GDM: An Update
- 1. Dr. Rumella Afroze Registrar (Obst. & Gynae) M Abdur Rahim Medical College Hospital Dinajpur 1
- 2. Definition GDM has traditionally defined as any degree of glucose intolerance with onset or first recognition during pregnancy
- 3. Incidence •About 1-14% of all pregnancies are complicated by DM •90% of them are GDM
- 4. Pathogenesis • Insulin Resistance • Increased lipolysis • Changes in gluconeogenesis
- 5. Low risk -Age < 25 years - Members of Ethnic group with low prevalence of GDM - No history of DM in first degree relative - No history of abnormal glucose metabolism - BMI ≤ 25 - No history of adverse obstetric outcome
- 6. High risk -age > 35-40 years - BMI > 30 - History of GDM -Heavy glycosuria -History of unexplained stillbirth -Strong family history of DM
- 7. Screening for Diagnosis of GDM • One step strategy: 75g OGTT at 24-28 weeks of gestation GDM is diagnosed if: FBS ≥92 mg/dl (5.1mmol/L) Post 1 hour ≥180 mg/dl ( 10.0 mmol/L) Post 2 hour ≥153 mg/dl ( 8.5 mmol/L)
- 8. Two Step strategy • Step 1: 50g GLT at 24-28 weeks of gestation plasma glucose level after 1 hour 130mg/dl,135mg/dl or 140 mg/dl then proceed to next step.
- 9. • Step 2: 100g OGTT GDM is at least two of the following plasma glucose level are met Glucose Measured Level of glucose Carpenter & Coustan Criteria NDDG criteria FBS 95 mg/dl ( 5.3 mmol/L) 105 mg/dl ( 5.8 mmol/L) 1 hour 180 mg/dl ( 10.0 mmol/L) 190 mg/dl ( 10.6 mmol/L) 2 Hour 155 mg/dl ( 8.6 mmol/L) 165 mg/dl ( 9.2 mmol/L) 3 Hour 140 mg/dl ( 7.8 mmol/L) 145 mg/dl ( 8.0 mmol/L)
- 10. WHO Recommendation Glucose measured Level Of glucose Fasting Blood glucose > 6.9 mmol/L 2 hours after 75g glucose > 7.7 mmol/L
- 11. Effects Of DM on Pregnancy • Preeclampsia • Preterm labour • Polyhydramnios • UTI • Maternal distress • ketoacidosis
- 12. • Prolonged labour • Shoulder dystocia • Perineal injuries • PPH • Operative interference
- 13. • Puerperal sepsis • Lactation failure
- 14. • Fetal macrosomia, growth restriction, malformations • Hypoglycemia • Hyperbilirubinemia • Hypocalcemia • RDS
- 15. • Medical Nutrition Therapy Total calorie intake varies according to BMI of Women BMI < 25kg/sqm – 3000kcal/day Overweight (BMI 25-30kg/sqm) -2500kcal/day Morbid obesity (BMI >40 kg/sqm) -1200kcal/day
- 16. • Total calorie requirement Carbohydrate <45% Protein 30% Fat 25% Carbohydr ate 45% Protein 30% Fat 25% Nutritional Requirements GDM Carbohydrate Protein Fat
- 17. Excercise According to NICE guideline: Around 30 minutes of mild to moderate exercise daily
- 18. Pharmacotherapy • Oral hypoglycemic agents: Metformin Glyburide
- 19. Insulin • Gold standard Short acting Regular Insulin Rapid acting analogue-Aspart, lyspro Intermediate acting-NPH Insulin Long acting- Detemir
- 20. When to Start Insulin? • Insulin should be started -FBG exceeds 90mg/dl - 2 hour PPG more than 120mg/dl
- 21. Insulin Dosing • Dose varies fromm 0.6-1 U/kg/day • Total daily requirement=2/3 in morning + 1/3 at night • Morning dose=2/3 NPH +1/3 Short acting • Predinner dose= ½ NPH + ½ short acting
- 22. Antenatal Care • If Excellent control by diet alone -Fetal surveillance with nonstress testing or biological profile may be initiated at 40 weeks • If uncontrolled -Fetal surveillance & USG should be advised
- 23. Timing & Mode Of Delivery • Spontaneous delivery up to 40 weeks in uncomplicated case • Elecive delivery at around 38 weeks -Complicated cases -Who require insulin
- 24. • Usual bed time insulin prior to the day of induction • No breakfast and morning insulin • Blood glucose measured by glucometer • Normal saline infusion begun and induction done by LRM • If no contraindication then oxytocin drip started
- 25. • An IV drip of 1 L 5% DA is set up with 10 units of soluble insulin • Blood glucose level monitored hourly • Epidural analgesia is ideal for pain relief • If labor fails starting within 6-8 hours or progress un satisfactorily then CS
- 26. • Continuous monitoring of FHR • Partograph must be charted • Care during second stage • Both traumatic and atonic PPH must be maintained • Baby should be evaluated by a neonatologist
- 27. Precaution during Caesarean Section • Anesthetist must be consulted • Consent & blood availability • Light meal & night dose of insulin are given morning dose is omitted • FBS level should be done
- 28. • Normal saline Infusion should be started • 5% DA 1 L + 10 Units insulin Drip • Performed as first case in morning • Adequate incision size • Post operative glucose monitoring
- 29. Postpartum Management • Insulin requirement reduces • It can be stopped if glucose level become normal • Wound care is important • Prolonged antibiotic therapy
- 30. Prognosis 50% risk of developing DM within 10-15 years
- 31. Follow-Up • All patient with GDM should have 2 hour 75g OGTT approximately 6 weeks postpartum • If normal glucose tolerance reassess every 3 years • If IGT or IFG then re-evaluate annually