 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

Gestational Diabetes Mellitus

HISTORY

Introduction
Mrs. ………………………, …… year old, mother of …… children, in her …..nd pregnancy, presented with raised
blood sugar level at …….. weeks of period of amenorrhoea. She’s a house wife who lives at …………….

 LRMP(Accurate dating is important as delivery done Other Presentations

early as 38 wks)  Screening – High PPBS
o Date  SFH>Dates
o Whether she is sure about the date  Reduce/loss of fetal movements
 High BP/Pre-eclampsia
o Regularity or an irregularity
 Confinement
o Is it similar to previous period
o On any hormonal contraceptives
o Breast feeding

 Expected date of delivery

 If she is a chronic diabetic,

o When she was diagnosed?
o By whom?
o Initial FBS levels
o Regular follow up
o Good control
 Follow up investigations
 Complications (Diabetic retinopathy is a contraindication for pregnancy)
 Last HbA1C level (If <7%, risk of congenital abnormalities are same as non diabetic
pregnancy. If >7% there’s a 25% higher risk of congenital abnormalities than non
diabetic pregnancy)  risk of neural tube defects, congenital heart defects & other
spinal anomalies including caudal regression syndrome (10 teachers pg.186)
 Dietary control/Life style modifications
 Anti diabetic medications she is on
o Presence of other associated diseases : Hypertension/IHD

 Hx of present pregnancy
T1(0-12 wks)
o Is it a planned pregnancy
o Pre-pregnancy folic acid taken /not (will continue up to 5 months after delivery)
o Rubella vaccination taken or not
o when she was concerned about the pregnancy
o Date of confirmation of preg. & how
o Booking visit ( At what POA) – in SL <8wks
o Tests done : Urine – Sugar, Albumin
Blood – Group/DT, Hb, VDRL, PPBS(Screening +ve if >140mg/dl)
BP (They are at risk of PIH)
o Specialized care : on which POA : In an uncomplicated pregnancy – 20wks(Anomaly
scan), 32wks(Growth scan), 38wks(To confirm the presenting part)
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

o Complications :
 Hyperemesis gravidarum
 Bleeding PV (Risk of miscarriage)
 UTI, RTI, Wound infection, Candidiasis (They are at risk of infection)
 Drugs taken
o Ultra sound scans done ( Dating scan 11 -13wks)  Measure crown-rump length
 To confirm EDD (Calculated date taken if within one week of scan date)
 Detect congenital anomalies(Anencephaly, Spina-bifida)
 Chorionicity if twin pregnancy
 Identify maternal gynaecological abnormalities(Ovarian cysts, Fibroids)
 Identify the site of the fetus in uterus (Fundal is normal)

T2 (12-28 wks)
o Regular antenatal visits, Quickening, Tetanus, Complications
o PPBS(after 28 wks)
o Anomaly scan (18-22wks) (They are more prone to congenital anomalies)
 To identify placentation (Low lying placenta : <28wks  Should undergo repeat
USS at 28 weeks  If still low lying  Placenta praevia
o FeSO4, Vit C (Given at night after meals from T2 to 6 months after delivery)
o Calcium lactate and Folic acid (Given in mornings from T2 to 6 months after delivery)
o Infections
o Detection of GDM/PIH

T3(28 wks onwards)

o PV bleeding, GDM, HT, Antepartum haemorrhage, Growth retardation
o Weight gain (Macrosomic babies)
o Fetal movements
o Growth scan (after 28 wks…. In case of growth problem 2weekly repeat scans done)
 BPD, HC, FL, AC measured. To identify IUGR compare HC & AC
 Detection of fetal macrosomia

 Management up to now
o Screening tests done and results
 PPBS (best) - >140 mg/dl +ve
 Glucose challenge test - >140 mg/dl +ve
o Diagnostic tests
 OGTT/75g glucose tolerance test (Fasting value >95mg/dl +ve, 2 hr glucose
value >140 mg/dl)
 PPBS (>200mg/dl)
 FBS (>125 mg/dl)
o In a woman with previous GDM. Do OGTT at 20wks & 28 wks
o Do PPBS in booking visit & 28wks in all pregnant women
o Dietary control
o Whether the assessment of dietary control done after 2wks with blood sugar series
o Insulin/metformin started
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

o CTG
o Fetal movement monitoring
o Doppler studies

 Past obs Hx
o Year of previous pregnancy
o Problems in antenatal period (GDM/PIH)
o Onset of labour : Spontaneous/Induced
o Date ,place ,mode of delivery (NVD/Instrumental/LSCS) – Risk of shoulder dystocia
o Alive/not, Birth-weight (Macrosomia) Previous baby > 4.5Kg is a risk factor for GDM
o Postnatal complications
o Breast feeding ,Developmental mile stones – Shoulder dystocia  hypoxic damage
o Now the child is looked after by whom
o Recurrent miscarriages
o Preterm delivery
o Early onset of pre-eclampsia
o Congenital abnormalities (risk factor for GDM)
o Macrosomic baby(GDM)
o Unexplained still birth (Is a risk factor for GDM)

 Menstrual & contraceptive Hx

 Gynaecological history - PCOD
 PMHx – Heart disease, DM, HT, Epilepsy, DVT, Thyroid disease
 SHx
 Drug Hx
o Allergies to drugs, plaster
o Anti-diabetic medications
o Insulin
o Compliance
 FHx – DM among 1st degree relatives ,HT, Thalassemia, Consanguinity, Multiple pregnancies
 Social Hx
o Mother
 Educational level
 Occupation
 Knowledge about the disease
 Knowledge about insulin use/storage
o Husband
 Occupation
 Educational level
 Monthly income
 Substance misuse
o Living condition/ Nearest hospital/Availability of a transport method
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

EXAMINATION
General Examination
 Features of chronic diabetes mellitus
 Infections

Abdominal Examination
 Inspection – Signs of pregnancy
 SFH (Less than POA/Compatible with POA/More than POA) - Macrosomia
 Lie
 Presentation
 Position
 Liquor (Can get polyhydroamnios)
 EFW (Macrosomia)
 FHS
o Rate
o Regularity

CVS
 Pulse
 BP (left lateral or seated)
 Murmurs

RS
 RR
 Lungs

CNS

INVESTIGATIONS
 Screening
 Done on all pregnant women.
 Do PPBS at booking visit and 28 weeks in all pregnant women.
o Screening tests
 FBS (Not reliable)
 RBS
 PPBS (Best) - +ve if >140mg/dl
 Glucose challenge test - +ve if >140mg/dl

o Diagnostic tests
 OGTT/75 glucose tolerance test (Diagnostic values : Fasting>95mg/dl, 2hr >140mg/dl)
 PPBS > 200mg/dl (1st measurement diagnostic)
 FBS > 125 (1st measurement diagnostic)

MANAGEMENT
 Explain the condition to mother
o Risks to the mother
 PIH/Eclampsia
 Infections
 Hypo/hyperglycaemia
 Ketoacidosis
 Retinopathy (Progression)
 Temporary worsening of nephropathy
 Coronary artery disease
 Thromboembolic state
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

o Risks to the fetus

 IUD (> risk if pregnancy continued more than 38 wks)
 Macrosomia  Shoulder dystocia  Hypoxic brain injury
 Polyhydroamnios
 Miscarriage
 Congenital defects
 Neural tube defects
 Congenital heart disease More risk if high blood
 Other spinal abnormalities sugar at early pregnancy
 Caudal regression syndrome (rare)

o Outcome to mother
 Risk of GDM in future pregnancies
 Future risk of developing Diabetes

o Outcomes to neonate
 Hypoglycaemia (in 1st 24 hrs)
 Hyperbiliribinaemia (Fetal hyperglycaemia   Fetal insulin secretion  Bone marrow
hyperstimulation Increase RBC production  Break down of RBC after birth 
Unconjugate bilirubinaemia)
 Congenital abnormalities
 Macrosomia  Birth asphyxia & traumatic birth injuries
 Respiratory distress
 Hypomagnesaemia
Apnoeic episodes & fits
 Hypocalcaemia
 Respiratory distress syndrome

 Advice on dietary control

o Avoid all refine sugars, white starch & fatty meals
o Take 3 main meals along with 2 snacks in between
o Total calorie intake should be 2000Kcal/day (In non pregnant state it is 1500Kcal/day)
o Meal should include
 50% CHO
 25% Protein
 25% Fat
o Educate about hypoglycaemic symptoms and initial treatment.

 Dietary control and monitoring (Home blood sugar monitoring is ideal)

• With advancing pregnancy strict dietary control is needed as anti-

insulin hormone level increases rapid

•After 2 wks of dietary control, BSS should be done. Following I of poor control
•Pre-meal value >95mg/dl
•Post-meal value > 140mg/dl

• Repeat BSS on 2-3 week intervals, through-out the pregnancy

• In case of poor dietary control start Insulin (If soluble insulin tds,
Mixtard BD)
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

 Metformin
o If she was on metformin prior to pregnancy, can continue the drug during pregnancy.
o Metformin is usually not started in newly diagnosed diabetic mother

 Insulin
o Close monitoring should be done by FBS + PPBS( pre& post lunch) while taking insulin
o Advice the patient about dose/storage/site(Best is around the umbilicus and thigh)

 Monitoring of mother
o Should be done in consultant led hospital
o Combined care with physician
o Accurate dating is important
 Delivery should be done at 38 weeks.
 Very early delivery is unfavorable as it take long time for their lungs to get mature
o Monitor for PIH
o Anomaly scan at 20 weeks
o Growth scan at 28 weeks onwards in 2-3 week intervals
o Fetal well being
 34 weeks onwards
 CTG
 Fetal movements
 Doppler studies
o IUGR can occur in GDM patients in following conditions
 Fetus with congenital abnormalities
 Long standing DM with vasculopathy
 PIH with placental insufficiency

 Delivery of the baby

o At <38 weeks of POA only indicated in
 PIH
 Fetal distress
 Macrosomia
o Others are delivered at 38 weeks
o During labour
 Short active phase (6-8 hrs)
 Low threshold for LSCS
 Complications during the labour
 Fetal distress
 Lack of progression at 1st and 2nd stage
 Shoulder dystocia
 PPH
 Maternal hypo/hyperglycaemia
 Hourly blood glucose monitoring during labour
 Inform PBU and PHO
 Anticipate shoulder dystocia
 In whom the labour has been induced
 Patient with oxytocin infusion
 Prolonged 2nd and 3rd stage of labour
 Head is retracting after crowning( bad sign)
 Anticipate PPH

 After delivery
o Take normal diet
o Check FBS, PPBS  If very high levels  Start insulin  Check FBS after about one week
o Advice her on healthy diet
o Advice on weight reduction (exercise)
o Repeat OGTT 6 weeks post partum
 Nisal Fernando – Batch 19, FOM – University Of Kelaniya

 Planning of elective LSCS

o Stop the morning insulin dose
o Start on IV 5% dextrose
o When inserting cannula take blood for FBS
o Mark 1st on the theatre list

DISCUSSION

 How to perform following tests

o PPBS
 No fasting
 Take normal lunch
 Measure blood sugar 2 hrs after lunch
 Screening +ve if > 140mg/dl

o Glucose challenge test

 Can be done at any time of the day
 Don’t take sugar containing foods /drinks 30 mins prior to the test
 50g glucose is given and blood taken for sugar after 2 hour
 Overnight fasting is not required
 No food or drink except water in between drinking glucose and taking blood sample
 Screening +ve if >140 mg/dl

o OGTT/75g glucose tolerance test

 Need overnight fasting
 2 blood collections : fasting and 2 hr blood glucose
 Cannot eat or drink anything except water during the test
 Should be done on all screening positives

 What’s the patho-physiology of GDM

o During pregnancy there is an increase in human placental lactogen and cortisol, both which are
insulin antagonists and therefore mother develops relative insulin resistance.
o These changes are more marked during 3rd trimester
o To balance these changes maternal pancreas secretes increase amounts of insulin to maintain
CHO metabolism
o In contrast, following a CHO challenge, the levels of glucose are higher than in the non-pregnant
state.

 Definition of GDM
Glucose intolerance detected for the 1st time during pregnancy at any gestational age.

 Long term monitoring during pregnancy can be done using

- PPBS
- HbA1C