GESTATIONAL

DIABETES
MELLITUS
Dr Sajid Ali Gorsi
Resident Medicine
AIMS Mzd AJK
Learning objectives;
1. Define GDM
2. Types of diabetes encountered during pregnancy
3. Pathophysiology
4. How to screen
5. When and whom to screen
6. Complications of GDM
7. Management of GDM
 Definition
• “GDM is defined as any degree of glucose tolerance with onset
or first recognition during pregnancy”

 This is a condition in which women without previously

diagnosed with diabetes, exhibit higher blood glucose levels
during pregnancy and especially during the third trimester.
Pre Gestational Diabetes:

• Pre gestational diabetes is a condition in which a woman with

diabetes (most common type 1 or type 2 diabetes) before the
onset of pregnancy becomes pregnant and is therefore
vulnerable to increased risk for maternal and fetal adverse
outcomes.
GDM:
 It represents the most common metabolic complications during
pregnancy.
 It complicates 10-15 % of pregnancies.
 More than 50% women have GDM in subsequent pregnancy.
 Approximately 50% of women with GDM progressed to DM
within 5 years duration.
 35-65% of women with GDM progressed to type 2 diabetes
mellitus within 10 years duration.
 Type Of Diabetes Encountered in
pregnancy;
 Type 1 Diabetes:
∏ Absolute insulin deficiency due to autoimmune destruction of
the pancreatic Ɓ cell.
∏ Presents typically under age of 20.
∏ Not associated with obesity.
∏ Account for 5% of diabetes outside pregnancy

 Type 2 Diabetes:
∏ Relative insulin deficiency & peripheral insulin resistance.
∏ Presents typically over age of 20 years.
∏ Strongly associated with obesity.
∏ Accounts for 90% of all diabetes outside pregnancy.
 Gestational diabetes mellitus.
• Represents 90% of cases during pregnancy and remaining
10% include both type 1 and type 2
• White classification of GDM
1. GDM A1; good glycemic control with diet and exercise
alone
2. GDM A2; Require medication for good glycemic control
 Pathophysiology:
• GDM is characterized by:
 Peripheral insulin resistance. How it occurs?
 During early pregnancy Insulin sensitivity increases to promote
uptake of glucose into the adipose tissue in preparation for the
energy demand during later half of pregnancy.
 As pregnancy progress insulin resistance occurs due to number of
placental hormones especially placental lactogen, leptin,
progesterone, prolactin, cortisol and adiponectin causing increase
blood glucose level.
 This mild peripheral insulin resistance also promotes endogenous
glucose production and breakdown of fat stores causing further
increase in blood glucose level and FFA.
 Screening;

 Screening:
Screening for diabetes in pregnancy is to detect previously
undiagnosed type 2 diabetes and diabetes developing during
pregnancy
No single screening method has been shown to be perfect in terms
of sensitivity and specificity
 Acc to NICE guideline screening is targeted at high-risk group;
Higher risk groups:
 BMI > 30
 Previous macrosomia of 4.5 or above
 Previous hx of GDM
 Family hx of DM
 Family origin with increased prevalence of diabetes including
South Asia ( Pakistan)
 Polyhydromnias and macrosomia in current pregnancy
 When to screen.
According to NICE guidelines;
If previous hx of GDM; 16-18 weeks and repeat at 28 weeks
If no history; 24-28 weeks.
 GDM is diagnosed by a 75g OGTT using following criteria
 NICE guidelines (2015): fasting blood glucose ≥5.6mmol/L
(100mg/dl)and or 2 hour (post-75g glucose load) of ≥ 7.8mmol/L
(140mg/dl)
 WHO guidelines (2013): diagnosis with fasting glucose of ≥
5.1mmol/L (92 mg/dl) and or 1 hour (post-75g glucose load) of ≥
10mmol/L (180mg/dl) or 2 hour of ≥ 8.5mmol/L (153mg/dl)
Whom to screen?
 Low risk: no screening
 Average risk: at 24-28 weeks
 High risk: as soon as possible
 Screening is ideally initiated between the 24th and 28th weeks of
pregnancy or earlier if any of the risk factors are present
 Complications of GDM:
Maternal Complications:
During Pregnancy:
• pre-eclampsia ; three fold more risk of preeclampsia in GDM
• Increased risk of infection
• PPH
• Shoulder dystocia
• Increased risk of operaive delivery
 Fetal Complications:
1ST TRIMESTER:
Congenital Anomalies:
 Cardiac (ASD, VSD)
 Neural tube defects
 Sacral agenesis
 Cardio renal syndrome
 Polycystic kidney disease
 Renal agenesis
 Duodenal atresia
 Trache-o-esophageal fistula
2ND TRIMESTER:
 Fetal macrosomia
3RD TRIMESTER:
 Stillbirth
 IUD
DURING DELIVERY:
 Birth asphyxia
 Shoulder dystocia
 Erb`s palsy
After Delivery:
 Respiratory distress syndrome
 Hypoglycemia
 Polycythemia
 Hyperbilirubinemia (neonatal jaundice)
Management:
 Pre-conception counselling:
 The aim of pregnancy counselling is to achieve best possible
glycemic control before pregnancy and to educate diabetic
women about complication of pregnancy
 Advice include:
1. Multidisciplinary management:
 Women with diabetes should be managed throughout their
pregnancy by multi discplinary team including
<> Diabetic specialist midwives & nurses
<> Dietician
<> Obstetrician & Physician
 2. Optimise Glycemic control:
 The level of HbA1c in early pregnancy directly related to the risk
of early fetal loss and congenital anomalies.
 HBA1C between 7-8.5 risk is 5%
 HBA1C >10% risk is 22%
 Aim ; HBA1C <6.1 %
 If HBA1C > 10% pregnancy should be avoided.
 Monthly testing of HbA1c should be offered to women planning
pregnancy.
 Most common congenital anomalies include
1. Neural tube defect
2. Cardiac anomalies
3. Macrosomia
3. Discuss hypoglycemia:
 More vigorous control will increase risk of hypoglycemia.
 Women should be informed of increased risk of hypoglycemia
in post natal period. Particularly if they are breast feeding.
4. Review diet & weight loss:
 Women with body mass index of >27kg/m2 be supported to
loose weight
 Nutritional assessment including iron & vit D should be
discussed
5. Discuss complications of pregnancy:
 Pre-eclampsia: risk of pre eclampsia is increased threefold in
women with diabetes and particularly in those with underlying
microvascular disease.
 Blood pressure should be kept at 120-130/70-80.
 Birth trauma
 Fetal macrosomia
 Increased risk of C-section
6. Prescribe Folic acid 5mg:
 To be taken pre-conception & for first 12 weeks of pregnancy
7. Review renal function and Retinal assessment.
 Should be offered pre conception unless this has been performed
within last 6 months
 NICE guidelines recommend digital imaging retinal accessment
using tropicamide mydriasis at booking
 If retinopathy present at booking repeat assessment recommended at
16-20 weeks and 28 weeks gestation
 Retinopathy can progress in pregnancy and during post partum
period.
9. Review of other medications:
 ACE inhibitors, ARB’s, Statins should be discontinued prior to
pregnancy.
10. Cessation of smoking
11. Screeing for down syndrome:
 Nuchal transluancy
 Beta hcg
 Pregnancy assosiated plasma protein
 AFP
 ANTENATAL CARE:
 Monitor blood glucose levels by test fasting, pre-meals, 1 hour
post-meals and bedtime blood glucose levels
 Advise pregnant ladies to maintain their capillary plasma glucose
below target levels without causing problematic hypoglycemia.
 Fasting = 5.3mmol/lit (95mg/dl)
 1 hour after meals = 7.8mmol/lit (140mg/dl)
 2 hour after meals = 6.4mmol/lit (115mg/dl)
 Advise pregnant women with diabetes who are taking insulin to
maintain their levels above = 4mmol/lit (72mg/dl)
 Monitor HbA1c : significant in 1st trimester only when
organogenesis is occuring, and significant only in women with pre
existing diabetes
 For women with GDM who have fasting plasma glucose level
below 7mmol/lit (126mg/dl) offer trial of diet and exercise
changes
 If target blood glucose levels are not met with diet and exercise
changes within 1-2 weeks offer metformin.
 If metformin is contraindicated or unacceptable to woman, offer
insulin
 If target BSL are not met with diet, exercise plus metformin, offer
insulin as well

 For women with gestational diabetes who have a fasting plasma

glucose level of 7.0mmol/lit (126mg/dl) or above at diagnosis,
offer = immediate treatment with insulin, with or without
metformin + diet and exercise
Role of ultrasound
 Preferably done in 1st trimester to confirm gestational age by dates
 Repeated at 18-20 weeks gestation to evaluate the fetus for congenital
anomalies
 Particularly important in pre existing type 1 and type 2 diabetes and
elevated 1st trimester HbA1c (>6.5%)
 Should be done at 30-32 weeks and 36-38 weeks of gestation to
evaluate fetal size, amniotic fluid index, and to help ascertain the
mode of delivery
 Women should be booked for early scan before 10 weeks
 Fetal anomaly scan at 18-22 weeks with assessment of cardiac outflow
tract
 Serial growth scans to assess fetal growth and diagnose macrosomia &
polyhydramnios
Insulin therapy;
1. 4 times daily regime; short acting insulin before meal to
control post prandial hyperglycemia
intermediate acting before bedtime to control fasting
hyperglycemia
2. Biphasic regime; combination of both.
2/3rd of dose before breakfast and 1/3rd Evening
 Intrapartum Care:
 Discuss timing and mode of delivery with pregnant women with
diabetes in esp 3rd trimester
 Advice women with GDM to have an elective birth by induced labor
or if needed by caesarean section, no later than 40 weeks plus 6 days
of pregnancy.
 In general the pregnancy gone well, the aim would be to achieve
vaginal delivery at b/w 38 & 39 weeks.
 However development of macrosomia or maternal complications such
as pre eclampsia together with failed induction increase c-section rate
as high as 50%
 If antenatal corticosteroids are indicated additional insulin therapy is
required to maintain normoglycemia
 Consider elective birth before 40 weeks in GDM with complications
 Strict BSL monitoring during general anesthesia
Neonatal Care:
 Monitor blood glucose levels
 Start feeding to babies within 30 minutes and then at interval
of 2 to 3 hours to prevent hypoglycaemia.
 Post natal care:

 Offer lifestyle advice

 Wound care
 Offer fasting blood glucose test 6 to 13 weeks after birth to exclude
diabetes, or can offer HbA1c
 Early self monitoring of blood glucose or OGTT in future
pregnancies
 Encourage breastfeeding: glycemic control is better in women with
breastfeed as compared to bottle feed.
 Breast feeding increases frequency of hypoglycemia thus women
should advise to have snack before or during breast feeding.
Contraception & Follow up:
 Contraception should be discussed and need for planning of
future pregnancies should be emphasized.
 Follow up for contraceptive use, comorbidities, vascular
disease & obesity.
THANK YOU !