Gestational Diabetes Mellitus

GESTATIONAL DIABETES
MELLITUS
Marcella Jane
406148022
Classification
Diabetic in pregnancy was classified in 2 differential:
1. diabetic pragestational
2. diabetic gestational
Definition
Diabetic pragestasional: a condition in which the woman
has been diagnosed with diabetes before pregnancy
occurs
Diabetic gestasional: A condition where women without
previously diagnosed with diabetes and the normal
condition will return after pregnancy ends
Pathophysiology
Increasing diabetogenic hormones ( GH,

Pregnancy
Placental lactogen, progesterone)
Increasing insuline resistance
Guarantee nutrition and fuel supply to the fetus

all the time
Pancreas cant over come this Pancreas can over come this
condition condition
Diabetic
Normal
gestational
Pathophysiology
GDM characterised by hyperinsulinaemia and insulin
resistance resulting in abnormal carbohydrate
intolerance.
In first trimester and early second trimester, increased
insulin sensitivity occurs due to relatively higher levels of
estrogen
in late second and early third trimesters, increased
insulin resistance and rreduced sensitivity due to a
number of antagonistic hormones especially, placental
lactogen, leptin, progesterone, prolactin, cortisol and
adiponection
Gestational Diabetes
Risk Factors
maternal age >25
Family history
glucosuria
prior macrosomia
previous unexplained stillbirth
ethnic group: Hispanic, Black, Asians
EFFECTS OF DIABETES ON
PREGNANCY
Chronic maternal
Hyperglycaemia in 1st hyperglycemia Glycosylated
trimester Hb carries less
oxygen
Fetal hyperglycaemia molecule and
Impaired
O2 binds more
organogenesis
Fetal avidly and
hyperinsulinaemia releases O2
Congenital less
abnormalities Increased fetal oxygen
demand
Decreased Oxygen Increased

tension (hypoxaemia) erythropoiesis
Increase in anaerobic Polcythaemia and

metabolism hyperviscosity
increased lactate and

acidaemia RBC breakdown and
neonatal
hyperbilirubinaemia
Abortion/ IUD
Maternal
hyperglycaemia
Decreased cortisol Fetal Fetal

production hyperglycaemia hyperinsulinaemia
Fetal osmotic fetal hypoglycaemia

decreased
surfactant synthesis diuresis
in lung Increased IGF
Polyhydramnios
Respiratory distress Fetal macrosomia
syndrome
Polyhydramnios
Obstructed labour
Shoulder Dystocia
Erb's palsy/ Birth

Asphyxia
Maternal Complications of GDM
During Pregnancy During labour
Abortion Prolonged labour

Preterm labour (due to infection or Shoulder dystocia
polyhydramnios) Perineal injuries
Pre-eclampsia PPH
Polyhydramnios Operative interference
Maternal distress due to oversized fetus and Increased risk of Caesarean
polydramnios delivery
Microangiopathy
Nephropathy, retinopathy, neuropathy Puerperium
Large vessel disease
Coronary artery disease Puerperal sepsis
Thromboembolic disease Lactational failure
Infection
Hypo and hyperglycaemia
Fetal Complications
1st trimester 2nd Trimester

Congenital Macrosomia
abnormalities
Cardiac : ASD, VSD Delivery
NTD
Sacral agenesis/ CRS
Birth asphyxia
PCKD Shoulder dystocia
Renal agenesis
Duodenal atresia After delivery
Tracheoesophageal RDS
fistula
Hypoglycaemia
Polycythaemia
neonatal jaundice
DIAGNOSIS
Symptoms Signs
Asymtomatic Elevated serum glucose:

Insidious onset severely elevated blood glucose
Polyuria, polyuria, polyphagia level on random glucose testing
excludes the need for screening
Vague symptoms of fatige
and abdominal discomfort and GLycosuria is od uncertain
weight loss significance during pregnancy
Women with established Ketonuria

diabetes may have symptoms
such as retinopathy or Elevated glycosylated
neuropathy haemoglobin
Ultrasound features such as

greater than normal abdominal
circumference
Diagnose and screening of diabetic
gestational
Gestational Diabetes
Management :
Diet
Exercise
Insulin therapy
MEDICATIONS AND
OTHER THERAPIES
Human insulin is treatment of choice when blood
glucose is not adequately controlled by diet
Insulin therapy is indicated when diet does not

maintain blood glucose levels at 5.8mmol/L for fasting
blood glucose, 8.6mmol/L for 1 hr or 7.2mmol/L for
2hour postprandial blood glucose (Obs today)
Insulin therapy also recommended if blood glucose

levels are not controlled adequately by diet alone after
two week trial
Give actrapid 4-6U
TDS
Regular insulin is the preferred short
acting insulin for pregnant patients. Monitor for 2 weeks
NPH insulin is the preferred
intermediate acting insulin for pregnant If still elevated
patients increase until 12 U
tds
Therapy is based preferably by self
monitoring of blood glucose levels If still cannot control
A patient newly started on insulin will add intermittent
acting insulin
begin at doses of 50-75% of the (monotard)
calculated dose
Insulin dose should be individualised If total of >30U per
and adjusted according to the patient's day, it indicate
blood glucose levels moderate-severe
poor control of DM.
Adverse effects
Hypoglycaemia
Lipoatrophy or lipohypertrophy
Flushing
Rash
Urticaria
Acute edema
Hepatomegaly in high doses
Sulfonylureas Meglitinides
Biguanides
Insulin secretagogues Decrease insulin
GLipizide, glyburide resistance
Increase insulin
secretion, decrease
hepatic glucose
production with
resultant reversal or
hyperglycaemia and
indirect improvement of
insulin sensitivity
Alpha glucosidase
inhibitors eg acarbose)
Thiazolidinediones decrease intestinal
Eg rosiglitazone and absorption of starch
pioglitazone and glucose
Oral Antidiabetic agents
Has not been recommende in the part because of
concerns of potential teratogenicity and transport of
glucose across the placenta
Glyburide: does not cross the placenta in significant
amounts and recent trials have said it is safe to use
American College of Obstetricians and Gynecologists
and ADA recommend not to prescribe it until further
studies support its safetly and efficacy
Include: Sulfonyl ureas (insulin secretagogues)

Time and mode of delivery
All pregnant women advised during the antenatal care about
the potential risks of pregnancy progressing beyond term
Gestational diabetes
GDM on diet with no complications can be delivered at 40 weeks
GDM on insulin should be delivered by induction of labour at 38-39
weeks
Pre-existing diabetes
Diabetes itself not an indication for Caesarean Section
Pregnant women with diabetes who have a normally grown fetus should
be offered elective birth through induction of labour, or by elective
caesarean if indicated, after 38 completed weeks
Pregnant women with ultrasound features of macrosomic fetus (fetal
weight more than 4.5kg) and poorly controlled blood sugar are
delivered by elective caesarean section.
Diabetes and C-section
Preoperative considerations
Patient should take their evening dose of NPH insulin the

night before the procedure
Do not take the morning dose of insulin
If necessary, intravenous insulin infusion can be aded to
maintain normoglycaemia
Postpartum Management
Blood glucose levels usually decline rapidly after delivery

Blood glucose levels should be reassessed at 6 weeks after
delivery, if not before, an then at 3 year intervals if levels are normal.
If impaired fasting glucose or impaired glucose tolerance are
observed postpartum, the patient should be tested annually for
diabetes.
All women with gestational diabetes should be counselled regarding
diet, weight loss (if needed), and exercise in order to decrease the
longterm risk of type 2
patient with pre-existing diabetes should be transitioned to
appropriate treatment postpartum (eg oral agent or adjusted insulin
dosage)
Contraception
After 6 weeks or more following delivery, can diagnose
Diabetes Mellitus if symptoms of diabetes mellitus are
present
Random blood glucose 11.1mmol/L
Fasting blood glucose 7.0mmol/L
2hour post prandial 75g glucose 11.1mmol/L

tolerance test
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GESTATIONAL DIABETES

Increasing diabetogenic hormones ( GH,

Increasing insuline resistance

Guarantee nutrition and fuel supply to the fetus

Decreased Oxygen Increased

Increase in anaerobic Polcythaemia and

increased lactate and

Decreased cortisol Fetal Fetal

Fetal osmotic fetal hypoglycaemia

Erb's palsy/ Birth

Abortion Prolonged labour

1st trimester 2nd Trimester

Asymtomatic Elevated serum glucose:

Women with established Ketonuria

Ultrasound features such as

Insulin therapy is indicated when diet does not

Insulin therapy also recommended if blood glucose

Include: Sulfonyl ureas (insulin secretagogues)

Patient should take their evening dose of NPH insulin the

Blood glucose levels usually decline rapidly after delivery

Random blood glucose 11.1mmol/L

Fasting blood glucose 7.0mmol/L

2hour post prandial 75g glucose 11.1mmol/L

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