7 °C > BMI: 32.05 (Obese)

Skin Fair, moist and warm to touch, no lesions, no jaundice

Anicteric sclerae, pink palpebral conjunctivae, pupils equally round and briskly
reactive to light, full EOMs, no ptosis, no eye discharge; well-formed pinna, no
Head and Neck
tonsillopharyngeal congestion; trachea is at midline; thyroid is not enlarged, no

COURSE
cervical lymphadenopathies.

Chest and Lungs Equal chest expansion, clear breath sounds bilaterally, no retractions
 SUBJECTIVE
SALIENT
FEATURES PHYSICAL EXAM ON ADMISSION

Heart Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs

OBJECTIVE
Globular, Gravid uterus (+) linea nigra (+) scar
Abdomen L1 - Breech > L2 - Fetal back is on maternal right > L3 - Cephalic, unengaged
FH - 38cm ; EFBW: 4,030g; FHT - 140s

Pelvic Internal exam: cervix 3 cm dilated, 50% effaced, cephalic, station -3, intact membrane

Full and equal pulses, capillary refill time <2 seconds, no cyanosis, (-) bipedal edema,

COURSE
Extremities
full range of motion

Heart Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs
 SUBJECTIVE
SALIENT
FEATURES COURSE IN THE WARDS
On admission, patient has stable vital signs with
contractions noted to be moderate, occurring every

OBJECTIVE
3 minutes lasting for 30-40 seconds. Baseline CBG
was 111 mg/dl. HbA1c was also requested showing
normal value (5.6%). Patient was referred to DM
service for co-management. CBC was also

COURSE
requested which revealed normal result and
Hepatitis B Profile with reactive anti-HBc.
 SUBJECTIVE
SALIENT
FEATURES admitting diagnosis

G3P2 (2002) pregnancy uterine 38 4/7 weeks AOG by LMP, cephalic, in

OBJECTIVE
labor, advance maternal age, GDM, unknown control, lost to follow-up,
Acute vs Chronic Hepatitis B infection, s/p LTCCS secondary to
cephalopelvic disproportion (2005) and Elective CS (2011)

COURSE
classification of diabetes
mellitus in pregnancy

PREGESTATIONAL (pgdm) OR OVERT DM (odm)

Refers to type 1 or type 2 DM diagnosed prior to pregnancy
Diagnosis of overt DM during pregnancy should be
confirmed postpartum
classification of diabetes
mellitus in pregnancy

gestational dm (gdm)
Carbohydrate intolerance of variable severity with its onset
or first recognition during pregnancy
Induced by exagerated physiological changes in glucose
metabolism
More than 50% of women with GDM ultimately develop overt
diabetes in the next 20 years
classification of diabetes
mellitus in pregnancy
classification of diabetes
mellitus in pregnancy
NORMAL PREGNANCY VS. GESTATIONAL DM
SCREENING FOR
GESTATIONAL DIABETES

Screening for GDM according to the

Philippine Practice Guidelines on the
Diagnosis and Management of
Diabetes Mellitus (2011)
SCREENING FOR
GESTATIONAL DIABETES GUIDELINES
All pregnant women All pregnant women should
should be screened for be evaluated at the first
gestational diabetes prenatal visit for risk
factors for diabetes

High-risk women Routine testing for

should be screened at gestational diabetes is
the soonest possible recommended at 24 to 28
time weeks age of gestation for
women with no risk factors
RISK FACTORS
Prior history of GDM
Glucosuria
Family history of diabetes
First degree relative with type 1 or type 2 diabetes
Prior macrosomic baby
Age ≥ 25 years old
Diagnosis of PCOS
Overweight/obese before pregnancy
Macrosomia in current pregnancy
Polyhydramnios in current pregnancy
Intake of drugs affecting carbohydrate metabolism
 75g OGTT
SCREENING FOR
GESTATIONAL DIABETES
Other tests needed:
TESTS NEEDED
Capillary Blood Glucose
FBS
RBS
HbA1c
Fructosamine
Urine Glucose

CVD and Metabolic Syndrome

screening
SCREENING FOR
GESTATIONAL DIABETES
Low Risk
Low risk ethnic group
No 1st degree DM Family
history
Age < 25 years old
Normal pre-pregnancy weight
Normal weight at birth
No abnormal glucose
metabolism
No poor obstetric outcomes
POGS SCREENING
Average Risk High Risk
Perform blood glucose testing Severe obesity
at 24-28 weeks using either: Impaired glucose
50g OGCT followed by metabolism, glucosuria
diagnostic 100g OGTT for (+) family history of type 2
those meeting the DM, previous history of GDM
threshold value in the GCT
One-step 100g OGTT
LOW RISK
SCREENING FOR
GESTATIONAL DIABETES
Low Risk
Low risk ethnic group
No 1st degree DM Family
history
Age < 25 years old
Normal pre-pregnancy weight
Normal weight at birth
No abnormal glucose
metabolism
No poor obstetric outcomes
POGS SCREENING
Average Risk High Risk
Perform blood glucose testing Severe obesity
at 24-28 weeks using either: Impaired glucose
50g OGCT followed by metabolism, glucosuria
diagnostic 100g OGTT for (+) family history of type 2
those meeting the DM, previous history of GDM
threshold value in the GCT
One-step 100g OGTT
SCREENING FOR
GESTATIONAL DIABETES
Low Risk
Low risk ethnic group
No 1st degree DM Family
history
Age < 25 years old
Normal pre-pregnancy weight
Normal weight at birth
No abnormal glucose
metabolism
No poor obstetric outcomes
POGS SCREENING
Average Risk High Risk
Perform blood glucose testing Severe obesity
at 24-28 weeks using either: Impaired glucose
50g OGCT followed by metabolism, glucosuria
diagnostic 100g OGTT for (+) family history of type 2
those meeting the DM, previous history of GDM
threshold value in the GCT
One-step 100g OGTT
high RISK
DIAGNOSIS OF
ODM & GDM OVERT DIABETES IN PREGNANCY

Based on ADA and WHO

Plasma glucose levels >200mg/dl measured 2
hours after 75g OGTT
DIAGNOSIS OF
ODM & GDM gestational diabetes
DIAGNOSIS OF
ODM & GDM gestational diabetes
The OGTT procedure should be
performed in the morning, after at
least 3 days of unrestricted
carbohydrate intake of more than
150g daily.
Should not be done during acute
illness as the results will not
reflect patient's glucose
Test should be implemented after
an overnight fast of 8-14 hours
(water is allowed) .
DIAGNOSIS OF
GDM

75 gram OGTT 75 gram OGTT 75 gram OGTT

(ADA) (IADPSG) (POGS)
2-HOUR OGTT
≥ 92mg/dl but less
Fasting plasma ≥ 95mg/dl ≥ 92 mg/dl
than 126mg/dl
glucose

1-hour ≥ 180 mg/dl ≥ 180 mg/dl ≥180 mg/dl

≥ 153 mg/dl
2-hour ≥ 155 mg/dl ≥ 153 mg/dl

Criteria for
At least 2 At least 1 At least 1
Diagnosis
DIAGNOSTIC
WORK-UP
Acute Hep A Acute Hep B Acute Hep C

HEPATITIS PROFILE Anti-HAV IgM + - +

HBsAg _ + _

Anti HBc IgM - +

HCV- RNA - - +
 SUBJECTIVE
case Test Results of the Patient
follow-up
BLOOD FASTING: 105.4 mg/dl
Blood 1 hr: 135mg/dl
working DIAGNOSIS Blood 2 hours: 102 mg/dl
G3P2 (2002) pregnancy uterine 38 Baseline CBG: 111 mg/dl

OBJECTIVE
4/7 AOG by LMP, cephalic in labor HbA1c: 5.6%
EFBW 4030kg (LGA); obese class 1,
GDM unknown control, acute vs. HBsAg: Reactive
chronic Hepatitis B infection, Hepatitis B profile with reactive anti-Hbc

previous LTCCS secondary to

CBC: Normal results

COURSE
cephalopelvic disproportion (2005)
and Elective CS (2011), AMA
PERINATAL
MATERNAL OUTCOMES
OUTCOMES
Overt Diabetes GDM

Pre-gestational BMI 26.2 ± 6.1 24.9 ± 5.7 kg

Insulin Therapy 85.6% 34.1%

Glycated
6.8 ± 1.1% 5.8 ± 0.5%
Hemogblobin

Fasting-114.5 +/- 32.2 Fasting- 90.5 +/- 11.8

Glucose on 75 OGTT 1 hour- 237.2 +/- 47.1 1 hour- 200.8 +/- 32.1
2 hour- 227.6 +/- 43.5 2 hour- 177.7 +/- 34.2

PERINATAL
MATERNAL OUTCOMES
OUTCOMES
Overt Diabetes GDM

15-20% (T1DM);
Pre-eclampsia 6.1% (IR)
10-14% (T2DM) (IR)

Gestation HTN 10.1% (IR) 6% (IR)

Risk of Primary C-
2.5X increased risk 1.8X increased risk
section
PERINATAL
MATERNAL OUTCOMES
OUTCOMES
Overt Diabetes GDM

Gestational age at
37.8 ± 2.5 weeks 38.1 ± 2.1 weeks
delivery

Prevalence of
1.2% 0%
Retinopathy

Prevalence of
8.6% 6.5%
Symptomatic UTI
PERINATAL
OUTCOMES

OTHER MATERNAL OUTCOMES

Diabetic Nephropathy
Diabetic Neuropathy- diabetic gastropathy
Diabetic Ketoacidosis
Infections
PERINATAL
OUTCOMES

OTHER MATERNAL OUTCOMES

GDM: POSTPARTUM
CVD events at younger age - increased
Hospitalization for CVD events - higher
Serum HDL - lower
Risk for Cancer - increased
eGFR levels - increased
PERINATAL
FETAL OUTCOMES
OUTCOMES
Overt Diabetes GDM

Congenital 2- to 9-fold Only slightly increased from

Malformations increased risk general population (OR 1.1-1.3)

Altered Fetal Macrosomia: 40% inc. risk Macrosomia: 30% inc. risk
Growth IUGR: 10% inc. risk

Preterm
3.34 (OR) 1.69 (OR)
Delivery

Spontaneous abortion
Other Similar outcomes as in Overt
Unexplained fetal demise
Outcomes DM but with decreased risk
Hydramnios

Williams (25th ed.)

Riskin, A. & Prats, J. (2020, Feb 10). Infants of Women with Diabetes. UpToDate. Retrieved from https://www.uptodate.com/contents/infants-of-women-with-diabetes
PERINATAL
NEONATAL OUTCOMES
OUTCOMES
Overt Diabetes GDM

Not substantially higher than

Stillbirth 4- to 5-fold increased risk
general population

Hypoglycemia: 5-fold inc. risk Hypoglycemia: 1-4% inc. risk

Metabolic
Hypocalcemia Hypocalcemia
Complications
Hypomagnesemia Hypomagnesemia

Respiratory Distress
Syndrome
Other Similar outcomes as in Overt
Polycythemia
Outcomes DM but with decreased risk
Hyperbilirubinemia
Cardiomyopathy

Williams (25th ed.)

Riskin, A. & Prats, J. (2020, Feb 10). Infants of Women with Diabetes. UpToDate. Retrieved from https://www.uptodate.com/contents/infants-of-women-with-diabetes
PERINATAL
OUTCOMES

LONG-TERM OUTCOMES
Long-term cognitive development
Autism spectrum disorders
ADHD
Developmental delays
Inheritance of Diabetes
Obesity
Adiposity
Adnormal glucose metabolism
Williams (25th ed.)
Riskin, A. & Prats, J. (2020, Feb 10). Infants of Women with Diabetes. UpToDate. Retrieved from https://www.uptodate.com/contents/infants-of-women-with-diabetes
MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN LIFESTYLE MODIFICATION

DIET

EXERCISE
MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN NUTRITION THERAPY

GOALS
Achieve normoglycemia
Prevent ketosis
Provide adequate nutrition and weight gain based on
maternal BMI
Contribute to appropriate fetal growth and
development
MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN NUTRITION THERAPY

Individualized nutritional counseling based on prepregnancy BMI and

weight gain goals
Caloric Requirement
Carbohydrates: 40%, Protein: 20%, Fats: 40%
Give 3 meals and 2-4 snacks daily
Low glycemic index carbohydrates
30% caloric restriction for obese women
Monitored for ketonuria
MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN
RECOMMENDED WEIGHT GAIN
Rate of weight gain in the 2nd and 3rd trimester
Pregravid BMI Category Total Weight Gain kg (lbs)
kg (lbs)

Underweight (<18.5) 12.5-18 (<28-40) 0.44–0.58 kg/week (1-1.3 lbs/week)

Normal (18.5-24.9) 11.15-16 (25-35) 0.35–0.50 kg/week (0.8-1 lbs/week)

Overweight (25-29.9) 7-11.5 (15-25) 0.23–0.33 kg/week (0.5-0.7 lbs/week)

Obese (>30) 5-9 (11-20) 0.17–0.27 kg/week (0.4-0.6 lbs/week)

2009 Gestational weight gain guidelines (Institute of Medicine, 2009)

MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN EXERCISE GUIDELINES FOR
GESTATIONAL DIABETES MELLITUS
Type of Exercise Intensity Duration Frequency

Aerobic (large muscle activities in a

≤ 30 min continuously
rhythmic manner) No more than two consecutive days
Moderate (up to 45 min if self-
e.g., walking, running, swimming and without exercising
paced)
cycling

Resistance (multi joint exercises,

No more than two consecutive days

large muscle groups)
Moderate 60 min without exercising
e.g., dumbbells, resistance band and

At least 2 but ideally 3 times a week

pregnancy Pilates

Padayachee C, Coombes JS. Exercise guidelines for gestational diabetes mellitus. World J Diabetes. 2015 Jul 25;6(8):1033-44. doi:
10.4239/wjd.v6.i8.1033. PMID: 26240700; PMCID: PMC4515443.
MANAGEMENT NON-PHARMACOLOGIC TREATMENT
PLAN BREASTFEEDING
Improves maternal glucose metabolism
May reduce the glucose levels obtained during a
postpartum glucose tolerance test (GTT)
Significantly reduced maternal risk of developing
type 2 diabetes later in life
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN GOALS OF TREATMENT

Failure to achieve Minimizing incidence of

target glucose levels Fetal Overgrowth
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN INSULIN TREATMENT
Insulin is the standard therapy in Gestational
Diabetes Mellitus.

This is added to the treatment if fasting levels

persistently exceed 95 mg/dL

This does not cross the placenta, thus safe for

pregnant use.
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN INSULIN TREATMENT
ACOG RECOMMENDATION FOR INSULIN TREATMENT
Fasting blood sugar >95 mg/dL

1-hr postprandial >140 mg/dL

2-hr postprandial >120 mg/dL

Dose: 0.7 - 2.0 units/kg/day in divided doses

A combination of intermediate-acting and short-acting insulin may be used.

MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN INSULIN TREATMENT
RECOMMENDED DOSE
First Trimester 0.7-0.8 units/kg

Second Trimester 0.8-1.0 units/kg

Third Trimester 1.0-2.0 units/kg

2/3 is given before breakfast and 1/3 before dinner.

Morning Dose Evening Dose

1/3 regular insulin and 2/3 NPH 1/2 regular insulin and 1/2 NPH
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN ORAL HYPOGLYCEMIC AGENTS

ACOG recognizes this as a reasonable alternative for

pharmacologic treatment
Not FDA Approved as GDM treatment

Crosses the Placenta

Increase in NICU admission, respiratory
distress, and neonatal hypoglycemia
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN ORAL HYPOGLYCEMIC AGENTS

GLYBURIDE METFORMIN

500 mg once daily with food for 1 week at

DOSAGE 2.5 mg orally with morning meal (initially)
initiation, then increases to 500 mg twice daily

Promotes closure of K-channels in pancreatic B cell Inhibits hepatic and renal gluconeogenesis →
MOA
→
membrane stimulate endogenous insulin release reduces postprandial and fasting glucose levels

↑ birth weight ↓ maternal weight gain

COMPARISON WITH
more macrosomia ↑ preterm births
INSULIN
more frequent neonatal hypoglycemia ↓ severe neonatal hypoglycemia
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN HEPATITIS B TREATMENT
MANAGEMENT PHARMACOLOGICAL TREATMENT
PLAN HEPATITIS B TREATMENT
MANAGEMENT OBSTETRIC MANAGEMENT
PLAN
TIMING AND MODE OF DELIVERY
If with adequate glucose control may await spontaneous
delivery (at 39+0 to 41+0 weeks) if:
Antenatal testing, fetal kick counts, EFM remain reassuring
Fetus is not macrosomic (<4000g)
If macrosomic, elective CS at 39+0
Over-estimation of EFW via UTZ (Scrifes et al. 2015)
If with sub-optimal glucose control delivery or CS can be done
earlier at 37+0 to 38+6

CPG on Diabetes Mellitus in Pregnancy. POGS. (2018)

Diabetes and Mellitus. Medscape. (2011)
Guidelines for Intrapartum Care of Diabetic women. Lamber RMJ. (2007)
Williams 25th ed
https://www.uptodate.com/contents/gestational-diabetes-mellitus-obstetric-issues-and-management.
 Macrosomia: ≥4000g
under local guidelines

https://www.uptodate.com/contents/gestational-diabetes-mellitus-obstetric-issues-and-management
MANAGEMENT OBSTETRIC MANAGEMENT
PLAN INDICATIONS FOR CS

Williams (25th ed.)

MANAGEMENT OBSTETRIC MANAGEMENT
PLAN POST-DELIVERY MANAGEMENT
Target of control during labour:
Plasma glucose: 80-120 mg/dL
Capillary glucose: 70-110 mg/dL
Target of control:
Fasting capillary glucose: <95 mg/dL
If elevated, should be confirmed with fasting plasma glucose (>126 mg/dL) or post-
prandial glucose (>200 mg/dL)
Maintain/modify nutrition therapy (with or without pharmacologic therapy) to
maintain glycemic control and to provide sufficient calories during lactation

CPG on Diabetes Mellitus in Pregnancy. POGS. (2011)

ADA Standards of medical care in diabetes. Diabetes Care. (2011)
Metzer BE et al. Diabetes care (2007)
Williams 25th ed.
MANAGEMENT OBSTETRIC MANAGEMENT
PLAN POST-PARTUM MANAGEMENT
50% of women with GDM will develop overt diabetes in 20 years (O' Sullivan, 1982).
Recommend patients with GDM to undergo postpartum evaluation with fasting
glucose or 2 hour 75g OGTT at 4 to 12 weeks to diagnosis for overt diabetes
ADA recommend testing at least every 3 years in women with history of GDM
Women with GDM are at risk for cardiovascular complications associated with
dyslipidemia, hypertension and obesity
GDM women were 2.6 times more likely to be hospitalized for cardiovascular
morbidity (Kessous et al., 2013).
GDM associated with risk for subsequent diabetes and complicating at least
one subsequent pregnancy (Varner, 2017)

Williams (25th ed.)

ACOG Clinical Management Guidelines for GDM 2018
MANAGEMENT OBSTETRIC MANAGEMENT
PLAN HEPATITIS MANAGEMENT

Request for Hepatitis B profile panel

Administer Hep B vaccine and HbIg to the newborn
within 12 hours
According to a study being HBsAg positive, advanced
age, and pre-pregnancy obesity were all revealed to
be independent risk factors for GDM
 Ayoub, W., & Cohen, Erica. (2016).
Hepatitis B Management in the
Pregnant Patient: An Update.
Journal of Clinical and Translational
Hepatology, 4(3), 241–247.
doi:10.14218/JCTH.2016.00014

DISCHARGE
INSTRUCTIONS POST-DELIVERY
DM screening at 6-12 weeks postpartum
Lifelong screening for DM every 3 years
Encourage breastfeeding with proper latching,
which decreases maternal risk for subsequent
GDM and overt DM; also decreases fetal risk for
diabetes
DISCHARGE
INSTRUCTIONS POST-DELIVERY
General activities are allowed
Encourage physical activity but not too strenuous
and with enough rest
Maintain proper wound care
Well-balanced diet with good fiber and fluid intake
Stool softeners
Counseling about weight loss and family planning
 ank you
Th !

ARE
THERE AN QUESTIONS?
Y
 esources
R
American College of Obstetricians and Gynecologists. Gestational Diabetes Mellitus. ACOG Practice Bulletin No. 190. Obstet Gynecol 2018; 131(2):49-64.
Available from: https://journals.lww.com/greenjournal/Abstract/2018/02000/ACOG_Practice_Bulletin_No__190__Gestational.37.aspx.
Caughey, AB. (2022). Gestational diabetes mellitus: Obstetric issues and management. Uptodate.com. Published 2022. Accessed February 11, 2022.
https://www.uptodate.com/contents/gestational-diabetes-mellitus-obstetric-issues-and-management
Cunningham, F.G., Leveno, K., Bloom, S., Dashe, J., Hoffman, B., Casey, B., Spong, C. (2014). Williams Obstetrics (24th edition). New York: McGraw-Hill
Education.
Durnwald, C. (2022). Gestational diabetes mellitus: Glycemic control and maternal prognosis. Uptodate.com. Published 2022. Accessed February 11,
2022. https://www.uptodate.com/contents/gestational-diabetes-mellitus-glycemic-control-and-maternal-prognosis#H14
Garrison A. Screening, diagnosis, and management of gestational diabetes mellitus [Internet]. American Family Physician. 2015 [cited 2022Feb1].
Available from: https://www.aafp.org/afp/2015/0401/p460.html
Kominiarek MA, Peaceman AM. Gestational weight gain. Am J Obstet Gynecol. 2017 Dec;217(6):642-651. doi: 10.1016/j.ajog.2017.05.040. Epub 2017 May 24.
PMID: 28549978; PMCID: PMC5701873.
Luna, Obeplias, Soriano et al. (2022). Ob-Gyn Platinum.
Philippine Practice Guidelines on the Diagnosis and Management of Diabetes Mellitus [Internet]. Diabetesphilippines.org. 2011 [cited 2022Feb1].
Available from: https://diabetesphilippines.org/HOME/Forms/clinical_practice_guidelines_draft.pdf
Rani PR, Begum J. Screening and diagnosis of gestational diabetes mellitus, where do we stand. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH.
2016Apr;10(4).