MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Introduction
Global increase in prevalence of DM.
Individual importance - Hyperglycemia in
pregnancy has adverse effects on both mother
and fetus.
Public health importance – rising epidemic of
DM in part attributed to the diabetic
pregnancies.
Prevention of type 2 DM should start
intrauterine and continue throughout life.
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4. Epidemiology
 In India, one of the most populous country
globally, rates of GDM are estimated to be 10-14.3%
which is much higher than the west.
 GDM has been found to be more prevalent in
urban areas than in rural areas.
 In Pan India study conducted by FOGSI and
DIPSI shows about one-third of the pregnant
women are diagnosed with GDM during the first
trimester and over quarter of them have a history of
fetal loss in the previous pregnancies.
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5. Hyperglycemia in pregnancy
Diabetes in pregnancy
Diagnosed before the
start of pregnancy OR
Hyperglycemia diagnosed for the
first time in pregnancy. Meets
WHO criterion for diabetes
mellitus in the nonpregnant
state
May occur any time during
pregnancy including the first
trimester
Gestational diabetes
mellitus
Hyperglycemia during
pregnancy that is not
diabetes
Hyperglycemia diagnosed for
the first time during
pregnancy
May occur any time during
pregnancy but most likely
>24 weeks
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6. 615-Jun-18
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7. 7
Pregnancy is a DIABETOGENIC
physiological event
Factors implicated in reduced insulin sensitivity during
pregnancy are :
1. Increased Insulin Resistance
2. Degradation of Insulin
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8. 8
Diabetogenic
Effects Of Pregnancy
• ↑ production of cortisol,oestriol & progesterone.
• Insulin resistance.
• ↑ lipolysis.
• Mother uses fat for her caloric requirements and
saves glucose for fetal needs.
• Fetus uses alanine and other amino acids and
deprives the mother of a major gluconeogenesic
source.
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9.  ↑ Maternal age
 High parity
 Obesity / Excess wt gain in index pregnancy
 Pregnancy state (Lower insulin response to oral glucose)
 Short stature
 PCOS
 F/H of DM
 BOH
 GDM in previous pregnancy, PET
 Multifetal pregnancy
GDM on rise globally
• ↓age of onset of DM
• ↑age at marriage
• ↑age at 1st child
• Obesity
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10. MATERNAL AND FETAL RISKS
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11. Maternal Complications
• Worsening retinopathy – 10% new DR, 20%
mild NPDR and 55% mod-severe NPDR
progresses
• Worsening proteinuria. GFR decline depends
on preconception creatinine and proteinuria
• Hypertension and Cardiovascular disease
• Neuropathy – No worsening (gastroparesis,
nausea, orthostatic dizziness can be
worsened)
• Infection
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12. Fetomaternal
Complications
 Macrosomia: 63 percent
 Cesarean delivery: 56 percent
 Preterm delivery: 42 percent
 Preeclampsia: 18 percent
 Respiratory distress syndrome: 17 percent
 Congenital malformations: 5 percent
 Perinatal mortality: 3 percent
 Spontaneous abortion, third trimester fetal deaths,
Polyhydramnios, Preterm birth,
Adverse neurodevelopmental outcome
 Risk for type 2 DM
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13. Neonatal complications
• Morbidity associated with preterm birth
• Macrosomia ± birth injury (shouldeer dystocia,
brachial plexus injury)
• Polycythemia and hyperviscosity
• Hyperbilirubinemia
• Cardiomyopathy
• Hypoglycemia and other metabolic abnormalities
(hypocalcemia, hypomagnesemia)
• Respiratory problems
• Congenital anomalies
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14. Congenital Anomalies
• 2/3rd CVS or CNS,– 13-20 times common
• Cardiac( including great vessel anomalies) : most
common
• Central nervous system (spina bifida / anencephaly)
: 7.2%
• Skeletal: cleft lip/palate, caudal regression syndrome
• Genitourinary tract: ureteric duplication
• Gastrointestinal : anorectal atresia
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15. Universal Screening For
Gdm
 Maternal & newborn outcome depend on
maternal glycemic control.
 Testing is the only route to diagnosis and
management.
 Testing only women with risk factors will
miss half of women with GDM.
 Higher incidence in Indian women.
 Universal testing is cost effective.
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17. What test? When? Repeat?
One step procedure :
75gm OGTT, at first visit and between 24-28 weeks,
irrespective of fasting status.
Blood glucose, 2hr PP: > 140mg/dl = GDM
Woman is given 75gms glucose in 300ml water to drink in
5 minutes. Plasma glucose measured 2hr after ingestion. If
she vomits within 30 min of ingestion, she is asked to repeat
test next day.
DIPSI (Nonfasting) IADPSG, ADA, IDF, WHO (Fasting and 2hrPP)
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18. 75gm oral glucose tolerance test
WHO criteria
Plasma glucose (2hr
PPPG)
Pregnant women Nonpregnant women
>200mg% Diabetes Diabetes
140-199mg% GDM Impaired Glucose
Tolerance
120-139mg% Gestational Glucose
Intolerance
Normal
<120mg% Normal Normal
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19. Protocols For Investigations
 Testing for GDM is recommended twice during ANC.
 The first testing should be done during first antenatal
contact as early as possible in pregnancy.
 The second testing should be done during 24-28 weeks
of pregnancy if the first test is negative. It is important to
ensure second test as many pregnant women develop blood
sugar intolerance during this period (24-28 weeks).
 Moreover, only one third of GDM positive women are
detected during first trimester. If it could not be done
during this time, then it can be done any time after 24
weeks of pregnancy.
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20. There should be at least 4 weeks gap
between the two tests.
The test is to be conducted for all pregnant
women even if she comes late in pregnancy
for ANC at the time of first contact.
If she presents beyond 28 weeks of
pregnancy, only one test is to be done at the
first point of contact
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If pregnant woman visits late for ANC at-least 1 testing has to be done.

22. Advantages of the DIPSI test
• Single test: Serves as both screening and
diagnostic procedure (universal testing is possible).
Fasting values alone fail to detect many women with
GDM particularly in the Asian setting.
• Convenient and feasible: Most women do not
come fasting for the prenatal visit. When asked to
come back again in the fasting state for the test, the
dropout rate is high, prolonged fasting, high patient
volume, causing discomfort and inconvenience.
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23. Management Issues
 Medical Nutrition therapy
 Pharmacological therapy
 Glycemic monitoring: SMBG and
targets
 Fetal monitoring: ultrasound
 Planning on delivery
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24. Management
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25. What is Medical nutritional therapy ?
• A carbohydrate controlled meal plan that provides
optimal nutrition with appropriate weight gain,
normoglycemia and absence of ketosis.
• Individualized food plan, based on BMI, BMR, PAL,
glucose levels, personal & cultural eating habits, &
expected physiological effects of pregnancy on woman &
fetus.
• Total amount of carbohydrates, distribution of
carbohydrates in meals and snacks, types (cereals,
pulses, starchy vegetable, fruits) of carbohydrates and
glycemic index can all be modified without affecting total
calorie intake.
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26. Medical Nutritional Therapy
• Calorie intake based on Prepregnancy BMI and desirable
weight gain.
– 35-40cal/kg desirable body weight for underweight women
– 30-35cal/kg desirable body weight for normal weight women
– 25-30cal/kg desirable body weight for overweight women.
• Limit carbohydrates to 35-45% of total calories.
• Minimum 175gm/day, divided into 3 meals and 2 - 4
snacks.
• Fiber 28gms/day, lowers lipid levels and glucose
excursions.
• Fats 10% of total calories, proteins 1gm/Kg + 23 gms.
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27. MNT, How To Calculate
Calorie Requirement?
Energy requirement (Calories)
= BMR x PAL + 350Kcal (2nd & 3rd T pregnancy)
Basal Metabolic Rate
18-30yrs = 14 x Wt(Kg) + 471
30-60yrs = 8.3 x Wt(Kg) + 788
Physical Activity Level
Sedentary work = 1.53
Moderate work = 1.8
Heavy work = 2.3
Body mass Index
= Weight in Kg /Height in Meter square
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28. Medical Nutrition Therapy
Carbohydrates
1 serve =15gms
2-3 serves at lunch & dinner
1-2 serves at breakfast
1 serve for snack x 2
Lunch & Dinner plate
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29. What about Physical activity?
 Planned physical activity 30mins/day.
 Physical activity improves metabolic control,
reduce insulin resistance, increases insulin
production by pancreas, reduce cardiovascular
risk, improve weight control and overall well
being.
 Monitor fetal activity and blood glucose
before and after exercise.
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30. Target weight gain in GDM
Prepregnancy BMI Category Total weight gain
<18.5 Underweight 12.5-18 Kg
18.5-24.9 Normal weight 11.5-16 Kg
25-29.9 Overweight 7-11.5 Kg
>30 Obese 5-9 Kg
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31. GDM: Antenatal Care
 Minimum of monthly antenatal checkups
 Review by obstetrician, diabetologist, diabetes
educator, nutritionist, perinatologist, 1-3 weeks as
needed.
 Clinical & sonographic growth assessments every
2-4 weeks from diagnosis to term.
 For fetal surveillance use kick-count,
cardiotocography and biophysical profile.
 Fetal anomaly scan if diagnosed before 20 weeks.
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32. How To Monitor Blood Glucose?
• Self monitoring of blood glucose by glucometer.
– How often – controversial
– Fasting & 2hr PP
– At least 4 times a day. Fasting & 2hr PP, 2-3 times
daily, rotating meals on different days of week.
– In low resource settings at least once daily
documenting relation to meals.
• Continuous glucose monitoring – subcutaneous
enzymatic sensor.
• HbA1c, reflects average glucose of past 3 months
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33. What are our Glycemic targets?
Targets for glucose control during pregnancy:
• Fasting glucose: <95mg/dl
• 1 hour PP: <140mg/dl
• 2 hour PP: <120mg/dl
Educate to recognize & treat hypoglycemia – ingest
15 gms of sugar, eat solid food, lie down for half
hour.
During labor & delivery
• Target blood glucose: 72-126mg/dl
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34. What if blood glucose (2hrPPPG)
>120mg/dl on MNT ?
• MNT for 2 weeks
• Repeat 2hr PPPG (Postmeal)
–If PPPG <120mg/dl, repeat test every 2
weeks in 2nd T and weekly in 3rdT.
–If PPPG > 120mg/dl, start medical
management. Either Insulin or OADs.
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35. When to start Insulin? Which?
• When blood glucose targets cannot be reached by MNT
or OADs, insulin is required.
• Pair rapid acting with intermediate or long acting insulin.
• Injection Human Insulin premix 30/70 advised, 40IU/ml by
insulin syringe or use prefilled insulin pen.
• Store insulin at 4-8 C, door of refrigerator, use open vials
within a month.
• Insulin requirements increase throughout pregnancy,
0.7units/kg/day in 1stT, 0.8units/kg/day between 18-26
weeks, 0.9units/kg/day from 26-36 weeks and 1.0
units/kg/day from 36 weeks to delivery.
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36. Pregnant women with GDM, not
controlled by MNT & OADs.
2 hr PPPG >120mg/dl
Start Human insulin premix 30/70, subcut.
30 mins before breakfast once daily.
BG 120-140mg/dl -4 units
BG 140-180mg/dl – 6 units
BG >200mg/dl – 8 units
FBG & 2hr PPPG every 3rd day
FBG <95mg/dl & PPPG
<120mg/dl
Continue same dose insulin
+ MNT
FBG <95mg/dl & PPPG
>120mg/dl
↑ insulin by 2U bf +MNT
FBG >95mg/dl & PPPG
>120mg/dl
Give insulin in 2 doses, M & E.
↑ insulin by 4U bf + evening
dose
Repeat FBG & 2hr PPPG every 3rd day, till dose of
insulin adjusted, to keep FBG <95mg/dl and 2hr
PPPG < 120mg/dl
Continue same dose of insulin + MNT, repeat FBG
& 2hr PPPG every 2 weeks before 30 weeks and
weekly thereafter.
Insulin type & regimes
should be individualised
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37. Caution
• Nausea /vomiting, not able to take food orally
• FBG >200mg/dl with or without insulin
• FBG >150mg/dl or post breakfast blood glucose
>250mg/dl even after insulin.
• Total insulin dose exceeds 20 units /day
• Hypoglycemic episodes more than once a day.
• Pregnant women refuses to take insulin & BG
>200mg/dl.
• Pregnancy complications- PIH, hydramnios, PTL
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38. Shift to Oral Antidiabetic drugs
Now considered in NICE , ACOG & FOGSI guidelines for GDM
Glyburide
• No difference in glycemic control between glyburide & insulin
treated group. However higher birth weight, 2 fold higher
neonatal hypoglycemia and fetal macrosomia.
Metformin
• Freely crosses placental barrier. No difference in glycemic
control & pregnancy outcome. Reduces PIH, weight gain,
neonatal hypoglycemia & NICU admission.
OAD are thus more convenient, less expensive, do not require
intensive education & have more treatment adherence compared
to insulin. May be used during 2nd & 3rd trimester instead of insulin
if MNT fails.
Among OADs, metformin may be better choice than glyburide.
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39. Timing & Mode of delivery in GDM
38-39 weeks
3800-4000gms or
large for gestation
Yes
>4000gms
<3800gms or
appropriate for
gestation
Continue to 40-41 weeks
No
Poor control
Poor compliance
Previous stillbirth
Vascular dse
Offer
elective
cesarean
section
Induce labor
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40. Labor
• Women with GDM prone to preterm labor.
• ↑ RDS in neonate due to delayed secretion of surfactant
(phosphatidylglycerol).
• Give antenatal steroids to mother if PTL between 24-34 weeks,
with close monitoring of BG and insulin dose adjustment.
• Monitor BG 2 hourly in labor, avoid morning dose of insulin, on
day of induction/labor.
• Start IV infusion of normal saline, add regular insulin to keep BG
90-120mg/dl Blood
glucose(mg/dl)
Insulin U in drip Rate of NS infusion
90-120 0 100ml/hr (16d/min)
120-140 4U 100ml/hr (16d/min)
140-180 6U 100ml/hr (16d/min)
>180 8U 100ml/hr (16d/min)15-Jun-18 40

41. Intrauterine Exposure To
Maternal Hyperglycemia
Erythropoietin↑
Polycythemia
Hyperbilirubinemi
a
Maternal excess
circulating glucose,
lipids, amino acids
Fetal substrates transfer ↑
Fetal hyperinsulinemia ↑
Fetal substrate uptake
Tissue oxygen consumption ↑ Macrosomia Lung surfactant
Synthesis ↓
Hypoxia Altered oxygen
delivery
Stillbirth,
perinatal
asphyxia
Myocardiopathy
Respiratory distress
syndrome
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42. GDM Positive: Post-delivery follow-up
 Prophylaxis against infection.
 Insulin requirements drop rapidly after delivery, perform
FBG and PPPG on 3rd post delivery day.
 Encourage & support breast feeding
 Contraception.
 Check glycemic status by 75gm oral OGTT 6-12 weeks after
delivery. If normal repeat at 6 months, then yearly.
Normal, 2hr PG <140mg/dl
Diabetes, 2hr PG > 200mg/dl
Impaired fasting glucose >120mg/dl
Impaired glucose tolerance, 2hr PG 141-199mg/dl
 Future risk of diabetes mellitus, advise – “intensive life
style” and metformin.
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43. Breast feeding:
should be encouraged (Gange et al, 1992).
. Reduces the insulin requirement by 25%
. Breast- feed babies have a much lower
risk of developing DM (Jovanovic,1998)
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44. Conclusion
• Gestational diabetes is a common problem in India.
• Risk stratification and screening is essential in all
Indian pregnant women.
• Tight glycemic targets are required for optimal
maternal and fetal outcome.
• Patient education is essential to meet these targets
• Long term follow up of the mother and baby is
essential.
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