GDM

CHARLES Z. ARIOLA JR.
,
MSN, LPT.
INTRODUCTION
• Diabetes occurs in 2-5% of all pregnancies and its
prevalence is raising .
• 40 years ago , the majority of women with DM

attending antenatal clinic had type 1 , but today the
majority of women have type2 or gestational DM .
• the prevalence of type 2 DM is predicted to increase

due to current trends in obesity and physical inactivity
.
GESTATIONAL DIABETES MELLITUS
* Development of diabetes for the first time during pregnancy.
* Raised blood glucose level >7.0 mmol/L or >11.1 mmol/L 2 hours
post‐prandial OGTT.
RISK FACTORS :
1. GDM previous pregnancy
2. Obesity (BMI >30)
3. Age > 35
4. Presence of glycosuria in >2 occasions
5. History of DM in first degree relatives
6. Previous big baby > 4.0 kg
7. Previous history of recurrent abortion or
unexplained stillbirth
8. Polyhydramnios
9. Previous congenital anomalies
Criteria for diagnosis of GDM
• Fasting blood
glucose > 105
mg/dl
• 1 hr > 190 mg/dl
• 2hrs > 165 mg/dl
• 3hrs> 145 mg/dl

Classification
The white classification distinguishes
between GDM type and pre-
gestational diabetes
GDM is subdivided into :
Type A Type A2
:- abnormal GTT :- abnormal GTT
- normal blood - abnormal blood
glucose level glucose level
,during fasting & 2 ,during fasting &
hrs after meal diet 2 hrs after meal
- modification is diet
sufficient to - additional therapy
control blood with insulin and
COMPLICATIONS
Maternal Fetal
• Nephropathy • Congenital
• Retinopathy abnormalities: cardiac
• Coronary artery and neural
diseases tube defect
• Hyperglycemia / • Macrosomia
hypoglycemia • RDS
/ketoacidosis • Hypoglycemia
• Pre‐eclampsia • Polycythemia
• Infection • Hyperbilirubinemia
General principles in Mx. Of
diabetic pregnancies
From the time of conception
through to the time of
delivery , is to strive for
maternal
EUGLYCEMIA
• To achieve the level of glycemic

control required to minimize
complications associated with
diabetic pregnancy
Preconceptional period
• When women with DM attend preconception
clinic , pregnancy outcomes are improved .
• folic acid supplements( therapeutic dose)

• assessment for complication ( aspirin or
heparin ) considered for those at risk of PE
or thrombophilia .
• HbA1c value , the measure of overall glycemic

control , are within the normal range the risk of
congenital abnormalities approaches that of non-
diabetic pop.
• to achieve this control , we need

treatment according to type
FIRST TRIMESTER
• Multidisciplinary diabetic team
• DATING U/S : 10 weeks
• Screening for DM complication :
- Retinopathy
- nephropathy
- Neuropathy
- Cardiovascular
• Screening for Non – diabetic Co-morbidities :
TYPE 1 : more susceptible to other
autoimmune disease. TYPE 2 : metabolic
syndrome .
• Assessment and optimization of glycemic
control
FIRST TRIMESTER
COMPLICATIONS
• MISCARAGE : due to
chromosomal anomaly
• Ketoacidosis : hostile environment

to the baby
• increase incidence of infection

candidiasis and UTI
23 years old woman , in 2nd
misse
d period , presented with
vaginal discharge : yellow in
color with
unpleasant odor and of
moderate amount.
Second TRIMESTER
• optimization of glycemic control : especially by
middle of second trimester
• screening for congenital anomalies :

between 18-20 weeks , namely the spine , skull ,
kindeys and heart
• Screening for chromosomal anomalies : DOWN

$
• Assessment of fetal growth :

at the end of 2nd trimester
* Base line measurment of fetal AC at 26weeks can be
compared with later scans to provide evidence for growth
acceleration or
third TRIMESTER
• maternal insulin resistance continues to increase along
with insulin requirement
• glucocorticoid steroid are required for lung
maturation , so insulin requirement may need to be
double
• If beclomethasone injections are required , the insulin
dose is either increased or I.V Insulin sliding scale can
be given in addition to her normal insulin dose
• Assessment of fetal growth :

• AB/HC ratio to identify macrosomia
• asymmetrical growth restriction may seen in type 1
DM associated with renal impairment , vascular
disease or hypertension
Third TRIMESTER
COMPLICATIONS
• Unexpected fetal death :
due to sudden
hyperglycemia
• Malpresentation : due
to polyhydermenia
• Placental insufficiency
In her 6th missed period , a
lady presented with vaginal
leaking !
I DON’T KNOW WHAT
SHOULD I DO
• 39-40 : WHEN GLYCEMIC CONTROL IS
GOOD AND THER IS NO
COMPLICATION such as abnormal
fetal growth
• 36-37 : IN BADLY CONTROLLED GDM

OR AT THE PRECENCE OF
COMPLICATION .
C/S indicated when :

• Baby weight is more than 4500 gm
• hydrocephaly
*The 1 hours postparndial glucose
level is more
effective in monitoring &should be
<7g/dl .&HbA1C<7%
* glycemic control should be carried out by

dietary control &insulin Therapy.
*Oral hypoglycemic agents are not

recommended in pregnancy as they cross
the placenta
Causing:
-Teratogenicity
Hyperinsulinaemia & uncontrollable
* by 3 major meals& 4
snakes
• last one at bed time with
30-35 kcal/kg . for non-
Obese& 25 kcal/kg/day for
obese women .
•40-60%
This is include :
Carbohydra
te
20-30% Protein
20-30% Fat
indicated
if :
1.FBS>6 mmol /l
2.1 hourpostprandial >7.2-
7.8mmol/l 3.Macrosomia in third
trimester. 4.Failed diatery control
after 2 weeks.
As follow :
- 0.5 IU/Kg/d.in 1st trimester
-0.6-0.7 IU/kg /d.in 2nd
trimester 0.8IU/Kg/d in 3rd
trimester
Which is subdivided to into

soluble & lenti insulin or
soluble Only with halving the night
dose to prevent nocturnal
hypoglycemia.
* glycemic control should be

Monitored 5x/day twice weekly in
INTRODUCTION
• Macrosomic infant means large for gestational age
associated with poorly controlled DM of the mother during
pregnancy .
• if DM is poorly controlled hyperglycemia

• Glucose will cross placenta ,while the insulin will not ,
causing :
- Congenital anomalies ( preconception period )
- decrease early growth below 20 weeks of gestation
- Hyperinsulinemia above 20 weeks of gestation (
pancrease development) which is leading to :
a) TNH (0-7 days)

b) RDS $
c) Jaundice : decrease in hepatic metabolism
INTRODUCTION
• HYPERGLYCEMIA & HYPERINSULINEMIA will cause :
- Macrosomia : because insulin is anabolic hormone , that
will cause increase in the organ size except the head .
• Macrosmoia complication :
- Birth trauma and asphyxia
- Transient tachypnea of newborn
- cardiomyopathy
- Fetal hypoxia : and this is chronic leads to polycethemia

with increase in hematocrit value > 65% causing
( jaundice , renal vein thrombosis , stroke )
Complication Of uncontrolled DM
ON
ON NEWBOR
FETUS N
- CONGENIT - Hypoglycemia
AL - Hypocalsemia
anomalies & hypoMg
- IUGR - Hperbilirubiene
- Macrosom mia
ia - Polycythemia
- RDS & TTN
PROGNOSIS
• INFANT OF DIABETIC MOTHYER increase risk of
1. DM later in life
2. childhood obesity
3. Neuro-mental delay especially those with birth asphyxia

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CHARLES Z. ARIOLA JR.

• 40 years ago , the majority of women with DM

• the prevalence of type 2 DM is predicted to increase

• 1 hr > 190 mg/dl

• 2hrs > 165 mg/dl

• 3hrs> 145 mg/dl

• To achieve the level of glycemic

• folic acid supplements( therapeutic dose)

• HbA1c value , the measure of overall glycemic

• to achieve this control , we need

• Ketoacidosis : hostile environment

• increase incidence of infection

• screening for congenital anomalies :

• Screening for chromosomal anomalies : DOWN

• Assessment of fetal growth :

• Assessment of fetal growth :

• 36-37 : IN BADLY CONTROLLED GDM

C/S indicated when :

* glycemic control should be carried out by

*Oral hypoglycemic agents are not

2.1 hourpostprandial >7.2-

7.8mmol/l 3.Macrosomia in third

trimester. 4.Failed diatery control

Which is subdivided to into

* glycemic control should be

• if DM is poorly controlled hyperglycemia

a) TNH (0-7 days)

- Fetal hypoxia : and this is chronic leads to polycethemia

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