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 2 hours post-prandial OGTT
- Gestational diabetes previous pregnancy
- Obesity (BMI >30)
- Age > 35
- Presence of glycosuria in >2 occasions
- History of DM in first degree relatives
- Previous big baby > 4.0 kg
- Previous history of recurrent abortion or unexplained stillbirth
- Previous congenital anomalies
Complication in GDM
- Coronary artery diseases
- Hyperglycemia / hypoglycemia /ketoacidosis
- Congenital abnormalities: cardia and neural tube defect
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.
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.
- Fasting from 12am till the next morning
- Take blood.
- Give patient to drink 75g glucose+ 250ml water ,drink in 10-15min.
- After 2 hrs,take blood again.
DIAGNOSIS OF DM IN PREGNANCY
|Normal (mmol/L||Diabetes (mmol/L)|
|Fasting||< 5.6||> 5.6|
|2 hours PP
Aim: to maintain blood glucose level
¡ 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
- FBS > 5.8mmol/L
- 2 hour post-prandial >7 mmol/L
- failed D/C (start insulin after 2 weeks on diet control(IV) )
- 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
- Renal profile (pre-existing)
- Home monitoring
- Early detection of complication.
- Biophysical profile
- Fetal kick chart
Blood Sugar Profile
¡ BSP- Blood Sugar Profile
¡ Do before starting and also to monitor insulin therapy
¡ 4 times
- 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
- 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:
▪ Suspicion of cephalo-pelvic disproportion
▪ A previous caesarean section
▪ 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
|< 4 mmol/L||To inform registrar start (IV bolus 10ml dextrose 50% if <2mmol/L)|
|>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
- Baseline BUSE should be traced within ½ hour admission to labour room. K+ level should be checked prior to commencing KCl infusion.
- KCl is added into dextrose sol(13mmol,1 ampule of KCl
- Separate infusion insulin such as 50 units actrapid in 49.5ml normal saline is maintain
- Important to ensure infusion is separated from syntocinon infusion. Do not override with syntocinon infusion.
¡ 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