Gestational DM

Diabetes Mellitus

Diabetes mellitus is an endocrine disorder of carbohydrate metabolism.

It is characterized by hyperglycemia resulting from the inadequate production or ineffective use of insulin.

Classification

Pregestational DM: type 1 or 2 DM that existed before pregnancy occurred.

Gestational DM (GDM): glucose intolerance

with onset during pregnancy.

Effect of pregnancy on Diabetes

Pregnancy has been called a diabetogenic state in which the need for glucose is increased, creating a resistance to insulin.

Maternal insulin dose not cross placenta. By the 10th weeks of gestation the fetus must secrete

his own insulin. During the first trimester maternal glucose levels

decrease as result of fetal demand for rapid cell division, N&V.

During the 2nd and the 3rd trimester rising levels of hormones ( estrogen, progesterone, human placental lactogen, cortisol, and insulinase) increase insulin resistance through their action as insulin antagonists.

Maternal insulin demands increases 3 folds. During labor, with increased energy needs, the DM

mother may require more insulin. Pp decrease in insulin requirements. Maternal tissues quickly regain their nonpregnant

sensitivity to insulin.

Pregestational DM

Pregnancy will affect glycemic control. Pregnancy may accelerate the progress of vascular

complications. OHA cannot be taken during pregnancy. During the 1st trimester, the mother’s blood glucose

levels are usually reduced and she may need less insulin.

Insulin resistance continues to rise until the last few weeks of pregnancy.

Risks and complications

Fetal complications

1. Maternal hyperglycemia may cause fetal anomalies.

2. Macrosomia and impaired fetal lung functions ( RDS) can occur.

3. At birth hypoglycemia may occur in the neonate.

4. Polycythemia, hypocalcaemia, hyperbilirubinemia, thrombocytopenia.

Two babies born to diabetic mothers in the Rijks hospital 1956.

One mother attended the center throughout pregnancy, the other didn’t.

Maternal complications

1. Spontaneous abortion.

2. Infections ( UTI, vaginal infections).

3. Polyhydrominios.

4. Gestational hypertension.

5. Hypoglycemia.

Assessment and management

The advised care plan:1. Monitoring diet.2. Exercise.3. Insulin administration. Assess the emotional status. Her knowledge of DM to determine her educational

needs. Physical examination include ECG to assess her

cardiovascular status.

Diet

The recommended diet is based on blood glucose levels.

Average diet may be 30-35 kcal/kg of body weight in the 1st trimester, and 35kcal/kg in the 2nd and 3rd trimester with carefully planned snacks.

About all women 1500-2000 kcal. A large bed time snack is recommended to prevent

overnight hypoglycemia. 40-50% of calories should be complex, high fiber

carbohydrates, 20% protein, 30-40% from fats

The woman is taught signs of hypoglycemia and hyperglycemia and home care of such events.

Vitamins and folic acid in the form of prenatal vitamins is recommended.

Exercise: individually prescribed exercise according to the prepregnant life style is recommended. Proper exercise enables muscle activity to help normalize glucose levels.

15-30 minutes of walking 4-6 time per week .avoid vigorous exercise ,must performed after meal ,if uterine contraction was felt, the exercise should be stopped immediately .

Insulin therapy : In 1st trimester the insulin dosage reduce to avoid hypoglycemia.

0.7 units /kg

In 2nd &3rd trimester the insulin dosage

0.8 units /kg in 18-26 week

0.9 units /kg in 27-36 week

1 unit /kg in 37 week

Gestational DM

GDM is diabetes mellitus defined as carbohydrate intolerance of variable severity, with the first recognition during pregnancy.

Some women with GDM exhibit the classical S&S of diabetes, including excessive thirst, hunger, urination, and weakness.

The routine urine analysis showing glucoseuria. The risk of congenital malformation and spontaneous

abortion is less than pregestational DM. GDM is usually diagnosed in the 2nd half of

pregnancy.

Diet often controls gestational diabetes, however 10-15% of women with GDM will require insulin to maintain glycemic control.

S&S of GDM may disappear a few weeks after the birth of the newborn. However 35-50% of women will show deterioration of CHO metabolism in the next 15 years of life.

Screening During Pregnancy

The usual time to screen is between 24-28 weeks gestation. Glucose challenge test commonly given for GDM is the 50-g, 1-

hour diabetes challenge test. If the plasma glucose 1 hour after ingestion 50 g glucose is

greater than 140 mg/dl, a follow up oral glucose tolerance testis performed for more accurate evaluation.

Oral glucose tolerance Test ( OGTT) gold standard test. Fasting BS before test, give100g glucose (3 hr) 1,2,3 hr BS

sample.

)OGTT( Positive for GDM two or more levels are met or

exceeded

Fasting Less than 95 mg/dl

1-hrLess than 180 mg/dl

2-hrLess than 155 mg/dl

3-hrLess than 140 mg/dl

Glucose monitoring

Aim of therapy strict BS control. Fasting BS 65-105mg/dl ( Euoglucemia) The goal of glucose monitoring is to maintain a level

between 80-120 mg/dl postprandial level. The evaluation of glycemic control is based a

glycosylated hemoglobin( HbA1c) level. Measuring the amount of glucose attached to HbA determine the glycemic control for the preceding 2-3 months.

Monitor daily blood glucose at home. Fasting + postprandial glucose weekly.

1. Adult Without Diabetes :- 2.2%- 4.8%2. Good Diabetic Control:- 2.5%- 5.9%3. Fair Diabetic Control:- 6% - 8 %4. Poor Diabetic Control:- > 8%

HbA1c level

Insulin therapy: Pregestational DM and GDM could be

managed by diet and exercise. Up to 20% need insulin. FBS more than 105 insulin should be started.

Elective induction of labor may be planned between 38-40 weeks in well controlled diabetic woman.

Intrapartum care: during labor and birth monitor BS every 2 hrs, range between 80-120, glucose IVF not commonly used.

C/s birth is common because of CPD. PP care: most GDM return to normal BS levels after

birth. ( 50% next pregnancy may develop GDM).

Fetal surveillance

Prenatal fetal assessment is essential during pregnancy and labor.

Tests include a biophysical profile, kick count, nonstress test.