MM COLLEGE OF NURSING

CLINICAL TEACHING ON:-

GESTATIONAL DIABETES MELLITUS

PRESENTED TO:- PRESENTED BY:-

MS.DEEPSHIKHA GINNI RANI
(ASSISTANT 1918027
PROFESSOR) BSC NURSING 4TH YEAR
 CONTENT
 Introduction of diabetes mellitus
 Define diabetes mellitus
 Classification of diabetes mellitus
 Risk factor of gestational diabetes mellitus
 Pathophysiology
 Clinical features of gestational diabetes mellitus
 Screening test for gestational diabetes mellitus
 Diagnostic criteria for gestational diabetes
mellitus
 Complication
 Management
 INTRODUCTION
 Diabetes mellitus is a common metabolic disorder.
 Gestational diabetes is a form of diabetes that
occur for the 1st time when a women is pregnant.
This type of diabetes is caused by a change in
insulin level during pregnancy. This change result in
elevated level of blood sugar also known as blood
glucose .
 Neonateare at risk of respiratory distress ,
hypoglycemia , hypocalecemia, hyperbilirubinemia.
 DEFINITION
 Diabetes mellitus is a chronic metabolic disorder due to
either insulin deficiency( relatively or absolute) or due
to peripheral resistance to the action of insulin, the
ultimate effect is hyperglycemia and it’s generally occur
in second half of pregnancy.
CLASSIFICATION OF GESTATIONAL
DIABETES MELLITUS
1. TYPE 1 DIABETES MELLITUS
( INSULIN DEPENDENT) – A
condition of absolute insulin
deficiency previously called IDDM .It
is characterised by young age onset
( juvenile) and absolute insulinopenia.
2. TYPE 2 DIABETES MELLITUS-
also called NIDDM .it is seen in
increasing age group or obese person.
TYPES OF DIABETES MELLITUS
DIABETES MELLITUS CLASSIFIED IN PREGANCY

Gestational diabetes mellitus : is defined as
carbohydrate intolerance of variable severity with onset or first
recognition during the first pregnancy.
1.TYPE A1 :abnormal OGTT but normal blood glucose level
during fasting and 1-2 hours after meals; diet modifications is
sufficient to control glucose level.
2.TYPE A2: abnormal OGTT compounded by abnormal
glucose level during fasting and / or after meals ; additional
therapy with insulin or other medication is used.

OVERT DIABTETES :- It is seen in women known to
be diabetic before or after or the onset of pregnancy. a
patient with symptoms of diabetes mellitus ( polyuria,
polydypsia, weight loss) and random plasma level of 200
mg/dl or more is considered overt diabetic .
 The condition may be pre existing or detected for the
first time during 1st Pregancy.
According to ADA diagnosis is positive if
1. The fasting plasma glucose exceed 126mg/dl.
2. The 2 hour post glucose (75g) value exceed 200mg/dl.
3. HbA1c is more than 6.5%
 IN OVERT DIABETES WHITE CLASSIFICATION
ON DIABETES DURING PREGNACY.
There are 2 classes of gestational diabetes mellitus which began during
pregnacy…
1.Class A1 : Diabetes existing prior to or detected during pregnancy ,
needed only diet ,no insulin treatment being necessary.
Class A2: diabetes appearing before or during pregnancy insulin treatment
2.
becoming necessary during pregnancy.
Class B : Diabetes pre existing and necessitating insulin treatment before
3.
conception , onset of diabetes after maternal age of 20 years and or
duration of diabetes is shorter than 10 years.
Class C : Duration of 10-19 years and /or onset of diabetes between 10-19
4.
years of maternal age insulin department diabetes .
THESE FOUR GROUPS ARE CHARACTERIZED BY THE ABSENCE OF DIABETIC
ANGIOPATHY
 5.Class D:-Onset insulin dependent diabetes
before the age of 10th years and duration
exceeding 20 years.all pregnant women with
discernible but not proliferative diabetic
retinopathy are classified as Group D.
6.Class E:-Overt diabetes mellitus with calcified
pelvic vessels.
7.Class F:-Severe proliferative diabetic
retinopathy and /or diabetic nephropathy before
or during pregnancy.
8.Class H:-ischemic heart disease.
9.Class T:-prior kidney transplant.
RISK FACTOR.
 Positive family history of diabetes.
 having a previous birth of an overweight baby of 4 kg or
more.
 obesity
 presence of polyhydramnios or recurrent vaginal
Candidiasis in present pregnancy .
 number of previous pregnancy
 Sedentary Lifestyle
 ethinic group (East Asian ,Pacific Island)
 Smoking
 PCOD current use of glucocorticoids
 persistent glycosuria
 CLINICAL FEATURES
 Gestational diabetes may not present any obvious sign and
symptoms as many of the changes can be similar to those that
occur during pregnancy.
However possible sign and symptoms includes
 Fatigue
 Blurred vision
 Extreme thrust
 Nausea
 Frequent bladder , vaginal or skin infections
 Frequent urination
 Sugar in the urine
SCREENING
Screening strategy for detection of
GDM are:-
1. Low risk- absence of any risk factor
as mentioned blood glucose testing
is not routinely required .
2.Average- some risk factor perform
screening test .
3.High risk – Blood Glucose Test
DIPSI ( DIABETES IN
PREGANCY SOCIETIES OF
INDIA)
It recommend 1 step procedure
with 75 g oral glucose without
regard to the time of last meal. A
venous plasma glucose value at 2
hour more than 140mg/dl is
diagnosed GDM.
 ADA recommended two step Procedure for screening and diagnosis of diabetes
in selective high risk population.
1. all pregnant women should undergo screening for glucose intolerance
2. the usual recommendation for screening is between 24 to 28 week of
gestation.
The recent Concept is to screen for glucose intolerance in the first trimester
itself as the fetal beta-cell recognise and respond to maternal glycemia level as
early as 16th week of gestation .
if found negative at this time the screening test is to be performed again around
24 to 28 week and finally around 32 - 34 week .
ADA (2003 )recommends 3 hour 100 gm OGTT and GDM is diagnosed if any two
value meet or exceed FPG more than 95 mg/dl, 1 hour PG more than 180 mg/dl,
2 hr PG more than 155 mg/dl and 3 he PG more than 140 mg/dl.
Now according to recent ADA guidelines 2021 it is recommended that 2 hour
OGTT with 75 gm glucose should used for screening .
DIAGNOSTIC CRITERIA
 For gestational diabetes mellitus
75 g OGTT unit mg/dl.
International Association of diabetes and pregnancy
study groups 75 g oral glucose mg/dl.
Time Value
Fasting Less than or equal to92 mg/dl

1 hour Less than or equal to 180

mg/dl

2 hour Less than or equal to 153

mg/dl
2.Criteria for diagnosis of impaired
Glucose tolerance and diabetes with
75 g oral glucose (WHO).
Time Normal tolerance Impaired Glucose Diabetes
tolerance
Fasting More than 100 Less than 100 and More than and
more than 126 equal to 126
2 hour PP More than 140 Less than 140 and more than and
more than 200 equal to 200
3.Diagnostic criteria for Overt
diabetes in pregnancy
 Fasting blood glucose level more than 126
mg/dl
 HbA1c value is more than 6.5%
 Diabetic retinopathy is definitely present.
 Usual blood glucose more than 200 mg /dl or 2
hour 75 g OGTT value is more than or equal to
200 mg/dl.
COMPLICATION
Diabetic complication during pregnacy
Diabetic ketoacidosis
1.
Deterioration of diabetic retinopathy
2.
Deterioration of diabetic nephropathy
3.
Hypoglycemia when using insulin.
4.
Obstetric complication during pregnacy
Spontaneous abortion
5.
Premature birth
6.
Pregancy induced HTN
7.
Polyhydyamnios
8.
Maternal distress
9.
 Obstetric complication during labour
1. Prolonged labour
2. Shoulder dystocia
3. Perineal injuries
4. PPH
5. Operative interference
 Obstetric complication during puerperium
1. Puerperal sepsis
2. Failing lactation
FETAL COMPLICATION
Antenatal complication.
1.Fetal distress / Fetal death.
2.Congenital malformation cardiac
abnormality.
3.Macrosomia
4.Delayed fatal development
Complication during birth

1.Birth injury due to shoulder dystocia.

MANAGEMENT
 Principlesin then management are:-
1.Careful antenatal supervision and
glycemic control to Maintain glucose
level.
2.To find out the optimum time and
method of delivery .
3.Arrangement for the care of the new
born.
PRECONCEPTION
MANAGEMENT
 Counselling
 Patientglycemic control and vascular status
are assessed .
 Folic
acid supplementation (0.4 mg/day)
should be started .
 HbA1Clevel should be measured to plan
pregnancy.
 Self glucose monitoring.
 Advice about diet and insulin is given.
 ANTENATAL MANAGEMENT
 Antenatal supervision should be at monthly intervals up to 20 weeks and
thereafter at 2 weeks interval .
 Diet- 30 kcal/kg for normal weight women, 24 kcal/kg for overweight women
and 12 kcal/kg for morbidly obese women.
 INVESTIGATION
1. self monitoring of blood glucose
2. HbA1c, kidney function test , peripheral blood
3. Continous glucose monitoring systems
4. Urine ketone test
5. Examination of ocular fundus
6. Sonographic evaluation
7. NST
8. Doppler umbilical artery velocimetry .
NON PHARMACOLOGICAL
MANAGAMENT
 Diet Therapy:-The diet for pregnant women with
diabetes includes at least 175 g /day of carbohydrate ,
28 g / day of fibre and 1.1 g of protein per kg/day
(Reader and Thomas 2008)
 Dietshould be planned to prevent postprandial
Hyperglycemia.
 Saturated fat intake should be 7% of total calories.
 Allpregnant women should take a prenantal vitamin
with 600 mcg of folic acid daily.
 All pregnant women should limit caffeine to 200 mg/day.
PHARMACOLOGICAL MANAGAMENT
 AACE guidelines recommend insulin as the optimal approach.
 Insulin therapy is required for the treatment of T1 DM during pregnancy. A
postprandial ( 2 hour ) plasma glucose level of more than that 140 mg even
on diet control is an indication of insulin therapy.
Oral Hypoglycemia drugs have been
found to be effective and safe.
Commonly used drugs are
sulfonylurea Glibenclamide and
metformin .Both the drugs cross the
placenta and not Tetrogenic effect
has been observed.
 INDUCTION OF LABOUR
 Diabetic women controlled on insulin are considered for induction of
labour after 38 completed weeks
 Women with vascular complications ( preeclampsia and IUGR) often
require indication after 37 weeks .
 METHOD :-prior to the day of induction of labor, the usual bed time dose
of insulin is administered. No break fast and no morning dose of insulin
are given on the day of induction. Capillary blood glucose level is checked
with a bed side glucose meter. normal saline infusion is begun.induction
is done by low ruptures of membranes. Simultaneous oxytocin drip is
started .An intravenous drip of one litre of 5% dextrose is set up with 10
units of soluble insulin. An infusion rate 100-125ml/hr Will maintain a
good glucose control to approximately 100mg/dl ( ACOG 2005) .Insulin
may also be infused from a syringe pump(0.25-2units/ hr).blood glucose
level are estimated hourly with a glucometer and dose is adjusted
accordingly.
Caseraean section
 Indication are:-
1. Fatal Macrosomia .
2. Diabetic with complication or difficult to
control.
3. Fatalcompromise as observed in antepartum
fatal monitoring .
4. Elderly primigravida.
5. Multigravida with bad obstetric history.
6. Obstetric complication .
PROCEDURES
 On day of operation breakfast and insulin dose are
omitted
 Capillary blood glucose level is checked.
 NS infusion is started .The administration of dextrose
drip and insulin dose are to be maintained.
 CONTINUOUS SUBCUTANEOUS INSULIN INFUSION with
insulin pump is preferred as it is more physiological .
Insulin ASPART and LISPRO are standard of care for
CSII .
FETAL MONITORING
 Constantwatch to note the fetal condition is
mandatory preferably with continuous electronic fetal
monitoring.
 Labour should not be allowed for more than an
arbitrary 12 hours and should be augmented by low
ruptures of membranes and oxytocin or delivered by
C-section.
 Cordshould be clamped immediately after delivery to
avoid hypervolemia.
EXAMINATION OF PLACENTA AND CORD
PUERPERIUM

Antibiotics
Insulin
Breastfeeding is encouraged .
500 k/cal daily in diet.
 CARE OF THE BABY
 Asphyxia is anticipated and treated effectively
 To look for any congenital abnormality
 All babies should have blood glucose to be
checked within 2 hours of birth to avoid
problems of Hypoglycemia ( blood glucose less
than 35mg/dl).
 All babies should receive 1 mg vitamin K IM
 Early breastfeeding within half to 1 hour is
advocated.
 NURSING DIAGNOSIS
 Risk of imbalanced nutrition related to inability to INGEST
sufficient quantity of nutrient/inability to utilize nutrients
appropriately/ lack of information about eating
appropriately.
 Riskfor fetal injury related to elevated maternal serum
glucose levels.
 Riskfor maternal injury related to tissue
hypoxia/increased maternal serum glucose level/ altered
immune response.
 Deficientknowledge regarding diabetic condition ,
treatment , prognosis and self care related to lack of
information unfamiliarity with information resources.
 RESEARCH ARTICLE
 OBJECTIVE :– To compare the rate of insulin treatment and perinatal
outcome in women with gestational diabetes mellitus under
Endocrinologist based versus diabetic nurse based metabolic
management.
 RESEARCH DESIGN AND METHOD:–In a retrospective analysis ,
maternal characteristics, rate of insulin treatment ,and perinatal
outcome of patients with GDM delivering between 1 January 1995
and 30 June 1997 (n =244) receiving endocrinologist based care were
compared with those delivering between 1 July 1997 and 31
December 1999( n=283) who received diabetic nurse based care. The
diabetic nurses role was similar to that of an advanced practice nurse
in the US. there was no change in the metabolic goals and
instruments or in obstetric and newnatal management. quantitative
data was compared with the mann-whitney U test and categorical
data with fisher’s exact test.
 RESULT:–Maternal characteristics ( age, BMI, family history of
diabetes ,prior glucose intolerance ,gestational age and blood
glucose at diagnosis of GDM) did not differ between groups treated
during the two periods.Rate of insulin treatment and perinatal
outcome (hypertension ,preterm delivery, cesarean section ,low
APGAR score, macrosomia ,small and large for gestational age
newborns ,obstetric trauma, major malformations, hypoglycemia,
hypocalcemia jaundice, respiratory distress and mortality) were
also similar in both groups.
 CONCLUSION:-Comparison of period of endocrinologist based and
diabetes nurse based metabolic management of women with GDM
showed no difference in the rate of insulin treatment and perinatal
outcome. This supports a more active role of nurse in the
management of women with GDM.
POST EVALUATION
 WHAT IS GESTATIONAL DIABETES MELLITUS?
 ENLIST ANY 5 RISK FACTOR FOR GESTATIONAL
DIABETES MELLITUS?
 EXPAND DIPSI? AND HOW IT IS PERFORMED?
 ENLIST FETAL COMPLICATION OF GESTATIONAL
DIABETES MELLITUS ?
 ADA RECOMMENDED ........... FOR MAINATAINING
BLOOD GLUCOSE ?
 EXPAND CSII ?
BIBLIOGRAPHY
Dutta DC “ textbook of obstetric “
published by Jaypee brothers,
edition 9th,page no. 262- 268 .