3. Glucose metabolism &
pregnancy
Due to placental production of anti-insulin
hormones, there is a state of insulin
resistance
hPL , cotisol ,prolactin, GH ,estrogen and
progesterone
Compare to non pregnant women
Low FBS with high PPBS
Low renal threshold for glucose & ↑ GFR leads to
glycosuria
Increased production of insulin and high fasting
insulin may lead to functional failure of the
Pancreas
4. Risk factors
1. Obesity
2. Previous history of GDM
3. Family history of diabetes
4. Racial origin
Asian and African-Caribbean
5. Maternal age more than 25
6. Previous macrosomic baby
7. Polycystic ovary syndrome
8. Multiple pregnancy
5. Screening & Diagnoses
75 g OGTT new diagnostics values
NICE/WHO IADPSG RECOMMENDED
mmol/l mg/l mmol/l mg/l mmol/l mg/l
FBS ≥7.0 126 ≥5.1 91.8 ≥5.1 91.8
1Hr ≥10.0 180 ≥10.0 180
2Hr ≥7.8 140.4 ≥8.5 153 ≥8.5 153
75g OGTT
Low risk group at 24 – 28 week
High risk group at booking if normal again 24 – 28 week
One abnormal value enough for diagnosis
6. Maternal complications
Cesarean section/Operative
deliveries/Trauma
Pre-eclampsia
Psychological morbidity.
Recurrence risk of GDM is
30-50%
30-60% lifetime risk in
developing , IGT or type 2
diabetes
7. Fetal complications
The accepted pathological mechanism by which GDM leads to
complications is known as the Pedersen hypothesis
Macrosomia
shoulder dystocia, birth trauma
and related complications
Unexplained IUD
Polyhydramnios and PPROM or PROM
Metabolic complications
Hypoglycemia, hypothermia,
Ca2+, Mg2+, Polycythemia & Jaundice
8. Rationale of treatment
o Its' treatment is also controversial.
o No clear guidelines and universally
accepted treatment plans available.
o However randomized trials show
benefits
o in treating the GDM
o The Australian Carbohydrate Intolerance Study
(ACHOIS) was published in 2005
o National Institute of Child Health and Human
development (NICHD) trial – USA 2009
9. Treatment plan
Multi disciplinary approach
Close monitoring & treatment of
GDM are very important for
mother & baby
Lifestyle modification
Pharmacotherapy
11. Monitoring
FBS 1hr PPBS 2hr PPBS
mmol/l mg/l mmol/l mg/l mmol/l mg/l
NICE UK 3.5-5.9 63-106 7.8 140
ACOG 5.3 95 7.2 130 6.7 120
5th international
GDM workshop
(2007)
5.3 95 7.8 140 6.7 120
You may have to test four times a day:
1. Fasting
2. 1 or 2 hours after breakfast
3. 1 or 2 hours after lunch
4. 1 or 2 hours after dinner
12. Lifestyle modification
Dietary recommendations
Dietary pattern & calorie distributions
Breakfast- 10%
Lunch- 30%
Dinner- 30%
Bed time snack- 30%
Calorie -2000-2200kcal/day
Normal weight:30kcal/kg
Lean 35kcal/kg
Obese:25kcal/kg)
Composition:
Carbohydrate - 40-50% complex, high fiber;
Protein - 20%;
Fat - 30-40%(<10%saturated)
A healthy diet is one that includes a balance of foods from all the food groups, giving the nutrients,
vitamins, and minerals necessary for a healthy pregnancy
13. Lifestyle modification
Exercise
Women with gestational diabetes
often need regular, moderate
physical activity to help control
their blood sugar levels by
allowing insulin to work better.
Walking
Prenatal aerobics classes
Swimming
However, a consultation and
approval by a health care provider
is needed before beginning any
physical activity during
pregnancy.
14. Pharmacotherapy-
Insulin
• When diet and lifestyle modifications fail to control blood glucose within 1 to 2 weeks then
pharmacological treatment should be commenced.
16. Pharmacotherapy -OHA
Metformin-(MIG Trial
Metfor. Vs Insulin in GDM)
& Glibenclamide (both
drugs safe in pregnancy,
both cross the
placenta but no short term
and intermediate fetal
adverse outcomes.)
30-45% of patients in OHA
need supplementary insulin
to control their blood sugar.
17. Antenatal care
Review every 1-2 weeks, more frequently if
complication ensue.
Anomaly scan at 18-20 weeks
Serial ultrasound from 28 weeks to detect
fetal macrosomia.
Monitoring of glucose every 1-2 week
Frequency & timing of antenatal fetal
monitoring is controversial . Complicated
GDM needs early antenatal fetal monitoring
as early as 32 wks.
Can give antenatal steroids for fetal lung
maturation and may need additional insulin
18. Antenatal care
Timing of delivery is controversial and if
uncomplicated can go up to 40wks.
However, decision should be made
according to the available informations.
Mode of delivery will depend on the
clinical as well as ultrasonographic
evidence available.
Diabetes should not be a
contraindication for VBAC
19. Intra natal care
GDM requiring pharmacological
therapy are best managed
intravenous insulin drips and
glucose monitoring hourly .
Others need only blood glucose
monitoring during labour.
Target blood sugar range 4-7mmol
per l(72-126mg per l)
Continuous fetal heart monitoring
is advisable during labour.
20. Postpartum care
Exclude persisting hyperglycaemia before
discharge ( FBS or PPBS)
Breast feeding should be encouraged & neonate
blood sugar to be check 2–4 hours after birth.
Lifestyle advice (including weight control, diet
and exercise).
OGTT at the 6 week.
Every three year thereafter.
Early screening for diabetes in future
pregnancies.
Contraception & preconception care.
