Gestational

Diabetes Mellitus –
One Disease Two Lives at Stake

Dr.ANSAR FATHIMA
ASSISTANT PROFESSOR,
DEPARTMENT OF GENERAL MEDICINE ,
TVMCH
 Introduction
 Gestational Diabetes Mellitus (GDM) is defined as
Impaired Glucose Tolerance (IGT) with onset or
first recognition during pregnancy

 Worldwide, one in 10 pregnancies is associated

with diabetes, 90% of which are GDM

 Undiagnosed or inadequately treated GDM can

lead to significant maternal & foetal complications

 Women with GDM and their offsprings are at

increased risk of developing Type 2 diabetes later
in life
 The Problem
 In India, prevalence of GDM is appox.10-
14.3% - much higher than the west
 As of 2010, India has:-
22 mill. women with diabetes in the age group of
20-39 with an additional 54 mill. women in this
age group with impaired glucose tolerance (IGT)

 In view of high prevalence of GDM in Indian

women, Govt. of India has released National
Guidelines for Diagnosis & Management of
Gestational Diabetes Mellitus in Dec 2014.
 Patho-physiology

 GDM is characterised by hyper-insulinaemia and

insulin resistance
 In first trimester and early second trimester,
increased insulin –due to high levels of
oestrogen
 In late second and early third trimesters, insulin
resistance - due to a number of antagonistic
hormones especially, placental lactogen, leptin,
progesterone, prolactin, cortisol and
adiponection
Implications of Diabetes in
Pregnancy

The risk of serious injury at birth -

Doubles

The likelihood of Caesarean delivery -

Triples

The incidence of Neonatal Intensive

Care Unit admission -
Quadruples
Pregnancy and Diabetes-
The vicious cycle
Effects of Pregnancy on Diabetes

 During pregnancy, there is altered

carbohydrate metabolism and impaired
insulin action
 Insulin requirement increases as pregnancy
advances
 Accelerated starvation----rapid activation of
lipolysis with short period of fasting
 Higher risks of Ketoacidosis complications
 Accelerates vascular changes
Effect of Diabetes
on Pregnancy:
1. Respiratory Distress
Syndrome

2. Polyhydramnios

3. Foetal macrosomia

4. Erb’s Palsy

5. Birth asphyxia

6. Abortion/Intra uterine death

7. Neonatal hyperbilirubinemia

8. Congenital malformations
 Maternal
Hyperglycaemia

Decreased Foetal Foetal

cortisol hyperglycaemia hyperinsulinaemia
production
Foetal osmotic Foetal
Decreased
diuresis hypoglycaemia
surfactant
synthesis in lung Increased IGF
Polyhydramnios
Respiratory Fetal macrosomia
distress syndrome
Polyhydramnios

Obstructed labour
Shoulder Dystocia

Erb's Palsy/
Birth Asphyxia
 Chronic maternal
Hyperglycaemia in hyperglycaemia Glycosylated
1st trimester Hb carries
less oxygen
Foetal molecule and
Impaired hyperglycaemia O2 binds
organogenesis
Foetal more avidly
hyper-insulinemia and releases
Congenital O2 less
abnormalities Increased foetal
oxygen demand

Decreased Oxygen Increased

tension erythropoiesi
(hypoxemia) s
Increase in Polcythaemia
anaerobic and hyper
metabolism viscosity

Increased lactate
and academia RBC breakdown and
Neonatal hyper-
bilirubinemia
Abortion/ IUD
 GDM: Risk Factors

 Age >25years
 Elevated fasting or
 BMI >25kg/m²
random blood glucose
 Increased weight gain during
pregnancy
levels during pregnancy
 Previous history of large for  Family history of diabetes
gestational age infants
in first degree relatives
 History of GDM during previous
pregnancies  History of metabolic X
 previous stillbirth with pancreatic syndrome
islet hyperplasia on autopsy
 Ethnic group ( East Asian,  History of type I or type II
Pacific Island ancestry) Diabetes Mellitus
 Unexplained fetal loss
 GDM: Maternal Complications
During Pregnancy During labour
• Abortion • Prolonged labour
• Preterm labour (due to infection • Shoulder dystocia
or polyhydramnios) • Perineal injuries
• Pre-eclampsia • PPH
• Polyhydramnios
• Operative
• Maternal distress due to oversized
interference
fetus and polyhydramnios
• Microangiopathy- Nephropathy,
• Increased risk of
retinopathy, neuropathy Caesarean delivery
• Large vessel disease
– Coronary artery disease
– Thromboembolic disease
Puerperium
– Infection • Puerperal sepsis
– Hypo and hyperglycaemia • Lactational failure
 GDM: Foetal Complications

2nd Trimester
1st Trimester
Congenital abnormalities  Macrosomia
 Cardiac : ASD, VSD
During delivery
 NTD
 Sacral agenesis/ CRS
 Birth asphyxia
 Shoulder dystocia
 PCKD
 Renal agenesis After delivery

 Duodenal atresia  RDS

 Hypoglycaemia
 Tracheo-esophageal
 Polycythaemia
fistula  neonatal jaundice
 GESTATIONAL DIABETES PRE-EXISTING DIABETES
• No increased risk of congenital • Higher risk of congenital
anomalies malformations and miscarriages
• Increases risk of foetal macrosomia • Recurrent urinary tract infections
• Vulvo-vaginal infections with poor
• Increases risk of having Caesarean control
section • Associated with risk of (PPPPRIM)
• Increased risk for metabolic syndrome • Pre-eclampsia,
and type II diabetes later in life (>50% • Polyhydraminos,
women with gestational diabetes • PPROM,
develop type II DM) • Preterm labour,
• Babies born to women with gestation • Risk of operative deliveries
diabetes are at increased risk for • IUGR
obesity, glucose intolerance and • Macrosomia
• Ketoacidosis in type I, progression of
diabetes in adolescence microvascular complications

• Caesarean section rates invariably

increased due to fetal macrosomia, poor
blood sugar control, polyhydramnios or
associated with failure of induction
The White classification, named after Priscilla White
on
the effect of diabetes types on perinatal outcome.
It distinguishes between gestational diabetes (type A) and
diabetes that
existed before pregnancy (pre-gestational diabetes).

There are 2 classes of gestational diabetes (diabetes which began

during pregnancy):
 Class A1: gestational diabetes; diet controlled
 Class A2: gestational diabetes; medication controlled

The second group of diabetes which existed before pregnancy

can be split up
into these classes:
 Class B: onset at age 20 or older or with duration of less than 10 years
 Class C: onset at age 10-19 or duration of 10–19 years
 Class D: onset before age 10 or duration greater than 20 years
 Class E: overt diabetes mellitus with calcified pelvic vessels
 Class F: diabetic nephropathy
 Class R: proliferative retinopathy
 Class RF: retinopathy and nephropathy
 Class H: ischemic heart disease
 Class T: prior kidney transplant
 GDM: Diagnosis
Symptoms Signs

 Asymtomatic  Elevated serum glucose

 Insidious onset  Glycosuria is of uncertain

significance
 Polyuria, polyuria,
polyphagia  Ketonuria

 Fatigue and weight loss  Elevated glycosylated

haemoglobin
 Women with established
diabetes may have  Greater than normal
retinopathy or neuropathy abdominal circumference
 Principles of
Management

(National Guidelines for

Diagnosis and Management of
GDM-2018)
 Who should be tested :
 The first testing - first antenatal contact as early as
possible
 The second testing -24-28 weeks of pregnancy if the first
test is negative
 At least 4 weeks gap between the two tests
 All Pregnant Women to be tested even if they come late in
pregnancy
 If presents beyond 28 weeks of pregnancy-only one test
to be done
 How to Test:

 Single step testing - 75 gm oral glucose & measure plasma

glucose 2 hour after ingestion

 75 gm glucose mixed with 300 ml water ingested whether the

PW comes in fasting or non-fasting state

 A plasma standardised glucometer should be used to evaluate

blood glucose 2 hours after the oral glucose load

 The threshold plasma glucose level of ≥140 mg/dl is taken

as cut off for diagnosis of GDM.
 Management of GDM
 All Pregnant women who test positive for GDM
for the first time should be started on Medical
Nutrition Therapy (MNT) and physical exercise
for 2 weeks. The woman should walk/exercise
for 30 mins a day.
 After 2 weeks on MNT and physical exercise, 2
hrs PPBS (post meal) should be done
 Antenatal care:
 All diabetic women are managed in a multidisciplinary combined
obstetric and diabetic clinic with specialist obstetrician,
diabetologist, specialist midwife, paediatrician and dietician

 All women should receive dietary instruction, with individual

recommendations based on weight and height

 Patient should receive nutrition counselling from a registered

dietician

 Daily calories should be made up approximately 40%

carbohydrate, 20% proteins and 40% fats.

 This should improve blood glucose levels

 Medical Nutritional Therapy:

Recommend
ed diet
should
provide

1800 Kcal/
day
 50%-60%
-
carbohydr
ate
 10-20% -
Proteins
 25-30% -
Fat
 Medical Management
 Metformin or Insulin therapy is the accepted medical
management of pregnant women with GDM not controlled on
MNT. Insulin is the first drug of choice and metformin can be
considered after 20 weeks of gestation for medical
management of GDM.

 Insulin can be started any time during pregnancy for GDM

management. If pregnant women with GDM before 20 weeks,
and Medical Nutrition Therapy (MNT) failed, Insulin should be
started.

 Metformin can be started at 20 weeks of pregnancy, if MNT has

failed to control her blood sugar. If the woman’s blood sugar is
not controlled with the maximum dose of metformin (2 gm/
day) and MNT, Insulin to be added. The dose of metformin is
500 mg twice daily orally up to a maximum of 2 gm/day.
 Role of Ultrasound:
 Preferably done in first trimester to confirm gestational
age by dates
 Repeated at 18 to 20 weeks gestation to evaluate the
foetus for congenital anomalies
 Particularly important in patients with pre-existing type 1
and 2 diabetes and elevated first trimester HbA1c
(>6.5%)
 Should be done at 30 to 32 weeks and 36-38 weeks of
gestation to evaluate foetal size, amniotic fluid index, and
to help ascertain the mode of delivery
 Tests of Foetal wellbeing

 Daily foetal movement counting:

32 weeks gestation and continue
until delivery.
 Amniotic fluid index and biophysical
profile.
 These tests are usually conducted
twice weekly and are instituted at
32 to 34 weeks of gestation in
women on insulin and can be done
from 34-36 weeks of gestation in
women whose diabetes is controlled
by diet.
 Some clinicians manage patients
with dietary control without any
additional testing.
 Time and Mode of Delivery
 All pregnant women advised during the antenatal care about
the potential risks of pregnancy progressing beyond term
 Gestational diabetes
 GDM on diet with no complications can be delivered at 40
weeks
 GDM on insulin should be delivered by induction of labour at
38-39 weeks

 Pre-existing diabetes
 Diabetes itself not an indication for Caesarean Section
 Pregnant women with diabetes who have a normally grown
fetus should be offered elective birth through induction of
labour, or by elective caesarean if indicated, after 38
completed weeks
 Pregnant women with ultrasound features of macrosomic fetus
(fetal weight more than 4.5kg) and poorly controlled blood
sugar are delivered by elective caesarean section.
 Post-delivery Follow up of GDM
Cases

 Women with GDM are at higher risk for Type 2 Diabetes

mellitus.
 Maternal glucose levels usually return to normal after delivery.
 GDM cases are not discharged after 48 hours unlike others,
FPG & 2 hr PPPG is performed on the 3rd day of delivery
 Subsequently, ANM to perform 75 g GTT at 6 weeks
postpartum

 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
Operational Aspects of
National GDM Guidelines
Role of Health Personnel at
different levels of Health
Facility:
Village Level
 ASHA: To mobilise & counsel PW for timely
testing & follow up

Sub-centre Level

 ANM: Testing/MNT/Referral of cases needing

medical
management
 Maintaining records, monitoring & follow up
Role of Health Personnel at
different levels of Health
Facility...contd.
PHC/ UPHC Level

 GDM controlled on MNT can be delivered by ANM/SN

 GDM on Medical management with Insulin therapy-

by MOs
 GDM not controlled by Insulin therapy/GDM with
complications should –to referred to higher facility
for care by a specialist

 Maintaining records, monitoring & follow up

Role of Health Personnel at
different levels of Health
Facility ..contd.
DH & All CEmOC centres
 All jobs as defined under PHC level
+
 Specialist/Gynaecologist/MO: Management of all
types of GDM cases

MC & other Super-speciality centres

 Comprehensive management of GDM including all
referral cases
Capacity building of Health personnel
under GDM Guidelines
Training needs for different cadres
Training needs for different cadres
Training needs for different cadres
 Screening for GDM

 Most patients with GDM have normal

fasting glucose levels.

 The challenge of glucose tolerance must be

done for most cases with GDM.
Screening –at the 24 weeks visit

OGTT should be done.

There are some controversies.
whether the universal or selective
OGTT should be done?
Which blood glucose level should be
the optimal cutoff for diagnosis?
 Screening Strategy

 Every pregnant woman to undergo OGTT

at about 24 weeks of gestation.

 If the GDM symptoms are present after 24

weeks, the OGTT should be done again.
Target Blood Glucose Values
 Ante-partum Management

 There is a consensus that once diabetes is

diagnosed, the treatment should be
recommended for diabetes during
pregnancy.
 The goals of treatment are to prevent
macrosomia, avoid ketosis, and detect
pregnancy complications (eg, hypertension,
intrauterine growth restriction, and fetal
distress).
 The management includes diet, exercise
and insulin.
 Diet Therapy

 The goals of diet therapy in GDM are to avoid

ketosis, achieve normal blood glucose levels,
obtain proper nutrition, and gain weight
appropriately.
 The amount and distribution of carbohydrate
should be based on clinical outcome measures
(eg, hunger, blood glucose levels, weight gain),
but a minimum of 175 g of carbohydrate per
day should be provided.
 Carbohydrate should be distributed throughout
the day in 5 to 7 meals and snacks.
 Use of a low–glycemic index diet decreases the
need for insulin to maintain euglycemia.
 Exercise

 Experts recommend that women with GDM

should exercise regularly to control blood
glucose levels.

 but an improvement in clinical outcomes

has not been demonstrated from
compliance with this recommendation.
 Insulin Therapy
 Traditionally, insulin is used if dietary
management does not maintain blood
glucose at normal levels.
 Insulin may be initiated at 0.7 U/kg actual
body weight/d given in divided dosages: two-
thirds of the daily dosage before breakfast
and the remainder of the dosage before
dinner.
 Insulin therapy require close monitoring and
adjustment based on blood glucose levels,
meal choices, and activity levels.
 Obstetrics Management
The goal of intra-partum GDM
management is to avoid operative
delivery, shoulder dystocia, birth trauma,
and neonatal hypoglycemia.
For patients who have maintained
excellent control of blood glucose levels
with diet and exercise, delivery is
recommended at 40 weeks.
For patients with medication-requiring
GDM, induction at 38 to 39 weeks’
gestation is recommended
Obstetrics management…contd

 In general, women with gestational

diabetes who do not require insulin
seldom require early delivery or other
interventions.

 Elective cesarean delivery to avoid

brachial plexus injuries in macrosomic
infants is an important issue.
 Postpartum Management

 In most women with GDM, hyperglycemia

rapidly resolves shortly after delivery.

 It is reasonable to measure a single random

or fasting blood glucose level before
discharge from the hospital.
Postpartum Management..contd
 Postpartum glucose tolerance testing is important for
women who had GDM.

 Women with GDM have a 7-fold increased risk of

developing type 2 diabetes mellitus compared with
those who had a normoglycemic pregnancy.

 At 6 to 12 weeks postpartum, only one-third of

women with persistent glucose intolerance have an
abnormal fasting blood glucose level.

 Therefore, to detect all women with glucose

intolerance, a 75-g, fasting, 2-hour, oral glucose
tolerance test is recommended.
 Summary- Key Points
 Universal testing of all PW for GDM

 Testing recommended twice in pregnancy at 1st

antenatal visit and then at 24-28 weeks of gestation

 Single step 75 g 2 hr PPPG test to be performed

 PW testing positive (2 hr PPPG > 140mg/dl) should be

started on MNT for 2 weeks

 If 2 hr PPPG ≥ 120 mg/dL after MNT, medical

management (Insulin therapy) of PW to be started

 PW to be monitored by 2 hr PPPG throughout

pregnancy
 Summary-Key Points..contd

 Antenatal visits 2 weekly in 2nd trimester & weekly in 3rd

trimester
 PW on Insulin therapy with uncontrolled Blood glucose levels
(2 hr PPPG ≥120 mg/dl) or insulin requirement >20 U/day
should be referred for delivery at CEmOC centres
 GDM pregnancies associated with delay in lung maturity of
foetus- routine delivery prior to 39 weeks not recommended.
 Vaginal delivery preferred, LSCS for only obstetric indications
or foetal macrosomia
 Postpartum evaluation of glycaemic status by a 75 g OGTT at
6 weeks after delivery.