Monday, March 28, 2011

Gestational Diabetes in pregnancy

Pregnancy causes increase in glucose intolerance. For some women, this can lead to gestational diabetes. In general, insulin requirement of a women increases during pregnancy. Approximately 8.6% of all pregnancy are complicated by gestational diabetes.

Definition of gestational diabetes (GDM)
  • The diagnosis of gestational diabetes is based on an oral glucose tolerance test (OGTT) in which a 75g load of glucose is given to the patient.
  • GDM is diagnosed if (ADA guidelines 2011)
  • - Fasting ≥92 mg/dl (5.1 mmol/l)

  • - 1 h ≥180 mg/dl (10.0 mmol/l)

  • - 2 h ≥153 mg/dl (8.5 mmol/l)

When and how to screen for Gestational Diabetes
There has been no consensus on this issue. The ADA and RCOG (Jan 2011) recommends the following:

  • Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria.

  • In pregnant women not known to have diabetes, screen for GDM at 24–28 weeks of gestation, using a 75-g 2-h OGTT

  • Screen women with GDM for persistent diabetes 6 weeks postpartum.

  • Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years.

In Singapore, the MOH reccommends OGTT only for high risk patients early in the pregnancy and at 26-28 weeks
In all other patients urine should be tested for glucose. If glucosuria 1+ or more, plasma glucose levels will be done. OGTT is done if glucose >6.6 more tahn 2 hrs after meal or >7.0 within 2 hrs after meal.

Risk Factors for Gestational Diabetes
  • Obesity
  • Family history of diabetes
  • Medical history of gestational diabetes
  • History of large baby more than 4kg
  • Previous unexplained stillbirth
  • PCOS
  • Polyhydramnious
  • Twin
Fetal Complications for diabetic women
  • Related to glucose levels
  • Congenital abnormalities
  • Pre-term labour
  • Polyhydramnios
  • Decrease fetal lung maturity
  • Large baby
  • Fetal distress and sudden fetal death more common.
  • Neonatal Hypoglycemia
Maternal Complications of Diabetes in pregnancy
  • Ketoacidosis (rare)
  • Hypoglycemia (too strict control)
  • UTI
  • Infection: Wound or endometrial
  • Hypertension and pre-eclampsia more common,
  • Diabetic retinopathy
Management of patients with gestational diabetes
  • Close surveillance
  • Dietary Control: Maintain fasting glucose at <5.5 mmol/L and 2hr post prandial glucose at <6.7 mml/L
  • Metformin and Glibenclamide has been used is oral agents
  • Insulin still the safest choice.
  • Mothers should monitor fetal movement in last 12 weeks of pregnancy
  • Ultrasound for congenital abnormalities at 18-22 weeks
  • Fetal growth ultrasound 29-33 weeks
  • Non stress cardiotocography with umbilical doppler flow may be considered.
  • Screen for hypertension.
  • Infants fed early and baby screen for hypoglycemia
  • Contraception: OCP in complicated diabetes or infection with IUCD.

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