CASE PRESENTATION ON MANAGEMENT OF

GESTATIONAL DIABETES MELLITUS

Presenter: Dr. MOHAMMED A.(GYNOB RESIDENT)

Moderator: Dr. DEREJE G ( GYNOB FINAL YEAR RESIDENT)
 OUTLINE

• Objective
• Case summary
• Discussion
• Outline management of gestational diabetes mellitus
• Comments
• References
 Objective

To use this case as an entry point to discuss management of

gestational diabetes mellitus
 Case summary

• Name: SB

• Age: 29

• MRN: 169909

• Address: Harari

• Date of Admission: 04/02/15

 Admission note on 04/02/15.E.C

C/c- Referred from private clinic

HPP-This is a GII PI (Alive 4.3kg by VD) mother whose LNMP was on 06/05/14E.C. that making
current GA 39WKs.

• She had ANC follow up at private clinic

• Currently referred with diagnosis of Full term pregnancy + GDM for priming and induction.

• Otherwise No hx of
• Headache
• Blurring of vision
• Decreased fetal movement
 Cont.…
P/E-G/A- well looking
• Vital Signs-BP=100/ 60, PR=80, RR=22, T0=36.20 BMI=23.8kg/m2

HEENT-Pink conjunctiva, NIS

Chest-clear chest with good air entry

CVS-S1 and S2 well heard, no murmur or gallop

Abdomen-Term sized gravid uterus, cephalic presentation,

• FHB-136bpm
• No Contraction

GUS- Cx-3cm dilated and mid position, 30% effaced

• Station-0
• Membrane- intact
• Bishop score 6/13
 Cont.…
IS/MSS-No edema or rash

CNS –COPPT

ASS: Multigravida + Full term pregnancy + GDM

Plan-Admit to labor ward

• To do
• CBC, BG &Rh, U/A,
• HBSAG, RBS
• Obstetric us RBS
• Consult senior resident
• Misoprostol 25mcg sublingual stat
 Investigations

• WBC-11.6 x109/L • SGOT-18.7

• HGB-13.2 • SGPT-15.8
• HCT-39.2% • Cr-0.47
• PLT-103 x109/L • Na-134
• BG & Rh-AB+ve • K+-3.22
• RBS-163mg/dl done on
04/2/15 • Postpartum- RBS
• RBS- 163mg/dl done on • 91mg/dl done on 6/2/15.E.C
5/2/15 • 116mg/dl done on 7/2/15.E.C
• Neonatal RBS 92mg/dl
 Decision note on 05/02/15.E.C.

• This is 29yrs old GII PI (Alive by VD) mother whose GA calculated

from her LNMP on 06/05/14E.C. is 39WKs.

• She had ANC follow up at private clinic from where she was referred
as a case of full term pregnancy + GDM for priming and induction.

• She was admitted overnight with assessment of Primiparous + full

term pregnancy + GDM

• She was ripened with misoprostol 25mcg sublingual single dose then
induction was started as per protocol.
 Cont.…
• After being on oxytocin for 3hrs the fetus developed minimal
variability and deceleration then intra uterine resuscitation was done
and CTG tracing was repeated.

• The second tracing was category I FHRP.

• Subjectively no new compliant

 Cont.…
PE:G/A- well looking
• VS- BP=100/ 65, PR=88, RR=20, T0=ATT

HEENT-Pink conjunctiva, NIS

Chest-clear chest with good air entry

CVS-S1 and S2 well heard, no murmur

Abdomen- Term sized gravid uterus, longitudinal lie,

• cephalic presentation
• Contraction-2C/10/30-40’’
• FHB-156bpm
 Cont.…
GUS-No active vaginal bleeding
• Cx-5cm dilated
• Station-1
• ARM done – GIIMSAF
• Bedside obstetric US
• Single tone IUP
• Cephalic presentation
• FHB+VE
• Placenta –fundal
• AFI-13cm
• No gross congenital
anomaly seen
• EFW-3.9KG
 Cont.…
ASS- Primiparous + Full term pregnancy+ Newly diagnosed GDM
+AFSOL+NRFHRP

Plan-Prepare for emergency CS

CTG
 Operation note 05/02/15.E.C

• After informed written consent was taken the patient was transferred to OR, on table
FHR=152bpm

• Intraop finding-GIII MSAF

• LUSTCS done to effect the delivery of alive male weighing 4.2kg with APGAR score of 5, 6
& 7 in the 1st , 5th and 1oth minutes respectively.

• The neonate cried immediately after birth even though hypotonic and was to taken to radiant
warmer, dried and stimulated

• Meconium was suck out from the mouth and oropharynx

• The neonate still was hypotonic and started to develop apnea then PPV with self inflating
mask for 30 seconds and still not responding then sent to NICU for further management with
possible endotracheal intubation.
 Order sheet
• Monitor V/s Q 15minutes for the 1st 1hr the Q 3ominutes for the next
4hrs then Q 6rs
• Put on MF(NS, DNS & RL)1000ml each for 8hrs for 24hrs
• Continue oxytocin 3oIU in 1000ml →30drops /min
• Ampicillin 2gm IV Q 6hrs for 3doses
• Tramadol 5omg IV TID
• Diclofenac 75mg IM PRN
• Determine RBS Q 6hrs act accordingly
• Follow vaginal bleeding and uterine contraction closely
• Determine neonatal RBS
• Counsel on EBF, EPI, and options of contraceptives
Vital signs
Cont.…
Cont.…
DISCUSSION

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Problem list

GDM

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 Introduction

• Diabetes is the most common medical complication of pregnancy.

• Women with diabetes are classified into those diagnosed with diabetes;
• Before pregnancy→ pregestational or overt diabetes
• Those diagnosed during pregnancy→ gestational diabetes

• The frequency of diabetes complicating pregnancy has generally been

estimated to be as high as 6% to 7%, with 90% of these cases representing
women with GDM.

In our patient she had gestational diabetes

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 Cont.…
• The word gestational implies that diabetes is induced by pregnancy.

• Gestational diabetes is defined as carbohydrate intolerance of variable

severity with its onset or first recognition during pregnancy (ACOG,
2019a).

• This term aims to communicate the need for enhanced surveillance

during pregnancy and to stimulate further testing postpartum.

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 Early Screening for Overt Diabetes and detection of
GDM
• Both the ADA and ACOG recommend early pregnancy screening
for undiagnosed type 2 diabetes in women with a previous history of;
• GDM
• Previous delivery infant weighing 4kg or more
• History of impaired glucose metabolism or cardiovascular
disease,
• Overweight or obese
• History of hypertension or PCOS
• A first-degree relative with diabetes

Our patient had Previous delivery baby weighing 4.3kg

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 Cont.…
• Overt diabetes criteria:
• Fasting plasma glucose ≥ 126 mg/dl
• HgbA1C ≥ 6.5%
• Random plasma glucose ≥ 200 mg/dl with classic symptoms
• 2-hr PG ≥ 200 mg/dl during 75-g OGTT

Our patient Early Screening was not done although she had
indication

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 Screening for GDM
• The ACOG (2019a) recommends universal screening of pregnant women;
• With a protocol that provides a 50-g oral glucose load and that is
followed in 1hr by a laboratory-based blood glucose test.

• Screening should be performed between 24 and 28 wks’ gestation in those

women not known to have glucose intolerance earlier in pregnancy.

• This 50-g screening test is followed by a diagnostic 100-g, 3-hr OGTT if

screening results meet or exceed a predetermined plasma glucose
concentration.

In our patient she experienced increasing weight gain then she went to private
clinic for evaluation

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 Cont.….
 Gestational diabetes
• Diagnosis can be made in women who meet either of the following
criteria :
• At any gestational age , Fasting plasma glucose ≥92 mg/dL , but <126 mg/dL

27
 Cont.….
 At 24 to 28 weeks of gestation:
• 75 gram two hour OGTT with at least one abnormal result:
• Fasting plasma glucose ≥92 mg/dL , but <126 mg/Dl or
• One hour ≥180 mg/dL or
• Two hour ≥153 mg/dl
• 100 gm oral glucose tolerance test with two abnormal results
• ≥Fasting 95mg/dl
• ≥One hour 180mg/dl
• ≥Two hours 155mg/dl
• ≥Three hours 140mg/dl

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 Maternal Effects of GDM

• During pregnancy, women with GDM have an increased risk for

hypertensive disorders such as preeclampsia and cesarean delivery.

• Women with gestational diabetes do not appear to have fetuses with

substantially higher rates of anomalies than the general obstetrical
population (ACOG, 2019a; Sheffield, 2002).

• That said, women with elevated fasting glucose levels have elevated
rates of unexplained stillbirths similar to those of women with overt
diabetes.

Our patient she delivered by CS

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 Fetal Effects of GDM

• The offspring of women with GDM are at increased risk of

macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder
dystocia, and birth trauma.

• The perinatal goal is to avoid difficult delivery from macrosomia and

concomitant birth trauma associated with shoulder dystocia.

The baby weight was 4.2kg

30
 Cont.…
• Maternal BMI is an independent and more substantial risk factor for
fetal macrosomia than is glucose intolerance (Ehrenberg, 2004;
Mission, 2013).

• The highest fraction of LGA neonates was attributable to maternal

obesity plus excessive gestational weight gain.

• In our patient BMI was normal but she had excessive gestational
weight gain

31
 Cont.…

• Hyperinsulinemia may provoke severe neonatal hypoglycemia within

minutes of birth, but only three fourths of these episodes occur in the
first 6 hours (Harris, 2012).

• The definition of neonatal hypoglycemia is debated, and

recommended clinical thresholds range from 35 to 45 mg/dL.

• The risk also rises with birthweight, independent of a maternal

diabetes diagnosis (Mitanchez, 2014).

• Frequent blood glucose measurements in the newborn and active early

feeding practices can mitigate this complication.

The RBS of the neonate was 92mg/dl

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 Management of the Woman With GDM

• The mainstays of treatment of GDM remain nutritional counseling and

dietary intervention combined with daily exercise.

• The optimal diet should provide caloric and nutrient needs to sustain
pregnancy without resulting in significant postprandial
hyperglycemia.

• Pharmacological methods are usually recommended if diet

modification does not consistently maintain;
• The fasting plasma glucose levels <95 mg/dL or
• The 2-hr postprandial plasma glucose <120 mg/dL (ACOG, 2019a).

33
 Cont.…
• The ACOG (2019a) suggests that carbohydrate intake be limited to 33
to 40 percent of the total daily calories.

• The remaining calories are apportioned to give 20 percent as protein

and 40 percent as fat.

Our patient she was managed with dietary intervention

combined with exercise

34
 Cont.…

• Once the diagnosis is established, women are begun on a dietary

program of 2000 to 2500 kcal daily.

• This represents approximately 35 kcal/kg of present pregnancy

weight.

• For women who are overweight or obese, a reduction in caloric intake

to 25 kcal/kg/day and 15 kcal/kg/day (present pregnancy weight),
respectively, may be advised.

35
 Cont.…

 Exercise
• The ACOG (2020b) recommends regular physical activity that
incorporates aerobic and strength conditioning exercise during
pregnancy and extends this to women with gestational diabetes.

• Women with GDM are advised to exercise daily for 30 minutes at

least 5 days a week or a minimum of 150 minutes per week.

• A program of moderate-intensity aerobic exercise such as brisk

walking is recommended.

36
 Cont.…

• Exercise can increase glucose consumption in muscle by up to 50-fold

and occurs independent of insulin signaling.

• Walking for 10 to 15 minutes after each meal may be especially

helpful in controlling postprandial glucose levels.

• A program of moderate exercise has been advocated by the ADA and

ACOG as part of the treatment of GDM.

37
 Cont.…

 Glucose Monitoring
• Once the patient with GDM is placed on an appropriate diet;
• Surveillance of blood glucose levels is necessary to be certain that
glycemic control has been established.

• Postprandial surveillance for gestational diabetes is superior to

preprandial surveillance.

• The ACOG(2019a) and the ADA (2019) recommend glucose

assessment four times daily.

• The first check is performed fasting, and the remainder are done 1 or 2
hrs after each meal.

38
 Cont.…
• Glycemic target thresholds recommended by both the ADA and ACOG are:
• Fasting glucose less than 95 mg/Dl
• 1-hour postprandial glucose less than 140 mg/dL,
• 2hr postprandial glucose less than 120 mg/dL

• If a patient repetitively exceeds these established thresholds in the fasting

and/or postprandial state and she is following the prescribed diet,
pharmacologic therapy is recommended.

In our patient her Glycemic target thresholds were within normal range
as she stated

39
 Cont.…
 Insulin Treatment
• Historically, insulin has been considered standard therapy in women
with GDM when target glucose levels cannot be consistently
achieved through nutrition and exercise.

• Insulin does not cross the placenta, and tight glycemic control can
usually be achieved.

40
 Cont.…
• Insulin therapy is typically added if fasting levels persist above 95
mg/dL in women with GDM.

• The ACOG (2019a) also recommends that insulin be considered in

women with 1-hr postprandial levels that persistently exceed 140
mg/dL or those with 2-hr levels >120 mg/dL.

41
 Cont.…
• The starting insulin dose is typically 0.7 to 1.0 U/kg/d and is given in
divided doses (ACOG2019a).

• A combination of intermediate-acting and short-acting insulin may be

used.

• Dose adjustments are based on glucose levels at particular times of the

day.

42
 Cont.…

 Oral Hypoglycemic Agents

• Both ACOG and ADA acknowledge that several studies support the
safety and efficacy of either metformin (Glucophage) or glyburide.

• The FDA has not approved glyburide or metformin use for treatment
of gestational diabetes.

• The ACOG (2019a) recognizes both as reasonable choices for second-

line glycemic control in women with gestational diabetes.

43
 Cont.…

• Oral agents may be used instead of insulin when patients are reluctant
to take injections.

• When there is concern about their ability to follow a regimen of

multiple insulin injections.

• When the cost of insulin is prohibitive for them.

• Moreover, no evidence suggested increased adverse neonatal

outcomes with the use of oral hypoglycemic agents.

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 Obstetrical Management

• Women with GDM that is well controlled are at low risk for an
intrauterine fetal demise.

• For this reason, it is not routinely instituted antepartum fetal heart rate
testing in uncomplicated diet-controlled GDM.

• Women with a hypertensive disorder, a history of a prior stillbirth, or

suspected macrosomia do undergo fetal testing.

• The ACOG (2019a, 2020c) endorses fetal surveillance in women with

gestational diabetes and poor glycemic control.

45
 Cont.…
• It is suggested that women with gestational diabetes to routinely
instruct to perform daily fetal kick counts in the third trimester.

• The ACOG (2019a) recommends that routine labor induction in

women with diet-treated gestational diabetes should not occur before
39 weeks’ gestation.

46
 Cont.…
• The ACOG (2019b) concludes that data are insufficient to determine
whether women with GDM whose fetuses have a sonographically
estimated weight ≥4.5kg should undergo CD to avoid risk of birth
trauma.

• Still, the ACOG (2020b) acknowledges that prophylactic CD may be

considered in diabetic women with an estimated fetal weight ≥4.5kg.

• In addition, those who require insulin or oral agents for treatment of

GDM undergo twice-weekly NSTs starting at 32 weeks’ gestation.

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 Timing of Delivery

• At present, the ACOG suggests that if GDM is well controlled on diet,

delivery should be planned at 39 0/7 up to 40 6/7 weeks’ gestation.

• Those patients requiring insulin and/ or oral medication are considered

for delivery at 39 0/7 up to 39 6/7 weeks’ gestation.

In our patient delivery was planned at GA of 39wks

48
 Cont.…
• If glycemic control is suboptimal, ACOG recommends that delivery
be considered at 37 0/7 weeks up to 38 6/7 weeks’ gestation.

• The decision to schedule late-preterm or early-term birth in such cases

should be individualized.

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 Intrapartum Management
• Patient is kept NPO after midnight

• Usual dose of intermediate-acting insulin is given at bedtime.Withhold morning (AM) insulin

injection.

• Begin and continue glucose infusion (5% d /w) at 100 – 150mL/hr

• Add 10 U of regular insulin to 1L of solution with 5% dextrose.

• Begin infusion of regular insulin if RBS is greater than 80 mg/dL.

• Use fluid without dextrose if RBS is more than 180 mg/dL.

• Begin oxytocin as needed.

• Monitor maternal glucose levels hourly. Adjust insulin infusion.

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Cont.…

51
 Postpartum Follow-up of women with GDM

• Recommendations for postpartum evaluation are based on the 50- to 75- percent
likelihood that women with GDM will develop overt diabetes within 15 to 25 years
(ADA, 2019).

• The ACOG (2019a) recommends either a fasting glucose assessment or a 75-g, 2hr
OGTT at 4 to 12 wks postpartum for the diagnosis of overt diabetes.

• The ADA (2019) recommends testing every 1 to 3 years in women with a history of
gestational diabetes but normal postpartum glucose screening.

52
 Effects of Breastfeeding on GDM

• Ample evidence shows that breastfeeding improves immediate

postpartum glucose tolerance.

• Yet much less is known about whether lactation prevents progression

to type 2 diabetes.

• For those women who breastfed, higher lactation intensity and

duration was associated with a significant reduction in the likelihood
of progressing to type 2 diabetes.

Our patient she is Breastfeeding

53
 Long-Term Effects of Glucose Intolerance on
Mother and Fetus

• Women with a history of GDM are at risk for cardiovascular

complications associated with dyslipidemia, hypertension, and
abdominal obesity.

• Related metabolic dysfunctions include:

• Hyperlipidemia
• Insulin resistance, and hyperinsulinemia
• Atherosclerotic vascular disease

• Moreover, mounting evidence implicates long-range complications

that include obesity and diabetes in their offspring.
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 CONTRACEPTION

• Barrier methods of birth control continue to be safe and inexpensive.

• When used correctly with a spermicide, the diaphragm has a failure

rate of less than 10%.

55
 Cont.…
• The intrauterine device, either with copper or levonorgestrel,
may be used safely in patients with diabetes.

• Both are highly effective and safe in this population.

• Finally, in those women with diabetes who have serious

vasculopathy, permanent sterilization should be discussed.

56
 Recurrent Gestational Diabetes

• Women with GDM are at high risk for recurrence in future

pregnancies.
• The risk for GDM in a third pregnancy was highest when both the
first and second pregnancies were complicated by GDM.

• Lifestyle behavioral changes that include weight control and exercise

between pregnancies would seem likely to prevent gestational
diabetes recurrence.

57
Prevalence of Gestational Diabetes Mellitus among pregnant women attending
antenatal care clinic of St. Paul’s Hospital Millennium Medical College, Addis
Ababa, Ethiopia

58
 Comments

• Family planning was not provided

• Senior resident was not evaluated this patient

• Why CS was not done when minimal variability and deceleration

detected

• Intrapartum fetal monitoring was inadequate- there was persistent fetal

tachycardia

59
 References

• Williams Obstetrics 26th Edition, chapter of Diabetes Mellitus

• Gabbe’s Obstetrics Normal and Problem Pregnancies 8th edition,
chapter of Diabetes Mellitus Complicating Pregnancy
• UPTODATE 2018
• 2018 ACOG Practice bulletin in Gestational Diabetes Mellitus,
Number 190
• Obstetrics Management Protocol For Hospitals 2021

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THANK YOU

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