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)

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

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

-BMI (obese)

rf :

-maternal obesity

-advanced maternal age

-family history of DM

-previous GDM

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

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

• 
  

• 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

• 
  

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

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

• 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

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

1) diet control and BSP

TX

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

• 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

• 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)

  
  

Monitoring:

SMBG, HbA1c

Management:

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

• BSP not optimise

Q9

• FPG </= 5.3

• 1hour PP : </= 7.8

• 2 hours PP </= 6.7

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

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

Pre meal <5.3

Post meal <6.7

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

• 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

fetal

1) macrosomia

2) shoulder dystocia

3) congenital anomalies (type 2 DM / exert)

maternal

1) microangiopathy

2) PPH

3) pre eclamp

4) IUGR

Fetal: macrosomia, polyhdramnios, shoulder dystocia

After delivery: baby hypoglycemic

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

Q12 : CBG maintain 4.0-7.0 mmol/L

insulin treatment : every 1-2hours

not insulin : every 4 hours

mode delivery (SVD)

Q12) MX glycaemic intrapartum

maintain CBG (4-7mmol/L )

if not controlled, IV insulin

• Svd, between 37+0-38+6weeks

Q12

• Stops subcutenous insulin or metformin

• Check capillary blood glucose 1-2 hourly

• Target cbg:4-7

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

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