Gestational Diabetes Mellitus

Dr. R V S N Sarma., M.D., M.Sc., (Canada)

Consultant Physician & Chest Specialist
Visit us at: www.drsarma.in

GDM
Gestational Diabetes Mellitus
Is it physiological?
Is it a disease?
Should we screen for gdm?
Does it require treatment?
Recent RCTs settled the issues GDM
Crowther et al. NEJM 2005;352
 GDM
Glucose Intolerance in Pregnancy

Prevalence
of GDM 3 to 18 %

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GDM - Definition
GDM
• 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
• GDM is a forerunner of T2DM
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Pathogenesis of GDM
GDM
• Pregnancy is Diabetogenic condition
• A Wonderful 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%
• Impaired 1st phase insulin, Hyperinsulinemia
• Islet cell auto antibodies (2 to 25% cases)
• Glucokinase mutation in 5% of cases
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Fundamental Defect in GDM
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

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 GDM
Normal Glucose Tolerance

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Abnormal GT in GDM
GDM

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Risk Stratification for GDM

• High Risk Group (Indians mostly)

GDM
– BMI  30; PCOD; Age > 35 years
– F h/o DM; Ethnic predisposition; Acanthosis
– Previous h/o GDM, IGT, Macrosomic baby
• 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
www.drsarma.in Adopted from ADA guidelines 9
Whom to Screen for GDM ?
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
www.drsarma.in Adopted from ADA guidelines 10
Indian Scenario
GDM
• Since the pregnant mothers without any of
the risk factors are so very few in India
• Since we boast of being in the DM capitol
• 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

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GDM – Two Step Screening
• Two Step Screening
GDM
– 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 > 180 mg% - Dx of GDM confirmed
– Result > 140 mg% - Dx of GDM suspected
– 140 to 180 – We need OGTT (100 g) to confirm
• One Step Screening
– OGTT – 3 hours after 100 g of oral glucose
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 GDM
Glucose Challenge Test (GCT)

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Please be specific
GDM
• Do not use the ‘loose’ word ‘Blood Sugar’
• Be specific to measure ‘Plasma Glucose’
• Always venous sample for OGTT
• No capillary blood testing for OGTT
• NaF to be added as anticoagulant to blood
• Centrifuge to separate plasma immediately
• Plasma glucose to be estimated a.s.a.p
• Glucometer can be used for monitoring
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 GDM
OGTT –100g –3 hour Test

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Some Questions
GDM
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
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GDM – Fetal Morbidity
• Macrosomia of the baby
GDM
• CPD – Shoulder Dystocia
• Intrapartum Trauma – Feto-maternal
• Congenital Anomalies, HCM
• Neonatal Hypoglycemia
• Neonatal Hypocalcemia
• Neonatal Hyperbilirubinemia
• Respiratory Distress Syndrome (RDS)
• Polycythemia (secondary) in the new born
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Macrosomia
GDM
• Birth weight > 4000 g - 90th percentile GA
• ↑ 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
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 GDM
Macrosomic Newborn (4.2kg)

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Shoulder Dystocia
GDM
Erb’s palsy

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Macrosomia
GDM
Neonatal Hypoglycemia
GDM
• 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

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Minor Adverse Health Effects
Normal GDM
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
GDM
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%
Caudal digenesis 0.1% 5.3%
Neonatal Complications
GDM
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
 GDM
Congenital Anomalies - 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
 GDM
Late effects on the offspring

• Increased risk of IGT

• Future risk of T2DM
• Risk of Obesity

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Maternal Morbidity
GDM
• Hypertension; Insulin Resistance
• Preeclampsia and Eclampsia
• Cesarean delivery; Pre term labour
• Polyhydramnios – fluid > 2000 ml
• Post-partum uterine atony
• Abruptio placenta

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Risk of T2DM after GDM
•
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)
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A Delicate Balance !
GDM
• Plasma Glucose values in pregnancy
hang on a delicate balance
• If the Mean Plasma Glucose (MPG) is
– Less than 87 mg% - IUGR of fetus
– More than 104 mg% - LGA of fetus
• It is imp. to screen for hypothyroidism

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Women with T2DM
GDM
• 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 and ketosis
• SMBG must be trained and started
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 GDM
GDM – Glycemic Targets

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GDM and MNT
•
GDM
Two weeks trial of Medical Nutrition Therapy
• Pre-pregnancy BMI is a predictor of the efficacy
• If target glycemia is not achieved initiate insulin
• MNT – extra 300 calories in 2 and 3rd trimesters
• Calories – 30 kcal/kg/day = 1800 kcal for 60 kg
• If BMI > 30; then only 25 kcal/kg/day
• 3 meals and 3 snacks – avoid hypoglycemia
• 50% of total calories as CHO, 25% protein & fat
• Low glycemic, complex CHO, fiber rich foods
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Diet therapy in GDM
GDM
• Small, frequent meals
• Avoid eating for two
• Avoid fasts and feasts
• Avoid health drinks
• Eat a bedtime snack
 GDM
Tips for diet management

• Small breakfast
• Mid morning snack
• High protein lunch
• Mid afternoon snack
• Usual dinner
• Bed time snack
GDM and Exercise
GDM
• Recumbent bicycle
• Upper body egometric exercises
• Moderate exercises
• Mother to palpate for uterine contractions
• Walking is the simplest and easiest
• Continue pre pregnancy activity
• Do not start new vigorous exercise

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GDM and Insulins
•
GDM
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?)
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Insulin Regimen
GDM
• 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

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GDM and Delivery
GDM
• 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
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punarapi jananam punarapi maranam
Once again is the birth, sure follows the death
punarapi jananee jaTarae sayanam |
Yet again, is the slumber in the uterine filth
iha samsaarae bahu dustaarae
he! what to say of this miserable troth
kripayaa paarae paahi muraarae ||
O! lord, save us from this cyclical myth
Jagad Guru Adi Sankaracharya’s Bhaja Govindam
 Punarapi Garbham
Yet another conception

Punarapi Prasavam

GDM
Yet another child-birth

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 Punarapi Jananee
Once again for the mom

Sisuvau KaTinam

GDM
and the babe, the miseries

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 Iha Madhu maehae
This Diabetes you see

Bahu Dustarae

GDM
Terrible to the core

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 Kripaya Nivaaare
Please put an end to this

Nipunarae vidyae

GDM
O! Doctor, the expert !

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Punarapi Jananam
GDM

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