Gestational Diabetes Mellitus (GDM)
·
= Any degree of glucose
intolerance with onset or first recognition during pregnancy
·
For most it consists of mild
glucose intolerance manifest during the 2nd or 3rd trimester and normalising following delivery
·
Affects 4 – 8 % of all
pregnancies (Indian women >> than European). Risk factors:
o Maternal age > 35 years
o Family history of diabetes
o Previous macrosomia, unexplained still birth
o Obesity
o Glycosuria on two or more separate occasions. 20% of women have glucose
in their urine Þ not a reliable indicator
·
Associated with:
o
Morbidity for mother – 1.5 times risk of caesarean delivery
o Increased risk of type 2 diabetes in the mother (up to 50% over next 10
years). ?Would have got it anyway. Also hypertension, hyperlipidaemia, etc.
o 2.5
times morbidity for baby, including:
§ Large for gestational age, macrosomia (birth weight > 4000 gm – but
most macrosomic babies‟ mothers have normal glucose tolerance)
§ Risk of
inter-uterine fetal death (IUFD)
§ Possibly neonatal jaundice, polycythaemia, post-natal hypoglycaemia, prematurity
– but not congenital malformations (unless IDDM mother)
o But in general risks are low
·
Is usually asymptomatic (ie no
polyuria and thirst). Risk factors have low predictive power Þ
universal screening usual
· NZ guidelines:
o All women should be tested for glucose intolerance following a 50g glucose load between 24 and 28 weeks, blood sample 1 hour later. Normal < 7.8. If very high risks (eg previous GDM) screen at 18 weeks as well
o If failed screening test then formal test is 75g fasting load with
samples at 0,1 and 2 hours. Normal is <5.5, < 11 and < 8.5 at 0,1 and
2 hours. If any one is abnormal then
GDM.
·
Exam: includes checks of eyes
(retinopathy) and hands and legs (neuropathy), urine for protein
·
Aetiology: human
placental lactogen (HPL, increases through pregnancy) ® insulin
resistance ® insulin production. May unmask sub-clinical NIDDM.
·
Management:
o Diet and exercise (but don‟t calorie restrict them – ketosis is bad for babies)
o Regular monitoring – home glucose monitoring and Hb A1C – normal is less than 6.5, under 8 acceptable. Aiming for pretty tight control
o Insulin used if unable to control levels, or evidence of macrosomia.
Stop once labour starts – requirements fall dramatically after delivery
o Sulphonylureas and metformin not approved in pregnancy
o ® ¯Frequency of macrosomia but less clear effect on perinatal mortality and rate of caesarean section
o Do GTT 6 weeks after delivery to check for type 1 or 2 diabetes
· IDDM:
o Need to conceive when Hb A1C < 8. Even if tightly controlled, 4 – 5%
risk of congenital abnormalities (2* general population). Most common are
neural tube and heart defects
o Check for retinopathy at least twice during pregnancy
o Get baseline renal function and ECG/Echo if cardiac problems
o Usual insulin injections have shorter action Þ control harder. In early pregnancy, insulin requirements may reduce. Later they usually increase.
o Usually induced before term
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