GESTATIONAL DIABETES

MELLITUS
SPEAKERS: Dr. Sukhendu Paik
Dr. Mouli Debangshi

MODERATOR: Dr. Prof. Barunoday Chakraborty

DEFINITION AND MAGNITUDE
GDM is defined as carbohydrate intolerance of variable severity with onset or first recognition during
the present pregnancy.

This definition applies whether or not insulin is used for treatment and undoubtedly includes some
women with previously unrecognized overt diabetes.

Indian Scenario:
6.5 Cr. Indians are Diabetics
20% Indians are overweight
10-14% pregnancies are complicated with diabetes
Among them 85-90% are pregnancy Induced Diabetes
10-15% are pre gestational Diabetes
ETIOLOGY
• Pregnancy It is a Diabetogenic condition

• In Pregnancy Estrogen, Progesterone, HPL, Cortisol, Testosterone, Growth Hormone,

Insulinase Enzyme. All these are responsible for Hyperglycemia.
• These hormones are highest in 3rd Trimester due to demand for glucose for fetus is
highest in 3rd Trimester. so Hyperglycemia will be highest in 3rd Trimester.
• So Physiological Hyperinsulinemia occurs in Pregnancy. But Glucose level still remain
high because Insulin Resistance is also increased. Maximum insulin resistance happens
in 3rd Trimester (34-36 weeks)
• Glucose Homeostasis in Pregnancy: Fasting Hypoglycemia and Post Prandial
Hyperglycemia observed in pregnancy ( that’s why small frequent meals are advised in
pregnancy). This effect is not seen in 1st Trimester
MATERNAL AND FETAL
PATHOPHYSIOLOGICAL CHANGES
• Physiological Glycosuria occurs in Pregnancy. Normal renal threshold for Glucose is 180mg%. But in pregnancy
it decreases to 135mg%

• In GDM there is maternal Hyperglycaemia and Hyperinsulinemia. Glucose crosses the placenta by facilitated
diffusion with the gradient by GLUT1 receptors & foetal blood glucose level closely follow the maternal level.
So there is foetal Hyperglycaemia. But maternal insulin dose not cross placenta. So beta cell hypertrophy
happens in foetus. ( Pederson’s Hypothesis)

This leads to foetal insulinemia.

This Insulin is very important for growth. So foetus will be macrosomic. Except for the fetal brain all tissues are
affected.
Also erythropoietin will be high. So Polycythaemia is seen.
Decrease surfactant formation. So respiratory distress syndrome is also present in these babies.

• GDM usually resolves with in 6 weeks of delivery.

Effect of diabetes on Pregnancy

Preterm labour (due to uterine over distention activate actine myosin filaments in uterus and
Increased incidence of pre-eclampsia (Abnormal placentation, placentomegaly)
Polyhydramnios (due to increase urine output of macrosomic fetus, also increase glucose in amniotic fluid
creates osmosis effect)
Sudden IUFD: Unexplained fetal death in last 4-8 weeks of Gestation.
GDM pts may develop Diabetes in future. (30-70% in next 15 years)
 Congenital Anomalies (in overt diabetic Pts.)
Diabetic nephropathy , retinopathy, neuropathy in pregnancy (in overt diabetic Pts.)
Diabetic ketoacidosis (mostly in overt diabetic Pts.)
Chronic Hypertension is more common in diabetic pts.
Coronary artery disease (due to glucose and free fatty acids damages endothelium)
Diabetic foot.
 Antepartum: Intrapartum: Post Partum: Neonatal:

• Preeclampsia, • Shoulder dystocia • PPH, • Hypoglycemia

• Polyhydramnios, and Brachial Plexus • Lactation Failure, (Blood Glucose <35
• Preterm labour, injury • Puerperal Sepsis mg/dl)
• Malpresentation, (due to increase • Hypocalcemia,
shoulder fat, • Hypomagnesemia,
• Fetal Macrosomia
• Prolonged Labour • Hyperbilirubinemia
• Sudden IUFD
• chances of • Polycythemia
• Abortions Instrumental (due to Chronic
(in overt DM- Delivery, C-section,
excess glucose is intrauterine
traumatic PPH hypoxia)
fetotoxic), increases,
• Congenital Anomaly • Respiratory distress
• Abruptio Placenta. syndrome
(in overt DM)
• IUGR • Transient
(in vasculopathy) Tachypnea of
Newborn
TYPES OF GDM
1. A1GDM - GDM that is adequately controlled without medication
2. A2GDM - GDM that requires medication to achieve euglycemia
SCREENING
• Essentially all Indian women have to be screened for gestational diabetes mellitus as they belong
to a high risk ethnicity
• LOW RISK GROUPS:
o 25 years age
o BMI< 25kg/sq.mm
o No h/o previous macrosomia
o No h/o maternal distress
o No h/o DM in first degree relatives
o Not members of high risk ethnic groups
o Member of an ethnic groups with a low prevalence of GDM
o No h/o abnormal glucose tolerance
o No h/o poor obstetric outcome
• INTERMEDIATE RISK:
at least one of the criteria in the list
• HIGH RISK:
marked obesity
prior GDM
Glycosuria
strong family history

• Screening should be done between 24 & 28 week of pregnancy

Value of screening during current pregnancy
Increased screening, identification and treatment can decrease the
morbidity and mortality of GDM
Decreased macrosomia , cesarean birth and birth trauma due to a >4000 g
infant
Decreased neonatal hypoglycaemia hypocalcaemia hyperbilirubinaemia
polycythemia
Identify women at future risk for diabetes and those with insulin resistance
Women are generally screened for GDM with glucose challenge test in the
late second trimester
If the result is abnormal oral glucose tolerance test is done
• Abnormal glucose challenge test but no GDM increased risk of future
cardivacular disease
• They have a lower risk than women who actually did have gestational
diabetes
• RETESTING:
 negative initial test but risk factor oresent
Obesity
> 33years of age
 positive 1 hour screen followed by a negative OGTT
3+/4+ glucosuria
• Low risk - no screening
• Average risk - at 24-28 weeks
• High risk - as soon as possible
Diagnosis
WHO/IADPSG (2011-2013)
• Diagnosis based on fasting and 2hr post 75gm OGTT blood sugar.
• One or more criteria should be met (WHO 2013, IADPSG)
ACOG 2step Diagnosis
Screening:

• high risk women - at first visit, one step - fasting and 2 hour post 75 gm
glucose
• Non high risk - 24-28 weeks of gestation - 50 gm 1 hr OGTT - venous blood
glucose

f/b 50 gm OGTT
Diagnosis - If 50 gm OGTT is >140 mg/dl do 3 hour 100 gm OGTT
IADPSG
• OGTT is done in the fasting state using 75 g of glucose at 24-28 weeks
and
• GDM diagnosed if any one of the following cut-off is met i.e.
Fasting > 92 mg/dl
1-hour ≥ 180 mg/dl
2-hour ≥ 153mg/d
 DIPSI, 2006
• non-fasting plasma glucose evaluation two hours after giving 75 g of
glucose load between 24 and 28 wk of gestation

Single step testing using 75 gm oral glucose & measuring blood sugar 2 hours after ingestion.
GOI, MOHFW, 2018
• Testing for GDM is recommended twice during ANC.
• The first testing should be done during first antenatal contact as early as possible in pregnancy.
• The second testing should be done during 24-28 weeks of pregnancy if the first test is negative.
• There should be at least 4 weeks gap between the two tests.
• Single step testing using 75 gm oral glucose & measuring blood sugar 2 hours after ingestion.

• 75 gm glucose is to be given orally after dissolving in approximately 300 ml water whether the pregnant women
comes in fasting or non-fasting state, irrespective of the last meal. The intake of the solution has to be completed
within 5-10 minutes.

• A plasma standardized glucometer should be used

• If vomiting occurs within 30 minutes of oral glucose intake, the test has to be repeated the next day, or else refer to a facility.
• If vomiting occurs after 30 minutes, the test continues.
• The threshold blood sugar level at 2 hrs of ≥140 mg/dL is taken as cut off for diagnosis of GDM.
Antepartum Testing And Fetal monitoring
Antenatal testing in women with poorly controlled or medication-requiring GDM is
initiated at 32 weeks of Gestation
• Baseline ultrasound : fetal size
• At 18-22 weeks major malformations & fetal echocardiogram
• 26 weeks onwards growth and liquor volume
• 3rd trimester frequent usg for accelerated growth ( abdominal : head conference)

if corticosteroids are administered

increased insulin requirement during the next 5 days should be anticipated, and the
patient's glucose levels should be closely monitored
TREATMENT
Treatment for gestational diabetes mellitus (GDM) is associated with
improved perinatal outcomes

MNT (MEDICAL NUTRITION THERAPY) is the first line

Upto 30% need pharmacologic treatment to maintain euglycemia

• Pharmacologic management - OHA or insulin

MEDICAL NUTRITION THERAPY

• Small frequent meals

• 6-7 meals daily ( 3 meals, 3-4 snacks)
• carbohydrate intake be limited to 33-40% of calories, protein (20%)
and fat (40%)
• Bed time snack to prevent ketosis
• complex carbohydrates may be preferred
• Energy requirements during the first 6 months of lactation require an
additional 200 calories above the pregnancy meal plan
SMBG (Self Monitoring Blood Glucose)
(ACOG)
• 4 times daily glucose monitoring performed as fasting and either 1 hour or 2 hours
after each meal.
• Those who meet glucose goals after a week of medical nutrition therapy can
perform SMBG every other day, rather than daily

• Targets for glucose control during pregnancy:

Fasting glucose 95 mg/dL

1-hour postprandial < 140 mg/dL

2-hour postprandial < 120 mg/dL

Switch to pharmacological Mx
• if fasting blood glucose levels are persistently greater than 95 mg/dL,
• if 1-hour levels are persistently greater than or equal to 140 mg/dL,
• or if 2-hour levels are persistently greater than or equal to 120 mg/dL.

OHA vs Insulin
• Insulin has historically been considered the standard therapy for GDM management in cases refractory to nutrition
therapy.

Insulin and oral medications are equivalent in efficacy, and either can be an appropriate first-line therapy in GDM
• OHA used: Glyburide and Metformin
• Insulin doesn't cross placenta, all OHAs do
• neither insulin, metformin, nor glyburide use during pregnancy has been associated with newborn birth defects
• long-term metabolic effects of offspring exposed in utero to oral hypoglycaemic agents are less well known
• Insulin Can achieve tight Blood Sugar control compared to OHAs. But requires multiple daily injections,

Theoretically: Insulin use is associated with an increased risk of hypoglycaemia.

Cochrane review - the rate of maternal hypoglycaemia was not significantly higher in women treated with insulin vs oral agents
in GDM
Insulin In GDM
• Starting dose: 0.7-1.0 units/kg daily. When both fasting and post prandial sugars are high
• This dosage should be divided with a regimen of multiple injections using long acting or
intermediate- acting insulin in combination with short-acting insulin

two thirds of the insulin in the morning and one third in the evening. Or half half

• isolated abnormal values at a specific time of day, - insulin regimen to correct the specific
hyperglycemia

For example,
 only elevated fasting values, night-time administration of intermediate-acting insulin, such as NPH insulin,

 elevated values only for breakfast postprandial, short-acting insulin before breakfast may be the only insulin
needed
• Rapid onset of action, enables the patient to administer her insulin right before
the time of a meal rather than 10-15 minutes or longer before an anticipated
meal
• Therefore prefer aspart or lispro over regular insulin for post prandial control
• Longer acting or basal insulins (eg, neutral protamine Hagedorn [NPH], glargine,
or detemir) are used to maintain euglycemia between meals and in the fasting
state.

Premixed insulins

• Human insulin premix 30:70 contains regular insulin and NPH in the ratio of
30:70
Compared with insulin, Metformin use in
GDM is associated with
Advantages
less maternal weight gain,
less gestational hypertension,
less neonatal hypoglycemia

Drawbacks
lower gestational age at delivery,
lack of superiority when compared with insulin,
the placental transfer of the drug,
absence of long-term data in exposed offspring

Administration of Metformin

⚫ starts at 500 mg nightly for 1 week at initiation, then increases to 500 mg twice to thrice daily

creatinine is checked at baseline to ensure adequate renal function.

FIGO GUIDLINE
Insulin should be considered as the first-line treatment (after MNT) in
women with GDM with following features
• Diagnosis of diabetes <20 weeks of gestation
• Need for pharmacologic therapy >30 weeks
• Fasting plasma glucose levels >110 mg/Dl
• 1-hour postprandial glucose >140 mg/dL
• Pregnancy weight gain >12 kg
Termination of Pregnancy in GDM
ACOG Guidline

• GDM with good glycemic control and no other complications - deliver

after 39 weeks
• poorly controlled GDM - delivery between 37 0/7 weeks and 38 6/7
weeks of gestation may be justified,
• Delivery from 34 0/7 weeks to 36 6/7 weeks of gestation should be
reserved for those women who fail in-hospital attempts to improve
glycemic control or who have abnormal antepartum fetal testing.
• If estimated fetal weight 4,500 g or greater, consider cesarean
delivery.
Termination of Pregnancy in GDM
FIGO Guideline
Sugar control in labor
• During induction of labor and active labor, maternal glycemia can be controlled with an intravenous
infusion of short-acting (commonly regular) insulin, an "insulin drip," titrated to maintain hourly readings
of blood glucose levels less than 110 mg/dL.
• Usual dose of intermediate-acting or long-acting insulin is given at bedtime.
• Morning dose of insulin is withheld or reduced based upon the timing of admission or delivery.
• Intravenous infusion of normal saline is begun.

• Once active labor begins or glucose levels decrease to less than 70 mg/dL, the infusion is changed from
saline to 5% dextrose and delivered at a rate of 100-150 cc/h (2.5 mg/kg/min) to achieve a glucose level
of approximately 100-110 mg/dL.

Glucose levels are checked hourly using a bedside meter allowing for adjustment in the insulin or glucose
infusion rate.

Regular (short-acting) insulin is administered by intravenous infusion at a rate of 1.25 units/h if glucose
levels exceed 100 mg/dL.
• The above may not be needed in GDM and most cases of pregestational type 2 diabetes. It is always
needed in women with type 1 diabetes
Follow up
Follow up in women with GDM

• FBS-PPBS or 75 gm 2hr OGTT at 3days after delivery.

• Repeat Test at 6weeks then after 6 months.
• Then yearly FBS-PPBS to be monitored till lifelong
THANK YOU