GESTATIONAL DIABETES MELLITUS (GDM)

AJAY RAJ

Diabetes mellitus is a chronic metabolic disorder due

to either insulin deficiency (relative or absolute) or due
to peripheral tissue resistance (decreased sensitivity) to
the action of insulin.
The pathophysiology involved are: (i) decreased
sensitivity of skeletal muscles and liver to insulin
(insulin resistance)
(ii) inadequate secretion of insulin ( cell dysfunction).
The defect lies both in insulin secretion and action.
The ultimate effect is the hyperglycemia.

 Two types are generally described.

Type1 (IDDM) is characterized by young age onset
(Juvenile) and absolute insulinopenia. They have
genetic predisposition with presence of autoantibodies.
Type2 (NIDDM) is characterized by late age onset,
overweight woman and peripheral tissue (skeletal
muscle, liver) insulin resistance (hyper insulinemia). Genetic
predisposition is also observed.
About 114 percent of all pregnancies are complicated by
diabetes mellitus and 90 percent of them are gestational
diabetes mellitus (GDM). Nearly 50 percent of women with
GDM will become overt diabetes (type-2) over a period of 5
to 20 years.

 Glycosuria in pregnancy ; During pregnancy renal treshold

is diminished due to the combined effect of increased GFR
and impaired tubular reabsorption of glucose.
Most commonly in mid pregnancy
If GTT is done glucose leaks out in the urine even though
the blood sugar is well below 180mg per 100ml
No treatment is required and the condition disappears after
delivery

GDM is defined as carbohydrate intolerance of variable severity with

onset or first recognition during the present pregnancy.
The entity usually presents late in the second or during the third trimester.
The potential candidates for GDM are:
(a) Positive family history of diabetes
(b) Having a previous birth of an overweight baby
of 4 kg or more
(c) Previous stillbirth with pancreatic islet hyperplasia revealed on autopsy
(d) Unexplained perinatal loss
(e) Presence of polyhydramnios or recurrent vaginal candidiasis in present
pregnancy

 (f)Persistent glycosuria
(g) Age over 30 years
(h) Obesity
(i) Ethnic group (East Asian, Pacific island ancestry).

Screening strategy for detection of GDM are:

(a) Low riskAbsence of any risk factors
as mentioned above blood glucose testing is not routinely required
(b) Average riskSome risk factors
perform screening test
(c) High riskBlood glucose test as soon as feasible.
The method employed is by using 50 gm oral glucose challenge test without regard to
time of day or last meal, between 24 and
28 weeks of pregnancy.
A plasma glucose value of 140 mg percent or that of whole blood of 130 mg percent
at 1 hour is considered as cut off point for consideration of a 100 gm (WHO 75 gm)
glucose tolerance test.
HAZARDS: (1) Increased perinatal loss is associated with fasting hyperglycemia.
(2) Increased incidence
of macrosomia
(3) Polyhydramnios

(4) Birth trauma (5) Recurrence of GDM in subsequent pregnancies is

about 50 percent.
MANAGEMENT: The patient needs more frequent antenatal
supervision with periodic check up of fasting plasma glucose level
which should be less than 90 mg percent.

Maintenance of mean plasma glucose level between 105 and 110

mg/dL is desirable for good fetal outcome

The control of high blood glucose is done by restriction of diet, exercise

with or without insulin.

Human insulin should be started if fasting plasma glucose level exceeds

90 mg/dL and 2 hours post prandial value is greater than 120 mg/dL.
(repetitive) even on diet control.

Exercise (aerobic, brisk walking) programs are safe in pregnancy and

may obviate the need of insulin therapy.

Obstetric management: Women with good glycemic control and who do not
require insulin may wait for spontaneous onset of labor.

Follow-up: Nearly 50% of women with GDM would develop overt diabetes over
a follow up period of 5-20 years
OVERT DIABETES
A patient with symptoms of diabetes mellitus (polyuria, polydipsia, weight loss)
and random plasma glucose concentration of 200 mg/dL or more is considered
overt diabetic. The condition may be pre-existing or detected for the first time
during present pregnancy.
According to American Diabetic Association diagnosis is positive if (a) the fasting
plasma glucose exceeds 126 mg/dL (b) the 2 hours post glucose (75 gm) value
exceeds 200mg/dL.

EFFECTS OF DIABETES ON PREGNANCY

Complications of diabetes outcome Maternal Fetal and Neonatal
MATERNAL
During pregnancy:
1. Abortion: Recurrent spontaneous abortion may be associated with uncontrolled diabetes.
2.Infection: Urinary tract infection and vulvo vaginitis.
3.Increased incidence of pre-eclampsia (25%).
4.Polyhydramnios (2550%) is a common association.
5.Maternal distress may be due to the combined effects of an oversized fetus and
polyhydramnios.

 Diabetic retinopathy, microaneurysms, hemorrhages and

proliferative retinopathy. Laser photocoagulation is the preferred
treatment.
Diabetic nephropathy
Ketoacidosis.
During labor: There is increased incidence of: (1) Prolongation of
labor due to big baby.
(2) Perineal injuries.
(3) Postpartum hemorrhage.
(4) Operative interference.

MANAGEMENT
Pre-conceptional counseling: Goal is to achieve tight control of diabetes before the onset of
pregnancy
Ideally a diabetic woman should be seen jointly by the diabetologist, obstetrician and
dietician.
.Women are taught for self glucose monitoring
.Appropriate advice about diet and insulin is given.

Principles in the management are: (1) Careful antenatal supervision and glycemic
control, so as to maintain the glucose level as near to physiological level as possible
(2) To find out the optimum time and method of delivery
(3) Arrangement for the care of the newborn.

ANTENATAL CARE: Antenatal supervision should be at monthly intervals up to

20 weeks and thereafter at 2 weeks intervals.
Frequent blood sugar estimation is required; monitoring by glucose meter gives an accurate idea.

Sonographic evaluation (Level II) in pregnancy (at 3-4 weeks interval) is helpful, to
diagnose varieties of congenital malformation of fetus and fetal macrosomia or
growth restriction (rare).
Assessment of fetal well being is to be made from 28 weeks onwards
Biophysical profile and NST should be performed weekly.
Doppler umbilical artery velocimetry is useful in cases with vasculopathy.
ADMISSION: In uncomplicated cases, the patient is admitted at 34-36 weeks. Early
hospitalization facilities :
(1) Stabilization of diabetes (2) Minimizes the incidence of pre-eclampsia,
polyhydramnios and preterm labor
(3) To select out the appropriate time and method of delivery.
Induction of labor: The indications are(i) Diabetic women controlled on insulin are
considered for induction of labor after 38 completed weeks
(ii) Women with vascular complications (pre-eclampsia, IUGR) often require
induction after 37 weeks.

Cesarean section:
The indications are
(1) Elderly primigravidae
(2) Multigravidae with a bad obstetric history
(3) Diabetes with complications or difficult to control
(4) Obstetric complications like pre-eclampsia, polyhydramnios, malpresentation
(5) Fetal macrosomia (> 4 kg). As such 50% of diabetic mothers are delivered by
cesarean section.

CARE OF THE BABY:

A neonatologist should be present at the time of delivery. The baby should
preferably be kept in an intensive neonatal care unit and to remain vigilant for at
least 48 hours, to detect and to treat effectively any complication likely to arise.
Asphyxia is anticipated and be treated effectively.
To look for any congenital malformation.
All babies should have blood glucose to be checked within 2 hours of birth to
avoid problems of hypoglycemia (blood glucose < 35 mg/dL).
All babies should receive 1 mg vitamin K intramuscularly.
Early breastfeeding within 1/2 1 hour is advocated and to be repeated at three
to four hourly intervals thereafter to minimize hypoglycemia and
hyperbilirubinemia.

Thank you