GDM
GDM
Wang yanming
1
Introduction
insulin deficiency
Diabetes
mellitus peripheral tissue resistance (decreased
sensitivity) to the action of insulin
insulin resistance
Classification
two situations:
Diabetes mellitus complicating
pregnancy Pregestational /overt diabetes
mellitus
Diabetes mellitus is diagnosed before this pregnancy.10%
estrogen, progesterone,
cortisol, HPL, etc
insulin secretion
physiological changes
GDM
Effects of pregnancy on diabetes
The patient with high risk factors and did not do any
examination of DM before present pregnancy ,should
examine at the first antenatal visit.
---FPG 7.0mmol/l 126 mg/dl
---HbA1C 6.5%
---typical symptom + random plasma glucose11.1mmol/l
The diagnosis of GDM
---Screening strategy(1)
The screening method employed is by using 75 g oral
glucose tolerance test between 24 weeks and 28 weeks
of pregnancy.
In our country, every pregnant woman is advised to do
75 g OGTT at about 24-28 weeks of gestation.
If the GDM symptoms are present after 28 weeks, the
OGTT should be done again.
method: 1 FPG
2 75g glucose+200-300ml water, oral in
5minutes
3 1-hour plasma glucose after oral glucose
4 2-hour plasma glucose after oral glucose
The diagnosis criteria
The diagnosis of GDM
---Screening strategy(2)
overt diabetes,class D or F
or R. ()
well controlled DM .()
can
canwe
wepregnant
pregnantor
ornot
not CHALLENGE!!!
Preconception counseling of PGDM Management
Diet :
Diet control is the main method of treatment of GDM
Meal plans: individualized.
Calories: 30 to 35 cal/kg (ideal body weight, IBW) per day.
carbohydrates 50%-60%, protein 20%-25%, fat 25%-30%
Avoid ketoacidosis
exercise:
Glycemic control during pregnancy Management
31
vaginal delivery
32
Cesarean section
On the day of operation, breakfast and the insulin dose are
omitted. A normal saline infusion is started.
Plasm glucose 6.67~10.0mmol/L in c-section.
The administration of dextrose drip and the insulin dose are
to be maintained until the patient is able to take fluids by
mouth (ACOG-2005). Continuous subcutaneous insulin
infusion with insulin pump is preferred as it is more
physiological.
The insulin requirement suddenly falls following delivery and
after the omission of the drip, pre-pregnant dose of insulin is
to be administered or adjusted from the blood glucose level.
Management
Postpartum Management
Puerperium: reducing the dose of insulin,
preventing infection
In clinic: Challenge
Blood glucose review Treatment is difficult
(every 2-4 weeks) to predict
Dietary advice and Demanding for
medication patient
adjustments and for the doctor
KEY POINTS
Gestational Diabetes Mellitus (GDM) is defined as carbohydrate
intolerance of variable severity with onset or first recognition
during the present pregnancy.
Potential risk factors for GDM
Complications of GDM
Pregnancy is a diabetogenic state due to several contra-insulin
factors causing decreased sensitivity of the peripheraltissues to
insulin (insulin resistance).
Metabolic events for a woman with diabetes in pregnancy is
maternal hyperglycemia Fetal hyperglycemia Fetal pancreatic
islet cells hyperplasia and hypertrophy Increased fetal insulin
secretion Excessive fetal growth Fetal macrosomia
Increased birth injury.
Fetal congenital malformations are high in diabetic woman
(pregestational diabetes); commonest is cardiovascular
Complications of diabetes in pregnancy are increased both for the
mother, fetus and the neonates
Screening for GDM is done between 24 and 28 weeks of pregnancy
Treatment of women with diabetes in pregnancy: Dietary therapy.
Insulin is given when glycemic control is not achieved with dietary
therapy. Oral hypoglycemic agents (glibenclamide, metformin) are
also being used to maintain glycemic control.
Close antenatal fetal assessment for women with both GDM and
pregestational diabetes is maintained. It depends on degree of
glycemic control, presence of vascular disease (nephropathy,
retinopathy) or hypertension.
A 32-year-old G0 woman with type 1 diabetes mellitus (T1DM)
presents for a preconception visit. She was diagnosed with T1DM
at age 4 and other than some challenges with glucose control
during her teenage years, she generally has good control per her
report. She uses a subcutaneous insulin pump. She has no history
of retinopathy, renal disease, heart disease, proteinuria,
peripheral neuropathy, or any other medical conditions. Her BP is
128/76 mm Hg.
During your counseling, which of the following do you NOT mention
that she or her fetus is at increased risk for during pregnancy?
a. Preeclampsia
b. Congenital abnormalities
c. Breech presentation
d. Cesarean delivery
e. Fetal macrosomia
A 29-year-old G2P1 woman with obesity, a history of GDM in the
prior pregnancy, and a strong family history for type 2 diabetes
mellitus (T2DM) presents at 7 weeks gestation by LMP. In her
previous pregnancy, she required insulin therapy. She delivered at
39 weeks and her baby boy weighed 4,300 g (or approximately 9
lb).