Practical tips in pregnancy Management of GDM
(Gestational Diabetes Mellitus).
How to monitor & adjust the dosage of Insulins as pregnancy
advances? There are two ways by which one can increase or decrease the
dose of insulin in pregnancy. (Dose adjustment in preg) i.e. either by blood
glucose or by noting serial growth circumference (girth) of foetal abdomen as
evidenced by repeated ultrasonography. Any disproportionate rise of abdominal
girth of foetus will speak for impaired insulin storage/ injection
missing-skipping the dose, errors in techniques of injection.
The
best area where insulin can be injected is at belly (not thighs). Preferable site is around the umbilicus. But
as pregnancy advances the skin over the umbilicus is stretched. Therefore, in
8-10 months of preg one can change the injection site to on the sides of abdomen,
say 2-4” away from the umbilicus. The thigh is an uncommon site of injection
for insulins. Because the insulin is going to be poorly absorbed from this site
and one may not get desired result. Always keep on changing the place of
injection at least one inch away from the injection site.
Q.1. What is the ideal Target after diagnosis? If target sugar
values of <90 mg% before meals and <120mg% after meals are not achieved
with diet within one or two weeks, consideration is given to drugs. In at least
half of our patients, with high risk features mentioned above, we start the drugs
as primary treatment, along with diet and exercise.
A) By Blood
sugar levels: - repeated CGMS-continuous glucose monitoring system is best for
GDM control. Adjust the dose of insulins/OHA according to BS/AC,
The target blood sugar should ideally be—
The therapeutic target:-
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FBS |
1hr.PPBS after 75Gm of
glucose. |
2 hr. after 75 gm of oral
glucose. |
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5.3 mmol/L( <95 mg) |
7.8 m.mol/Lit(140 mg_) |
6.7 m.mol/Lit120 mg) |
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Q.2. How to convert from Mg to m.mol as in your country?
For rapid conversion from mg to mmol/L, one should remember
that 92 mg=5.1 mmol; 125 mg blood sugar= 6.9 mmol; 140 mg=7.8 mmol/l; 153 mg of
blood sugar equates to =8.5 mmol/Lit; 180 mg of blood sugar= in mili.mol =8.5 m
mol/Lit.
.
Q. 3. How to Diagnoses Diabetes in Pregnancy
diagnosis of diabetes in pregnancy starts with
identifying high risk factors in the history (such as family h/o diabetes, previous pregnancy GDM,
large baby, IUFD of a large baby, shoulder dystocia, previous anomalous baby,
recurrent UTI) and in the examination findings (such as obesity, acanthosis
nigricans, acrocordons, abnormal waste-hip ratio and so on).
Q. 4. Routine screening of all Asian Pregnant women is
mandatorty.
Routine screening is done for all women with fasting BSL at their first
antenatal visit. Any report higher than 85 mg% is taken seriously; this woman
may develop GDM later in pregnancy. If higher than 92 mg% - we treat it as
diabetes. Confirmation with either a routine 75 g OGTT or as DIPSI suggests, by
single value 2-hour after 75 g glucose orally (>140 mg% being positive for
GDM). We also do 50 g OGCT between 16-24 weeks in otherwise low-risk women with
normal fasting BSL at first antenatal visit, taking 130 mg% as the cut off.
Q. 5. Why in some cases babies die in womb in a diabetic family? Not
testing for diabetes after 28 weeks may have been the prime reason for
unexplained stillbirths resulting from sugars becoming abnormal for the first time
after 28 weeks! High risk women are given counseling about diet even in the
absence of confirmed diagnosis, as a preventive measure.
Q.6. Management of Diabetes
once diagnosis is done, we start diet therapy and exercise.
Our dietary advice is
less elaborate and more practicable - No sugars, no sweet fruits, no sweets and half
the quantity of the roti/chapattis/rice and less oil in food.
Snacking with healthy fruits such as guava, apple, papaya,
orange etc. No referrals to dieticians and no precise or passionate counting of
calories
Limited exercise such as leisurely walk after meals helps.
If target sugar values of <90 mg% before meals and <120mg% after meals
are not achieved with diet within one or two weeks, consideration is given to
drugs. In at least half of our patients, with high risk features mentioned
above, we start the drugs as primary treatment, along with diet and exercise.
Q.7. Choice of What
drugs? In India Metformin but internationally insulin the ideal
preferred drug.
Insulin is better than
Metformin Tab drug for control of preg in DM: When insulin?
13. During labour, latent phase, if basal high do we give regular i.e.
Novo-Rapid ) insulin in 5% dextrose or saline in addition to plain saline ( for
hydration). And in what dose?
4. During active phase, to prevent the patient frm starvation ketosis, do we
start neutralizing dextrose drip ?
If glycemic control
yet not adequate despite 3 g of Metformin, then we add insulin. We feel that
the first insulin in GDM should be Glargine (or any other long-acting insulin).
This is basal insulin that works for 24 hours. The usual BSL profile in severe
GDM patients is that all seven values of the 7-point profile are raised with
narrow gap between pre- and post-meal values. A basal insulin will bring down
all the values proportionately with a single nightly dose of Glargine (total
‘frame shift’).
What monitoring in well-controlled GDM woman?
In a well-controlled
GDM woman, NO special maternal or fetal monitoring is required except for
weekly or bi-weekly tests for glycemic control.
Similarly, termination
of pregnancy happens as routine. NO elective inductions at 38 weeks etc. Unexplained IUFDs happen in
uncontrolled diabetics only and hence there is no need for any alarmist
type action/induction/cesarean in a well-controlled GDM patient.
She is allowed to go
into spontaneous labour till 40 weeks and 4-5 days, when priming of cervix and
labour induction is undertaken, like in any other low-risk gravida.
What special steps at Labour?
During labour, we
monitor BSL hourly. If using 5% Dextrose, we add 5-6 units of plain insulin
(‘neutralizing’ dose) to avoid fluctuating blood sugar values. Most women do
not require any separate insulin infusion for fine control of sugar values if
they have been treated with metformin alone. Occasionally insulin infusion may
be required when patient has been receiving insulin antenatally. Intrapartum
glycemic control is very easy. We make insulin solution in any concentration in
the infusion pump, say 25 units in 50 ml saline. No insulin if BSL is <100
mg%. Above that level, we set the rate of insulin infusion to BSL/100 units of
insulin per hour. For example, if BSL is 150, start insulin infusion at 1.5
units per hour for one hour when the next report will be available.
Care of baby?
The neonate at birth
gets its cord blood checked for BSL. Special management such as IV dextrose for
the neonate only if BSL < 30 mg%. Baby will be given early feeds and BSL
will be checked. Low BSL is likely only when insulin has been used. It does not
happen with metformin therapy.
Resistance to change
from Insulin in GDM among Gynecologists is almost as prevalent as Insulin
Resistance among our patients. Hope our experience narrated above sensitizes
some of us to the value of insulin sensitizers!
Sir I dint get u in One point.evn if she s gdm on insulin
u continue til 40wks?
·
As long as the sugars have remained controlled, there is no
urgency about early delivery,. Our GDM mothers give birth to babies with weight
between 2.5 to 3.5 kg
I think sir is mostly talking of well controlled diabetic
moms who will have a nearly normal course of pregnancy...that is by diet exercise and metformin regime...near euglycemic
will ensure that macrosomia does not ensue
Intra Uterine Death
of Foetus –when?
IUFD in diabetic mothers happens only if the sugars have been
uncontrolled. There was one woman three years ago who had IUFD at 35 weeks.
Subsequently found to have Protein C deficiency. She conceived again rather
soon and we managed both her problems very very carefully the second time and
she got her baby!
For how long do sugars increase after giving steroids and once the BS is stabilized
do we still need to do 7 checks every day ?
Sugars go into some instability for about 3-4 days after
steroids. As for the monitoring, once sugars are stabilized, we need to check
once a week. We do fasting and PP only.
·
The End.
.....!! Q.9. In cases with family history repeated testing is
essential:-In women found to have high risk factors in history and examination,
we give a hot chase
to the diagnosis of GDM with BSL/OGTT/DIPSI test till 36 weeks of gestation-
when HPL levels eventually plateau (HPL is one important factor that makes
pregnancy diabetogenic).
We have seen GDM first detected after 28 weeks in a vast number
of cases.
There has been a Paradigm Shift in the
management of Diabetes in Pregnancy in recent years.
A parallel Paradigm
Shift in the mindset of Gynaecologists can make the management of Diabetes in Pregnancy really easy.
I Magnitude of Problem
Diabetes in pregnancy is becoming even more common all over the world.
Especially in India. We should not complain too much about it though – besides
genes, it also reflects improving socio-economic conditions of the masses
6 March at 19:20 · Like · 3
·
Km Babu Dear friends ,
certain facts about GDM .The reason for the inconsistent screening and guidelines
is due to the lack of basic understanding of the sugar metabolism. Aim should
be to detect all the cases of GDM. Aim of management should be good
hypoglyce...See More
6 March at 23:01 · Like · 12
·
Savita Mahesh Nicely explained
sir . Many of my doubts cleared
7 March at 09:47 · Like · 1
·
Indu Chauhan Thanks a lot DrAmita Sharma luv
ur agility
7 March at 23:40 · Like · 1
·
Indu Chauhan It is wonderful
summary with very handy tips...specially when it is backed by first hand
experience thanx dr Bhupesh Goyal
8 March at 00:01 · Like · 3
, a few queries were
cming up in my mind. Kindly clarify. Our drug of choice is Metformin. We
start it as Metformin SR 1 g HS and increase up to 1 g TDS (with each meal)
till glycemic control is achieved. More than 90% GDM patients will be
successfully managed with this regimen of diet and metformin.
When Metformin?
1. Patient on metformin, if any one value of the 7point profile is abnormal,
how do we adjust the dose?
2. After delivery if BSL high , can we restart metformin ?
. Patient on metfrmin , if any one value of the 7point profile is abnormal ,
how do we adjust the dose?
2.aftr delivery if BSL high , can we restart mtfrmin ?
3. During labour , latent phase , if bsl high do we give reg insulin in 5%
dextrose or saline in addition to plain saline ( fr hydration). And in wat dose
?
4. Durng active phase , to prevent the patient frm starvation ketosis , do we
start neutralisng dextrose drip ?
31 May at 14:52 · Like · 1
·
Bhupesh Goyal Dr Manjula Singhal,
your concerns are very genuine and duly appreciated.
When we do the BSL profile of a GDM on metformin, the dose may require
adjusting depending upon the values. My target values are below 90 pre meal and
around 120-130 post meal. I...See More
31 May at 16:03 · Like · 2
·
Anupama Ravi Futela Shivkee Gautam tagging
you
Was discussing this post
·
Shivkee Gautam Anupama Ravi Futela so we r
following correct guidelines ... N that's why so many pts are found to be gdm
or intolerant even at 32wks.smile emoticon
31 May at 18:49 · Edited · Like
·
Manjula Singhal Thanx a lot ,
Sir !
·
Priyanka Shukla Sir , one of my patient
First baby female 3.5 kg
Second baby 4 kg male delivered normally but died....See More
1 June at 07:45 · Like · 3
·
Manisha Singh Very rightly
said Dr Bhupesh ,, there is a need fr change in our resistance levels to usage
of metformin !!! I still at times find myself slightly biased towards regular
insulin usage !!!
1 June at 08:18 · Like · 2
·
Pawan Dhir Very nice sir
..i take out baby at 37 wks..kal ho na ho ..
·
Bhupesh Goyal Dr Manisha Singh, you too well soon realize the magic of
metformin and will feel blessed! It makes GDM so pedestrian a concern!, I would
have done sugar testing more often. Can you share her GTT results with us-I
can't imagine a 4.2 kg baby in an average sized woman without GDM.
1 June at 21:17 · Like · 4
·
Yasmin Syed very nice and
informative....compilation...easy to revise...thanks alot sir....keep continue
with different topic.
·
Priyanka Shukla Oops ! I will
request pt to get her file , sir. Today she went with her baby to higher
centre. Will do it surely sir. As am too wondering that she showed all features
of GDM. poly with big baby and past history of large babies with a fetal
death..
1 June at 23:40 · Like · 1
·
DrAnita Rajpurohit Dr Bhupesh Goyal sir
you've explained management of gdm so nicely and in very easy way. Thanks for
the share.
·
Daljit Arora Bakshi Thx for such a
simple, clear elaborate and useful information !
3 June at 20:55 · Like · 1
·
Preeti S. Sareen Thanks such for
simplifying GDM and from now.on.I.will also start with metformin as the first line in GDM
4 June at 11:36 · Like · 1
·
Priyanka Shukla Dr Bhupesh Goyal sir,
sending GTT result of that pt.
6 June at 00:47 · Like · 1
·
Bhupesh Goyal Perfectly normal
report Dr Priyanka Shukla
6 June at 05:27 · Like · 1
·
Raseena Najeeb How do u manage
overt diabetic? Pt already on insulin...
·
Priyanka Shukla second baby was
4.5kg.
Sir , with such history , can we start metformin empirically ?will it help?
anyways metformin doesn't harm normoglycemics.
6 June at 08:12 · Edited · Like
Sir start a group ..where all seniors like u can post like
this ...so will not miss any post
Keep this gr for case discussion
Just suggestion as dnt want to.miss such a wonderful post
·
what are the height and weight of the patient and what was her
BMI? If sugars at present are as normal as these, I won't start metformin but
will keep repeating sugar testing every 4-6 weeks.
·
how much insulin is the overt diabetic taking? Is she obese and
showing features of hyperinsulinemia? Is she on insulin alone or also on
metformin? On a few occasions I have changed over from insulin
to metformin during pregnancy when the insulin dose being taken was small, say
20 units and patient showed features of obesity and insulin resistance
She was on insulin but sugars were not controlled..so
metformin was added..500mg tid yet her sugars were not controlled i admitted
her started monitoring sugars and insulin was given accordingly.. Nst was not
reactive at all no acclerations no decelerations since 34 wks any way i induced
her at term delivered asphyxiated baby of 3.75 kg baby was resuscitated
but.....
.
·
... I
Why edge is infavour of Metformin? too use metformin as
first line drug n so far no problem ... Metformin is easy, good n cheap option
for d patient ... I am almost doing d same practice as u mentioned but some of
ur points I had never thought...
Sir! I am slightly skeptical for such stringent sugar
levels F-90 & PP 120. Hyperglycemia takes time to bring problems whereas
Hypoglycemia is immediately hazardous. Most of the ladies have a fluctuating
life style..they'll fast one day a
·
ma'am I appreciate your view and your share. The reason
why we are comfortable about metformin is that it is actually an anti
hyperglycemia agent and not an oral hypoglycemic drug like Daonil. So we don't
encounter hypoglycemia in our patients. But I do agree that I would also not up
the dose if PP is around 130-135
Dr a
the more we read you the more we know how little we know. Take
care . you are indeed very precious
Bela Bhatt Great learning experience with all your posts, Dr Bhupesh Goyal
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