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Definition
GDM defined as glucose intolerance which first
Epidemiology
The incidence of GDM varies both with
studied
Pathogenesis
Pregnancy causes metabolic changes leading to
Diagnostic Criteria
No international consensus to the diagnostic criteria
Complications
Perinatal
Macrosomia
Shoulder dystocia
Birth injury ; fracture, nerve palsy
Caesarean
pre-eclampsia
Neonatal hypoglycaemia
Neonatal hyperbilirubinaemia
Late complications
Mother
Type 2 diabetes
Recurrent GDM in future pregnancies
Child
Pedersen Hypothesis
Accepted pathological mechanism which GDM leads to
complications
High maternal blood glucose lead to increased glucose
transport across placenta.
The fetal pancreas responds to this increased glucose
load with increased insulin secretion
Fetal hyperinsulinaemia then lead to excess fetal growth
as insulin is a growth factor
After delivery fetal hyperinsulinaemia may persists for a
period giving an increased risk of neonatal
hypoglycaemia
Screening
Selective screening in UK recommended by NICE
South Asian
Black Caribbean
Middle Eastern
Diagnostic tests
Fasting glucose is not recommended as a screening
ACOG Recommendation
Management
Should be under the care of multi-disciplinary
ACOG Recommendation
Fasting - <5.3mmol/l
1 hour post prandial - <7.2mmol/l
Pharmacological Treatment
If diet and lifestyle modifications fail to control
Insulin
Four injections per day
Regular insulin
Rapid acting insulin analogues- aspart, lispro
Oral sulphonylurea
Mechanism of action is to enhance insulin secretion by beta cells
Minimal passage occurs through placenta
(older sulphonylureas as tolbutamide and chlorpropamide have
been shown to cross the plaventa and cause fetal
hyperinsulinaemia and contraindicated in GDM)
Metformin
Obstetric Management
Growth should be assessed by serial ultrasound during 3 rd
trimester
Induction of labour often considered after 38 weeks
During labour maternal blood glucose should be maintained
between 4-7mmol/l using a sliding scale if necessary
In GDM blood glucose level usually normalize in hours and days
following delivery
Usually all treatments are discontinued as soon as the woman is
able to eat post partum and dietary restrictions are relaxed
Follow up testing 6 weeks by FBS (NICE recommendation)
should be performed to check for complete resolution of GDM
and to exclude type 2 DM
References
Gestational Diabetes : Ben Whitelaw, Carol Gayle :
Thank You