presentation on Gestational Diabetes 2024.pdf

OBSTETRIC AND GYAENECOLOGY

1. Gestational Diabetes
Catherine Kroamah Dwumfour (Ms.)
RM, BScN, MSc(ACP)
Department of Nursing, KNUST

2. Introduction
•Gestational diabetes mellitus (GDM) affects between 2%
and5%ofpregnantwomen.
•90%ofdiabetes seen in pregnancy areGDM.
•Pregnancy confers astateofinsulin resistance and
hyperinsulinemia that may predispose some women to
developdiabetes.

3. Introduction
•GDM should resolve shortly after the birth of the baby.
•The final diagnosis is therefore made in the postpartum
period.
•It is important that observations and outpatient follow-
up appointments are undertaken in the postnatal period.

4. Definition
•GDM is defined as glucose intolerance that was not
present or recognized prior topregnancy.
•GDM is also defined as carbohydrate intolerance
resulting in hyperglycaemia of variable severity, with
its onset or the first recognition during pregnancy.

5. ClassificationofDiabetes
•American Diabetes Association [ADA]: classification based on
disease aetiology.
•Type 1diabetes
•Type 2diabetes
•Gestationaldiabetes
•Impaired glucoseregulation

6. ClassificationofDiabetes
•Impaired glucose regulation (IGR)-is a metabolic
state between normal glucose homeostasis anddiabetes.
•IGR is grouped into 2categories
-Impaired glucose tolerance-raised post meal blood
glucoselevel>7.8mmol/L but <11.1 mmol/L or aftera
2-hour oral glucose test.

7. ClassificationofDiabetes
•-Impairedfastingglycaemia-fasting glucose
concentration lower than required to diagnose diabetes
but higher than normal range (>6.1mmol/L but <7.0
mmol/L).

8. Classifications of Gestational Diabetes
•Fasting glucose level >126 mg/dl (7.0 mmol/l) or
•Random glucose >200 mg/dl (11.1 mmol/l) meets the
threshold for the diagnosis of diabetes.

9. Classification of diabetes
The ADA categorize diabetes in pregnancy as:
•Pre existing diabetes
✓Type 1 diabetes
✓Type 2 diabetes
•Gestational diabetes

10. Normal blood glucoseregulation
•Regulationof blood glucose-pancreatic hormones
(glucagon andinsulin)
•Ingestionof carbohydrate increases blood glucose and
stimulate the pancreas to release insulinwhich reduce the
blood glucose level and vice versa.
•Normalglucoselevel for non pregnantwoman
-FBS (4.0 to 5.4mmol/L)
-2 hours after eating (under 7.8mmol/L)

12. Metabolicalterationsof Pregnancy
•During the first trimester, fasting blood glucose decreases
becauseofinsulin production, and sensitivity slightly
increases.
•By theendofthe first trimester, insulin sensitivity
decreases, with a responding increase in insulin
production; this change creates the diabetogenic state of
pregnancy.

13. Metabolicalterationsof Pregnancy
•Insulin resistance peaks in the last trimester to provide
more nutrients to the fetus.
•Euglycemia is maintained in pregnancy because the
pancreatic beta cells produce enough insulin to
counteract increasing insulin resistance
•Inpregnantwomen,hepaticglucoseproductionis1.3
timeshigherthanitisinnonpregnantwomen

14. Metabolicalterationsof Pregnancy
•American diabetes association recommends these
glucosetarget for pregnantwomen
•FBS: 95mg/dL /5.3 mmol/L orless
•1 hour after meals: 140mg/dL /7.8 mmol/L orless
•2 hours after eating 120mg/dL6.7 mmol/L orless

15. PathophysiologyofGDM
•In non pregnant women insulin secretion is proportional to
insulin requirement = noDM
•Pregnancy is a diabetogenic state
•Insulin resistance is as aresultofanti insulin hormones
produced by theplacenta.

16. Pathophysiology
•Pregnancy hormones interferes with or diminishes the
action of insulin on peripheral tissues as it binds to the
insulin receptor
•The beta cells compensate by increasing insulin
production to match insulin need, as a result there is no
glucose intolerance in thewoman.

17. Pathophysiology
•However in some women, the compensation effect of
the beta cells do notoccur.
•Hence, the insulin resistance which emerges in the
secondtrimesterprevents glucose from entering the
cells.
•Therefore, glucose remains high in thebloodstream
•Glucose travels across the placenta throughdiffusion

18. Pathophysiology
•The foetus is exposed to consistently higher insulin levels,
this leads to foetallevelsof insulin.
•The growth stimulatingeffectsofinsulin can lead to
excessive growth(macrosomia).
•After birth the high glucose environment disappears,
leaving these new-borns with ongoing high insulin
production and susceptibility to low blood glucoselevel.

19. RISK FACTORS FOR GDM
•Previous diagnosis of GDM
•Strong family history of type 2 DM
•Previous delivery of a macrosomic
infant (>4.5kg)
•Member of a high-risk population
(Aboriginal, Hispanic, South Asian,
Asian or African descent)
•Still births
•Age  35 years
•Obesity (BMI  30
kg/m
2
)
•Polycystic ovarian
syndrome and /or
hirsutism
•Corticosteroid use

20. Signs andsymptoms
•May have no symptoms
•Classic signs andsymptoms
•Polydipsia
•Polyuria
•Polyphagia
•Unexplained weightloss

21. Signs andsymptoms
•Other signs andsymptoms
•Fatigue
•Nausea
•Frequent vaginal, bladder and skininfections
•Blurredvision
•Glucose inurine

22. Screening fordiabetes during pregnancy
•Every pregnant woman should be assessed forGDM
•First assessment at the first prenatalvisit
•Patients with no known risk factors should undergo a 1
hour glucose test (glucose challenge test) at 24 to 28
weeksofgestation.
•Patientswithknownriskfactorsmaybetestedatthe
onsetofprenatalcare.Ifthisinitialscreenisnormal,
thenthetestisrepeatedafter24weeksofgestation.

23. Screening forGDM
•2 screening system arerecommended.
•Glucose challengetest
•Oral glucose tolerance testing(OGTT)

24. Screening forGDM
•Glucosechallengetest-measuresyourbloodresponsetoglucose.
•Thepatientreceives50gofglucose(sugarysolution).
•Onehourlater,bloodisdrawnforaplasmaglucose
determination.
•Aglucosevalueabove130to140mg/dL(7.2to7.8mmol/L)is
consideredabnormalandnecessitatesasecondtest,i.eglucose
tolerancetest.

27. Screening forGDM
•Oral glucose tolerance testing(OGTT)
•Fast at least 8hours
•Clinicians first draw a fasting glucose sample and then
administer 100gofglucose.
•Blood is drawn at 1 hour, 2 hours, and 3hours
•OGTT should always be used to diagnose GDM and IGR

28. Screening forGDM
•Plasma glucose criteria forGDM
•Fasting -95mg/dl(5.3)
•1hour-180mg/dl(10)
•2 hours -155mg/dl(8.6)
•3 hours –140 mg/dl(7.8)
•Diagnosis ismadeif 2 or more values are met orexceeded.
•A singleabnormalvalueshow adegreeof glucose intolerance.

29. Management
The main aim of management is to;
✓maintain blood glucose levels as near to normal as
possible.
✓prevent adverse pregnancy outcomes/ long term
complications.

30. Prepregnancy management
•Aim to;
✓Maintain glycosylated hemoglobin (HbA1c) <43 mmol/l
(6.1%) to reduce the risk of congenital malformations.

31. Pre pregnancy Management
•Pre-conception care
•Take comprehensive history
•Comprehensive assessment
•Education-is thecornerstoneof effective metabolic
management
-educate women on the need to establish good glycemic control
before conception and through out pregnancy to reduce
complications.

32. Prepregnancy Management
•Genetic counselling
•Individual target for self glucose monitoring: women with
HbA1c >86 mmol/l (10%) should avoid pregnancy.
✓offer HbA1c testing monthly.
•Review of anti diabetic drugs
✓Discontinue statins before pregnancy or as soon as pregnancy
is confirmed

33. Prepregnancy management
•Assess for renal, cardiovascular or retinal changes
•Nutritional and dietary advice
- complex carbohydrate and cellulose
•Folic acid supplementation (5g)

34. Monitoring a pregnant woman with
diabetes
•A multidisciplinary approach isused.
•Patient is asked to keep an accurate diary of their blood glucose
concentration.
•The glycemic targets associated with the best pregnancyoutcome;
Preprandial < 5.3mmol/L
1-hour postprandial < 7.8mmol/L
2-hour postprandial < 6.7mmol/L

35. Monitoring a pregnant woman with
diabetes
•Women with GDM should carry out frequent fasting and postprandial
home blood glucose monitoring to achieve glycemictargets.
•HbA1c: measurement ofmeasured every 4 weeks to detect average blood
glucoselevels.
-HbA1c <6.5% is an indicationof good diabeticcontrol.
•Eye examination and urine R/E.
•Urine check for ketones and proteins
•• Kidney function

36. Antepartum Management
•Aim- strict glucose control
•ANC Care
-patient is seen every 2 to 4 weeks until 28 weeks and then 1-2
weeks untilterm.
•Blood glucosemonitoring
-4 times in aday

37. Management
•Diet
- aim is to avoid single large meal and simple carbohydrates.
-high fiber diet is beneficial
-6 feeding per day-3 major meals and 3 snacks to limit glucose level in
the blood stream at a time.
-Standard diabetic diet - 2000-2500Cal/day is recommended.
-If overweight, client must not reduce intake to below 1800 calories.

38. ANC management
•In a diabetic mum, weight gained is directly correlated to weight of
infant
•Exercise
-Physical activity should be encouraged
-Daily 30 minutes walking is recommended at least 4 times a week
-Before exercising, the woman should check her blood glucose
and urine ketones.

39. ANC Management
•Education
-educate the client and relatives on signs of hypoglycemia
and hyperglycemia and its management
-Vaginal and urinary tractinfection
-Diet , medication, blood sugar monitoring etc.

40. ANC Management
•Medications
•Insulin-standardmedicationfor treatmentof GDM
-to achieveglucoseprofilessimilartothoseof non diabetic pregnant
women
•Oral HypoglycemicMedications
-Metformin
-Glyburide

41. ANC Management
•Antepartum Testing/fetalmonitoring
•USG -First trimester USG to assess pregnancy dating and viability
•Second trimester –anomalyscan
-a fetal echocardiogram to assess congenital cardiacanomalies.
•Third trimester USG to asses fetal growth (every 4-6weeks).
•Twice weekly testing -NST and amniotic fluid volume, beginning
at 32 weeks gestation to assess fetalwell-being.

42. ANC Management
•Antepartum Testing/fetalmonitoring
•Fetal heart ratecheck
•Foetal movementassessment
•Fetal umbilicaldoppler

43. ANC Management
•Glucose tolerancetest
•Check for ketones inurine
•Renal functiontest
•UrineR/E
•HbA1c

44. IntrapartumCare
Theaimof intrapartum care is to maintainnormoglycemia
Delivery
•Timing andmodeofdelivery isindividualized.
•Early delivery may be indicatedfor:
-women with poor glycemiccontrol
-pregnancies complicated by fetalabnormalities

45. Intrapartum care
•Otherwise, pregnancies are allowed to go to term and normal
birth is recommended in a hospital with NICU services.
•Fetal biophysical test- USG, CTG, umbilical doppler, NST
•No indications to pursue delivery before 40 weeks in patients
with good glycemic control however,NICE recommend labour
commence after 38 completed weeks to prevent the risk of late
fetal death.

46. Intrapartumcare
•Most common complication is shoulderdystocia
-31%ofneonates weighing>4,000g
•Data does not support theuseofC-section to avoid birth
trauma
-13% error rate estimating fetal weight byultrasound

47. Intrapartum mmanagement
Counsel for electiveC-section
•Estimated fetal weight>4kg
•Patient history andpelvimetry
•Discuss risks andbenefits
•Glucosemonitoring
-Check patient’s glucose every 1-2hours.

48. IntrapartumManagement
-Startinsulindriptomaintainaglucoselevelofbetween
80 to 110mg/dL (4.4 to 6.1 mmol/L).
- Start patient on a sliding scale

49. Postpartum
•NeonatalConsiderations
-Transfer baby to NICU
-Observe newbornclosely for hypoglycemia,
hypocalcemia, and hyperbilirubinemia afterbirth.
-neonatal hypoglycemia is a risk in the first 48 hours of
life and requires close monitoring and early intervention
to prevent seriouscomplications.
-frequent blood glucose check and early oralfeeding

50. Management
•Athoroughphysicalexaminationafterbirthinvolvingall
organsystemsisessentialtoidentifymalformationsthat
werenotdetectedprenatally.
•Encourage breastfeeding
•Nursesplayapivotalroleineducatingwomenaboutthe
lifelongriskofdiabetesandobesityintheiroffspring

51. PostpartumCare
•Immediatelyafterbirth,insulinresistancedramatically
improvesforallwomenwithdiabetes.
•Oralantidiabeticmedicationscanberesumediftheyare
compatiblewithbreastfeeding
•InwomenwithGDM,blood-glucosemonitoring
continuesuntilnormoglycemiaisevident.

52. Postpartum
•Breastfeeding
•Breastfeeding should be encouraged in allwomen
•Insulin requirements for breastfeeding women with
pregestational diabetes are usually lower and episodes of
hypoglycemia increased than for nonbreastfeeding
women with pregestationaldiabetes.
•Women with diabetes should eat a 15-g carbohydrate
snack before or duringbreastfeeding.

53. Postpartum
PostnatalOGTTisperformedat6weeks,ifresultsareabnormal
appropriatereferralshouldbemade.
Followup:
•Ifthepatient’spostpartumOGTTisnormal,sheshouldbere-
evaluatedataminimumof3yearsintervalwithafastingglucose.
•Allpatientsshouldbeencouragedtoexerciseandloseweight.

54. Management
•All patients should be evaluated for glucose intolerance or DM
before a subsequentpregnancy.

55. Fetal and neonatal complications
Congenital abnormalities
Latestillbirth
IUGR-type 1 diabetes due to maternal vasculardiseases
Increasedneonataland perinatalmortality
Respiratory distress syndrome (RDS)
Macrosomia
Birthtrauma

56. Fetal and neonatal complications
Hypoglycemia
Polycythemia
Hyperbilirubinemia
Jaundice

57. Maternal Complications
Hypoglycemia
Infection (UTI)
Ketoacidosis
Retinopathy
Miscarriage
Polyhydramnios
Shoulder dystocia and perineal tears

58. Maternal complications
Preeclampsia
Increased caesarean rate
Future type 2 diabetes

59. Complications
•LONGTERM
•Type 2 diabetes
•Coronary heartdisease
•Peripheral arterialdisease
•Diabeticnephropathy
•Diabeticretinopathy
•Diabeticneuropathy

60. References
•Marshall J. E. & Raynor, M. D. (2014). Myles textbook
for midwives (16th ed.). Edinburgh: Churchill
Livingstone.
•Ricci, S. S. (2016). Essentials of maternity, newborn,
and women’s health nursing (4th ed.). Philadelphia:
Lippincott Williams & Wilkins.

61. •THANKYOU