Professional Documents
Culture Documents
Mellitus
Prevalence
of GDM 3 to 18 %
GDM - Definition
Distinguish GDM from Pre-gestational DM
Abnormal Glucose Tolerance
Onset (begins) with pregnancy or
Detected first time during pregnancy
No h/o of pre pregnancy DM or IGT
Hb A 1 c is usually < 7.5 in GDM
In DM + Pregnancy it is > 7.5
Pathophysiology of GDM
Pregnancy is Diabetogenic condition
Metabolic Stress Test
Placental Diabetogenic Hormones
Progesterone, Cortisol, GH
Human Placental Lactogen (HPL), Prolactin
Insulin Resistance (IR), ↑ cell stimulation
Reduced Insulin Sensitivity up to 80%
Maternal insulin cannot cross Placenta,
fetus start secreting insulin after 12 wks
Fundamental Defect in GDM
Fetal hyperglycemia
9
Whom to Screen for GDM ?
1 hr 180
2 hr 153
12
GDM – Two Step Screening
Two Step Screening
Do a Random Glucose Challenge Test (GCT)
50 grams of oral glucose any time of day
1 hour post test for plasma glucose (1 hr PG)
Result > 140 mg% - Dx of GDM suspected
Confirmed by 2nd step OGTT
OGTT – 3 hours after 100 g of oral glucose
Glucose Challenge Test (GCT)
OGTT –100g –3 hour Test
Carpentar n Causten Criteria
15
OGTT 100g 3 hour test
NDDC
Fasting 105
1 hr 190
2 hr 165
3 hr 145
16
Some Questions
When to order for USG ?
Scan for anomalies at 20-weeks
Growth scans from 26-28 weeks
Breast feed or not after delivery ?
Must give breast feeding
This reduces maternal glucose intolerance
GDM – Fetal Morbidity
32
GDM – Glycemic Targets
33
GDM and MNT
Two weeks trial of Medical Nutrition Therapy
Pre-pregnancy BMI is a predictor of the efficacy
If target glycemia is not achieved initiate insulin
<25 3000
Overweight 25-30 2500
Morbid Obese >30 1250-1500
Diet therapy in GDM
Small, frequent meals
Avoid eating for two
Avoid fasts and feasts
Avoid health drinks
Eat a bedtime snack
Tips for diet management
Small breakfast
Mid morning snack
High protein lunch
Mid afternoon snack
Usual dinner
Bed time snack
GDM and Exercise
Moderate exercises
Walking is the simplest and easiest
Continue pre pregnancy activity
Do not start new vigorous exercise
GDM and Insulins
In 10 to 15% of GDM, MNT fails –Start on insulin
Good glycemic control – No increased risk
Human Insulins only – Not Analogs
Daily SMBG up to 7 times!
Insulin Glargine (Lantus) – Not to be used at all
Insulin Lispro tested and does not cross placenta
Insulin Aspart not evaluated for safty
CSII may be needed in some cases
Oral drugs not recommended (SU?, Metformin?)
Insulin Regimen
If MNT fails after 2 - 4 weeks of trial
Initiate Insulin + Continue MNT
Dose: 0.7, 0.8 and 0.9 u/kg – 1, 2 & 3 trim.
Eg. 1st trim – 64 kg = 0.7 x 64 = 45 units
Give 2/3 before BF = 30 units of 30:70 mix
Give 1/3 before supper = 15 u of 50:50 mix
Increase total dose by 2-4 units based on BG
After BG levels stabilize – monitor till term
GDM and Delivery
Delivery until 40 weeks is not recommended
Delivery before 39th week – assess the pulmonary maturity by
phosphatase test on amniocentesis fluid
C - Section may be needed (25 -30%)
Be prepared for the neonatal complications
Assess the mother after delivery for glycemia
May need to continue insulin for a few days
Pre-gestational DM–Insulin (30% less) or OAD
Thank you