GESTATIONAL DIABETES MELLITUS (GDM) What is Gestational

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Gestational Diabetes Mellitus (GDM)

• What is Gestational Diabetes?
• How is it diagnosed?
• What problems can it cause for mother and baby?
• How do you manage Gestational Diabetes?

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Gestational Diabetes

• Any degree of glucose intolerance with onset or
  first recognition during pregnancy
• 7 of all pregnancies
• More than 200,000 cases annually
• 2.3 of all pregnancies in Utah

American Diabetes Association, Diabetes Care 2004
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How things normally work
When you eat, your body breaks food down into
glucose. Glucose is a type of sugar that is
your bodys main source of energy.
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How things normally work
Glucose from food is absorbed into the
bloodstream. Your blood glucosethe amount of
glucose in your bloodbegins to rise.
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How things normally work
As blood glucose rises, the body sends a signal
to the pancreas, which releases insulin.
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How things normally work
Acting as a key, insulin binds to a place on the
cell wall (an insulin receptor), unlocking the
cell so glucose can pass into it. There, most of
the glucose is used for energy right away.
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Diabetes
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What causes GDM?

• Peripheral insulin resistance
• Placental lactogen, prolactin, estrogen, cortisol
• Impaired pancreatic insulin secretion

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Risk Factors for GDM

• Marked obesity
• Personal history of GDM
• A strong family history of diabetes
• Glycosuria
• Hispanic, African American, Mexican, Native
  American, Pacific Island, South or East Asian
  ethnicity

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Fetal growth is dependent upon maternal glucose

• Carbohydrates from maternal diet
• Stored glycogen converted to glucose
• High levels of glucose transported by diffusion
  to the fetus
• Fetal production of insulin

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Fetal / Neonatal Complications

• Macrosomia
• Birth trauma
• Polyhydramnios
• Jaundice
• Hypoglycemia
• Birth defects/ anomalies
• Still birth

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Maternal Complications

• Pre-term labor
• PIH
• C-section
• Type 2 DM

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Screening

• Average risk
• Low risk
• Age lt25 years
• Normal weight before pregnancy
• Ethnicity with low prevalence
• High risk
• Marked obesity
• Personal history of GDM
• Glycosuria
• Strong family history of diabetes
• No known first degree relatives with diabetes
• No history of abnormal glucose tolerance
• No history of poor obstetric outcome

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Screening

• Universal screening
• 1 hour 50 gram glucose load
• Venous plasma glucose
• 140mg/dl
• 130mg/dl

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100 gm oral GTT

• NDDG, 1979
• FBS 105
• 1hr 190
• 2hr 165
• 3hr 145

• Carpentar and Coustan, 1982
• FBS 95
• 1 hr 180
• 2 hr 155
• 3 hr 140

• Currently two diagnostic criteria acceptable

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Diagnosis

• gt200mg/dl on screening
• 3 hr 100gm glucose tolerance test (GTT)

2 abnormal values to be positive
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Gestational History Form
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Gestational History Form
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Management

• Medical Nutrition Therapy (aka, diet)
• Exercise
• Blood glucose testing
• Medication/ insulin
• Antepartum testing

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Medical Nutrition Therapy

• Multiple small meals and snacks
• Carbohydrate counting
• Breakfast and AM snack small
• No juice
• No cold cereal
• Ketone testing

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Exercise

• With MD clearance
• 3-4x/ week
• 30 minute sessions
• Brisk walking

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Blood Glucose Monitoring
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Blood Glucose Targets

• Pre-meal or fasting lt 95
• 2 hours post-meal
• lt 120
• Bedtime lt 95

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When How Often Should BG Be Tested?

• Diet/exercise 4 times per day
• On insulin 6-7 times per day

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Understanding Glucose Patterns

• Organize blood sugar records according to time of
  day.
• Look for patterns in blood sugars based upon time
  of day or day of the week.

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Medication / Insulin

• Medication
• Glyburide
• Glucophage
• Insulin
• Rapid acting
• Humalog
• Novolog
• Apidra
• Regular Humulin R and Novolin R
• Intermediate acting
• NPH (Humulin N and Novolin N)
• Peakless
• Glargine (Lantus) and Detemir (Levemir)

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Hypoglycemia (low blood sugar)
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Antepartum testing

• Kick counts
• NST
• Amniocentesis

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Post partum testing

• Immediate
• 6 week check up with 2 hour 75 gram oral glucose
  tolerance test (ACOG guidelines)
• Yearly DM screening

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Conclusion

• The goal of our educational programs should be
  not only to improve pregnancy outcome but also to
  promote healthy lifestyle changes for the mother
  that will last long after delivery
• Gabbe and Graves, 2003

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The End