Diabetes Melitus Gestasional

Classification Pregestational diabetes

Type 1 DM Type 2 DM Secondary DMGestational diabetes

Definition Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Pregestational diabetes precedes the diagnosis of pregnancy.

Whom to screen ? Risk stratification based on certain variables Low risk : no screening

Average risk: at 24-28 weeks

High risk : as soon as possible

To satisfy all these criteria

Age

High risk Marked obesity Prior GDM Strong family history

Intermediate risk At least one of the criteria in the list

How to screen? Oral glucose tolerance test ( OGTT) with 100 gm glucose Overnight fast of at least 8 hours

At least 3 days of unrestricted diet

and unlimited physical activity

> 2 values must be abnormal

Fasting95 mg/dl1-h180 mg/dl2-h155 mg/dl3-h140 mg/dl

Urine glucose monitoring is not useful in gestational diabetes mellitus

Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction

Urine monitoring

Problems of GDM: fetal

Increases the risk of fetal macrosomia Neonatal hypoglycemia Jaundice Polycythemia Hypocalcemia, hypomagnesemia Birth trauma Prematurity

Problems: fetal Cardiac( including great vessel anomalies) : most common

Central nervous system: 7.2%

Skeletal: cleft lip/palate, caudal regression syndrome

Genitourinary tract: ureteric duplication

Gastrointestinal : anorectal atresia

Poor glycemic control at time of conception: risk factor

Caudal regression syndrome

Problems of GDM: maternal Weight gain Maternal hypertensive disorders Miscarriages Third trimester fetal deaths Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus

Pregnancy in diabetic mother: risksProgression of retinopathy: esp. severe proliferative retinopathy

Progression of nephropathy: especially if renal failure +

Coronary artery disease: Post MI patients: high risk of maternal death

Management

Preconception counselling Diabetic mother : glycemic control with insulin/SMBG

Target: HbA1c < 7%

Folic acid supplementation: 5 mg/day

Ensure no transmissible diseases: HBsAg, HIV, rubella

Try and achieve normal body weight: diet/exercise

Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockers

Clinical parameters: checked at each visit

medications pre-pregnancy weight weight gain edema pallor blood pressure Fundal height

Patient education

Cornerstone in GDM management

Maternal complicationFetal complicationMedical Nutrition therapyGlycemic monitoring: SMBG and targetsFetal monitoring: ultrasoundPlanning on deliveryLong term risks

Glycemic targetsFasting venous plasma < 95 mg/dl2 hour postprandial

GDMFailure to maintain glycemic targets

INSULIN THERAPY Medical nutrition therapy

Medical nutrition therapyPromote nutrition necessary for maternal and fetal health

Adequate energy levels for appropriate gestational weight gain,

Achievement and maintenance of normoglycemia

Absence of ketones

Regular aerobic exercises

Medical nutrition therapyApproximately 30 kcal/kg of ideal body weight

> 40-45% should be carbohydrates

6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent ketosis

Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones

Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan.

Fetal monitoring Baseline ultrasound : fetal sizeAt 18-22 weeks: major malformations

fetal echocardiogram 26 weeks onwards: growth and liquor volumeIII trimester: frequent USG for accelerated growth

( abdominal: head circumference)

Management of labor and deliveryMaternal hyperglycemia in labor: fetal hyperinsulinemia,

worsen fetal acidosisMaintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )Feed patient the routine GDM diet Maintain basal glucose requirementsMonitor sugars 1-4 hrly intervals during labourGive insulin only if sugars more than 120 mg/dl

Post partum follow up Check blood sugars before discharge

Breast feeding: helps in weight loss

Lifestyle modification: exercise, weight reduction

OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes

Preconception counseling for next pregnancy

Increased risk of cardiovascular disease,future diabetes and dyslipidemia

Management of neonateHypoglycemia

Long term risk: offspring

Increased risk of obesity and abnormal glucose tolerance

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