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JEHAD AL-HARMI
DEPARTMENT OF OBS & GYN
FACULTY OF MEDICINE/ KUWAIT UNIVERSITY
DEFINITION
• Persistent state of hyperglycemia due to
lack, or diminished effectiveness, of
endogenous insulin
1. Type II or NIDDM:
• Usually adult onset
• Occurs more frequently in the obese
• Has a stronger familial component
CLASSIFICATION
MODIFIED WHITE CLASSIFICATION:
A1 GDM on diet
A2 GDM on insulin
B Onset after age 20 years, or duration less than 10 years
C Onset &/or duration between 10-20 years
D Onset before age 10 years, or duration more than 20 years
F Nephropathy
R Proliferative (not background) retinopathy
H Coronary artery disease
T Renal transplant
RISK FACTORS-1
WHAT ARE THE RISK FACTORS OF
GDM?
RISK FACTORS-2
– Whom?
– How?
– When?
DIAGNOSIS - 2
SCREENING:
• Glucose loading/challenge test (GLT):
– No special preparation
– 50 g glucose; measure plasma BS after 1
hour
– For low-risk: screen at 26-28/52
– For high-risk: screen at booking & if result
negative repeat at 26-28/52
DIAGNOSIS - 3
ANC - 1:
– Team approach (obstetrician, physician, nurse,
dietician)
– Additional testing:
• RFT, 24-hour urine collection for total protein &
creatinine clearance rate
• Fundoscopy
• MSU for C&S
• Fetal echocardiography
MANAGEMENT - 4
ANC - 2:
– Insulin dose & frequency may have to be
increased (up to 2-3 X in later pregnancy)
– Glucose home monitoring (as opposed to
repeated hospital admissions) increases
compliance, improves results, & reduces cost
– Visits every 2/52 till 32/52, then weekly till
delivery
MANAGEMENT - 5
ANC - 3:
– U/S in T1 for viability & confirmation of GA
– U/S at 20-24/52 for anomalies
– U/S at 32-36/52 for growth
– Daily FKC starting at 32/52
– Weekly NST starting at 32/52; increase to
twice weekly at 34-36/52
– Weekly BPP may also be carried out
MANAGEMENT - 6
GDM:
– Diabetic diet for 1/52
– BSP: 7 readings
– If controlled with diet, recheck FBS & PPBS
every 1-2/52
– If insulin is needed, admit to hospital
MANAGEMENT - 7
DIET:
– 30-35 kcal/kg of ideal body weight (range =
1800-2800 kcal/ day)
– 3 meals + 3 snacks
– 50 % CHO (complex & high fiber) + 30 % fat +
20 % protein
– 25 % breakfast + 30 % lunch & dinner + 5 %
each snack
– Consistency in dietary intake and activity level
MANAGEMENT - 8
INSULIN THERAPY - 1:
– If initial FBS > 9 mmol/l
– If diet does not provide satisfactory control
within 1-2/52
• FBS < 5.3 mmol/l
• Pre-prandial < 6 THIS IS
• 1-hour PPBS < 7.8 “TIGHT GLYCEMIC
• 2-hour PPBS < 6.7 CONTROL”
• Not less than 4
MANAGEMENT - 9
INSULIN THERAPY - 2:
– Total dose:
• T1 0.5 units/kg actual body weight
• T2 0.6
• T3 0.7
– Dose divided into 2/3 in am + 1/3 in pm
– AM dose further divided into 1/3 short-acting + 2/3
intermediate- acting
– PM dose divided in 1/2
MANAGEMENT - 10
INSULIN THERAPY - 3:
– Alternative regimen:
• 3 pre-prandial doses of short-acting insulin
• 1 dose of intermediate-acting insulin at bedtime if FBS high
– Reduced compliance but better glycemic control
– What is the role of continuous subcutaneous insulin infusion
pumps?
MANAGEMENT - 11
INSULIN THERAPY - 4:
– HR / Actrapid:
• Onset of action after 30 minutes
• Peak effect within 2 hours
– HN / Monotard:
• Onset of action after 2 hours
• Peak action within 10 hours
MANAGEMENT - 12
JAMEELA
– 24 year old
– G1
– GA = 26/5
– GLT = 11 mmol/l
– Weight = 100 kg
MANAGEMENT - 13
• IGTT:
– Repeat OGTT after 4/52 if test was done before 28/52
– Dietary advice; especially for those with high FBS.
Occasional FBS & PPBS
– FKC & NST as for normal pregnancy
• Others:
– Oral hypoglycemic drugs (Glyburide)
– Exercise (upper body CV training)
MANAGEMENT - 14
LABOR & DELIVERY - 1:
– DM on insulin IOL at 38-39/52
– GDM A1 IOL at 40/52
– IGTT IOL at 41-42/52 (overdue )
– Aim for vaginal delivery. But LCSC rates are
higher for diabetics (up to 60%) because of
FD & macrosomia
MANAGEMENT - 15
LABOR & DELIVERY - 2:
– On day of delivery:
• Reduce am dose of intermediate-acting insulin (1/3-1/2
usual dose)
• Start IV fluids D5% in NS at 125 cc/h
• RBS 1-2 hourly. Check urine each void for glucose &
ketones
• Start IV insulin if RBS > 6.7 mmol/l
• Continuos FHR monitoring
• Pediatrician to examine baby after delivery
MANAGEMENT - 16
PNC - 1:
– Insulin requirements decrease after delivery
– GDM A1 normal diet, FBS & PPBS after 2
days. 75-gram, 2-hour OGTT 6/52 later
– GDM A2 diabetic diet, BSP after 2 days,
OGTT 6/52 later
MANAGEMENT - 17
PNC - 2:
– 5-20% of GDM patients continue to have DM
after delivery
– Pre-existing diabetics can go back to pre-
pregnancy regimen
MANAGEMENT - 18
PNC - 3:
– Breast-feeding should be encouraged; take
into account increased caloric demand. How
much?
– 30-50% of patients with GDM develop type II
DM within 20 years; especially if obese
– Diabetogenic effect of pregnancy increased
by repeated pregnancies & obesity
MANAGEMENT - 19
FAMILY PLANNING:
– Advice regarding limiting size of family in
presence of retinopathy or nephropathy
– Low-dose OCP if young, non-obese, &
normotensive
– IUCD
– Barrier methods
– Sterilization
CASE - 1
SALMA
– 22 year old lady. MF 2/12
– IDDM since the age of 9 years
– Had renal transplant last year
– Attends for pre-conceptual counseling
– Outline management
CASE - 2
NADIA
– 30 year old lady. MF 5 years
– G6 P0+2+3+2. Previous LSCS X 2
– IDDM since the age of 22 years
– GA = 6/52
– Attends for her booking ANC visit
– Outline management
CASE - 3
FAWZIA
– 40 year old lady. MF 18 years
– G7 P5+1+0+7. Previous LSCS
– GDM on insulin
– GA = 37/52. Breech presentation
– EFW by U/S +/- 4000 g
– Outline management
CASE - 4
NAEEMA
– 30 year old lady. MF 5 years
– Juvenile DM. G6 P2+0+3+2
– G 4: LSCS for failed VE. BW = 3700g
– G 5: VBAC. BW = 3200g
– GA = 37/52. SFH = 42 cm. EFW = 4000g. Hb A1c = 12%
RIHAB
– 22 year old lady. MF 1 year
– G1 P1+0+0+1
– Delivered 3 days ago. FTND after IOL for
GDM A1. BW = 3200 g
– She plans to breast-feed her baby