Gestational Diabetes Mellitus (GDM)

 

Q1. What about  FBGE in casein DM ?

Glucose  handling is significantly altered  in pregnancy ; fasting levels  of glucose  are decreased   and serum levels following  a meal or glucose  load are increased  compared to the non pregnant state.

Q2 What about insulin sensation in preg ?

 Normal  women show  an approximate  doubling of insulin production from  the end of the first trimester to the third  trimester.

 

Q3 What  are the  anti insulin hormones  ?

Glucose   tolerance decreases progressively  with increasing gestation  this is  largely due to the anti insulin hormones secreted by the placenta in normal  pregnancy   particularly  human placental  lactogen  glucagon  and cortisol.

 

Q4. What is the relevance of glycosuria fail in preg ?

The renal tubular threshold for glucose falls during pregnancy . There is a tendency for  tested most pregnant  women will have glycosuria at some  time. Glycosuria  is not a reliable  diagnostic  tool for  impaired glucose  tolerance or diabetes in pregnancy .

 

Q5 How do we diag GDM?

The diagnosis of gestational diabetes  mellitus is arbitrary depending on where  the cut off  is placed on the normal  spectrum of glucose  tolerance  in pregnancy.

These  physiological   changes  are likely to underlie the increased insulin requirements of  women with established diabetes and the development of abnormal  glucose tolerance  in gestational  diabetes  where there is insufficient 

 

Q6 What happens in Type  2 DM in  non Preg ?

Type  2  is  caused by peripheral insulin resistance  and a state in which the body is unable  to compensate for this by increasing insulin secretion.

Individuals with type 2 can have hyperglycaemia for a long period of time without clinical symptoms. It is therefore important to screen for possible occult long term complications of the condition at the time  of diagnosis.

Although  insulin is sometimes required to treat these patients  they do not become ketotic if  it is withdrawn .

 

Q7. What  are the vascular changes in the DM case ?

Candida infection

Staphylococcal skin infections

Macrovascular arterial disease

Microvascualr disease

Women diabetes  have a reduced life expectancy related to accelerated arterial disease and microangiopathy.

 

Q8 What is the diag of Type 2 DM ?

Two hour  plasma glucose  concentration >11.1 mmol/ l 2 hours after 75 g anhydrous  glucose in an oral glucose  tolerance test.

A fasting plasma glucose concentration  > 7.0 mmol/l or

A random  venous plasma glucose concentration > 11.1 mmol/l

 

Q 9 What is the rate of unexplained  IUFD ?

Fetuses of diabetic mothers are at risk of sudden unexplained intrauterine  death . Again this risk is inversely related to the degree of diabetic control and is highest after 36 weeks  gestation. Various  factors  may explain  these sudden losses including  chronic  hypoxia  in the presence of hyperglycaemia  and lactic acidosis. It is  not possible to predict IUD from the cardiotocograph Doppler Velocimetry of biophysical profiles.

 

Q 10  Prevalence of GDM ?

11%

Q 11

Is there rise of cm in GDM ?

Unlike  pre existing diabetes there is no increase in the congenital abnormal pregnancy and hypergluycaemia  in the first trimester.

 

Q12 How to follow up after GDM preg is over ?

Careful follow up ( and  counselling of the woman  regarding the increased  risk and the advisability of regular blood glucose  checks and the need to seek medical advice  if she feels unwell ) is beneficial and may prevent  the development of micro vascular complications.

 

Q13 Follow up of GDM ?

Women  with GDM  should undergo formal 75 g OCTT 6 weeks  following  delivery to exclude impaired glucose tolerance or diabetes present  outside pregnancy .

Women with previous GDM should have fasting blood glucose  checked prior  to conception to detect diabetes  that may have developed since  the last pregnancy

 

Q14 What insulin in labour  Preg case?

It is often possible to manage even insulin treated women without insulin during delivery especially those on small doses of insulin . This is because  women do not eat much during labour. Those on larger doses of insulin are managed as women with pre existing diabetes with i.v.  dextrose and an insulin sliding scale.

 

 

Q 15  Do you induce labour  routinely at 38 weeks ?

The risks to the fetus in cases of diagnosed and treated GDM are less than with pre existing diabetes and therefore it is often not appropriate to advise  routine delivery  at 38 weeks  gestation especially if GDM is well controlled .

 

Q 16  Which oral agents is better in GDM ?

Despite  the usual advice  to avoid oral hypoglycaemic  drugs  in pregnancy  recent data suggest  that newer sulphonylura drugs that do not cross the placenta  in appreciable quantities may be safely and effectively used as an alternative to insulin in GDM .

Q 17 Insulin  in Preg women ?

Persistent postprandial hyperglycaemia despite compliance with diet  is an indication for the introduction of  insulin therapy . this should be in addition to not instead of dietary treatment  . Women  need to be remained of the importance of  dietary  modification although adherence to dietary advice is usually good during pregnancy.

Q18  What Type of Insulin ?

Insulin  is usually given as short acting  insulin before  meals although it may  only  be needed before some meals . In more severe cases where there is   fasting hyperglycaemia intermediate acting  insulin may in addition be required at night.

A four  times daily basal bolus insulin regime with adjustment according to postprandial rather than pre meal glucose readings gives  improved  glycaemic control and improved outcomes  compared to b.d. mixed insulin and adjustment based on pre meal glucose  values.

 

Q19 What about CBG ?

As with pre existing diabetes HBGM is an integral part of management since it allows the woman  immediate feedback.

Some units  favour screening  and diagnosis  using random or postprandial  and irreproducible  in pregnancy. Capillary or plasma  blood glucose  estimations are more easily repeated throughout pregnancy but again  there is no consensus concerning the ideal cut off for diagnosis. This  method does have the advantage of early  and easy diagnosis of women with pre existing but pre viously undiagnosed diabetes.

 

Q20 What about  Diet with bran?

The mainstay of treatment  is diet with reduced fat increased  fibre and regulation of carbohydrate intake. Carbohydrates with  a low glycaemic index are advised . Obese  women are given a reduced calorie diet the aim being  to maintain weight for the remainder of the pregnancy  Strict diets with  limited calorie intake are not advised  in pregnancy  because of the risk of ketonaemia.

Q21 What about  agent ?

Women with mild  degrees of  impaired glucose tolerance in pregnancy approaches to detection and treatment result  in unnecessary intervention maternal inconvenience and more harm than may be prevented.

 

Q22 long term  ill effect ?

Decreasing birth weight  across a population raises issues regarding  the relationship between low birth weight and adult  hypertension and cardiovascular disease.