Gestational diabetes mellitus

Posted by e-Medical PPT Sunday, July 29, 2012
Physiological changes in pregnancy
1· FBG: decrease
Glucose levels following a meal or glucose load: increase compared to the non-pregnant state.
2. GT: decreases progressively with increasing gestation {anti-insulin hormones secreted by the placenta; h pl lactogen, glucagon, cortisol}.
3. Doubling of insulin production from the end of 1st  trimester to 3rd  trimester: Increased insulin requirements in pre GD
4. The renal tubular threshold for glucose: falls: glycosuria
Glycosuria is not a reliable diagnostic tool
5. Starvation: early breakdown of triglyceride: liberation of fatty acids &  ketone bodies

Severe forms of GDM are linked to adverse outcome
Maternal problems
PET
Birth trauma (secondary to macrosomia)
Increased rate of CS
Later - Increased rate of T2DM, hypertension, CVD

Problems in offspring
Fetal
?Malformation ,IUFD ,Macrosomia ,Shoulder dystocia/hypoxia-acidosisl/Erb's palsy ,Iatrogenic prematurity
Neonatal
Hypoglycaemia,Polycythaemia,Hyperbilirubinaemia ,Hypocalcaemia,Cardiomyopathy
Adult
Obesity ,Increased rate of  T2DM, hypertension, CVD, ?Breast cancer

Screening
Advantage of detecting GDM
What is the most effective test for screening

The variation in recommendations
Diabetes UK: Routine screening
Urine testing at every ANC visit
RBG at booking, at 2l W and if glycosuria.
75 g GTT if FBG > (110mg/dl)6.1 mmol/L or RBG> (125mg/dl) 7.0 mmol/L within 2 h   of food

Scottish Guidance Network: Routine screening
Urine and RBG at every ANC visit

American Diabetic Association: Selective screening
Age> 25' years'
Overweight before pregnancy
Ethnic group with high prevalence GDM
Diabetes in first-degree relative
History of abnormal glucose tolerance'
History of poor obstetric outcome' .
With 50 g GCT. confirm with 100 g GTT
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