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1=-10-19
When to screen in Indian context?? At 16, 24 & 32
weeks: The prevalence of GDM in our country was 16.55%GDM is a
compensated metabolic abnormality & DIPSI
guidelines & also ADA guidelines aim at foetal long term benefit can
prevent Obesity, IGT and Diabetes in
the offspring & possibly
little attention is paid for maternal temporary short term compl. A)
first at16th week of::B) Second
screen : 24th – 28th week and finally C) around 32nd – 34thweek. Using a
different glucose challenge in pregnant versus non-pregnant patients leads
to confusion in the laboratory and may
result in errors in applying the
proper diagnostic criteria .The expected weight gain during pregnancy is
300 to 400 gm/week and total weight gain 10 to 12 kg by term. ADA) recommends two step procedures for screening
and diagnosis of diabetes and that too in selective (high risk)
population. Combination of regular and intermediate acting insulin before
dinner may be necessary if fasting blood sugar is high. This combination
of short and intermediate acting insulin in the morning and as well as in the
evening is known as mixed and split dose of insulin regimen
Q.
1, Screen all women :-The Diabetes In Pregnancy Study group India
(DIPSI)”has issued practice
guidelines for GDM in the Indian environment. Due to high prevalence, screening is essential for all Indian
pregnant women.
Q. 2: What is the recommendation of Study Group formed in
2002:-?? Ans: Between 24 and 28 weeks . -DIPSI recommends 2 hr PPBS after 75 Glucose -(to be
taken in empty stomach) that
as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral glucose load and at 2 hrs a venous blood
sample is collected for estimating plasma glucose. This one step
procedure of challenging women with 75 gm glucose and diagnosing GDM is
simple, economical and feasible.
Q.3;When to screen??
Between
24 and 28 weeks. Screening is
recommended between 24 and 28 weeks of gestation and the diagnostic criteria
of ADA (American Diabetic Association) are applicable. But, DIPSI members mentioned
that a team approach is ideal for managing women with GDM.
Summary
of the DIPSI:-What we the obstetricians must know:- Take home message from
the “The Diabetes In Pregnancy Study Group India (DIPSI)” Total 5
recommendations:-of - A) Implementation of DIPSI is like intelligent investment for future long term health benefit
of foetus and not mother, If followed
in preg can prevent Obesity, IGT and Diabetes in the offspring
can fairly be prevented by a short
term intensive care in pregnancy gives
a long term pay off in the primary prevention of as the preventive medicine
starts before birth. (DIPSI guidelines
therefore aim at foetal long term benefit)
B) DIPSI recommends 2hr PPBS after 75 Glucose -(to be taken in empty
stomach) that as a pregnant woman
walks into the antenatal clinic in the
fasting state, she has to be given a 75g oral glucose load and at 2 hrs a venous
blood sample C) ”Intensive monitoring by , diet and insulin are the corner stone of GDM management D) They , at that time 2002 expressed doubts
and concerns on the efficacy of oral
agents or analogues. At that time
during the study period ( 2002) use of ODA(oral Aantidiabetics ) use in GDM
was controversial though their use now slowly being established ..
Until there is evidence to absolutely prove
that ignoring maternal hyperglycemia when the fetal growth patterns appear
normal on the ultrasonogram, it is prudent to achieve and maintain normoglycemia in every pregnancy
complicated by gestational diabetes. The maternal health and fetal outcome
depends upon the care by the committed team of diabetologists, obstetricians
and neonatologists.
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SCREENING
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A) first
at16th week of::B) Second screen :
24th – 28th week and finally C) around 32nd – 34thweek.
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Methodà1::
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DIPSI Recommended Method
As a pregnant woman walks into the
antenatal clinician the fasting state, she has to be given a 75 g oral
glucose load and at 2 hrs a venous blood sample is collected for estimating
plasma glucose. This one step procedure of challenging women with 75 gm
glucose and diagnosing GDM is simple, economical and feasible
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Methodà 2:: ADA ::DIAGNOSTIC CRITERIA
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This ADA timings and design of
that study including glucose load
was meant primarily to diagnose and pick up women who are prone to develop DM in future and do
not refer to possibility of wellbeing of foetus .American Diabetes Association (Carpenter
and Couston) recommends 3 hour 100 gm OGTT and Gestational Diabetes
Mellitus is diagnosed if any 2 values meet or exceed FPG > 95 mg/dl, 1
hr PG > 180mg/dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140
mg/dl. This criteria was originally
validated against the future risk
of these women developing diabetes and not on the fetal outcome. ADA:- ADA:- What’s
wrong with ADA method?? American Diabetes Association (ADA) recommends two step procedures for screening
and diagnosis of diabetes and that too in selective (high risk)
population. Compared with selective screening, universal screening for GDM
detects more cases and improves maternal and neonatal prognosis..
Carpenter himself now recommends
a 2 hour OGTT with 75 gm glucose. The reason for this is that
“when a glucose tolerance test is administered to non-pregnant individuals,
it is standard to use the 75-g, 2-hour OGTT. Using a different glucose
challenge in pregnant versus non-pregnant patients leads to confusion in
the laboratory and may result in errors in applying the proper diagnostic
criteria. Further, the 75-g, 2-hour OGTT is in use during pregnancy in many
countries around the world, typically using the same thresholds as in
non-pregnant individuals”.
Depending on the risk of the women developing diabetes and not on the fetal
outcome. American Diabetes
Association (Carpenter and Couston) recommends 3 hour 100 gm OGTT and Gestational
Diabetes Mellitus is diagnosed if any 2 values meet or exceed FPG > 95
mg/dl, 1 hr PG > 180 mg/ dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140
mg/dl. This criterion was originally validated against the future
risk of these women developing diabetes
and not on the fetal outcome. Carpenter himself now recommends a 2 hour OGTT with 75
gm glucose. The reason for this is that “when a glucose tolerance test is
administered to non-pregnant individuals, it is standard to use the 75-g, 2-hour
OGTT. Using a different glucose challenge in pregnant versus non-pregnant
patients leads to
confusion in the laboratory and may result
in errors in applying the proper diagnostic criteria. Further, the 75-g,
2-hour OGTT is in use during pregnancy in many countries around the world,
typically using the same thresholds as in non-pregnant individuals”.
Methodà 3 :- A) first
at16th week of::B) Second screen :
24th – 28th week and finally C) around 32nd – 34thweek. WHO:-:-the World Health
Organisation
(WHO)To standardize the diagnosis of GDM, the World Health Organisation
(WHO) proposed using a 2 hour 75 gm OGTT with a threshold plasma
glucose concentration of greater than 140 mg/dl at 2 hour, similar to that
of IGT, outside pregnancy. Still all these recommendations (ADA and WHO)
have not projected the influence of the glycemic level on fetal outcome.
To standardize the diagnosis of GDM, the World
Health Organisation (WHO) proposed
using a 2 hour 75 gm OGTT with a
threshold plasma glucose concentration of greater than 140 mg/dl at 2 hour,
similar to that of IGT, outside
pregnancy.
The fallacy is
still on as all these recommendations (ADA and WHO) have not projected
the influence of the glycemic
level on fetal outcome.
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Clarity
in Labeling The Different Magnitude of Abnormal Glucose Intolerance on
Pregnancy
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Increasing maternal carbohydrate intolerance in pregnant
women without GDM is associated with a graded increase in adverse maternal
and fetal outcomes implying that fetal morbidity starts at a lower
maternal glycemic level (< 140 mg/dl). A number of prospective and
retrospective studies have substantiated the observation that the
frequency of adverse fetal outcome increases with 2hr PG > 120mg/dl .
Surprisingly,
taking care of these women had resulted in a better fetal outcome. Thus,
the data is robust and indicates that 2 hr > 120mg/dl needs
cognizance.
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The term ‘Impaired Gestational Glucose Tolerance
(IGGT)’ is used by few authors to indicate pregnant women whose 2 hr PG is > 120mg/dl
but below 140 mg/dl. . It may be appropriate to use the term ‘Decreased Gestational glucose tolerance (DGGT)’ instead of
impaired gestational glucose tolerance.
The use of the term ‘Decreased’ is appropriate as
it implies only ‘Low’ whereas the term ‘Impaired’ means both high and low.
Further, quiet frequently we come across, labeling any abnormal value in the OGTT not meeting
the diagnostic criteria of GDM as IGT. The use of this term ‘IGT’ during
pregnancy may be confusing, as this terminology is also being used in non
pregnant adult with 2 hr PG > 140mg/dl.
This level is also applied to diagnose GDM by WHO
criteria. Hence it may be prudent to label 2 hr plasma glucose value
> 140 mg/dl as GDM
and a 2 hr plasma
glucose value > 120 mg/dl as ‘Decreased Gestational Glucose Tolerance’
(DGGT).
The term IGT should not be used to denote any abnormal
value during pregnancy. The figures suggested below are easy to remember.
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With 75 gm OGTT (WHO criteria);
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In Pregnancy
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Outside Pregnancy
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2 hr = 140 mg/dl
2 hr = 120 mg/dl
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Diabetes
GDM (2 hr = 200 mg/dl
DGGT
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Diabetes
IGT
—
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Gestational
Weeks at Which Screening is Recommended
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Screen timings: A) first at16th week of::B) Second screen : 24th – 28th week and
finally C) around 32nd – 34thweek.20
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Practically all
the pregnant women should undergo screening for glucose intolerance. The
usual recommendation for screening
is between 24 and 28weeks of gestation. The recent concept is to screen
for glucose intolerance in the first trimester itself as the fetal beta
cell recognizes and responds to maternal glycemic level as early as 16th week of
gestation. If found negative at this time, the screening test is
to be performed again around 24th – 28th week and finally around 32nd –
34thweek.
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The maternal metabolic adaptation is to maintain
the mean fasting plasma glucose of
74.5 ± 11 mg/dl and the post
prandial peak of 108.7 ± 16.9mg/dl.
This fine tuning of glycemic level during pregnancy is
possible due to the compensatory hyperinsulinaemia, as the normal
pregnancy is characterized by insulin resistance. A pregnant woman who is
not able to increase her insulin secretion to overcome the insulin
resistance that occurs even during normal pregnancy develops gestational
diabetes. GDM recurs approximately in
50% of subsequent pregnancies. The future risk of developing diabetes for
age gestational diabetic is twofold, if she becomes overweight. But
maintaining ideal weight approximately halves the risk. The requirement
of insulin in addition to diet to maintain euglycemic during the
index pregnancy is also predictive
of future diabetes.
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The metabolic goals of
pregnancy are
1) in early pregnancy to develop anabolic stores to meet metabolic
demands in late pregnancy and
2) in late pregnancy to provide fuels
for fetal growth and energy needs.
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Gestational Diabetes Mellitus (GDM) is defined as ‘carbohydrate intolerance with
recognition or onset during pregnancy’, irrespective of the treatment
with diet or insulin. The importance of GDM is that two generation is at risk of developing diabetes in
the future. Women with a history
of GDM are at increased risk of future
diabetes, predominately type 2 diabetes, as are their children. The maternal health and fetal outcome depends upon
the care by the committed team of diabetologists, obstetricians and
neonatologists. A short term intensive
care gives a long term pay off in the primary prevention of
obesity, IGT and diabetes in the offspring, as the preventive medicine
starts before birth.
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GDM occurs when the woman’s
beta cell function is notable to overcome the antagonism created by the
anti-insulin hormones of
pregnancy and the increased fuel consumption required to provide for the growing
fetomaternal unit.-
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MANAGEMENT OF GDM
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A team approach is ideal for managing women with GDM.
The team would usually comprise an obstetrician, diabetes physician, a diabetes educator,
dietitian, midwife and pediatrician.
In practice, however, the team approach is not always possible due to
limited resources.
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In such circumstances, management by an obstetrician and
physician, with the assistance of an appropriately skilled dietitian,
diabetes educator, is acceptable.
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A) Patient Education
The importance of educating women with GDM (and their partners) about
the condition and its management cannot be overemphasized.
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The compliance with the treatment plan depends on the
patient’s understanding of:
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• The implications of GDM for her baby and herself
• The dietary and exercise recommendations
• Self monitoring of blood glucose
• Self administration of insulin and adjustment
of insulin doses
• Identification and treatment of hypoglycemia(patient
and family members)
• Incorporate safe physical activity
• Development of techniques to reduce stress and cope
with the denial.
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Care should be taken to minimise the anxiety of the
women.
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B) Medical Nutrition Therapy
(MNT)
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a) General Principles: All women with GDM should
receive nutritional counseling. The meal pattern should provide adequate
calories and nutrients to meet the needs of pregnancy. The expected weight
gain during pregnancy is 300 to 400 gm/week and total weight
gain 10 to 12 kg by term.
Hence the meal plan aims to provide sufficient calories
to sustain adequate nutrition for the mother and fetus and to avoid excess
weight gain and post prandial hyperglycemia. Calorie requirement depends on
1) age, 2) activity, 3) pre pregnancy weight and 4) stage of pregnancy.
Approximately 30 to 40 Kcal/kg ideal bodyweight or an
increment of 300 kcal/day above the
basal requirement is needed. Pregnancy is not the ideal time
for obesity correction. Underweight subjects or those not gaining weight as
expected, particularly in the third trimester, require admission to ensure
adequate nutrition to prevent low birth weight infants.
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b) Calorie Counting : As a part of the medical nutrition
therapy, pregnant diabetic woman are advised to wisely distribute their
calorie consumption especially the breakfast. This implies splitting the usual breakfast into two
equal halves and consuming the portions with at two hour gap in
between. By this the undue peak in plasma
glucose levels after ingestion of the total quantity of breakfast at one
time is avoided.
For example if
2 chappathi or 2 slices of
bread (applies to all type of breakfast menu) is taken for breakfast at 8
am and two hours plasma glucose at
10 am is 140mg:
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This advice has scientific basis as the peaking of
plasma glucose is high with breakfast (due to Dawn phenomenon) than with lunch and
dinner. Further in a normal person, insulin secretion is also high
with breakfast than with lunch or dinner.
GDM mothers have deficiency in first phase insulin
secretion and to match this insulin deficiency the challenge of quantity of
food at one time should also be less.
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Insulin
Therapy
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Insulin is essential if medical nutrition therapy fails to achieve euglycemia. Various criteria
have been proposed for the initiation of insulin therapy. Fourth
International Workshop on GDM recommended lowering capillary blood glucose
concentration to 140mg/dl at 1 hour and 120 mg/dl at 2 hours
whereasADA
recommended the option of measuring 1 hour postmeal values with cut off of
120mg/dl.
These
recommendations are based on one single determination, which reflects
a “snap shot” of glucose evaluation rather than a “video” of continuous glucose profile.
The continuous glucose monitoring
system has established that in normal pregnancy, peak plasma glucose occurs
at 60 minutes and the value was 108.7 ± 16.9 mg/dl.
In a woman with
GDM, the peak occurs between 70 – 110minutes (at approximately 90 minutes)
and with a goodglycemic control the value was 103 ± 26 mg/dl.20However,
being interstitial fluid glucose it has its own limitation.
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If the FPG concentration on the OGTT is >120mg/dl, then
the patient is started on insulin immediately along with meal plan. Other
GDM women are seen within 3days and are also taught self
monitoring of blood glucose (SMBG). SMBG is to be performed
in fasting and 1 ½hours after each meal. GDM women usually have high
post breakfast plasma glucose level compared to post lunch and post
dinner. A few GDM women do have post dinner plasma glucose also high.
When to initiate insulin??
Ans:-Insulin is started within 1 to
2 weeks, if the majority (i.e., at least four of seven per week) of
fasting values exceed 90 mg/dl. Similarly, if the majority of post prandial
values after a particular meal exceed 120 mg/dl, insulin is started. Pen injectors are very useful and the
patient’s acceptance is excellent.
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What will be the initial dose??
The initial dose of NPH insulin could be as low as 4 units and the dose of insulin can be adjusted on follow-up. A
few GDM patients may require combination of short acting insulin and
intermediate acting insulin in the
morning and evening. When
to initiate insulin : If MNT fails to achieve control i.e., FPG = 90mg/dl
and/or1 ½ hr PPG = 120mg/dl, insulin may be initiated
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Problem 1: elevated pre lunch blood sugar:-What to
do?? ; • If a patient has elevated pre lunch blood sugar, add
regular insulin is usually necessary in the morning to handle
the post breakfast hyperglycemia, as there is a lag period before the intermediate-acting
insulin begins to work. The above regimen of regular and intermediate-acting
insulin in the morning controls hyperglycemia
in most cases.
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• Problem 2:-If the post dinner blood sugar is high,
a small dose of regular insulin is necessary before dinner in addition to the regular and
intermediate acting insulin given
in the morning.
• Problem 3: if fasting blood sugar is high.
:- Combination of regular and intermediate acting insulin
before dinner may be necessary if fasting blood sugar is high.
D. What do we mean by mixed and split dose of insulin
regimen.? Ans:- This combination of short and intermediate acting
insulin in the morning and as well as in the evening is known as mixed
and split dose of insulin regimen.
In this regimen two-third of the total daily dose of
insulin is given in the morning and one third in the evening. For
each combination one-third dose should be regular insulin and two-third
intermediate acting insulin.
With this regimen if the patient continues to have fasting
hyperglycemia, the intermediate acting insulin has to be given at bedtime
instead of before dinner. Insulin dose is individualized.
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Target
Blood Glucose Levels
Maintenance of Mean Plasma Glucose (MPG) level ~105 mg%
is ideal for good fetal outcome. This is possible if FPG and post prandial
peaks are around 90 mg/dl and 120 mg/dl respectively (MPG should not be
< 86mg/dl as this may cause small for gestational age infants).
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Species
of Insulin
It is ideal to use human insulin are least immunogenic. Though insulin
does not cross the placenta, the insulin antibodies due to animal source
insulin can cross the placenta, and stress the fetal beta cell, increase insulin production and
induce macrosomia.
Rapid acting insulin analogues,(Novorapid/Humalog)
have been found to be safe
andeffective in achieving the targeted post prandial glucose value during
pregnancy. Lyspro the first
analogue to get category B approval by US FDA and aspart has also been
used in pregnancy.
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Oral
Antidiabetic Drugs
Recently reports have shown good fetal outcome in GDM
women who were on GLYBURIDE (micronised
form of Glibenclamide).
A randomized unblinded clinical
trial compared the use of insulin and glyburide in women with GDM who were
not able to meet glycemic goals on meal plan. Treatment
with either agent resulted in similar perinatal outcomes.
All these patients were beyond the first trimester of pregnancy at the
initiation of therapy.24
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More studies are required before
routinely recommending Glibenclamide during pregnancy especially during the
first trimester itself. Metformin has been found to be useful in women with
polycystic ovarian disease (PCOD) who failed to conceive. Continuing this drug after conception
is still a controversy. But there are a few studies favoring
continuation of metformin throughout pregnancy.
Currently, oral agents are not
routinely recommended during pregnancy though emerging data on Glibenclamide and metformin is
interesting.
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MONITORING GLYCEMIC CONTROL
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The success of the treatment for
a woman with GDM depends on the glycemic control maintained with meal plan
or pharmacological intervention. To know the effectiveness of treatment, monitoring
of glycemic control is essential.
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• Once diagnosis is made, medical nutritional therapy (MNT) is
advised initially for two weeks. When to initiate insulin : If MNT fails to
achieve control i.e., FPG = 90mg/dl and/or1 ½ hr PPG = 120mg/dl,
insulin may be initiated.
• Once target blood glucose is
achieved, woman with GDM till the 28th week of gestation require lab
monitoring of both fasting and 1 ½ hr post breakfast once a month and at
other time of the day as the clinician decides.
• After the 28th week of
gestation, the laboratory monitoring should be more frequent at least once
in2 weeks, if need be more frequently.
• After 32 weeks of gestation,
lab monitoring should be done once a week till delivery.
• In high risk pregnancies,
frequency of monitoring may be intensified with SMBG.
• Continuous glucose monitoring
devices are availablebut these equipments need special training and are
expensive. These devices may be useful in high risk pregnancies to know the
glycemic fluctuations and to plan
proper insulin dosage.
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Throughout the stages and
phases of a diabetic woman, he health status is directly dependent on her
nutritional status and her blood glucose control. As a woman ages, to
prevent the increased risk of osteoporosis and cardiovascular disease of
the diabetic woman, exercise and hormonal replacement therapy can
minimize the ravages of diabetes per se on the aging process.
Normoglycemia throughout the lifecycle of a diabetic woman results in a
lifecycle of health.-
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HbA1c
Levels
If the glucose intolerance is
detected in the early pregnancy, HbA1c level will be helpful to differentiate
between a pre gestational diabetic and GDM. If theHbA1c level is more than 6%, she is likely to be a preg DM.
HbA1c is useful in monitoring the glucose control during
pregnancy, but not for the day to day management. A1c level may serve as a
prognostic value. Estimation of fructosamine during
pregnancy is less frequently used.
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Measuring
Other Parameters
The blood pressure has to
be monitored during every visit. Examination of the fundus and estimation of microalbuminuria, every trimester is recommended.
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e) Ultrasound Fetal Measurement : The management of
gestational diabetes, based on the foetal growth by ultrasonogram demands
that the fetus at risk must first manifest
overgrowth before treatment decisions are made. Further, the cost of
performing a number of ultrasonogram
to monitor the foetal growth and recommending therapy has to be kept in
mind. Until there is evidence to absolutely prove that ignoring maternal
hyperglycemia when the fetal growth patterns appear normal on the
ultrasonogram, it is prudent to achieve and maintain normoglycemia in every
pregnancy complicated by gestational diabetes.
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Until there is evidence to
absolutely prove that ignoring maternal hyperglycemia when the fetal
growth patterns appear normal on the ultrasonogram, it is prudent to achieve
and maintain normoglycemia in every pregnancy complicated by gestational
diabetes.-
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OBSTETRIC CONSIDERATIONS
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Fetal
Evaluation
An ultrasound scan has to be performed around 18 –20 weeks of gestation
focusing on structures namely the spine, skull, kidney and heart. Fetal echocardiography has to be done
around 20 – 24 weeks which allows to view all the four chambers of
the heart. From 26th week onwards,
fetal growth and liquor volume has to be monitored every 2-3 weeks.
Fetal
abdominal circumference provides baseline for further serial measurements
which gives growth acceleration or restriction. Fetal movements are monitored
from 20 weeks onwards. Screening for
chromosomal anomalies is necessary in pre GDM. Screening should be done
for Down’s syndrome, alpha fetoprotein for neural defects and human
chorionic gonadotrophin to identify any chromosomal abnormalities (16 – 20
weeks of gestation).
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The obese fetus of GDM mother
is also hyperinsulinemic, thus
interaction between leptin and insulin may be a link between maternal
diabetes and increased adiposity in the fetus.- GDM
or severe obesity is superimposed to pregnancy; the resulting metabolic
syndrome becomes detrimental for the fetus, evolving towards fetal
overgrowth with increased adiposity
at birth. This may be one major component for in utero programming of
obesity later in life.-
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Timing
of Delivery
Sudden intrauterine fetal demise
in the third trimester of diabetic pregnancy is not uncommon. To avoid this
risk, preterm delivery is recommended. But with this, respiratory distress
syndrome (RDS) is likely to occur. Administering steroids for lung maturity
or ß adreno receptor agonist to inhibit premature uterine contractions are
likely to induce adverse metabolic effects due to their glycolytic, glycogenolytic and lipolytic
effects. In this situation, extra insulin may be required to maintain euglycemia.
Foetal demise can also occur due to
preeclampsia, which can produce fetal hypoxia via decreased
uteroplacental perfusion. Some centres allow women with uncomplicated
diabetes to go into spontaneous labor irrespective of the gestational age,
but most still advocate delivery at 38 weeks as perinatal mortality and
morbidity appear to increase after this time. Induction at 38 weeks
gestation may be slow or unsuccessful due to unfavourable conditions of the
cervix but this has to be balanced against the poorly defined and
predictable risk of late intra uterine death ,if pregnancy is allowed to
continue more than 38 weeks. Fetal health may deteriorate suddenly, hence obstetric
management should not be rigid and each case needs individual care and
attention. Having a neonatologist support at the time of delivery is
advisable.
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Intra
Partum Management
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• If labor is to be induced in
GDM, the usual evening insulin dose
should be taken the night before, but no subcutaneous insulin is given
the following morning when induction begins.
• Once labor begins, insulin is
not necessary.
• In a gestational diabetic the
requirement of insulin is likely to fall precipitously and no insulin may be
required immediately after expulsion of placenta.
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DELIVERY
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A pediatrician experienced in
resuscitation of ‘the newborn should be present whether delivery is vaginal
or by caesarean section. As soon as the infant is born, the following
actions are mandatory:
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• early clamping of the cord, i.e.
within 20 seconds of delivery, to avoid erythrocytosis;
• evaluate vital signs; Apgar
scores at 1 and 5 minutes;
• clear oropharynx and nose of
mucus; later empty the stomach - be aware that stimulation of the pharynx
with the catheter may lead to reflex bradycardia and apnoea;
• avoid heat loss, keep neonate
warm, transfer to incubator pre-warmed to 34oC;
• perform a preliminary physical
examination to detect major congenital malformations;
• monitor heart and respiratory
rates, colour, and motor behaviour for at least the first 24 hours
afterbirth;
• start early feeding,
preferably breast milk, at 4-6hours after delivery: aim at full caloric
intake (125kcal/kg/24 hours) at 5 days, divided into six to eight feeds a day;
• promote early infant-parent
relationship (bonding).
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The neonate is usually best cared for, in a specialized neonatal
unit. Interference with the infant
should be minimal. The neonate should be observed closely after delivery
for respiratory distress. Capillary blood glucose should be monitored at 1
hour of age and before the first four breast feedings (and for up to 24
hours in high- risk neonates). Amperometric blood glucose meters are
acceptable for use in neonates, provided that suitable quality-control
procedures and operator training are in place. The cut-off of 44mg% (2.6
mmol/l) is now currently used as the working definition for hypoglycemia. This
“Operational threshold”
is not a diagnosis of a disease but an indication for action. If the baby is obviously macrosomic,
calcium and magnesium levels should be
checked on day 2. Breastfeeding, as always, should be encouraged in women with GDM.
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Both maternal pregravid obesity
and GDM are significant risk factors for obesity in the offspring of the
woman with GDM both at birth and at the time of long term follow up.- Dr
Patrick Catalano
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GDM may be viewed as:
1.An unidentified preexisting
disease, or
2.The unmasking of a compensated metabolic abnormality by the added stress
of pregnancy, or
3.A direct consequence of the altered maternal metabolism stemming from the changing
hormonal milieu.
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Gestational diabetic women
require follow up. Glucose tolerance test with 75g oral glucose is
performed after 6 weeks of
delivery and if necessary repeated after6 months and every year to
determine whether the glucose
tolerance has returned to normal or progressed. A small proportion of
gestational diabetic women may continue
to have glucose intolerance.
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Prevention of adverse maternal
and perinatal outcomes in GDM are based in achieving maternal blood
glucose as close to normal as possible. Precise glycemic threshold remain
undetermined. Prepregnancy BMI, duration and severity of maternal hyperglycemia
during pregnancy, are most important predictors of the progression to
abnormal glucose tolerance/diabetes in the follow up.-
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Obesity, IGT and Diabetes in the offspring can fairly be prevented by
a short term intensive care in pregnancy gives a long term pay off in the primary prevention of as the preventive
medicine starts before birth.
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