Diabetes in Pregnancy, Risk and  Diagnosis 

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of varying degree with onset or first recognition during pregnancy. Any carbohydrate intolerance present prior to pregnancy is pre-gestational Diabetes Mellitus type 1or type 2.

Risks of diabetes:

Fetal risks- miscarriage, congenital malformations, polyhydramnios, sudden intra uterine death, macrosomia(big baby), still birth, birth injury and shoulder dystocia or difficult delivery.

Maternal risks –increase chance of vaginal infection specially fungal infection ,breathing difficulty due to big baby or polyhydraminos, obstructed labor, in pre-gestational diabetic womenpregnancy induced hypertension & pre-eclampsia may occur and diabetic retinopathy or diabetic nephropathy may worsen.

How to diagnose? Universal screening of all pregnant women is recommended for our country.

·         By GCT ( glucose challenge test)-it is a single step test “screening plus diagnostic”. Take 75 gram glucose in 300ml water, drink it with in5 -10 minute and time noted at first sip of it.Blood Sample will be collected 2 hours after oral administration of glucose. It is done irrespective of meal.

·         It is done at 24-28 weeks of pregnancy or earlier if you have any family history or any mishap in your previous pregnancy which indicate may be undiagnosed diabetes.

·         GDM is diagnosed if 2 hour plasma glucose is ≥ 140 mg/ dl.

·         Values between 120-139mg/dl are termed as Gestational Glucose Intolerance (GGI).

What to do after diagnosis of GDM?

Medical nutrition therapy (MNT): It is the first line of management in gestational diabetes. A total of 6 meals per day are advised, with 3 major meals and 3 snacks to limit the amount of energy intake. You should include foods with complex carbohydrates and cellulose, such as whole grain breads and legumes. Avoid High GI( glycemic index) foods like sugar and sugary foods, sugary soft drinks, white bread, potatoes, white rice etc.

Exercise- you continue their pre-pregnancy exercises like daily brisk Walking 2 – 3 kilometers per day or Cycling –Treadmill 10-15 min/ Swimming.

Medical Thearpy:

If target Blood glucose Fasting glucose ≤ 95 mg/dl, 1 hour after meals ≤ 140 mg/dl& 2 hours after meals ≤ 120 mg/dl is not achieved, woman should be admitted in hospital for further management. Insulin is the treatment of choice.But insulin is in injection form so not cumbersome to patient. Metformin is a oral hypoglycemic agent and alternative to insulin.  Dose is adjusted according to the blood sugar profile which is done 7 times a day, (before breakfast, lunch and dinner, 1or 2 hrs after breakfast, lunch and dinner and at 2am.

Patient can be discharged once control is achieved and advised to report once a week with her fasting and post prandial sugar values.

        Fetal monitoring-

• fetal movement count- woman should perceive 10-12 fetal count in a day
• fetal growth by clinical examination at your every antenatal visit.
• NTNB scan at 3rd month, Anomaly scan( level II scan), Fetal growth and amniotic fluid volume should be measured every 4 weeks from 28 to 36 weeks to rule out macrosomia and polyhydramnios

When to deliver?

Most women do not require delivery before 39 weeks’ gestation with good glycemic control on medical therapy 

Indications for elective caesarean section - Estimated fetal weight >4000gms (if EFW is 3.5 to 4 kg, pelvic assessment to be done by specialist), abnormal presentations, untreated proliferative retinopathiy or any other obstetric indication

During Postpartum Period After delivery, insulin requirement falls sharply and the insulin dose should be decreased to 25–40% of the pre-delivery dose to prevent hypoglycemia. Breast-feeding which should be stimulated as much as possible, leads to even lower insulin requirements and insulin dose should be decreased further if necessary to prevent hypoglycemia. Neonatal care should be done as advised by your pediatrician.