Case Presentation On Management of Gestational Diabetes Mellitus
Case Presentation On Management of Gestational Diabetes Mellitus
Case Presentation On Management of Gestational Diabetes Mellitus
• Objective
• Case summary
• Discussion
• Outline management of gestational diabetes mellitus
• Comments
• References
Objective
• Name: SB
• Age: 29
• MRN: 169909
• Address: Harari
HPP-This is a GII PI (Alive 4.3kg by VD) mother whose LNMP was on 06/05/14E.C. that making
current GA 39WKs.
• Currently referred with diagnosis of Full term pregnancy + GDM for priming and induction.
• Otherwise No hx of
• Headache
• Blurring of vision
• Decreased fetal movement
Cont.…
P/E-G/A- well looking
• Vital Signs-BP=100/ 60, PR=80, RR=22, T0=36.20 BMI=23.8kg/m2
CNS –COPPT
• She had ANC follow up at private clinic from where she was referred
as a case of full term pregnancy + GDM for priming and induction.
• She was ripened with misoprostol 25mcg sublingual single dose then
induction was started as per protocol.
Cont.…
• After being on oxytocin for 3hrs the fetus developed minimal
variability and deceleration then intra uterine resuscitation was done
and CTG tracing was repeated.
• After informed written consent was taken the patient was transferred to OR, on table
FHR=152bpm
• LUSTCS done to effect the delivery of alive male weighing 4.2kg with APGAR score of 5, 6
& 7 in the 1st , 5th and 1oth minutes respectively.
• The neonate cried immediately after birth even though hypotonic and was to taken to radiant
warmer, dried and stimulated
• The neonate still was hypotonic and started to develop apnea then PPV with self inflating
mask for 30 seconds and still not responding then sent to NICU for further management with
possible endotracheal intubation.
Order sheet
• Monitor V/s Q 15minutes for the 1st 1hr the Q 3ominutes for the next
4hrs then Q 6rs
• Put on MF(NS, DNS & RL)1000ml each for 8hrs for 24hrs
• Continue oxytocin 3oIU in 1000ml →30drops /min
• Ampicillin 2gm IV Q 6hrs for 3doses
• Tramadol 5omg IV TID
• Diclofenac 75mg IM PRN
• Determine RBS Q 6hrs act accordingly
• Follow vaginal bleeding and uterine contraction closely
• Determine neonatal RBS
• Counsel on EBF, EPI, and options of contraceptives
Vital signs
Cont.…
Cont.…
DISCUSSION
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Problem list
GDM
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Introduction
• Women with diabetes are classified into those diagnosed with diabetes;
• Before pregnancy→ pregestational or overt diabetes
• Those diagnosed during pregnancy→ gestational diabetes
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Cont.…
• The word gestational implies that diabetes is induced by pregnancy.
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Early Screening for Overt Diabetes and detection of
GDM
• Both the ADA and ACOG recommend early pregnancy screening
for undiagnosed type 2 diabetes in women with a previous history of;
• GDM
• Previous delivery infant weighing 4kg or more
• History of impaired glucose metabolism or cardiovascular
disease,
• Overweight or obese
• History of hypertension or PCOS
• A first-degree relative with diabetes
Our patient Early Screening was not done although she had
indication
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Screening for GDM
• The ACOG (2019a) recommends universal screening of pregnant women;
• With a protocol that provides a 50-g oral glucose load and that is
followed in 1hr by a laboratory-based blood glucose test.
In our patient she experienced increasing weight gain then she went to private
clinic for evaluation
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Cont.….
Gestational diabetes
• Diagnosis can be made in women who meet either of the following
criteria :
• At any gestational age , Fasting plasma glucose ≥92 mg/dL , but <126 mg/dL
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Cont.….
At 24 to 28 weeks of gestation:
• 75 gram two hour OGTT with at least one abnormal result:
• Fasting plasma glucose ≥92 mg/dL , but <126 mg/Dl or
• One hour ≥180 mg/dL or
• Two hour ≥153 mg/dl
• 100 gm oral glucose tolerance test with two abnormal results
• ≥Fasting 95mg/dl
• ≥One hour 180mg/dl
• ≥Two hours 155mg/dl
• ≥Three hours 140mg/dl
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Maternal Effects of GDM
• That said, women with elevated fasting glucose levels have elevated
rates of unexplained stillbirths similar to those of women with overt
diabetes.
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Cont.…
• Maternal BMI is an independent and more substantial risk factor for
fetal macrosomia than is glucose intolerance (Ehrenberg, 2004;
Mission, 2013).
• In our patient BMI was normal but she had excessive gestational
weight gain
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Cont.…
• The optimal diet should provide caloric and nutrient needs to sustain
pregnancy without resulting in significant postprandial
hyperglycemia.
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Cont.…
• The ACOG (2019a) suggests that carbohydrate intake be limited to 33
to 40 percent of the total daily calories.
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Cont.…
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Cont.…
Exercise
• The ACOG (2020b) recommends regular physical activity that
incorporates aerobic and strength conditioning exercise during
pregnancy and extends this to women with gestational diabetes.
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Cont.…
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Cont.…
Glucose Monitoring
• Once the patient with GDM is placed on an appropriate diet;
• Surveillance of blood glucose levels is necessary to be certain that
glycemic control has been established.
• The first check is performed fasting, and the remainder are done 1 or 2
hrs after each meal.
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Cont.…
• Glycemic target thresholds recommended by both the ADA and ACOG are:
• Fasting glucose less than 95 mg/Dl
• 1-hour postprandial glucose less than 140 mg/dL,
• 2hr postprandial glucose less than 120 mg/dL
In our patient her Glycemic target thresholds were within normal range
as she stated
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Cont.…
Insulin Treatment
• Historically, insulin has been considered standard therapy in women
with GDM when target glucose levels cannot be consistently
achieved through nutrition and exercise.
• Insulin does not cross the placenta, and tight glycemic control can
usually be achieved.
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Cont.…
• Insulin therapy is typically added if fasting levels persist above 95
mg/dL in women with GDM.
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Cont.…
• The starting insulin dose is typically 0.7 to 1.0 U/kg/d and is given in
divided doses (ACOG2019a).
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Cont.…
• The FDA has not approved glyburide or metformin use for treatment
of gestational diabetes.
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Cont.…
• Oral agents may be used instead of insulin when patients are reluctant
to take injections.
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Obstetrical Management
• Women with GDM that is well controlled are at low risk for an
intrauterine fetal demise.
• For this reason, it is not routinely instituted antepartum fetal heart rate
testing in uncomplicated diet-controlled GDM.
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Cont.…
• It is suggested that women with gestational diabetes to routinely
instruct to perform daily fetal kick counts in the third trimester.
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Cont.…
• The ACOG (2019b) concludes that data are insufficient to determine
whether women with GDM whose fetuses have a sonographically
estimated weight ≥4.5kg should undergo CD to avoid risk of birth
trauma.
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Timing of Delivery
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Cont.…
• If glycemic control is suboptimal, ACOG recommends that delivery
be considered at 37 0/7 weeks up to 38 6/7 weeks’ gestation.
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Intrapartum Management
• Patient is kept NPO after midnight
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Cont.…
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Postpartum Follow-up of women with GDM
• Recommendations for postpartum evaluation are based on the 50- to 75- percent
likelihood that women with GDM will develop overt diabetes within 15 to 25 years
(ADA, 2019).
• The ACOG (2019a) recommends either a fasting glucose assessment or a 75-g, 2hr
OGTT at 4 to 12 wks postpartum for the diagnosis of overt diabetes.
• The ADA (2019) recommends testing every 1 to 3 years in women with a history of
gestational diabetes but normal postpartum glucose screening.
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Effects of Breastfeeding on GDM
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Cont.…
• The intrauterine device, either with copper or levonorgestrel,
may be used safely in patients with diabetes.
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Recurrent Gestational Diabetes
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Prevalence of Gestational Diabetes Mellitus among pregnant women attending
antenatal care clinic of St. Paul’s Hospital Millennium Medical College, Addis
Ababa, Ethiopia
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Comments
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References
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THANK YOU
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