Adverse Pregnancy Outcome Of GDM

Dr . YASMIN AKTAR

MD Phase-B Resident Department of Endocrinology

BSMMU

Gestational diabetes mellitus (GDM)

It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy, whether or not the condition persisted after pregnancy, and not excluding the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy

Incidence

3 to 15% of all pregnancies are complicated by diabetes

0.2% to 0.5% of all pregnancies occur in women with pre-existing diagnosis of type 1 DM

similar number has pre-existing type 2 DM

Pathophygiology

Insulin resistance

Production of placental Somatomamotropin

Increased production of cortisol, estriol, progesterone

Increased insulin destruction by kidney & placenta

Increased lipolysis

Mother uses fat for her caloric needs

& serves glucose for fetal needs Changes of gluconeogenesis

Fetus preferentially utilizes alanine & other amino acids deprivng the mother of major neoglucogenic source

White classification

Based on maternal and obstetric risk factors, graded from A (best) to F (worst) designed to predict pregnancy outcomes

1971 and further updated in 1980 to incorporate ischemic heart disease and renal transplantation

Criteria for GDM(ADA)

Test 75 gm OGTT Measurement

Plasma glucose

Fasting ≥ 5.1mmol/L 1h ≥ 10.0 mmol/L 2h ≥ 8.5 mmol/L

WHO recommended 75gm OGTT criteria for GDM

Time point of OGTT Glucose values (mmol/L)

0 hour ≥ 6.102 hour ≥7.8

(Satisfying both or any of these values)

GDM risk assessment: ascertain at 1st ANC

Low risk

Age < 25 yrs

No known DM in 1st degree relative

Weight normal before pregnancy

Weight normal at birth

No hx. Of abnormal glucose metabolism

No history of poor obstetrics outcome

Average risk :

Perform blood glucose testing at 24-28 wks using:

One-step procedure: Diagnostic OGTT on all subjects

High-risk:

Perform blood glucose testing as soon as feasible :

Maternal age >35 yrs

BMI >30kg/m2

Strong FH. of type II DM

Previous Hx. Of : GDM, impaired glucose metabolism, or glucosuria

If GDM is not Dx. repeated at 24-28 wks or at any time a pt. has a symtoms or signs suggestive of hyperglycemia

Adverse outcome

Newborn baby

Related to fetus Macrosomia (> 4kg, 20–30% of infants

whose mothers have GDM)

FBS > 105 mg/ dl

Maternal hyperglycemia

Fetal hyperglycemia

Fetal hyperinsulinemia

Excessive Fetal growth & adiposity

Macrosomic baby Normal baby

Related to fetus cont……… Shoulder dystocia or birth injury Stillbirth Perinatal mortality Congenital malformation ( women with

fasting hyperglycemia ) Polycythemia (Hyperglycemia is a

stimulus for erythropoietin production)

Related to neonate

Hypoglycemia(maternal hyperglycemia

causing fetal hyperinsulinemia)-<1.7mmol/l Hyperbilirubinemia- ≥20mg/dl Hypocalcemia Intensive neonatal care RDS Neonatal death

Long-term complications

Increased risk of glucose intolerance Diabetes

Obesity

Related to mother

Preeclampsia(≥140mmhg SBP or ≥90 DBP + proteinuria- + or more or UTP-≥300mg/dl)

Hypertension(related to insulin resistance) Premature delivery Ketoacidosis Urinary and genital tract infections

Related to mother

Polyhydramnios

Increased risk of cesarean delivery

Increased risk of developing diabetes after pregnancy

Management of gestational diabetes Initial management is with diet and

exercise women with GDM need to be taught to

SMBG and perform daily tests fasting and 1 - hour after meals

If glycemic targets are not met within 2 weeks antidiabetic therapy is required

Maternal assessment

BP Wt A/E-for hydromnios, fetal growth Urine for glucose,protein & pus cell

Fetal assessment

USG

macrosomia

polyhydromnios Fetal monitoring

Fetal kick count

NST

BPL

Time of delivery

Duration of pregnancy Control of diabetes Presence of complications-

PIH,macrosomia Past obstetrics history Tests o fetal well being

Mode of delivery

Parity Bishop’s score of cervix Adequacy of pelvis Estimated fetal wt or macrosomia Associated maternal & fetal complication

Postnatal management Breastfeeding

Prevent hypoglycemia

Reduce insulin requrement by 25%

Diabetes following GDM screening &

Prevention

Women with GDM are at increased risk of developing diabetes

Risk factors:

• Family origin with high prevalence of diabetes (e.g. South Asian, Afro- Caribbean, Middle Eastern)

• Treatment with insulin in pregnancy;

• Maternal obesity

• Weight gain postpartum &

• Family h/o diabetes

Acknowledgement

THANK YOU