16 Gestational Diabetis

DIABETIS MELLITUS
Laston Kastom,
BscBMS(RH),Dip.Clin.Med
Definition
• A metabolic disorder of multiple aetiology that
affects the normal metabolism of
carbohydrates, fats and protein characterized
by chronic hyperglycemia as a result of
defective in insulin secretion, insulin action or
both
diagnosis
• Fasting plasma concentration: >7.8 mmol/L
• 2 hour plasma concentration(OGTT): >11.1
mmol/L
• If two hours level are between 7.8 and
11.1,most likely pt. have impaired glucose
tolerance test.(pre diabetes)
classification
1. Type 1(IDDM)
2. Type 2(NIDDM)
3. Gestational diabetes
4. Others -genetic defects in insulin processing or action
-endocrinopathies
-drugs
-exocrine pancreatic defects
-genetic syndromes associated with dm
Diabetes in pregnancy
GESTATIONAL DIABETIS MELLITUS
• Defined as glucose intolerance of

variable severity with onset or first
identified during the present pregnancy.
• Constitutes 90 percent of diabetes in
pregnancy
• Generally occurs in the latter half of
pregnancy.
• Therefore it has no effect on
organogenesis and does not cause
congenital defects
• Disappear after delivery
Gestational Diabetis Mellitus
• Either type 1(iddm) or type 2(niddm)

• Type 1 occurs in younger age group and
end organ complications is likely to be
more. Hence they to have increased
maternal and obs risks
• Type 2 usually occurs in obese patients
and have less maternal and obs
compared to type 1
Pregnancy as a diabetogenic state
• Pregnancy alters carbohydrate in such away more glucose is made available to the
fetus
What cause the diabetogenic state?

• Elevated placental hormones such as estrogens, progesterone, prolactin, human
placental lactogen.
• Plasma cortisol also rises during pregnancy.
• Cause ‘contrainsulin’ effect and state of insulin resistance
• Further aggravated by increase body weight and increase caloric intake during
pregnancy
• Gestational diabetes develops when the pancreas ,despite the production of
insulin cannot overcome the effect of these counter regulatory hormones.
• In contrast pregestational diabetes becomes worse during pregnancy
Risk factors
1. Historical factors
• Age>30 years
• Previous gdm
• Family history of dm
• Bad obs history
• History of macrosomia
• Prev. fetal anomalies
• History of recurrent abortions or unexplained stillbirth
• Drug history-steroids, tocolytic drug
2. Clinical factor in the present pregnancy

• Congenital fetal anomalies
• Pre-eclampsia
• Obesity>90 kg
• Recurrent uti, vaginal candidiasis
• Presence of glycosuria on more than 2 occasions
Screening for diabetes
• Gdm is asymptomatic ,hence we need screening test to detect gdm
1. Universal screening(all pregnant women)
2. Selective screening(presence of risk factors for gdm)
 for universal screening –do the glucose challenge test

No special preparation is needed for this test
50 grams of oral glucose is given between 24 to 28 weeks pog
Blood glucose is determined 1 hours later.
A plasma glucose level of > 7.8 is considered significant to perform confirmation
diagnostic test.
Selective screening-oral glucose tolerance test

75 grams of oral glucose is given

Only 2 reading are taken-fasting glucose level and 2 hour post glucose

The diagnosis of dm is made when fasting glucose level are ≥7.8 and or 2 hour level
of >11.1

If the 2 hours levels are between 7.8 and 11.1,the patient is said to have impaired
glucose tolerance test and should be treated as gdm.
Maternal complications
1. Pre-eclampsia
2. Recurrent infection-vaginal candidiasis,uti
3. Retinopathy
4. Nephropathy
5. Neuropathy
6. Micro/macroangiopathy
7. Polyhydramnios—pprom, cord prolapse,
8. ketoacidosis
9. Increased instrumental and CS rates
10. Study shows that after gdm,40-60% of women
develop type 2 dm within 10 years
Fetal complications
1. Miscarriage
2. Congenital anomalies(4 fold)-sacral
agenesis,ntd,cardiac and renal anomalies
3. Macrosomia
4. Respiratory distress syndrome
5. Hypoglycemia-result of hyperplasia of beta cell
6. SIUD
7. Prematurity
8. Malpresentation
9. Shoulder dystocia.
10. Polycythemic -jaundice
Investigation
1. Blood sugar level-weekly assessment is required.
Useful in deciding whether to start insulin or
adjusting insulin dosage
2. Urine microscopy and culture-to exclude
uti(bacteriuria)
3. HbA1c-done in first trimester. It gives retrospective
assessment 12 weeks ago. High HbA1c at the end of
first trimester indicates sugar control was poor
during organogenesis period.
4. Maternal serum AFP-done between 16 to 20 weeks
pog
5. Diagnostic imaging-gestational age, fetal
abnormities, fetal growth, liquor volume.
6. Doppler of umbilical artery-done in cases of
diabetic vasculopathy
Management-
the key to successful management in diabetic pregnancy is early diagnosis which allows
treatment to be started early.
Antenatal management
• Plasma glucose level should be maintained between 4-6 mmol/L
• Early dating and scan to exclude fetal abnormalities
• Diet control should be attempted first. If failure insulin should be
started.
• Admission-poor blood sugar control, PIH, polyhydramnios. BSP should
be monitored
• Timing for delivery-if on insulin,38 weeks, if on diet control, can
prolonged to term
• Mode of delivery-lscs if macrosomia baby,malpresentation,evidence of
fetal compromise
• Check BP
• Fetal growth chart
• Monitor closely with continuous ctg
treatment
 Oral hypoglycemic drug are generally not recommended as
it can cause teratogenic effect towards fetus and can cross
placenta causing hypoglycemia
• Diet therapy
– Total calories advised is 24-30 kcal/kg of the present body
weight.In obese diabetic pt. 24kcal/kg is advised
– The calories should be distributed between 3 meals and 3
snacks
– Dietary control decrease postprandial glucose level and it
also improve insulin action.
– Blood glucose level and weight gain can be used to
formulate a meal plan
• Exercise
– Light exercise help by lowering fatty acid
– Contracting muscle help stimulate glucose
transport hence decrease blood sugar
– Better done after meals
– Exercise involving the muscle of upper part of the
body is sufficient to lower down glucose level.
• Insulin regimes
– 15% required insulin therapy
– Insulin is indicated in all pregestational diabetes
and poorly controlled gdm
– The popular regimes use a mixture of short acting
and medium acting insulin
Pre-pregnancy counselling
• This play an important roles for pregestational

diabetes in order to prevent early pregnancy loss
and congenital anomalies.
• Complete assessment of diabetic status should
be done to find out whether she is fit to go
through pregnancy. HbA1c can be done to
evaluate blood glucose control 12 weeks ago.
• Those with oral hypoglycemic should be switched
to insulin therapy.
The rule of 15 for gdm
• 15% of pt. with positive glucose challenge test
will have gdm
• 15% percent of GDM will required insulin
• 15% of GDM will have macrosomia
• 15% of GDM will have impaired drop after
delivery

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DIABETIS MELLITUS

• Defined as glucose intolerance of

• Either type 1(iddm) or type 2(niddm)

What cause the diabetogenic state?

2. Clinical factor in the present pregnancy

 for universal screening –do the glucose challenge test

• This play an important roles for pregestational

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