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Q11 : insulin treatment pre existing diabetes : should reduce insulin immediately and monitor blood glucose , expalin there is risk of hypoglycemia, advice proper meal

screenign for DM

GDM on insulin should discontinue insulin immediately

MOGTT at six weeks post delivery

FPG at 6-13 weeks after delivery

Contraception

Breastfeeding at least 3 month

Lifestyle intervention

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Induce labor between 37-38weeks

12. Stop insulin. Monitor capillary blood glucose 1 to 2 hrly

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Q11

Svd, between 37+0-38+6weeks

Q12

Stops subcutenous insulin or metformin

Check capillary blood glucose 1-2 hourly

Target cbg:4-7

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Q11) time (37 - 38 + 6)

mode delivery (SVD)

Q12) MX glycaemic intrapartum

maintain CBG (4-7mmol/L )

if not controlled, IV insulin

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Q11 : delivery via Svd between 37 week - 39 weeks

Q12 : CBG maintain 4.0-7.0 mmol/L

insulin treatment : every 1-2hours

not insulin : every 4 hours

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Q10

Maternal

Polyhydramnious

Pre eclampsia and Gestational hypertension

Csec

Increase risk of type II dm

Dka

Increase risk infection

FETAL

Lga and macrosomia

Congenital malformation

Stillbirth

Neonatal comorbidities

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Maternal: pre eclampsia, traumatic delivery, diabetic ketoacidosis

Fetal: macrosomia, polyhdramnios, shoulder dystocia

After delivery: baby hypoglycemic

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complications :

fetal

1) macrosomia

2) shoulder dystocia

3) congenital anomalies (type 2 DM / exert)

maternal

1) microangiopathy

2) PPH

3) pre eclamp

4) IUGR

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Q10

Maternal - PE, DKA, microangiopathy, polyhydramios

fetal before delivery- IUGR, macrosomia, congenital abnormalities, preterm labour

fetal after delivery- shoulder dystocia, fetal hypoglycaemia, jaundice, respiratory distress syndrome

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8) All BSP result is high

9) target bsp :- pre meal < 5.3mmol/l, post meal <6.7mmol/l and should be more than 4 mmol/l

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Comment of BSP result: all elevated including fasting (not compliance to treatment)

What is target of BSP: need to be maintained at 4.0-7.0mmol/l

Pre meal <5.3

Post meal <6.7

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comment : not controlled - start insulin

target BSP :FBG <=5.3 , 2HPP <=6.7

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Q8

BSP not optimise

Q9

FPG </= 5.3

1hour PP : </= 7.8

2 hours PP </= 6.7

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Treatment: medical nutrition therapy (diet control), oral antidiabetic medication (metformin), insulin therapy (rapid and long acting)

Monitoring:

SMBG, HbA1c

Management:

Diet control, exercise, monitoring (SMBG, BSP, urine to look for glycosuria, excessive weight gain)

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Q6

Diet control

Q7

Diet control

Oral antidiabetic , metformin(ind: diet n exercise donot control the blood glucose within 1-2 weeks)

Insulin(ind: blood glucose not control after diet control n metformin, metformin contraindicated, FPG >/= 7.0 at diagnosis with or without metformin, FPG 6-6.9 with complication)

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Q6-

Medical nutritional therapy and exercise

self monitor BSP

If worsen after 2 weeks, metformin should be offered

look out for any cx

Q7-

oral anti diabetic

insulin therapy ( blood glucose target doesn’t met after MNT and metformin, metformin contraindicated/unacceptable, FPG >/same than 7mmol/l at diagnose, FPG 6-6.9 mmol/l with cx

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plan of MX

1) diet control and BSP

TX

GDM - MNT , after 2 weeks - metformin , not adequate met / FBG > 7 -insulin

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pathophysiology of GDM

fetal

1)chronic hyperglycemia - decreased O2 tension( o2 cannot dilute in blood) - increase anaerobic metabolism- increase lactate and reduce pH - IUD.

2) hyperglycaemic - glucose cross placenta - fetal hyperglycaemic - fetal osmotic diuresis - polyhydramnios .

maternal

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Q5

Increased in fetal demands after 18 weeks - increase carbohydate intake- increase insulin requirement

Placenta counter regulatory hormone opposed the act on insulin - increase insulin resistance

These 2 conditions lead to the pancreatic beta cells to work harder to keep up with the insulin demand

Eventually, beta cells tired out - unable to keep up with the insulin demand- plasma glucose rise- GDM

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1st trimester insulin sensitivity increases (hypoglycaemia)

2nd and 3rd trimester, hormonal changes trigger progressive insulin resistance that result in hyper glycaemia

Pathogenesis
inability of the maternal pancrease to respond to the increased insulin requirement of pregnancy.

-pregnancy is a state of insulin resistance which results in a need of an increase in insulin secreted from the pancreatic beta cells

-pregnancy hormone (human placental lactogen, prolactin, progesterone and oestrogen) create a re-orientation of maternal metabolism from glucose to lipid utilization in order to facilitate glucose supply for the developing fetus.

-The reduction of insulin sensitivity, combined with an inadequate response from the pancreatic beta cells to increase the insulin production results maternal hyperglycaemia

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procedures

fasting 8hrs prior - then have 75g Oral glucose to 250ml - drink 10 -15 min - rest (no smoke/drug) - fasting blood glucose, 2hrs post prandial

how do u interpret result ?

result -

normal - FBG < 5.1 , 2hours <7.8

GDM - FBG >= 5.1, 2 hours <7.8

overt FBG >= 7.0 , RPG >=11.1 , MOGTT

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Q3

Ensure normal dietn physical activity for 3 days prior

Smoking not permitted during test

Record all medications n any acute medical illness

Overnight fast min 8 hours

Collect fasting blood sample

Give 75 g oral glucose in 250ml-300ml water within 5 minutes

Patient rest must not eat

Record blood glucose after 2 hours

Q4

gdm doagnosed : any one of FPG >/= 5.1, 2hous pp : >/=7.8

Overt dm suspect when : fpg >/= 7.0, RPG >/=11.1 with sx

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Q1-

Q3-

overnight fast 8hrs

take fasting plasma glucose before drink

75mg sachet + water 250cc

drink slowly

no exercise just rest

take again blood after 2 hrs post prandial

Q4-

fasting plasma glucose must be less than 5.1 mmol/L

2HPP less than 7.8 mmol/L

Q5

increase insulin sensitivity in 1st tri

hyperplasia of islet cell

doubled insulin production

by 2nd tri insulin resistance occur

due to diabetogenic hormones

hyperglycaemia leads to glycosuria

GDM occurs when there’s insufficient beta cell compensation

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Practice normal diet 3 days before OGTT

Fast at least 8 hours before the test

Take venous glucose reading at 0 hour

Drink 75g of oral glucose + 250cc water

Finish within 5-10 mins

If vomit give maxolon

Record reading after 2 hours

How diabetes diagnosed:

FBG =/>5.1

2 hours post prandial =/>7.8

Overt need another test

7

11.1

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risk factor for maternal:

-BMI (obese)

rf :

-maternal obesity

-advanced maternal age

-family history of DM

-previous GDM

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Q1

BMI >27

Age >25yo

Q2

Previous h/o GDM

First degree relative of DM

H/o macrosomic baby >4kg

Poor obstetric history(eg unexplained IUD, congenital anomalies, shoulder dystocia)

Glycosuria>/= 2+ on 2 occassions

Current obstetric problem

When to do

1) women at risk of GDM: at booking

2)>25 no risk 24-28weeks

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Why need MOGTT at booking?

1) risk : BMI (28)

indications and when

1) have risk factors - at booking and 24-28 w

2) >= 25 y/o without risk -at 24 - 28 weeks

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Risk factor in this patient: Overweight (BMI 28), age more than 25 y/o

Other risk factors: first degree relative with DM, previous history of GDM, History of macrosomia, Bad obstetric history (eg: recurrent miscarriage), glycosuria =/> 2+ in 2 occasion, current obstetric problem (PIH, essential hypertension, on steroid, polyhydramnios)