Gestational Diabetes

Mellitus

Capt Narendra Sarlam

MH Gwalior
 Gestational Diabetes
Mellitus
Is it physiological?
Is it a disease?
Should we screen for gdm?
Does it require treatment?
Glucose Intolerance in Pregnancy

Prevalence
of GDM 3 to 18 %
GDM - Definition
 Distinguish GDM from Pre-gestational DM
 Abnormal Glucose Tolerance
 Onset (begins) with pregnancy or
 Detected first time during pregnancy
 No h/o of pre pregnancy DM or IGT
 Hb A 1 c is usually < 7.5 in GDM
 In DM + Pregnancy it is > 7.5
Pathophysiology of GDM
 Pregnancy is Diabetogenic condition
Metabolic Stress Test
 Placental Diabetogenic Hormones
 Progesterone, Cortisol, GH
 Human Placental Lactogen (HPL), Prolactin
 Insulin Resistance (IR), ↑  cell stimulation
 Reduced Insulin Sensitivity up to 80%
 Maternal insulin cannot cross Placenta,
 fetus start secreting insulin after 12 wks
Fundamental Defect in GDM

 The hormones of pregnancy cause IR

 They also cause direct hyperglycemia
 But, the basic defect is
 The maternal pancreatic  cells are unable to
compensate for this increased demand
Maternal hyperglycemia

Increased glucose Transfer to

Fetus

Fetal hyperglycemia

Fetal Insulin Hypertrophy of fetal B cells

Secretion
Risk Stratification for GDM

 High Risk Group (Indians mostly)

 BMI  30
 PCOD
 Age > 30 years
 H/o DM, IGT
 Ethnic predisposition; Acanthosis
 Previous h/o GDM,
 h/o still birth/ IUD/ Miscarriages
 Macrosomic baby

Adopted from ADA guidelines

 Low Risk Group
 Age < 25,
 BMI < 23,
 No F h/o DM or IGT
 No bad obstetric history; No ↑ risk ethnicity
Intermediate Risk Group
 Not falling in the above two classes

9
Whom to Screen for GDM ?

 Low Risk Group

 No screening required for GDM
 Intermediate Risk Group
 Screen around 24–28 weeks of gestation
 High Risk Group
 As soon as possible after conception
 Must - before 24–28 weeks of gestation
 Better do a full 3 hr OGTT for GDM
 If negative – screening in 2nd & 3rd trimester

Adopted from ADA guidelines

Indian Scenario
 Since the pregnant mothers without any of the risk factors are so
very few in India
 We need to screen all pregnant women
 And identify early the GDM problem
 We have enough tough maternal problems
 Let us at least treat a treatable problem
One Step Screening
75g OGTT 2hr test
Fasting 92

1 hr 180

2 hr 153

12
GDM – Two Step Screening
 Two Step Screening
 Do a Random Glucose Challenge Test (GCT)
 50 grams of oral glucose any time of day
 1 hour post test for plasma glucose (1 hr PG)
 Result > 140 mg% - Dx of GDM suspected
 Confirmed by 2nd step OGTT
 OGTT – 3 hours after 100 g of oral glucose
Glucose Challenge Test (GCT)
OGTT –100g –3 hour Test
Carpentar n Causten Criteria

15
OGTT 100g 3 hour test
NDDC

Fasting 105

1 hr 190

2 hr 165

3 hr 145

16
Some Questions
When to order for USG ?
 Scan for anomalies at 20-weeks
 Growth scans from 26-28 weeks
Breast feed or not after delivery ?
 Must give breast feeding
 This reduces maternal glucose intolerance
GDM – Fetal Morbidity

 Macrosomia of the baby

 CPD – Shoulder Dystocia
 Intrapartum Trauma – Feto-maternal
 Congenital Anomalies
 Neonatal Hypoglycemia
 Neonatal Hypocalcemia
 Neonatal Hyperbilirubinemia
 Respiratory Distress Syndrome (RDS)
 Polycythemia (secondary) in the new born
Macrosomia
 Birth weight > 4000 g
 ↑ Intrapartum feto-maternal trauma
 Increased need for C- Section
 20 – 30% of infants of GDM – Macrosomic
 Maternal factors for Macrosomia
 Uncontrolled Hyperglycemia
 Particularly postprandial hyperglycemia
 High BMI of mother
 Older maternal age, Multiparity
Macrosomic Newborn (4.2kg)
Shoulder Dystocia
Macrosomia
Neonatal Hypoglycemia
 Due to fetal hyperinsulinemia
 Neonatal plasma glucose < 30 mg%
 Poor glycemic control before delivery
 Increases perinatal morbidity
 Congenital anomalies – 3 to 8 times more
 More if periconception hyperglycemia
 Assoc. maternal fasting hyperglycemia
Minor Adverse Health Effects
Normal GDM DM P

Birth Wt (g) 3303±64 3649±51 3849±72 <0.01

Macrosomia(%) 8 36 47 <0.01
C-S 5 10 14 <0.01
Hypoglycemia 2 28 52 <0.01
Hypocalcemia 0 4 7 <0.01
Hyperbilirubinemia 15 23 21 <0.01
Polycythemia 0 7 11 <0.01
Cord C-Pep 1.18±0.1 2.07±0.12 2.98±0.22 <0.01
Cord Glu 100±3.6 103±2.9 114±5.5 <0.01
Major Adverse Health Effects
Normal DM
CNS 6.4% 18.4%
Congenital heart disease 7.5% 21.0%
Respiratory disease 2.9% 7.9%
Intestinal atresia 0.6% 2.6%
Anal atresia 1.0% 2.6%
Renal & Urinary defect 3.1% 11.8%
Upper limb deficiencies 2.3% 3.9%
Lower limb deficiencies 1.2% 6.6%
Upper + Lower spine 0.1% 6.6%
Neonatal Complications
DM GDM Normal p-value
T. hypoglycemia(%) 52 28 3 <0.01
P. hypoglycemia(%) 6 2 0 <0.01
Hypocalcemia(%) 5 5 0 <0.01
Hyperbilirubinemia(%) 21 23 15 <0.01
Trans tachypnea(%) 5 2 0 <0.01
Polycythemia(%) 11 7 0 <0.01
RDS(%) 5 2 0 <0.01
IUGR(%) 2 1 0 <0.05
 Congenital Anomalies vs DM
Control
Maternal HbA1c levels
< 7.2 Nil
7.2-9.1 14%
9.2-11.1 23%
> 11.2 25%
Critical periods - 3-6 weeks post conception
Need pre-conceptional metabolic care
Late effects on the offspring

 Increased risk of IGT

 Future risk of T2DM
 Risk of Obesity
Maternal Morbidity
 Hypertension; Insulin Resistance
 Preeclampsia and Eclampsia
 Cesarean delivery; Pre term labour
 Polyhydramnios – fluid > 2000 ml
 Post-partum haemorrhage
 Abruptio placenta
 PROM
Risk of T2DM after GDM
 IGT and T2DM after delivery in 40% of GDM
• R.R of T2DM for all with GDM is 6 (C.I. 4.1 – 8.8)
• Must be counseled for healthy life style
• Re-evaluate with 75 g OGTT after 6 wk, 6 months
• More risk - if GDM before 24 wks of gestation
• High levels of hyperglycemia during pregnancy
• If the mother is obese and has +ve family h/o
• GDM in previous pregnancies and age > 35 yrs.
• High risk ethnic group (like Indians)
Women with T2DM
 T2DM patients must plan their pregnancy
 Preconception Hb A1c  7.00; MAU estimate
 OADs should be discontinued; Folic acid +
 Start on Insulin and titrate for euglycemia
 Nutrition and weight gain counseling
 ACEi and ARB must be substituted
 Screening for retinopathy; nephro (eGFR <90)
 Must avoid hypoglycemia
GDM- Management

32
GDM – Glycemic Targets

33
GDM and MNT
 Two weeks trial of Medical Nutrition Therapy
 Pre-pregnancy BMI is a predictor of the efficacy
 If target glycemia is not achieved initiate insulin

BMI Recommended Calorie

intake in kcal per day

<25 3000
Overweight 25-30 2500
Morbid Obese >30 1250-1500
Diet therapy in GDM
 Small, frequent meals
 Avoid eating for two
 Avoid fasts and feasts
 Avoid health drinks
 Eat a bedtime snack
Tips for diet management

 Small breakfast
 Mid morning snack
 High protein lunch
 Mid afternoon snack
 Usual dinner
 Bed time snack
GDM and Exercise

Moderate exercises
Walking is the simplest and easiest
Continue pre pregnancy activity
Do not start new vigorous exercise
GDM and Insulins
 In 10 to 15% of GDM, MNT fails –Start on insulin
 Good glycemic control – No increased risk
 Human Insulins only – Not Analogs
 Daily SMBG up to 7 times!
 Insulin Glargine (Lantus) – Not to be used at all
 Insulin Lispro tested and does not cross placenta
 Insulin Aspart not evaluated for safty
 CSII may be needed in some cases
 Oral drugs not recommended (SU?, Metformin?)
Insulin Regimen
 If MNT fails after 2 - 4 weeks of trial
 Initiate Insulin + Continue MNT
 Dose: 0.7, 0.8 and 0.9 u/kg – 1, 2 & 3 trim.
 Eg. 1st trim – 64 kg = 0.7 x 64 = 45 units
 Give 2/3 before BF = 30 units of 30:70 mix
 Give 1/3 before supper = 15 u of 50:50 mix
 Increase total dose by 2-4 units based on BG
 After BG levels stabilize – monitor till term
GDM and Delivery
 Delivery until 40 weeks is not recommended
 Delivery before 39th week – assess the pulmonary maturity by
phosphatase test on amniocentesis fluid
 C - Section may be needed (25 -30%)
 Be prepared for the neonatal complications
 Assess the mother after delivery for glycemia
 May need to continue insulin for a few days
 Pre-gestational DM–Insulin (30% less) or OAD
Thank you