GDM Case Discussion

– History –

  • DM Sx: increased thirst, hunger, urination frequency, frothy urine?
  • Complications: headache, blurred vision, numbness, kidney\heart problems?
  • Obstetric Hx: same same
  • PMHx: comorbid ds (HTN, DM, DLP), previous GDM
  • On medications?
  • FHx
  • Social: smoking, alcohol, recreational drugs, exercise, diet

 

– Counseling –

» Risk factors?

  • Age > 35
  • High parity
  • Maternal obesity
  • Prev Hx of GDM or delivery of LGA baby (>4 kg), or impaired 2-hr glucose tolerance test, or unexplained still birth
  • Glycosuria on the first prenatal visit
  • First degree FHx
  • Dx of: HTN (essential or pregnancy), PCOS
  • Use of steroids
  • Race (Latino, African America, middle east)

 

» Screening?

  • When? If no risk factors -> at 24-28 wks, if risk factors -> at first visit
  • How? 2-hr 75 g OGTT
  • GDM is diagnosed if any of the following values are abnormal:
    • Fasting: Blood Glucose > 92 mg/dL (5.1 mmol/L)
    • 1-hr 75g OGTT: ≥ 180 mg/dL (10 mmol/L)
    • 2-hr 75g OGTT: ≥153 mg/dL (8.5 mmol/L)

 

» Ante-partum management?

  • Once diagnosed -> start with diet modification and exercise, and see the pt after 1 wk to repeat FBS and 2-hr 75g OGTT
  • If controlled -> continue diet and exercise and follow up every two weeks w\ FBS + 2-hr 75 OGTT
  • If uncontrolled -> admit the pt + start her on insulin

 

» Diet and exercise?

  • Restrict caloric intake to 15-24 kcal\kg (diabetic diet 1800-2000 kcal\d)
  • 10% breakfast, 30% lunch, 30% dinner, 30% snacks
  • 35–­40% carbohydrate, 20–25% protein, 35–40% fat
  • Moderate exercise three times per week, for 20-30 mins
  • Folic acid (5mg\d) 3 mo before conception until 12 wks of gestation

 

» Glycemic targets?

  • FBS <5.3 mmol\L
  • 1-hr postprandial <7.8 mmol\L
  • 2-hr postprandial <6.7 mmol\L

 

» Insulin?

  • 1st trimester: body weight in Kg x0.8 U/day
  • 2nd trimester: body weight Kg x 1 U/day
  • 3rd trimester: body weight Kg x 1.2U/day
  • The doses should be divided in a 50/50 or 75/25 between regular insulin (NPH; before bed time) and rapid acting insulin (before meals)

 

» Consider doing the following:

  • HgbA1C: at first visit and each trimester
  • Renal status: 24-hr urine collection (total protein and Cr clearance)
  • Retinal status: for proliferative retinopathy

 

» Intra-partum management?

  • Uncomplicated managed on diet alone: assess fetal wt at 37-39 wks
  • Uncomplicated on insulin or poorly controlled: twice weekly NST and AFT starting at 32 wk (bi-weekly until 36 wks and then weekly)
  • US screening at 18-20 wks and repeated at 34-37 wks (MC defect is cardiac septal defect)
  • During labor:
    • Keep maternal blood glucose level between 80 and 100 mg/dL using 5% dextrose in water and insulin drip
    • Check random BG every 1 hr, if initial blood glucose < 4 mmol or at any time during labor give 25 ml of 50% Dextrose.

 

» Delivery?

  • Uncomplicated managed on diet alone -> deliver at 40 wks
  • Uncomplicated on insulin or poorly controlled -> deliver at 38 wks
  • C\S: any case of GDM w\ a fetal wt > 4500 g

 

» Post-partum management?

  • Stop insulin, resume regular diet
  • Screen for persistent glucose intolerance after 6 wks using 75g OGTT
  • Diagnose according to usual diabetes guidelines:
    • FBG >= 126 mg/dL
    • HA1C > 6.5 %
    • OGTT with the 2-h postload value >=200 mg/dl
    • Symptoms with a random plasma glucose >=200 mg/dl

 

» Complications?

  • Macrosomia
  • Pre-eclampsia
  • Still birth
  • Polyhydramnios
  • Neonatal metabolic abnormalities: hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia
  • Maternal morbidity: C\S, perineal tears, PPH, maternal DM
  • Shoulder dystocia

 


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