combined clinical rounds pregnancy in diabetes/...

COMBINED CLINICAL ROUNDS

PREGNANCY IN DIABETES/ DIABETES IN PREGNANCY

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIT- 1

CASE-I

A 30 year old Hindu female , housewife , uneducated , from low socioeconomic class, presented to the

antenatal OPD of MGH at term pregnancy.

HISTORY CHIEF COMPLAINTS OF - 1. Amenorrhea of 9 months 2. Loss of foetal movements - 2 day HISTORY OF PRESENT ILLNESS - Patient had gone nearby PHC with above complaints a day before, advised ultrasound and referred to tertiary centre as ultrasound suggested IUFD. • Regular ANC visits at the same PHC. • Investigated in first trimester • Took Iron and Calcium supplements , immunized • One 1st trimester USG, s/o single live foetus of 14 weeks 3 days • Antenatal period uncomplicated • No history of fall or trauma • No history of fever, bleeding or discharge per vaginum, vomiting, burning micturition,

itching, headache, blurring of vision or any other complaints

HISTORY

OBSTETRIC HISTORY -

Gravida2Para1Live0

P1L0 - FTVD- female child –STILLBIRTH ( home delivery ) 2year back Patient took no ANC visits during previous pregnancy

MENSTRUAL HISTORY -

LMP- 27/9/17

EDD- 4/7/18

POG-38+2 weeks

Previous menstrual history- 3-4/28-30 days ,regular normal flow

HISTORY PAST HISTORY -No history of hypertension, asthma, TB, diabetes, thyroid

disorder,chronic illness, heart disease, blood transfusion, drug allergy

SURGICAL HISTORY -Not significant

FAMILY HISTORY - Not significant

PERSONAL HISTORY - Vegetarian

- Normal bowel and bladder habits

- Normal and adequate sleep

- No h/o of drug abuse , alcohol intake, smoking

- No use of contraceptives

EXAMINATION

• Patient was conscious, cooperative and well oriented to time, place and person.

• PULSE- 86/min, regular, good volume, no radio-radial delay or radio-femoral delay

• BP-130/70 mmHg (right arm in sitting position)

• TEMP- 98.80F ( axillary)

• HEIGHT-160 cm

• WEIGHT-65 kg

• BMI- 25.3 kg/m2 (pre pregnancy not known)

GENERAL PHYSICAL EXAMINATION

• BUILD and NOURISHMENT- average

• PALLOR- absent

• ICTERUS- absent

• CYANOSIS- absent

• ORODENTAL HYGIENE- average

• No neck swelling, dilated veins

• No lymphadenopathy

• No clubbing

• Breast- NAD

• No edema

SYSTEMIC EXAMINATION-

CNS- NAD

CVS- S1 , S2 normal

No murmur

RESPIRATORY SYSTEM- B/L air entry equal

No added sound

ABDOMINAL EXAMINATION-

INSPECTION - Abdomen uniformly enlarged - Uterine ovoid longitudinal - Striae gravidarum and Linea niagra present. - No scar marks, dilated veins, any skin lesion or visible pulsations PALPATION - Uterus- term size - Cephalic , left occipito anterior - Head fixed , 2/5th - Relaxed, Non tense Non tender - Clinically liquor adequate - Foetal Heart Sound not localized- neither on stethoscope nor on hand Doppler

GENITAL EXAMINATION-

LOCAL EXAMINATION-

1. External genitalia normal and healthy

2. No bleeding, leaking or discharge

PER VAGINAL EXAMINATION-

Os closed, cervix soft, posterior, Uneffaced Vertex station -3, Pelvis adequate

BISHOP SCORE- 2/13

PROVISIONAL DIAGNOSIS

30 year old, G2P1L0 female, 38+2 weeks POG with Intrauterine Foetal death, with no clinically evident medical or obstetric cause

Patient was advised admission for further management

INVESTIGATIONS

• A positive

• CBC- Hb- 10. 1gm/dL, platelets- 2.3lac/cumm, TLC /DLC – WNL Blood indices WNL

• TSH- 3.04 mIU/ml

• RBS- 186mg%

• URINE ROUTINE- within normal limits except sugar ++

• HIV- Non reactive

• HBsAg- Negative

• VDRL- Non reactive

• ANTI-HCV- Non reactive

INVESTIGATIONS

ULTRASONOGRAPHY for CONFIRMATION of IUD AND ANOMALY ASSESSMENT

Intrauterine dead foetus of 37+1 week Cephalic, AFI 10 cm Placenta –posterior upper segment grade II EFBW-3.8kg, EDD- 10.7.18 No evidence of Loop of Cord around neck No Retroplacental clots No Gross congenital anomaly seen

SPECIAL INVESTIGATIONS

• HbA1c - 8.1%

• Coagulation Profile Within normal Limit

• LFT Within Normal Limit

• RFT Within Normal Limit

• Serum Electrolytes Within normal limit

• Urine for ketones Absent

• Fundoscopy Normal

FINAL DIAGNOSIS

30 year old G2P1L0 female , 38+2 weeks POG with Intrauterine Foetal death and Gestational Diabetes Mellitus

MANAGEMENT

General Management

Counselling done, consent taken, IV line secured, crossmatch sent, sugar charting done

Medical Management Insulin therapy for GDM started under endocrinologist guidance

Obstetric Management

• INDUCTION of LABOR by Dinoprostone gel was decided

• Patient delivered a single dead Female child of 3.9 kg, vaginally, after 8 hours of induction with no gross congenital anomaly

CASE II

A 28 year old Hindu female, educated till high school , of middle socioeconomic class, came for

routine ANC check up at MGH

HISTORY

CHIEF COMPLAINTS

Amenorrhoea- Four and a half months for routine antenatal check up

HISTORY OF PRESENT PREGNANCY

– Had one visit at nearby practitioner, at 8week, where she was advised

Blood group B+ve

Hemoglobin 12.gm/dl Ultrasonography Single live fetus of 8 week 2 days.

– Took folic acid, iron and calcium supplements regularly .

– 1st trimester uncomplicated

– No history of fever, bleeding or discharge per vaginum, hyperemesis, burning micturition, itching, headache, blurring of vision, radiation exposure or any other complaints

HISTORY MARRIED LIFE- 3 years

OBSTETRIC HISTORY-

Gravida3 Abortion2

• A1 and A2 both at 2 ½ months, spontaneous abortions- each followed by D&E

• Last abortion-2 years back

MENSTRUAL HISTORY-

LMP- 7.2.18

EDD- 14.11.18

POG -18+1WEEK

Previous Menstrual History 2-3/28-30 days, regular normal flow

HISTORY

PAST HISTORY - No history of hypertension, asthma, TB, diabetes, thyroid disorder,

chronic illness, heart disease, blood transfusion, drug allergy

SURGICAL HISTORY - Not significant

FAMILY HISTORY - Not significant

PERSONAL HISTORY - Vegetarian

- Normal bowel and bladder habits

- Normal and adequate sleep

- No h/o of drug abuse , alcohol intake, smoking

- No use of contraception

EXAMINATION-

• Patient is conscious , cooperative and well oriented to time, place and person.

• PULSE- 90/min, regular, good volume, no radio-radial delay or radio-femoral delay

• BP-120/70 mmHg (right arm in sitting position)

• TEMP- 98.80 F (axillary)

• HEIGHT- 152 cm

• WEIGHT-73 kg

• BMI- 30 kg/m2 (pre-pregnancy)

GENERAL PHYSICAL EXAMINATION-

• BUILD- obese

• NUTRITION- average

• PALLOR- absent

• ICTERUS- absent

• CYANOSIS-absent

• ORODENTAL HYGIENE- average

• No neck swelling, dilated veins

• No lymphadenopathy

• No clubbing

• Breast- NAD

• No edema

SYSTEMIC EXAMINATION-

CNS- NAD

CVS- S1 , S2 normal

No murmur

RESPIRATORY SYSTEM- B/L air entry equal

No added sound

ABDOMINAL - No Hepatosplenomegaly

All hernial sites free

OBSTETRIC EXAMINATION

PER ABDOMEN INSPECTION - Uterus globular - Striae gravidarum present - No scar marks, dilated veins, any skin lesion or visible pulsations PALPATION - Uterus 20 week External ballottement present LOCAL EXAMINATION- 1. External genitalia normal and healthy 2. No bleeding, leaking or discharge After history taking and examination routine investigations were advised

INVESTIGATIONS

• AB positive

• CBC- Hb- 12.1gm/dL, platelets- 1.8lac/cumm TLC /DLC -WNL Blood indices -WNL

• TSH- 3.12 mIU/ml

• GCT-290 mg%

• URINE ROUTINE- within normal limits except sugar ++

• HIV- Non reactive

• HBsAg- Negative

• VDRL- Non reactive

• ANTI-HCV- Non reactive

INVESTIGATIONS

• ULTRASONOGRAPHY for FETAL WELL BEING AND ANOMALY ASSESSMENT

Single live fetus of 19+1 weeks with absence of cranial vault with direct visualisation of brain tissue - Anencephaly variable lie AFI -18-20cm Placenta- fundo posterior grade 2 Foetal weight 334gm

SPECIAL FINDINGS-

• HbA1c 9.6%

• LFT WNL

• RFT WNL

• Serum Electrolytes WNL

• Urine for ketones Absent

• Fundoscopy Normal

• TORCH IgG and IgM negative

• APLA Negative

• Karyotyping of both partners advised

FINAL DIAGNOSIS

A 28 year old female G3A2 18+1 weeks POG with Pregestational (Overt) Diabetes mellitus with congenitally malformed fetus

Patient was advised admission for further management

MANAGEMENT Decision of termination of pregnancy was taken in view of poor prognosis

of the foetus and incompatibility to life.

General Management

Counselling done & consent taken, IV line secured, cross match sent,

sugar charting done

Medical Management Insulin therapy for GDM started under endocrinologist guidance

Obstetric Management

• TERMINATION of PREGNANCY by MISOPROSTOL was decided

• Patient aborted a single live congenitally malformed male foetus of 400gm after 12 hours of induction Grossly- Absence of cranial vault with typical appearance of face due to absent frontal bones and shallow orbits causing protrusion of the eyeballs. No other gross anomaly seen.

• Patient was advised fetal autopsy but refused

PREGNANCY IN DIABETES/ DIABETES IN PREGNANCY

CASE 1 (GDM)

• 30 year G2P1L0 38+1 week POG

• Referred in view of Term IUD

• RBS 209mg% Urine sugar ++ HbA1C 8.1 %

• Pregnancy terminated

CASE 2 (Pregestational DM)

• 28 year 18+1 week POG

• Routine check up

• GCT 290mg% Urine sugar ++ HbA1C 9.6% USG s/o anencephaly

• Pregnancy terminated

Diabetes and pregnancy

DR. SAMTA BALI RATHORE

PROFESSOR

DEPT. OF OBST AND GYNAE

Globally diabetes has reached pandemic status

415 million people have diabetes1

As of 2015

318 million people have prediabetes*,1

* Prediabetes is the number of people estimated to have impaired glucose tolerance, a precursor to developing type 2 diabetes Source: IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015

Numbers are also rapidly increasing in India

Number of adults (20–79) with diabetes in India

20091 20152 20402

124 million people

69 million people 51 million

people

1. IDF Diabetes Atlas, 4th edn. Brussels, Belgium: International Diabetes Federation, 2009 2. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015

36 million people are undiagnosed

(52%)2

What does diabetes have to do with maternal health and

pregnancy?

Difference between diabetes in pregnancy and GDM

Source: Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. International Journal of Gynecology and Obstetrics: the official organ of the International Federation of Gynecology and Obstetrics. 2015;131:S173.

Gestational diabetes is the most common cause of hyperglycaemia in pregnancy1

1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. 2. Feig DS, Corcoy R, Jensen DM, et al. Diabetes in pregnancy outcomes: A systematic review and proposed codification of definitions.

Diabetes/metabolism research and reviews. 2015;31(7):680–690.

15% of cases Diabetes in pregnancy2

DIP maybe either pre-existing diabetes (type 1 or type 2) antedating pregnancy, or diabetes first detected during pregnancy

85% of cases Gestational diabetes2

Glucose intolerance with first onset during pregnancy

Hyperglycaemia is one of the most common medical conditions associated

with pregnancy1

1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. 2. HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study associations with neonatal anthropometrics.

Diabetes. 2009;58(2):453-459.

20.9 million live births are affected by hyperglycaemia

in pregnancy1

Globally

30% (6.2 million) are in India1

Hyperglycaemia in pregnancy in India

1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. 2. Nielsen, K. K., Damm, P., Kapur, A., Balaji, V., Balaji, M. S., Seshiah, V., & Bygbjerg, I. C. (2016). Risk Factors for Hyperglycaemia in

Pregnancy in Tamil Nadu, India. PloS one, 11(3), e0151311.

6.2 million live births are affected by hyperglycaemia in pregnancy1

5.9 million are due to GDM1

Difference in GDM urban/rural distribution

Urban areas Semi-urban areas Rural areas

17.8% 13.8% 9.9%

Of which,

GDM prevalence 27.6%1

How does GDM impact pregnancy outcomes?

• Pre-eclampsia • Polyhydramnios • Prolonged labour • Obstructed labour • Caesarean Section • Uterine atony • Postpartum haermorrhage • Infection

Gestational diabetes is associated with a number of maternal complications

1.Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. New England Journal of Medicine. 2005;352(24):2477–2486. 2. The HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. 3. Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. International Journal of Gynecology and Obstetrics: the official organ of the International Federation of Gynecology and Obstetrics. 2015;131:S173. 4. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. 5. Ehrenberg HM, Durnwald CP, Catalano P, Mercer BM. The influence of obesity and diabetes on the risk of cesarean delivery. Am J Obstet Gynecol. 2004;191(3):969-974. 7. Rudge MV, Calderon IM, Ramos MD, Peracoli JC, Pim A. Hypertensive disorders in pregnant women with diabetes mellitus. Gynecol Obstet Invest. 1997;44(1):11-15. 8. Yogev Y, Xenakis EM, Langer O. The association between preeclampsia and the severity of gestational diabetes: the impact of glycemic control. American journal of obstetrics and gynecology. 2004;191(5):1655-1660.

MATERNAL COMPLICATIONS

• Congenital anomalies • Intra Uterine Growth Restriction (IUGR) • Increase in still-births • Macrosomia • Increased respiratory problems • Jaundice • Shoulder dystocia • Birth injuries • Neonatal hypoglycaemia • Infant respiratory distress syndrome

Diabetes is associated with a number of consequences for the foetus

1.Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. New England Journal of Medicine. 2005;352(24):2477–2486. 2. The HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. 3. Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. International Journal of Gynecology and Obstetrics: the official organ of the International Federation of Gynecology and Obstetrics. 2015;131:S173. 4. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. 5.

FOETAL COMPLICATIONS

Complications Of Maternal Diabetes Detected By USG In Fetus

By Dr. Vipasha singh Department of radiodiagnosis

USG finding in the present case Live intrauterine pregnancy of 18weeks +1 day with Anencephaly

USG image of the foetus

It is characterized by an absence of cortical tissue (although the brainstem and cerebellum may be variably present) as well as

absence of cranial vault.

Intrauterine Complications

• Diabetic embryopathy

• Polyhydroamnios

• Growth abnormalities—

1. Macrosomia (more common)

2. IUGR ( Fetal Growth Restriction )

DIABETIC EMBRYOPATHY

• Spectrum of fetal anomalies that precipitate when the mother has underlying diabetes .

• Causes increased rates of spontaneous abortions and major malformations .

• Affects neural , cardiac , GIT, and skeletal systems.

Screening for diabetic embryopathy

• First trimester (upto 13weeks 6days)

• Early second trimester( 15 to 16 weeks)

• Second trimester anamoly scan ( 18 to 20 weeks)

• Third trimester (29 weeks onwards)

Lost intracranial translucency Raise suspesion of spina bifida

NORMAL

ANENCEPHALY

spared

1St trimester -

Early 2nd trimester –

Myelomeningocele

Arnold chiari malformation

Ventricular septal defect

CARDIAC ANOMALIES

2nd Trimester anomalies

Central Nervous System Anomalies–

Spina Bifida Herniation of brain tissue

CAUDAL REGRESSION SYNDROME (most specific )

Postnatal image of fetus

SIRENOMYLIA

The lower extremities typically appear fused into single limb

Duodenal atresia

DOUBLE BUBBLE SIGN

GIT ANOMALIES

ANORECTAL MALFORMATION

IMPERFORATE ANUS – causing distended rectosigmoid colon and dilated proximal bowel loops

RENAL ANOMALIES

Presence of more than five digits in hand or foot

Syndactyly

Congenital fusion of two or more digits

Polydactyly

Focal femoral hypoplasia

Skeletal anomalies

Polyhydroamnios

If the deepest vertical pocket Is more than 8cm or AFI is more than 95th percentile for Corresponding gestational age (more than 25cm)

GROWTH ABNORMALITY

• Fetal macrosomia --It is defined when estimated fetal weight is greater than 90th percentile ( gestational age and country specific)

• IUGR- Paradoxical IUGR can occur because of utero-placental insufficiency.

CRITERIA FOR IUGR

CONCLUSION

• Prognosis of anencephaly in our patient- incompatible with life.

Children born to mothers with GDM are up to 8-times more likely to develop type 2 diabetes and obesity in their teens or early adulthood.

Gestational diabetes also increases the risk for type 2 diabetes in both mother and child

Approximately 50% of women with GDM go on to develop type 2 diabetes within five year of pregnancy.

SOURCES: 1. Kim C, Newton KM, Knopp RH. Gestational Diabetes and the Incidence of Type 2 Diabetes: A Systematic Review, Diabetes Care 25, 2002. 2. Clausen TD, Mathiesen ER, Hansen T, et al. High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes the role of intrauterine hyperglycemia. Diabetes care. 2008;31(2): 340-346 3. Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) l of Gynecology and Obstetrics. 2015;131:S137 4. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015.

All of this goes hand in hand with a general rise of the diabetes pandemic

Gestational diabetes risk factors

• Personal history of IGT or GDM in a previous pregnancy • ETHINICITY • Family history of diabetes, especially in first degree

relatives • BMI >30 kg/m2 • Maternal age >25 years of age • Previous delivery of a baby > 4.1 kg

• Previous unexplained perinatal loss • Glycosuria at the first prenatal visit • Medical condition/setting associated with

development of diabetes, such as metabolic syndrome, polycystic ovary syndrome (PCOS), current use of glucocorticoids, hypertension

SOURCES: 1. Solomon, et al. (1997). A prospective study of pregravid determinants of gestational diabetes mellitus. Jama, 278(13), 1078-1083. 2. Kim, C, et al. (2009). Does frank diabetes in first-degree relatives of a pregnant woman affect the likelihood of her developing gestational diabetes mellitus or nongestational diabetes?. American journal of obstetrics and gynecology, 201(6), 576-e1. 2. Hedderson, et al. (2008). Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus. American journal of obstetrics and gynecology, 198(4), 409-e1.

Risk increases when multiple risk factors are present

In a recent study (2015) from Tamil Nadu, globally recognised risk factors were not significant:1

Although risk factors, to some extent, point to additional risk among certain women, testing according to risk factors would imply missing out on 20-30% of hyperglycaemia in pregnancy cases1

Why Universal Screening ?

Source: Nielsen, K. K., Damm, P., Kapur, A., Balaji, V., Balaji, M. S., Seshiah, V., & Bygbjerg, I. C. (2016). Risk Factors for Hyperglycaemia in Pregnancy in Tamil Nadu, India. PloS one, 11(3), e0151311.

Screening and diagnostic testing for diabetes are performed because identifying pregnant women with diabetes followed by appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia, shoulder dystocia,and pre-eclampsia.

Universal testing for GDM is recommended1

Screening and diagnostic testing

Sources: 1. National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus

Are there national guidelines for diagnosis and management of GDM?

Testing for GDM

Considering the high prevalence of GDM in India and the maternal & foetal morbidity associated with untreated GDM all pregnant women should be tested for GDM

Testing for GDM

• Testing for GDM is recommended twice during antenatal care (ANC) • First testing done during first ANC contact • Second testing done during 24-28 weeks of pregnancy if first test is negative

• There should be at least 4 weeks gap between the two tests • If a woman presents beyond 28 weeks of pregnancy only one test is done

• If the test is positive at any point, protocol management should be followed

Source: National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus

SCREENING AND DIAGNOSIS of

GESTATIONAL DIABETES MELLITUS

GESTATIONAL DIABETES (GDM)

• Glucose intolerance of variable degree with onset or first recognition during pregnancy.

• Characterized by hyperinsulinaemia and insulin resistance resulting in abnormal carbohydrate intolerance.

• National guideline for diagnosis and management of Gestational Diabetes (February, 2018) endorse the single step test recommended by WHO for diagnosis of GDM

• This test uses a 75gm anhydrous glucose, through Glucose Challenge Test (GCT) irrespective of the last meal with a threshold value of 2-hour BS >140 mg/ dL.

• Guidelines advocate for universal screening of all pregnant women at first antenatal contact.

• If the first test is negative, second test should be done at 24-28 weeks of gestation.

• In the postpartum period, OGTT should be repeated at 6 weeks after delivery, if blood sugar is raised.

Methodology Of Single Step Testing

• 75 gm anhydrous glucose given orally after dissolving in approximately

300 ml water irrespective of the last meal.

• Intake of the solution to be completed within 5-10 minutes.

• Patient should be NBM for 2 hour and should be resting.

• Blood sugar is measured 2 hours post glucose.

• The threshold blood sugar level of

≥140 mg/dL is the cut off for diagnosis of GDM.

• If vomiting occurs within 30 minutes of oral glucose intake, the test has to be repeated the next day.

Two strategies have been proposed • One step approach • Two step approach

One-step strategy

• Perform a 75-g OGTT- plasma glucose measurement fasting, 1 and 2 h, at 24-28 weeks.

• Performed with morning fasting sample.

• The diagnosis of GDM is made when values are:

• Fasting sample : ≥ 92 mg/dL (5.1 mmol/L)

• 1 hr postprandial : ≥ 180 mg/dL (10.0 mmol/L)

• 2 hr postprandial : ≥ 153 mg/dL (8.5 mmol/L)

Two-step strategy

• Step 1: 50-g GCT (non fasting),

with plasma glucose measurement at 1 h,

at 24–28 weeks of gestation

• If the plasma glucose is ≥ 130 mg/dL, proceed to a 100-g OGTT.

• Step 2: The 100-g OGTT (fasting).

• GDM is diagnosed if at least two of the following four plasma glucose levels are met or exceeded:

Cut off values

Fasting 95 mg/dL

1-hr postprandial 180 mg/dL



100-g OGTT

As the IADPSG (International Association of the Diabetes and Pregnancy Study Groups )criteria “one-step strategy” have been adopted internationally, and may be the preferred approach.

Management of GDM

GDM is managed initially with Medical Nutrition Therapy (MNT) and if not controlled with MNT, insulin therapy is added to the MNT

Management of GDM

Pregnant woman with GDM

Medical Nutrition Therapy

2 hr Post Prandial Plasma Glucose (PPPG)

2 weeks

≥ 120 mg/dl Start Insulin Therapy

< 120 mg/dl Continue MNT

• Monitor FBG & 2 hr PPPG every 3rd day or more frequently till Insulin dose adjusted to maintain normal plasma glucose levels

• Monitor 2 hr PPPG once weekly

Monitor 2 hr PPPG • Up to 28 wks: Once in 2 weeks • After 28 wks: Once a week


• A foetal anatomical survey by USG at 18-20 weeks.

• A foetal growth scan at 28-30 weeks gestation & repeated at 34-36 weeks gestation.

• The frequency of antenatal visits should be increased to every 2 weeks in second trimester and every week in third trimester.

• Monitor for abnormal foetal growth (macrosomia/growth restriction) and polyhydramnios at each ANC visit .

Special Obstetric Care for Women with GDM Antenatal Care


GDM pregnancies are associated with delay in lung maturity of the foetus; so routine delivery prior to 39 weeks is not recommended.

• Vaginal delivery should be preferred and LSCS should be done for obstetric indications only.

• In case of foetal macrosomia (estimated foetal weight > 4 Kg) consideration should be given for a primary caesarean section at 39 weeks to avoid shoulder dystocia.

Labour and Delivery


• All babies are to be checked for hypoglycaemia at or within one hour of delivery by glucometer.

• Early breastfeeding to prevent hypoglycaemia.

• Newborn should be monitored for hypoglycaemia (capillary blood glucose <44 mg/dl). Monitoring should be started at 1 hour of delivery and continued every 4 hours (prior to next feed) till four stable glucose values are obtained.

• Neonate should be also be evaluated for other neonatal complications like respiratory distress, convulsions, hyperbilirubinaemia.

Immediate neonatal care for baby of mother with GDM


• These women are at high risk to develop Type 2 Diabetes mellitus in future.

• Maternal glucose levels usually return to normal after delivery.

• Nevertheless, a FPG & 2 hr PPPG is performed on the 3rd day of delivery at the place of delivery. For this reason, GDM cases are not discharged after 48 hours unlike other normal PNC cases.

• 6 weeks post partum: 75 g GTT at 6 weeks to evaluate glycaemic status of woman.

• Cut offs for normal blood glucose values are:

– Fasting plasma glucose: ≥ 126 mg/dl

– 75 g OGTT 2 hour plasma glucose

– Normal: < 140 mg/dl

– IGT: 140-199mg/dl

– Diabetes: ≥ 200 mg/dl

Post-delivery follow-up of women with GDM


Bringing blood glucose in good control is almost entirely in the hands of the pregnant woman with GDM

It is important that:

• The pregnant woman understands both the short- and the long-term potential consequences of her condition (for her and her unborn child)

• Her family (husband and in-laws) understand what GDM is and why a change in the woman’s/family’s dietary habits may be necessary

• The pregnant woman understands the importance of attending the clinic for observation and follow-up

• The pregnant woman understands that, while GDM is transitional, both her and her child at at increased risk of type 2 diabetes in the future

Patient Education - Key to good outcomes

TAKE HOME MESSAGE

Preventive Measures Against Type – 2 Diabetes Should Start During

Intrauterine Period

THANK YOU

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