GESTATIONAL DIABETES MELLITUS

Posted: July 15, 2010 by gerardloh in O & G

DIABETES MELLITUS

A metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbance of carbohydrate, fat and protein metabolism resulting from defects of insulin secretion, action or both

GESTATIONAL DIABETES MELLITUS

*Gestational diabetes mellitus is any degree of glucose intolerance during pregnancy

raised blood glucose level >7.8 mmol/L or not >11.1 mmol/L 2 hours post-prandial OGTT

RISK FACTORS

  1. Gestational diabetes previous pregnancy
  2. Obesity (BMI >30)
  3. Age > 35
  4. Presence of glycosuria in >2 occasions
  5. History of DM in first degree relatives
  6. Previous big baby > 4.0 kg
  7. Previous history of recurrent abortion or unexplained stillbirth
  8. Previous congenital anomalies
  9. Polyhydramnios

Complication in GDM

Maternal

  • Nephropathy
  • Retinopathy
  • Coronary artery diseases
  • Hyperglycemia / hypoglycemia /ketoacidosis
  • Pre-eclampsia
  • Infection
  • TE

Fetal

  • Congenital abnormalities:  cardia and neural tube defect
  • Macrosomia
  • RDS
  • Hypoglycemia
  • Polycythemia
  • Hyperbilirubinemia

Management of diabetes in pregnancy !!!

v      Prepregnancy counselling.

v      Combined diabetic-antenatal clinic.

v      Dietary advice.

v      Routine antenatal care.

v      Ultrasound            : early for dating

v                                                      : detailed TRO fetal                                                                                              abnormality

v      Insulin therapy.

v      Monitoring.

SCREENING FOR DIABETIC IN PREGNANCY…

After 12-14 weeks gestations as soon as the risk factors are identified.

In women whose GTT is normal but have significant risk factors, a repeat test must be perform at 24-28 weeks gestation and again at 32-34 weeks gestation.

MOGTT PROCEDURE

  1. Fasting from 12am till the next morning
  2. Take blood.
  3. Give patient to drink 75g glucose+ 250ml water ,drink in 10-15min.
  4. After 2 hrs,take blood again.

DIAGNOSIS OF DM IN PREGNANCY

Normal (mmol/L Impaired glucose tolerance (mmol/L) Diabetes (mmol/L)
Fasting < 6.0 6.0 – 7.9 > 8.0
Or And And/or
2 hours < 8.0 8.0 – 10.9 > 11.0

Antenatal care

Aim: to maintain blood glucose level

at 4-6mmol/L

Glucose control

¡         Dietary Control (D/C)- by dietitian

(Requirement: 30 – 35 kcal/kg per day for non-obese and 25kcal/kg per day for obese patient)

OHA is not recommended due to:

v      possible teratogenic effect

v      difficult to establish tight control

  • Insulin Therapy
    1. FBS > 5.8mmol/L
    2. 2 hour post-prandial >7 mmol/L
    3. failed D/C (start insulin after 2 weeks on diet control(IV) )
    4. fetal macrosomia (AC > 95th centile) between 29 – 33 week gestation despite good glycaemic control

¡         require 3 or 4 daily doses of insulin.

¡         2 forms of insulin used in combination:

short acting : actrapid, humulin R

given before meals

Long acting : Monotard, humulin L

given before bed

*educate the pt about correct way of insulin injection.

¡         fetal supervision with ultrasound for growth and well being – usually every trimester.

Assessment for GDM patient

Maternal-

  • BSP
    • HbA1c
    • Renal profile (pre-existing)
    • Home monitoring
    • Early detection of complication.

Fetal

-          Ultrasound

-          Biophysical profile

-          CTG

-          Fetal kick chart

Blood Sugar Profile

¡         BSP- Blood Sugar Profile

¡         Do before starting and also  to monitor insulin therapy

¡         4 times

-          pre-breakfast

-          pre-lunch

-          Pre-dinner

-          Pre-bed time

Normal range- 4-6 mmol/L

Monitoring of glycaemic control

BSP (blood sugar profile)

If on Insulin therapy: BSP every 2 weeks

If on D/C: BSP every 4 weeks

    • fasting < 5.5 mmol
    • pre-meals level of 4-6mmol/L
    • 2-hour postprandial capillary level < 7.0 mmol/L

HbA1c

    • 3 month control
    • level < 7%

Timing for delivery

¡         If on insulin- terminate by 38th week

¡         If on D/C – can prolonged till 40th weeks

DO NOT EXCEED DUE DATE!!!

Mode of Delivery

¡         Aim for SVD !!

¡         C-Section if:

▪           Macrosomia

▪          Suspicion of cephalo-pelvic disproportion

▪          A previous caesarean section

▪          Malpresentation

▪          Polyhydramnion

▪          Evidence of fetal compromise

▪          Bad obstetric history

▪          Poor diabetic control

Management in labour

¡         Mother admited to LR  NBM

¡         Omit morning dose of insulin injection.

¡         GSH, 2 units

¡         Hrly glucometer monitoring

¡         4 hrly BUSE, RBS

¡         pain relief – epidural is ideal

¡         monitor fetal heart closely, CTG

¡         Capillary blood sugar on admission and follow sliding scale:

Sliding scale regime

DEXTROSTIX INSULIN INFUSION
< 4 mmol/L To inform registrar start (IV bolus 10ml dextrose 50% if <2mmol/L)
4-6.9mmol/L Omit insulin
7-9.9mmol/L 1 unit/hour
10-12mmol/L 2 unit/hour
>12mmol/L Inform registrar (change to Hartmann with 3 unit/hour & ½ hourly dextrostix monitoring untill 11 mmol/L is achieved, then change back to standard regime).

Preparation of glucose-insulin-kalium regime. (GIK)

- A constant infusion of 500ml of 5% dextrose water 100ml/hour

  1. Baseline BUSE should be traced within ½ hour admission to labour room. K+ level should be checked prior to commencing KCl infusion.
  2. KCl is added into dextrose sol(13mmol,1 ampule of KCl
  3. Separate infusion insulin such as 50 units actrapid in 49.5ml normal saline is maintain
  4. Important to ensure infusion is separated from syntocinon infusion. Do not override with syntocinon infusion.

Post-partum..

¡         If GDM, off all insulin and repeat MOGTT at 6 weeks following delivery

¡         If known diabetic, on insulin or oral hypoglycemic, start back their pre-pregnancy dose the next day when taking normal diet

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Comments
  1. nurain mohd noor says:

    I am not sure whether there is any typing error. The diagnosis of gestational diabetes mellitus is when the 2 hours post glucose challenge is > 7.8 mmol/ not > 11 mmol/l . Gestational diabetes mellitus is any degree of glucose intolerance during pregnancy . Thanks

  2. Jasmin says:

    Is DM II carrier OK to work in Malaysia?

  3. vin says:

    may i know where are the references from

    • gerardloh says:

      the references are from compilation from over 1000 of us medical students in CSMU, who did elective posting in msian hospitals..and ofcourse from your common medical books

  4. truuuu says:

    are u sure this is updated? coz WHO use <7 for fasting and <7.8 for 2H … and theres another latest guideline used by IADPSG but only pratised in KELANTAN… please share

    • Kev Chao says:

      Fasting venous blood sugar < 5.6 is followed ADA (american diabetic association) n current malaysia cpg followed WHO which fasting < 6.1 to diagnose GDM
      just reminder.. to diagnose DM in medical, the fasting venous blood sugar is 7.0…
      This is because there is niether impaired fasting glucose nor impaired glucose tolerance in pregnant women

  5. chao85 says:

    my registrar said, if a pregnant women having gdm on insulin therapy that required high dose insulin regime, the post partum management will be required 1/2 dose of the insulin therapy 1st and keep monitoring dxt till normal then off
    e.g. a pregnant women that used to take s/c actrapid 18u tds, insulatard 16u ON, she will need post partum insulin therapy of s/c actrapid 9u tds and insulatard 8u ON.
    is this apply to other hospital too?

  6. amin ismail says:

    2 types of investigations done usually. 1. screening test 2. diagnostic test. screening test done are random blood sugar, post prandial plasma venous blood sugar levels. normal value for random blood glucose level 11.1 mmol/l whereas for fasting blood glucose 7.0mmol/l. another screening test is glycosylated hb which should be kept less than 7%. for diagnostic test, we can do the mODIFIED gLUCOSE tOLERANCE TEST (the 75 oral glucose tolerance test). this test is practiced in hospital melaka.fasting >5.6mmol/l or 2 hour >7.8mmol/l indicative for GDM.

    FOR Blood sugar profile (BSP), fasting 5.6mmol/l and other next 3 reading must be <7 mmol/l. if 1 abnormal reading, continue with diet control, then repeat BSP every 4 weeks. if 2/more abnormal readig, proceed with insulin control. repet BSP weekly.

  7. Lavon says:

    I like it when people come together and share opinions.
    Great site, continue the good work!

  8. Azhar Hussein says:

    Hi . I would like comment on the Diagnostic Criteria .

    This i have taken from CPG Protocol O&G Department HKL ,2009 .
    Venous plasma (mmol/l) which also based on WHO Diagnostic Criteria .

    Normal:
    fasting — (<6mmol/l) ………. 2hrs PP— (7.8mmol/l)………………2hrs PP — ( >11.8)

    if you have updates on latest WHO Diagnostic Criteria , pls give ur reference/weblink. Thank you

  9. Aryche Em says:

    any info on the latest cutoff points for mOGT?

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