It explains in detail about gestational diabetes mellitus and its effect on the mother and fetus

1. Diabetes Mellitus
in Pregnancy

2. What is Diabetes
Mellitus?
• A metabolic condition characterized by chronic
hyperglycemia as a result of defective insulin
secretion, insulin action or both.
• Diabetes is the most common medical
complication of pregnancy.
• Impact of elevated blood sugar:
1. Pregnancy complications
2. Multi-organ dysfunction
3. Excess mortality

4. Gestational Diabetes
• Defined as carbohydrate intolerance of variable severity
with onset or first recognition during pregnancy.
• The entity usually presents late in the second or
during the third trimester.
• Gestational diabetes affects 3–9% of pregnancies,
affecting 1% of those under the age of 20 and 13% of
those over the age of 44.

5. Risk Factors
1. Strong familial history of diabetes
2. Body mass index >30 kg/m2
3. Previous gestational diabetes.
4. Have given birth to large infants (4 kg or
more)
5. Previous polyhydromnios.
6. Previous unexplained fetal losses
7. Over the age of 30
8. Ethnic group (East Asian, pacific island
ancestry)

6. Pathophysiology
Insulin
Resistance

7. Insulin resistance is a normal phenomenon emerging
in the second trimester of pregnancy, which in cases
of GDM progresses thereafter to levels seen in a non-
pregnant person with type 2 diabetes.
Factors that mediate insulin resistance during
pregnancy : Cortisol and progesterone are the main
culprits, but human placental lactogen, prolactin and
estradiol contribute, too with tumor necrosis factor
alpha which is named as the strongest independent
predictor of insulin sensitivity in pregnancy.

8. Screening

9. Oral glucose tolerance test (OGTT)
Procedure :
• CHO intake of at least 150 g/day 3 days prior then Fast for 10 to 16
hours
• 100 grams or 75 grams of anhydrous dextrose powder
Drink within 5 minutes (first swallow is time zero)
Terminate test should nausea and vomiting occur
• Abstain from tobacco, coffee, tea, food and alcohol during test
• Sit upright and quietly during the test , Slow walking is permitted but
avoid
vigorous exercise
• Collect samples at 0, 1 ,2 and 3 hours
Result:
 Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

10. 1- Diet :
• Recommendations are 30 kcal/kg for women with a BMI
of 22 to 25, 24 kcal/kg for women with a BMI of 26 to
29, and 12 to 15 kcal/kg for women with a BMI above
30.
• The recommended overall dietary ratio is 33% to 40%
complex
carbohydrates, 35% to 40% fat, and 20% protein.
• This calorie distribution will help 75% to 80% of GDM
women become normoglycemic.
Management :

11. • Avoid concentrated sweets and highly processed foods -
contribute to unwanted weight gain:
• soft drinks, ice cream, cakes and sweet.
• restrict CHO to those found in vegetables and dairy products like cheese and cottage
cheese
• Small frequent meals (4 hourly) instead of fewer larger meals
• Breakfast should be especially small and low in carbs because
insulin resistance is highest in the morning.
• Foods rich in antioxidants have a role in reducing the incidence
of
fetal anomalies therefore fruits and vegetables are
recommended
Management :

12. 2 Exercise
3 Glucose Monitoring
• Daily self blood-glucose monitoring had fewer
macrosomic infants and gained less weight after
diagnosis.
• Glycosylated hemoglobin should be determined at the
end of first trimester and three months thereafter.
HBA1C level of 5- 6% is desirable.
Management :

13. 4- Medications
A- Insulin Therapy : Recommended when standard dietary
management does not consistently maintain fasting plasma glucose
at <95 mg/dL or the 2hour postprandial plasma glucose < 120
mg/dL .
• Total dose of 20 to 30 units OD, before breakfast, is commonly
used to initiate therapy which is divided into two-thirds
intermediate-acting insulin and a third short-acting insulin.
• Alternatively, weight-based split-dose insulin is administered twice
daily.
• During the stabilization process of insulin dose, frequent blood
sugar estimation especially at night may be necessary
Management :

14. B- Oral Hypoglycemic Agents (OHA): is usually avoided due
to fearful effects of these drugs on the fetus but now Metformin
can be used in certain circumferences due to its safety in
pregnancy , especially if it was associated with Polycystic
ovarian syndrome.
If blood glucose cannot be adequately controlled with a single
agent, the combination of metformin and insulin may be better
than insulin alone
Management :

15. 1. On initial calculation of insulin dose, especially in unreliable
patients
2. Patient with Pregnancy-induced Hypertension.
3. Sever vascular diabetic disease
4. At any time if there are concerns about glycaemic control,
especially if hyperemesis gravidarum develops
5. In cases of diabetic complications ,e.g,diabetic ketoacidosis
Indications of hospitalization

16. • Insulin requirements drop to prepregnancy values immediately
following delivery of the placenta.
• For women who had diabetes before pregnancy , can be restarted on
their appropriate medication following the pregnancy .
• Insulin (For women with type 1 DM) is not excreted into breast
milk and is considered completely safe for use during
breastfeeding. The use of Metformin (for women with type 2 DM)
by breastfeeding mothers is also considered safe, as very little of
the drug is excreted in breast milk.
• Schedule 75-g OGTT after 6 weeks
Post-partum Follow-up

17. Prognosis :
• 60-70% chance of developing GDM in subsequent
pregnancies.
• 40-60% chance of developing type 2 diabetes in the future.
• A second pregnancy within 1 year of the previous pregnancy
has a high rate of recurrence.
• Children of women with GDM have an increased risk for
childhood and adult obesity and an increased risk of
glucose intolerance and type 2 diabetes later in life.
Prognosis and Complications :

18. Complications :
1- Maternal Complication
a. During Pregnancy:
1. Preterm labour (20%)
2. UTI
3. Increased incidence of preeclampsia (25%)
4. Polyhydramnios
5. Maternal distress
6. Diabetic retinopathy and Diabetic
nephropathy
7. Ketoacidosis
Prognosis and Complications :

19. Complications :
1- Maternal Complication
b. During Labor
1. Prolongation of labour due to big
baby
2. Shoulder dystocia
3. Perineal injuries
4. Postpartum hemorrhages
5. Operative interferences
c. Puerperium:
1. Puerperal sepsis
2. Lactation failure
Prognosis and Complications :

20. Complications :
2- Fetal and Neonatal Complication
a. Fetal complications
1. Fetal macrosomia (%30-40)
2. Congenital Malformations (%10) such as Neural tube
defect or VSD.
3. Birth injuries (brachial plexus)
4. Growth restriction (less common)
5. Unexplained fetal death
Prognosis and Complications :

21. Complications :
2- Fetal and Neonatal Complication
a. Neonatal complications
1. Hypoglycemia
2. Respiratory distress syndrome
3. Hyperbilirubinemia
4. Polycythemia
5. Hypocalcemia
6. Hypomagnesemia
7. Cardiomyopathy .
Prognosis and Complications :

22. Thank
you!