Gestational diabetes

Gestational diabetes

Introduction:

o Diabetes mellitus, is a group of metabolic diseases in which a person

has high blood sugar, either because the pancreas does not produce
enough insulin (insulin deficiency), or because cells do not respond
to the insulin that is produced (insulin resistance).

o This high blood sugar produces the classical symptoms of polyuria,

polydipsia and polyphagia.

I. Definition of gestational diabetes:

Gestational diabetes is appearance of diabetes for the first time

during pregnancy and disappears postpartum. The ideal blood glucose
level during pregnancy should fall between 70 and 110 mg/dL.
Symptoms of diabetes mellitus may disappear a few weeks following
delivery. However, approximately 50% of women will develop diabetes
mellitus within 5 years.

II. Incidence of gestational diabetes:

 1: 350 pregnancies.
 2-12% of pregnancies are complicated by diabetes mellitus.
 90% are gestational diabetes (onset of diabetes or first time
recognition during pregnancy).
 10% had diabetes mellitus before pregnancy (pregestational or
preconceptional diabetes mellitus).

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 Gestational diabetes

III. Classification:
a- Classification during pregnancy

o Known to have diabetes before pregnancy; pregestational.

o Diagnosed during pregnancy; gestational.

b- Classification according to severity:

IV. Effects of pregnancy on diabetes:

1. Diabetes may appear only during pregnancy or become aggravated by
pregnancy (Pregnancy is diabetogenic) because the human placental
lactogen, prolactin, estrogens, progesterone and cortisol antagonize

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 Gestational diabetes

insulin. In addition, the placental enzyme insulinase that destroys

insulin
2. Diabetes becomes difficult to control in pregnancy as:
o During the early months of pregnancy the insulin needed may be
reduced because nausea and vomiting lead to maternal hypoglycemia.
o Insulin requirement gradually increases after the third month until
term.
o During labor, there is liability to hypoglycemia because of uterine
activity.
o After delivery the insulin requirement decreases due to drop in the
level of placental hormones
3. Diabetic retinopathy may be aggravated in pregnancy.

Risk factors of gestational diabetes:

1. Obesity
2. Maternal age older than 25 years
3. Family history of diabetes mellitus
4. Previous delivery of an infant that was large or stillborn

V. Effect of gestational diabetes on pregnancy:

o Diabetes is associated with increasing morbidity of the mother and
fetus.

 Maternal:

o Preterm labor.
o Increased incidence of pre-eclampsia (PE) (40%).
o Increased incidence of polyhydramnios (10-20%) Malpresentation.

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 Gestational diabetes

o Increased liability to infection as urinary tract infection and vulvo

vaginal mycosis.
o Inertia, Prolonged labor & Obstructed labor due to large baby.
o Postpartum hemorrhage & puerperal sepsis.
o Difficulty in control of diabetes leading to ketoacidosis or
hypoglycemic coma.

 Fetal:
o Increased incidence of congenital malformation (5-10%), It is related
to maternal hyperglycemia during the period of organogenesis & so
NO increased risk in G.D.M cases. Commonest lesion is cardiac
anomalies (VSD). The most specific is sacral agenesis (caudal
regression syndrome).
o Intrauterine death (5% of cases) especially after 36 weeks. It may be
due to maternal ketosis, hypoglycemia, congenital malformation, as
sociated pre-eclampsia or placental insufficiency.
o Macrosomia: due to maternal hyperglycemia which leads to fetal
hyperglycemia and fetal hyperinsulinemia. Insulin is anabolic
hormone leads to formation of glycogen, fat and protein. There is
increase in body fat, muscle mass and organomegaly.
o Intrauterine growth restriction which is less frequent. It occurs
when diabetes is complicated by vascular disease leading to placental
insufficiency (class D and above).
o Neonatal death (5%) due to prematurity, respiratory distress
syndrome, congenital anomalies, and hypoglycemia resulting from
fetal hyperinsulinaemia.
o Fetal birth injuries due to macrosomia.
o The infant may inherit diabetes which may appear later in life.

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 Gestational diabetes

VI. Diagnosis of gestational diabetes:

1. History:

 History of diabetes or symptoms suggesting it as loss of weight,

polydepsia (thirst), polyuria and polyphagia.
 History of frequent severe pruritis (recurrent monilial infection).
 History of repeated abortions, intrauterine fetal deaths or delivery
of oversized babies.

2. Physical assessment findings:

 Hypoglycemia
 Shaking
 Clammy pale skin
 Shallow respirations
 Rapid pulse
 Hyperglycemia
 Vomiting
 Excess weight gain during pregnancy

3. Investigations
 Pregestational diabetes:
o Fasting hyperglycemia (>125mg/dl) early in pregnancy.
o Random plasma glucose level >200 mg/dL
o Classic signs and symptoms such as polydipsia, polyuria,
unexplained weight loss and ketoacidosis

 Pregestational diabetes: (For whom?... When...By what?)

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 Gestational diabetes

A- Low Risk: Blood glucose testing not routinely required if all the
following are present:
o No known diabetes in first-degree relatives
o Age < 25 years
o Weight normal before pregnancy
o Weight normal at birth
o No history of abnormal glucose metabolism
o No history of poor obstetrical outcome

B- Average Risk: Perform blood glucose testing at 24 to 28 weeks

using :
o Two-step procedure: 50-g oral glucose challenge test (GCT), followed
by a diagnostic 100-g oral glucose tolerance test (GTT) for those
meeting the threshold value in the GCT.

C- High Risk:
o Perform blood glucose testing as soon as feasible, if one or more of
these are present:
 Severe obesity
 Strong family history of type 2 diabetes
 Previous history of GDM, impaired glucose metabolism, or
glucosuria.
1- Positive urine test: during routine antenatal care.

2- Fasting and 2 hours postprandial venous plasma sugar.

Fasting 2h postprandial Result

<100 mg/dl < 145mg/ dl. Not diabetic
>145 mg/ dl >200 mg/ dl. Diabetic

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 Gestational diabetes

100-145 mg/dl 145-200 mg/dl. Border line indicates

glucose tolerance test.
N.B. The whole blood glucose values are 15% lower.

o If GDM is not diagnosed, blood glucose testing should be repeated at

24 to 28 weeks or at any time there are symptoms or signs suggestive
of hyperglycemia.

3- 50-g oral glucose challenge test: Plasma glucose level is measured 1

hour after a 50-g glucose load without regard to the time of day or
time of last meal. A value of 140 mg/dL or higher is considered
positive→

4- Followed by a diagnostic 100-g oral glucose tolerance test (3 hours

100gm GTT)
o prerequisites:
 Normal diet for 3 days before the test.
 No diuretics 10 days before.
 At least 10 hours fast.
 Test is done in the morning at rest.

o Oral glucose tolerance test

 Fasting blood sugar is measured then patient is given 100 gm

glucose then blood sugar is measured after 1, 2 & 3 hours
o Criteria for glucose tolerance test:
 Plasma Glucose Criteria for Gestational Diabetes

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 Gestational diabetes

 If two or more results are abnormal, the patient is diagnosed as a

diabetic.

o Indications of performing glucose tolerance test:

 Positive urine test.

 First degree family history of diabetes.
 Gross obesity.
 Previous macrosomic babies.
 Previous unexplained intrauterine or neonatal deaths.
 Previous 2 or more unexplained abortions.
 Current or previous congenital anomalies.
 Current or previous polyhydramnios.

5- Glycosylated haemoglobin (Hb A1): It is normally accounts for 5-

6% of the total hemoglobin mass. A value over 10% indicates poor
diabetes control in the previous 4-8 weeks. If this is detected early in
pregnancy, there is a high risk of congenital anomalies and in late
pregnancy it indicates increased incidence of macrosomia and
neonatal morbidity and mortality.
6- Fetal assessment:
o Biophysical profile to ascertain fetal well-being
o Amniocentesis with alpha-fetoprotein

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 Gestational diabetes

o No stress test to assess fetal well-being

VII. Management of pre gestational diabetes:

a. Before pregnancy:
o Good control of blood glucose level.
o Keep HBA1c < 6% before conception (pregnancy is better avoided if
level > 9.5%).
o The diabetic woman should take folic acid 5 mg daily before
conception and for the first 12 weeks of pregnancy to reduce the
incidence of neural tube defects.
o Early booking for antenatal care when pregnancy occurs.

b. During pregnancy:
 Diet:
 Average caloric intake (2200 - 2400 Kcal/day)
 50-60% CHO, 15-20 % proteins &the remaining fat
 Divided in 3 main meals & 3 snacks in between.
 Insulin:
 Start by 0.7 u/kg in 1st trimester, 0.8 u/kg in 2nd trimester and 0.9
u/kg in 3rd trimester. according to the patient’s weight, the insulin
dose is calculated as following:
 In the first trimester ............patient’s weight x 0.7
 In the second trimester.........patient’s weight x 0.8
 In the third trimester............patient’s weight x 0.9
 Given in 2 doses, 2/3 in the morning (2:1 NPH:regular) and 1/3 at
evening (1:1 NPH:regular).
 Other regimens are: three-injection, four injections, and continuous
subcutaneous insulin infusion.
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 Gestational diabetes

 Keep FBS between 60 and 90 mg/dl & 2hrs PP ≤120 mg/dl.

 Supervision: Admission to hospital is indicated if diabetes is not
controlled or complicated by hypoglycemic episodes.
 Antepartum assessment:
 Maternal assessment:
 Preeclampsia
 Ophthalmologic, cardiac, and renal function
 Urine culture in every trimester for asymptomatic bacteruria

 Fetal assessment:
 Sonography: viability, fetal anomalies, fluid volume and fetal
growth.
 Fetal well-being: Daily kick count and non-stress test done twice
weekly (testing starts at 28-30 weeks).

c. Delivery:
 Timing of delivery:
 With good metabolic control and assuring antepartum surveillance→
delivery at term (complete 38 weeks) or at the onset of spontaneous
labor
 Fetal hypoxia, PE or previous history of IUFD → delivery before 38
weeks → amniocentesis to determine lung maturity → If no evidence
of lung maturity, dexamethazone for 48 hours (6 mg IM every 12
hours for 4 doses) then deliver.

 During labor:
 Blood glucose is determined every 2 hours.
 Urine is checked for ketones every 2 hours.
 Continuous monitoring of the fetal heart rate.
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 Gestational diabetes

 During Puerperium:
 The patient is given one -third to one-half her dose of insulin.
 Encourage breast feeding.
 Infection if present should be treated.

 During Puerperium:

 Managed as a preterm baby irrespective of its weight.

 Liable to develop respiratory distress syndrome (RDS), hypoglycemia,
hypocalcaemia (tetany), hyperbilirubinemia, or polycythemia.

 Contraception:
 Contraception options for diabetic women without vascular
complications are the same as for nondiabetic women. In women with
an increased risk for embolism, hormonal contraception containing
estrogen is nut recommended.
 Levonorgestrel intrauterine system (Mirena), can be offered.
 Permanent sterilization to women who completed childbearing.

Management of gestational diabetes:

 Usually controlled by diet only.
 If insulin is needed, dose and follow up as in pregestational DM.
 Delivery may be safely delayed in most cases until term or the onset
of spontaneous labor.
 GTT should be done 6-12 wks after delivery
 Recurrence: GDM has 70% risk of recurrence in subsequent
pregnancy.

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 Gestational diabetes

 20-50% of GDM will develop overt D.M. within 5-10 years.

Antenatal care
 Frequent antenatal visits: for maternal and fetal follow up.
 Control of diabetes:
o Diet: is arranged to supply 1800 calories/ day with restriction of
carbohydrates to 200 gm/ day, less fat and more proteins and vitamines.
o Exercise: exercise improved cardiorespiratory fitness without improving
pregnancy outcome. Also, physical activity during pregnancy reduced
the risk of gestational diabetes and diminished the need for insulin
therapy in overweight women with gestational diabetes.
o Insulin therapy:
 Oral hypoglycaemics are contraindicated during pregnancy, labor and
early puerperium as they are not adequate for controlling diabetes, have
teratogenic effects and may result in neonatal hypoglycaemia.
 Doses of insulin tend to increase in the first half of pregnancy, then
stabilize and finally rise in the last quarter, to be decreased again
postpartum.
 Twice daily (before breakfast and before dinner) injections of a
combination of short and intermediate acting insulins are usually
sufficient to control most patients.
 according to the patient’s weight, the insulin dose is calculated as
following: 0.7 u/kg in 1st trimester, 0.8 u/kg in 2nd trimester and 0.9
u/kg in 3rd trimester

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 Gestational diabetes

 Blood sugar analysis is carried out 4 times daily to regulate the doses as
follow: The aim is to achieve normoglycaemic values as in GTT.
 Hospitalization: if diabetics are not controlled as outpatients or
complications develop.
 Evaluation of fetal well - being by (ultrasound weekly, cardiotocography
weekly & amniocentesis before delivery for detection of phosphatidyl
glycerol that indicates lung maturity. L/S ratio is less reliable in
diabetics)

Delivery
 Timing: pregnancy is terminated at 37 completed weeks to avoid
intrauterine fetal death.
 Mode of delivery: vaginal delivery is induced in normal presentation,
favorable cervix, average sized baby and no fetal distress. Otherwise,
caesarean section is indicated.
 Insulin therapy:
o Day prior to delivery:
 Normal diet, - normal morning insulin,
 reduce evening insulin by 25%
o Day of delivery:
 5% glucose infusion in a rate of 125 ml/hour + short acting insulin 1-2
units/hour.
o Postpartum:
 Continue 5% glucose + insulin till oral feeding is established. When
oral feeding is allowed the pre-pregnancy dose of insulin is given.
Neonatal care:
o The neonate is managed as a premature baby as it is more liable
for RDS.

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o 5% glucose may given IV at a rate of 0.24 gm / kg/ hour to guard

against possible neonatal hypoglycaemia.

Contraception:
 Mechanical and chemical methods or sterilization are allowed but
hormonal methods are diabetogenic and IUDS may cause PID.
Progestogen only contraception may be used if the patient will
accept the high possibility of menstrual irregularity.

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