– 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?
- 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)
- 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
- 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.
- 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
- Still birth
- Neonatal metabolic abnormalities: hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia
- Maternal morbidity: C\S, perineal tears, PPH, maternal DM
- Shoulder dystocia