Gestational diabetes mellitus

1. By: DR. LATA CHANDRA
JUNIOR RESIDENT
ANMMCH GAYA
GESTATIONAL DIABETES
MELLITUS

2. INTRODUCTION
• Any degree of glucose intolerance that either
commences or is first diagnosed in pregnancy.
• Prevalence - 18%
• Increase in prevalence due to life style, dietary
habits, older age at first conception, PCOD,
obesity etc.,

4. WHITE CLASSIFICATION

5. EARLY GDM
 ACOG introduced a new term called early
gestational diabetes mellitus in 2017.
 This classifies the patients who are high risk
for developing gestational diabetes.
 These patients are screened early leading to
early and effective treatment.
 This also reduces maternal and fetal
complications to a great extent.

6. EPIDEMIOLOGY
• GDM happens in about 7 of every 100
pregnancies.
• The recent data on the prevalence of GDM in
India was 16.55% by WHO criteria of 2 hr PG ≥
140 mg/dl .
• Significant disturbances in carbohydrate
metabolism occur in about 1 % pregnancies .
• The incidence of GDM increases by approximately
8 times for pregnant women aged 35 years and
over compared with women aged 25 years or
under.

7. PATHOPHYSIOLOGY
 The maternal metabolic adaptation is to maintain the
mean fasting plasma glucose of 74.5 ± 11 mg/dl and
the post prandial peak of 108.7 ± 16.9mg/dl.
 This fine tuning of glycemic level during pregnancy is
possible due to the compensatory hyperinsulinaemia,
as the normal pregnancy is characterized by:-
 Increased insulin resistance and
 Decreased insulin sensitivity.
 A pregnant woman who is not able to increase her
insulin secretion to overcome the insulin resistance
that occurs even during normal pregnancy develops
gestational diabetes.

8. INCREASED INSULIN RESISTANCE
 Due to hormones secreted by the placenta
that are “diabetogenic”: -
 Growth hormone
 Human placental lactogen
 Progesterone
 Corticotropin releasing hormone
Transient maternal hyperglycemia occurs after meals
because of increased insulin resistance.

9. RELATIVE BASELINE HYPOGLYCAEMIA
 Proliferation of pancreatic beta cells (insulin-
secreting cells) leads to increased insulin
secretion.
 Insulin levels are higher than in pregnant than
nonpregnant women in fasting and postprandial
states.
 Hypoglycemia between meals and at night
because of continuous fetal draw
Blood glucose levels are 10-20% lower.

10.  24-hour insulin requirement before conception is
approximately 0.6 units / kg.
 In the first trimester, the insulin requirement rises to
0.7units / kg of the pregnant weight – more unstable
glycemia with a tendency to low fasting plasma glucose
and high postprandial excursions and the occurrence of
nocturnal hypoglycemia.
 By the second trimester, the insulin requirement is 0.8
units per kilogram. From 24th wk onwards steady
increase in insulin requirement and glycemia stabilizes.
 By third trimester the insulin requirement is 0.9 - 1.0
unit /kg pregnant weight per day.
 Last month – may be a decrease in insulin and
hypoglycemia especially nocturnal.

12. SCREENING OF GDM

22. SCENARIO IN INDIA
 HAPO study says – Asians have higher insulin
resistance.
 Indian women belong to high risk ethinicity
group.
 This validates universal screening in Indian set-up.
 Most woman don’t come fasting for ante natal
check up.
 Drop-out Rate increases when they are asked to
come back for an OGTT .
 So single step procedure is best in India.

25. GDM GUIDLINES FEB 2018 GOI INTRODUCES IN RCH AND NPCDCS
Recommonded by FOGSI and WHO
GDM screening done-same as DIPSI….Screening done ASAP at 1st visit
• IF2hr BI.SUGAR<140mg/dl
REPEAT TESTINNG AT 24-28 WK
IF BL.SUGAR<140-GDM –VE
IF BL.SUGAR>140-GDM+VE
v
n
m
m
e
m
IF BL.SUGAR >140mg/dl
MNT+EXERCISE+LIFE
STYLE MODIFICATION
(FOR 2WK)
IF BL.GLUCOSE<120-GDM-VE
IF BL.GLUCOSE>120-GDM+VE
(START NSULINE/METFORMIN)

26. INSULIN THERAPY A/C TO BLOOD
SUGAR
BLOO GLUCOSE INSULIN
120-160 = 4 UNIT
160-200 = 6 UNIT
>200 = 8 UNIT
On third day again OGTT repeat
1) FBG = <95
PPBG=<120
2) FBG=<95
PPBG>120
ALL
GIVEN
AS
SINGLE
DOSE 30
MIN
BEFORE
BREAKFA
ST
CONTIN
UE
INSULIN
KEEP INSULIN SAME BUT ADD 2 UNIT BEFORE
BREAKFAST

27. • FBG>95
PPBG>120
Only Human insulin premix 30:70 used
40 IU SYRINGE USED;ONLY SC inj. given
KEEP DOSE SAME BUT SPLIT THE DOSE IN
MORNING(+2U) AND EVENING DOSE(+4U)
WE TITRATE IT ON EVERY THIRD DAY
UNTIL WE REACH THE TARGET OF
FBS<95
PPBS<120 ACHIEVED

28. MANAGEMENT

29. MEDICAL NUTRITION THERAPY
 First line therapy for GDM patients.
 Individualized diet plan (according to BMI) by an
experienced dietician.
 Caloric allotment – CHO 33-40%, protein 20% & fat
40% .
 3 meals & 2-3 snacks/ day – distribute carbohydrate
intake and reduces blood glucose fluctuations.
 Avoid canned foods, carbonated drinks. Take high fibre
diet.
 Avoid starvation.

30. MATERNAL COMPLICATION OF GDM
 PREECLAMPSIA
PRE-TERM LABOUR
POLYHYDRAMNIOS
RPL
RETINOPATHY
NEPHROPATHY
NEUROPATHY

32. FETAL COMPLICATIONS OF GDM:-
GROWTH ABNORMALITIES
FETAL OXYGENATIONS PROBLEMS
CHEMICAL IMBALANCES
LONG TERM SEQUELAE

38. Role of Exercise
• 30 min of moderate intensity aerobic exercise
for atleast 5 days/ week.
• 10 to 15 min of Brisk walking after each meal
is commonly recommended.
• Easier to control weight gain.
• Important to maintain balance and avoid falls
in glucose levels.

39. INSULIN THERAPY
• Gold standard in GDM treatment.
• Diabetologist opinion to be taken.
• Rapid acting , short and intermediate acting
insulins can be used.
• Long acting – mitogenic effect – high affinity
to IGF RECEPTOR – macrosomia.
• Dose of insulin – 0.6 – 1 U/kg/day.
Total insulin required= 2/3rd in morning + 1/3rd in night.
• Morning dose = 2/3rd NPH + 1/3rd short acting
• Pre dinner = ½ NPH + ½ short acting

41. ROLE OF ORAL HYPOGLYCAEMIC
DRUG IN GDM
1. METFORMIN
 Metformin is a reasonable second line drug in
GDM treatment .
 It reduces the insulin requirement & total wt
gain.
 Absence of long term neonatal follow up after in
utero exposure to metformin – ADA still
recommends insulin as first line therapy.
 It should be started at 500mg HS, dose is slowly
increased as needed to a maximum of 2.5g –
3g/day in divided doses.

42. 2. GLYBURIDE:
Several studies also indicate that :-
 use of glyburide doesn’t yield glycemic control
equavalent to insulin.
 it has worse fetal outcomes
 so it is not recommended for GDM patients .

45. TIMING AND MODE OF DELIVERY
GDM well controlled with Diet only:-
 Not before 39 wks, unless obstetrically indicated
 ACOG recommends expectant management upto 40
6/7 wks .
 GDM well controlled with medications:-
 From 39 0/7 to 39 6/7 weeks

47. MODE OF DELIVERY IN GDM

48. PRECAUTION TAKEN DURING LABOUR
• Consent to be taken regarding the need for.
• Instrumentation and emergency section if
needed.
• Monitor vitals , fluid intake & output, urine
ketones and blood sugar levels 1-2 hrly.
• Fetal heart should be monitored and partograph
is charted.
• Instrumental delivery, if needed, should be under
taken with care.
• Traumatic & atonic PPH should be watched for.

49. INTRAPARTUM MONITORING
• High risk Consent taken.
• Aim is to keep glucose level b/w 72 and 126 mg/dL
• Two I.V lines to be secured.
• If glucose level is not maintained then dextrose-insulin
neutralizing drip is started.
• 50 units of regular insulin in 50ml of normal saline in
one line.
• 10% dextrose drip @ 125mL/hr is given through other
line.
• Attempts for instrumentation should be undertaken
with care.
• Prepare for both traumatic & atonic PPH.

50. DOSE OF INSULINE A/C TO
BL.GLUCOSE
• BL.GLUCOSE
• <90mg/ml
• 90-120mg/ml
• 120-180mg/ml
• 180-240mg/ml
• >240mg/ml
• INSULINE
• 0.5U/hr
• 1U/hr
• 2U/hr
• 3U/hr
• 4U/hr

51. INTRAPARTUM MONITORING A/C TO
MOHFW
BLOOD SUGAR LEVEL AMOUNT OF INSULIN IN
500 ML NS
RATE OF NS INFUSION
90-120mg/dl 0 100 ml/hr(16 drops/min)
120-140 mg/dl 4u 100ml/hr(16 drops/min)
140-180 mg/dl 6u 100ml/hr(16drops/min)
>180 mg/dl 8u 100ml/hr(16drops/min)

53. PRECAUTION DURING LSCS IN GDM:
• Night dose of insulin should be given
• Usually take up as the first case in the morning
• Morning insulin dose is omitted.
• Sliding scale of insulin can be started and
continued in post-op period.
• Adequate incision size to allow delivery of big
baby.
• Early mobilization.
• Severely obese patients – thromboprophylaxis.