Screening Test & Management of GDM

A) MGTT
Steps of MGTT:
1) patient MUST be on normal diet for 3 days prior to test (STUDENT ALWAYS
MISS THIS), meaning fasting month is not suitable to do MGTT.
2) Patient should fast 6- 8 hours before test
3) Fasting blood sugar is taken; drink 75g of glucose dissolved in 250ml of water.
Must finish everything within 5 15minutes, cannot vomit
4)2 hours postprandial glucose level is taken.
Normal value: <5.6(fasting) | <7.8 (2hours post prandial) (just
remember 5,6,7,8)
If deranged (Any value): confirmed diagnosis of GDM provided no
pregestational diabetes, and start patient on diet control. BSP is check

Question: when should I subject patient to MGTT??

Ans:
-Depends on the risk factors present on the patient. According to NICE guidelines,
Patient with high risk factors (Previous GDM, family history, and glycosuria 1+ in 2
occasions / 2+ in 1 occasions) should be tested on 16-18 weeks once and 24 -28
weeks once more if previous result was normal.
-If patient is presented with other risk factors, most appropriate time to do MGTT is
on 28-32 weeks of POA as its the most diabetogenic state in pregnancy
-MGTT should not be done before 16 weeks because mother is subjected to
hyperemesis.
- If patient already have established type 2 DM , DO NOT DO MGTT anymore,
straight away monitor using BSP.
B) Blood Sugar Profile (BSP)
Clearing of concept
BSP is done straight after MGTT if showed mother has GDM and is used to
access the efficiency of diet control of GDM mother
BSP is done in 2 ways (Depending on Hospital) :
1. Venous blood taking (Done in HUKM)
2. Dextrostix (capillary blood taking)
Accepted value for HUKM is 5/6/6/7mmol/L , while in other places is
4-6/4-6/4-6/4-6.8 mmol/L. The pre-bed can be higher is because normally

after 10pm, no meals will be taken and there is longer hours before reaching
breakfast, so patients blood glucose level can be allowed to be slightly higher.
Assess at 8am for pre-breakfast, 11am for pre-lunch, 5pm for pre-dinner,
10pm for pre-bed.
Venous blood taking BSP
Advantage:
More accurate value as access venous blood which is the level of glucose after
utilization by cells
Cost-effective as no need to used glucose strip and buy glucometer
Disadvantage:
Need to fix a date and come to hospital to do for all 4 readings on the same
day.
Only review 2- 4 week once. Patient can cheat (poor controlled for first 3
weeks, then good controlled for 1 week, BSP will reveal good result when
taken in hospital) however, if patient result is normal and there are signs of
poor control such as polyhydramios, we can compensate by doing HbA1c or
Fructosamine that trace the control of sugar for past 3 months and 3 weeks
respectively
Dextrostix BSP.
Advantage:
Can monitor by own self at home and is monitored EVERYDAY. Normally do
1st day pre-breakfast, 2nd day- pre-lunch, 3rd day pre-dinner, 4th day pre-bed
and the cycle continues for 2 -4 weeks, patient cannot cheat on their diet
control.
Disadvantage:
Costly (glucostrip and glucometer) , but can be compensated by monitoring
one reading per day only as mentioned above rather than monitor 4 values
every day.
Not as accurate as venous blood taking
-

Patient with one deranged value are advice to have better diet
control
Patient with 2 or more deranged values of BSP (eg 6/5/5/10) are
started on insulin control. First, patient will be admitted to ward
and subjected to classic triad counseling of diabetic
educator( explain complication of diabetes), dietician , and also
pharmacist (to teach method on how to inject insulin)
Patient is also admitted for the reason of optimal adjustment of
insulin dose (based on BSP) beside to have the triad counselling.
After achieving an optimal dose which is defined as capability of
maintaining acceptable glucose level in mother without the
presence of hypoglycaemia symptoms, patient is discharged and

GDM on Insulin Commencement

Insulin commencement is started when patient have 2 deranged value of BSP
Patient is admitted in ward once the medical practitioner decides to start
patient on insulin for adjustment of dose as explained above. (that is why case
note will write patient is admitted for GDM on insulin commencement)
Rule of thumb of Insulin commencement in GDM MUST BE combination of short
acting insulin (actrapid) + intermediate acting insulin (insulatard).
Insulatard is normally BD dosage, but is used as OD dose in GDM
The dosage of insulin is based on the BSP result. The higher the BSP
derangement, the higher the dose of insulin to be started.
Normally, patient will be started on 8/8/8/8 (actrapid/ actrapid/ actrapid/
insulatard). Insulin 4 dosage per day sum up cannot be more than 80units.
However, if the value of actrapid is too high (eg 20/20/20), despite not
exceeding 80 units, we give BD dose of insulatard instead of 3 doses of
actrapid (insulatard/actrapid/actrapid/insulatard). This is because if actrapid
values are too high, patient will tend to be hypoglycemia all the time and tend
to eat more, causing worsening of the diabetes. Values of insulin to be started
and the increment are based on home-glucose monitoring value and
experience on the doctor.
Patient should be reviewed 2 weeks once.
-

Patient on diet control will be started on insulin if 2 values

deranged from the BSP. If patient home -glucose monitoring
level is still high, we step up the insulin dosage. If after dose
increment and the glucose level is still high, we start
metformin+ insulin
Sequence of management : diet control-> BSP deranged ->
insulin -> home-monitoring glucose level still high -> insulin
dose increment-> glucose level still high-> insulin+metformin

When monitoring blood glucose in diet control, when review patient we check
the BSP. However in GDM with insulin control, we just review the home
glucose monitoring result, no need do BSP.
Question 1: when to deliver when patient on diet control/ insulin?
Ans: diet control: can deliver from 38 weeks onwards (not conventional 40weeks) but
not more than 40 weeks/ post-date due to the risk of sudden IUD and the decline
function of the placenta that normally start at 38 weeks.
Insulin control: deliver at 38 weeks on the dot because the higher risk of IUD
compared to GDM on diet control.

Question 2: In mother with poorly control GDM, and there is a risk of delivering the
baby at 34 weeks, do we give IM dexamethasone to patient?
Ans: Yes. First admit patient, then administer dexa with concurrent monitoring
maternal blood glucose level, if the glucose level is high, we can increase the dose of
insulin. (Reason to be is although corticosteroid can worsen diabetes in the mother,
we still give because risk of Respiratory Distress Syndrome in baby born to GDM
mum is higher)
Management of GDM patient in Labour( Intrapartum)
Once GDM patient (on diet control/ on insulin) / pregestational diabetic is
admitted to labour room, glucose level must be check using Dextrostix
(hourly) and insulin infusion should be started based on sliding scale regime.
The amount of insulin to be infused varies based on the hourly dextrostix
reading. In HUKM , if the reading of glucose is 7mmol/L, Dr normally
check dextrostix 4 hourly instead of 1 hourly.
BUSE must be done 4 hourly to check for ketone level, as presence of ketone
indicates ketoacidosis and must be treated promptly or if will causes
complicated labour.
GIK regime is started intrapartumly :

GIK Regime
Clearing of concept GIK regime is the main regime used in patient with Diabetes in pregnancy
which is in labour. Sliding scale regime is just a subset within GIK regime for
the insulin control/ I part only of the GIK regime.
Patient who presented with GDM on diet control /insulin control /
Pregestational diabetes are all subjected to GIK regime during labour.
Question:
1) Why patient is diabetic and we still give glucose?
Ans: we still give glucose because mother is keep NBM during labour and labour
is a process which uses a lot of energy, we dont want the mother to go into
diabetic ketoacidosis state
2) What is the role of potassium in GIK regime?
Ans: Potassium is given because K-ATP channels is involved in glucose uptake in the
target tissues of insulin; high insulin infusion causes extra decrease level of potassium
in the ECF as more potassium is involve in transporting glucose into the cells, that is
why we must supply patient with potassium to prevent hypokalemia that will lead to

cardiac arrhythmia. Amount of potassium given is based on a scale that is calculated

that coincide with the amount of insulin given (I dont know which scale). If glucose
level is within range and no insulin is given based on sliding scale regime, then no
need give potassium la~

Question: when should detailed scan be offered in diabetes in pregnancy?

Ans: Pregestational diabetes & patient who is diagnosed with early GDM (16-22
weeks) should be offered detailed scan. Detailed can be done starting 16- 22 weeks,
however, we normally do the scan at 18-22 weeks. The reason is 16-17 weeks; the
heart is too small to be visualized while after 24 weeks, the rib formation will obscure
the view.