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DIABETES MELLITUS

DURING PREGNANCY
HOW PREVALENT IS DM IN
THE PREGNANT
POPULATION?
EPIDEMIOLOGY
PREVALENCE
WORLDWIDE
APPROX. 7% OF ALL PREGNANCIES COMPLICATED WITH GDM
WESTERN PACIFIC REGION
7.6% OF POPULATION HAVE DM TYPE II (INCLUDING GDM)
HIGHEST AMONG OTHER REGIONS STUDIED
PHILIPPINES
1.9% OF PREGNANT WOMEN ADMITTED IN THE LAST 5 YEARS HAVE GDM
5.1% OF WOMEN SURVEYED HAD TYPE 2 DIABETES MELLITUS OR GDM
CHANGES IN GLUCOSE METABOLISM
DURING NORMAL PREGNANCY
INCREASED INSULIN SECRETION
DECREASED INSULIN SENSITIVITY
ELEVATED POSTPRANDIAL GLUCOSE LEVELS AND PROLONGED GLUCOSE
PEAK
INCREASED HEPATIC GLUCOSE PRODUCTION
INCREASED CARBOHYDRATE USE (BY FETUS)
ACCUMULATION OF MATERNAL FAT STORES IN EARLY PREGNANCY
ENHANCED FAT MOBILIZATION IN LATE PREGNANCY


DIAGNOSIS AND
SCREENING
WHO SHOULD BE
SCREENED?
UNIVERSAL SCREENING FOR GDM IS RECOMMENDED
FOR ALL FILIPINO GRAVIDAS!
SHOULD BE SCREENED FOR TYPE 2 DIABETES MELLITUS IN THE
FIRST PRENATAL VISIT
EITHER USING FASTING BLOOD SUGAR [FBS], GLYCOSYLATED
HAEMOGLOBIN [HBA1C] OR RANDOM BLOOD SUGAR [RBS])

DIAGNOSIS AND SCREENING
DIABETES MELLITUS RECOGNIZED DURING PREGNANCY
SHOULD NOW BE CLASSIFIED AS EITHER GESTATIONAL
DIABETES MELLITUS (GDM) OR OVERT DIABETES
MELLITUS BASED ON PLASMA GLUCOSE LEVELS
A DIAGNOSIS OF OVERT DIABETES MELLITUS IS GIVEN
AMONG WOMEN WITH ANY OF THE FOLLOWING
RESULTS IN THEIR FIRST VISIT:
FBS >= 126 MG/DL (7 MMOL/L)
RBS >= 200 MG/DL (11.1 MMOL/L)
HBA1C >= 6.5%
2 HOUR 75 G ORAL GLUCOSE TOLERANCE TEST (OGTT) >
200MG/DL (11.1 MMOL/L)

A DIAGNOSIS OF GDM IS MADE IF ANY ONE OF THE FOLLOWING
PLASMA VALUES ARE EXCEEDED:
FBS > 92 MG/DL
1 HOUR >180MG/DL
2 HOURS >153 MG/DL

FOR FILIPINO PREGNANT WOMEN, POGS CPG CONSENSUS PANEL
RECOMMENDS THE FOLLOWING CUT-OFF VALUES FOR THE
DIAGNOSIS OF GDM:
FBS >92 MG/DL
2 HOURS >140 MG/DL
FOR FILIPINO GRAVIDAS WITH NO OTHER RISK FACTORS ASIDE FROM
RACE OR ETHNICITY AND THE INITIAL TEST (FBS OR HBA1C OR RBS) IS
NORMAL:
SCREENING FOR GDM SHOULD BE REPEATED AT 24-28 WEEKS
USING A 2 HOURS 75G OGTT
IF THERE ARE OTHER RISK FACTORS IDENTIFIED:
INITIAL SCREENING SHOULD PROCEED IMMEDIATELY TO 2 HOUR
75G OGTT


IF THE OGTT AT 24-28 WEEKS IS NORMAL,
SHOULD BE RE-TESTED AT 32 WEEKS
OR EARLIER IF CLINICAL SIGNS AND SYMPTOMS OF HYPERGLYCEMIA ARE
PRESENT IN THE MOTHER AND THE FETUS
THE OGTT SHOULD BE PERFORMED IN THE MORNING AFTER AN
OVERNIGHT FAST OF 8 HOURS FOLLOWING THE GENERAL
INSTRUCTIONS FOR THE TEST


PRECONCEPTION COUNSELLING AND
MANAGEMENT
WOMAN WHO ARE DIABETIC AND ARE CONTEMPLATING
PREGNANCY SHOULD BE EVALUATED AND IF INDICATED, SHOULD
BE SCREENED AND TREATED FOR RETINOPATHY, NEPHROPATHY
AND CARDIOVASCULAR DISEASE
MEDICATIONS TAKEN BY SUCH WOMEN SHOULD BE EVALUATED
PRIOR TO CONCEPTION
HBA1C LEVELS SHOULD BE AS CLOSE AS POSSIBLE (<7%) IN AN
INDIVIDUAL PATIENT BEFORE CONCEPTION IS ATTEMPTED

SINCE MANY PREGNANCIES ARE UNPLANNED, CONSIDER THE
POTENTIAL RISKS AND BENEFITS OF MEDICATIONS WHICH ARE
CONTRAINDICATED IN PREGNANCY IN ALL WOMEN OF
CHILDBEARING POTENTIAL, AND COUNSEL WOMEN USING
MEDICATIONS ACCORDINGLY
MANAGEMENT OF PRE-EXISTING DIABETES MELLITUS-
RELATED COMPLICATIONS:
1. HYPERTENSION
A GOAL OF SYSTOLIC BLOOD PRESSURE < 130 MMHG IS
APPROPRIATE FOR MOST PATIENTS WITH DIABETES MELLITUS
PATIENTS WITH DIABETES MELLITUS SHOULD BE TREATED IF
DIASTOLIC BP FALLS < 80 MMHG

2. NEPHROPATHY
TO REDUCE THE RISK OR SLOW THE PROGRESSION OF
NEPHROPATHY, OPTIMIZE GLUCOSE AND BLOOD PRESSURE
CONTROL
PERFORM TEST TO ASSESS URINE ALBUMIN EXCRETION AND
SERUM CREATININE IN TYPE 1 DIABETES MELLITUS PATIENTS
WITH DISEASE DURATION OF 5 YEARS OR MORE AND IN ALL TYPE
2 DIABETES MELLITUS PATIENTS STARTING AT DIAGNOSIS.

3. RETINOPATHY
TO REDUCE THE RISK OR SLOW THE PROGRESSION OF
RETINOPATHY, OPTIMIZE GLYCEMIC AND BLOOD PRESSURE
CONTROL.
WOMEN WITH PRE-EXISTING DIABETES MELLITUS WHO ARE
PLANNING PREGNANCY OR WHO HAVE BECOME PREGNANCY
SHOULD HAVE A COMPREHENSIVE EYE EXAMINATIONS AND BE
COUNSELLED ON THE RISK OF PROGRESSION OF RETINOPATHY
EYE EXAMINATION SHOULD OCCUR IN THE FIRST TRIMESTER
WITH CLOSE FOLLOW-UP THROUGHOUT PREGNANCY AND FOR 1
YEAR POSTPARTUM
ANTEPARTUM MANAGEMENT
MEDICAL NUTRITION THERAPY (MNT)
CONSISTS OF AN ASSESSMENT OF FOOD INTAKE, PHYSICAL ACTIVITY AND
MEDICATIONS HISTORY, AND INTAKE AS WELL AS WEIGHT STATUS, DURING
AND AFTER PREGNANCY

***NUTRITION REQUIREMENTS ARE THE SAME FOR PREGNANT WOMAN WITH
AND WITHOUT GDM!
WEIGHT MANAGEMENT AND ENERGY INTAKE
*** PREGNANCY WEIGHT GAIN RECOMMENDATIONS FOR
WOMEN WITH GDM WHO HAD NORMAL WEIGHT OR WERE
UNDERWEIGHT PRE-PREGNANCY = WOMEN WITHOUT GDM
ENERGY INTAKE FOR OVERWEIGHT OR OBESE WOMEN
WITH GDM MAY BE MODESTLY RESTRICTED AS LONG AS
WEIGHT GAIN IS APPROPRIATE WITH HER PREGRAVID BODY
MASS INDEX (BMI)
WEIGHT GAIN ISSUES
***MORE THAN WEIGHT GAIN, IT IS GLYCEMIC CONTROL THAT
IS PREDICTIVE OF BIRTHWEIGHT
MATERNAL WEIGHT REDUCTION DURING PREGNANCY = NO
EFFECT ON BLOOD PRESSURE CONTROL (PRE-ECLAMPSIA)
MAY BE HARMFUL TO THE FETUS (RESULTING IN LOW
BIRTHWEIGHT)
HIGH PROTEIN SUPPLEMENTATION (TO HAVE LOW
CARBOHYDRATE DIET) = SIGNIFICANTLY INCREASED RISK
OF SMALL FOR GESTATIONAL AGE (SGA)

CARBOHYDRATE CONSUMPTION
LOW > HIGH GLYCEMIC INDEX

HOW ABOUT THE USE OF SUGAR SUBSTITUTES?
INTAKE OF SUGAR SUBSTITUTES SUCH AS ACESULFAME
POTASSIUM, ASPARTATE AND SUCRALOSE = ACCEPTABLE DURING
PREGNANCY AND LACTATION
SACCHARIN AND CYCLAMATES ARE NOT RECOMMENDED DURING
PREGNANCY
LIFESTYLE CHANGES
STOP ALCOHOL CONSUMPTION
SMOKING CESSATION
SUFFICIENT LEVEL OF PHYSICAL ACTIVITY AND EXERCISE
ANTEPARTUM BLOOD GLUCOSE CONTROL
INSTITUTED ONCE DIET AND EXERCISE HAVE FAILED AS EVIDENCED BY
ABNORMALITY IN MORE THAN HALF OF SELF-MONITORED GLUCOSE OR AN
ABNORMAL VALUE IN THOSE WOMEN TESTED WEEKLY
INSULIN = TRADITIONAL DRUG OF CHOICE
TOTAL INSULIN NEEDS MAYBE COMPUTED AS FOLLOWS:
0.7 TO 0.8 U/KG ACTUAL BODY WEIGHT IN THE FIRST TRIMESTER
1.0 U/KG ACTUAL BODY WEIGHT IN THE SECOND TRIMESTER
1.2 U/KG ACTUAL BODY WEIGHT IN THE THIRD TRIMESTER


GUIDELINES FOR OUTPATIENT GLUCOSE MONITORING AND TARGETS
FOR PREGNANT DIABETICS:
FOR GDM, TREATMENT GOALS ARE:
PREPRANDIAL GLUCOSE CONCENTRATION OF <= 95MG/DL
1-HOUR POSTMEAL GLUCOSE VALUE OF <= 140MG/DL
2- HOUR POSTMEAL GLUCOSE VALUE OF <120MG/DL

FOR WOMEN WITH PRE-EXISTING TYPE 1 OR TYPE 2 DIABETES
MELLITUS WHO BECOME PREGNANT, GLYCEMIC GOALS ARE:
PREMEAL, BEDTIME, AND OVERNIGHT GLUCOSE VALUES OF 60-99 MD/DL (3.3
- 5.4 MMOL/L)
PEAK POSTPRANDIAL GLUCOSE VALUE OF 100-129 MG/DL (5.4 7.1 MMOL/L)
HBA1C VALUE OF <=6.0%

ALTHOUGH INSULIN IS THE PREFERRED TREATMENT APPROACH,
METFORMIN AND GLYBURIDE HAVE BEEN SHOWN TO BE
EFFECTIVE ALTERNATIVES WITHOUT ADVERSE EFFECTS IN SOME
WOMEN
PATIENTS ALREADY NEEDING PHARMACOLOGIC TREATMENT
SHOULD BE REFERRED TO A SPECIALIST PERINATOLOGIST OF
AN ENDOCRINOLOGIST WHO HAS CONFIDENCE AND EXPERIENCE
IN INSULIN THERAPY

ANTEPARTUM FETAL SURVEILLANCE
SUGGESTED FETAL SURVEILLANCE MODALITIES ARE:
1. SCREENING FOR CONGENITAL ANOMALIES (1
ST
AND LATE 2
ND

TRIMESTERS)
2. MONITORING FOR FETAL WELL-BEING (FETAL MOVEMENT COUNTING,
NONSTRESS TEST (NST), CONTRACTION STRESS TEST (CST), DOPPLER
VELOCIMETRY, BIOPHYSICAL PROFILE (BPP))
3. ULTRASOUND ASSESSMENT FOR ESTIMATED FETAL WEIGHT (EFW)
(MACROSOMIA OR INTRAUTERINE GROWTH RESTRICTION (IUGR))
MATERNAL FETAL KICK COUNTING IS ADVISED TO BE STARTED AT
28 WEEKS FOR ALL DIABETIC GRAVIDAS
ANTEPARTUM FETAL SURVEILLANCE
WELL-CONTROLLED GDMS *
AT LOW RISK FOR IN-UTERO FETAL DEATH
ANTEPARTUM SURVEILLANCE MAY BEGIN AT 40 WEEKS WITH
WEEKLY NSTS
THOSE WITH COMPLICATIONS LIKE HYPERTENSION, PREVIOUS
STILLBIRTH, PREECLAMPSIA, AND ALL PREGESTATIONAL
DIABETICS SHOULD BEGIN ANTENATAL TESTING AT 32 WEEKS
WITH TWICE-WEEKLY NSTS.


ANTEPARTUM FETAL SURVEILLANCE
ABSENCE OF FETAL HEART RATE (FHR) REACTIVITY AND THE
PRESENCE OF PERSISTENT AND CONSISTENT LATE
DECELERATIONS = FETAL DISTRESS!*
REQUIRES CAESAREAN SECTION DELIVERY
DOPPLER VELOCIMETRY IS ONLY USEFUL IN DIABETES MELLITUS
WITH VASCULAR COMPLICATIONS, WHICH PREDISPOSES THE
PATIENT TO DEVELOP PREECLAMPSIA AND OR IUGR
INTRAPARTUM MANAGEMENT
INTRAPARTUM BLOOD GLUCOSE CONTROL
WOMEN WITH GDM ON INSULIN THERAPY
BEST MANAGED WITH INTRAVENOUS INSULIN DRIPS AND GLUCOSE
MONITORING PROTOCOLS *
INSULIN MANAGEMENT DURING LABOR, DELIVERY AND
IMMEDIATE POSTPARTUM SHOULD BE HANDLED BY A
SPECIALIST ADEPT IN GIVING SUCH AS THERAPEUTIC
MODALITY

WOMEN WITH VERY MILD GDM MAY NOT REQUIRE
INSULIN THERAPY BUT SHOULD HAVE BLOOD GLUCOSE
ASSESSMENT DURING LABOR

THE FOLLOWING ARE CLINICAL STRATEGIES
THAT THE OBSTETRICIAN MUST KNOW:
DURING LABOR:
1. MONITOR PLASMA GLUCOSE EVERY 1-4 HOURS
2. TARGETS OF CONTROL DURING LABOR:
A. PLASMA GLUCOSE 80-120MG/DL (4.4-6.66 MMOL/L) OR
B. CAPILLARY GLUCOSE 70-110 MG/DL (3.9-6.1 MMOL/L)
FOR CAESAREAN SECTION PATIENTS AND IMMEDIATE
POSTPARTUM PERIOD:
1. DETERMINE RANDOM PLASMA GLUCOSE IMMEDIATELY PRIOR TO
CAESAREAN SECTION
2. PLASMA GLUCOSE SHOULD BE KEPT BELOW 120MG/DL
3. DISCONTINUE IV INSULIN IMMEDIATELY PRIOR TO DELIVERY
4. CHECK PLASMA GLUCOSE 2 HOURS POST CAESAREAN SECTION TO 24
HOURS (EVERY 4-6 HOURS)
5. ADMINISTER INSULIN SUBCUTANEOUSLY WHEN INDICATED (FOR
LEVELS >120MG/DL)

INTRAPARTUM FETAL SURVEILLANCE AND
DELIVERY
INTRPARTUM FETAL SURVEILLANCE
INTRAPARTUM ELECTRONIC FETAL SURVEILLANCE MAY BE
BENEFICIAL*
DURING LABOR AND DELIVERY, CONTINUOUS ELECTRONIC FHR
MONITORING IS RECOMMENDED AND FETAL BLOOD SAMPLING
SHOULD BE AVAILABLE WHEN REQUESTED
UNCOMPLICATED GDM, WELL-CONTROLLED WITH DIET
MAY POSE MINIMAL RISKS TO BOTH MOTHER AND FETUS
AND MAYBE MONITORED LIKE THAT OF A LOW-RISK OR
NORMAL PREGNANCY

TIMING OF DELIVERY
THE TIMING OF THE DELIVERY SHOULD BE INDIVIDUALIZED*
THERE ARE NO DATA SUPPORTING DELIVERY OF WOMEN WITH
GDM BEFORE 38 WEEKS GESTATION IN THE ABSENCE OF
OBJECTIVE EVIDENCE OF MATERNAL OR FETAL COMPROMISE
IF AN ELECTIVE DELIVERY HAS TO BE PERFORMED AMONG
DIABETIC PREGNANCIES, IT IS TYPICALLY ON OR AFTER 39
WEEKS RATHER THAN 38 WEEKS GESTATION NOR EARLIER TO
REDUCE NEONATAL RESPIRATORY MORBIDITY
PATIENTS WITH WELL-CONTROLLED DIABETES MELLITUS AND NO
COMPLICATING FACTORS, MAY AWAIT SPONTANEOUS LABOR AND
BE ALLOWED TO PROGRESS TO THEIR EXPECTED DATE OF
DELIVERY AS LONG AS ANTENATAL TESTING REMAINS
REASSURING AND THE FETUS IS NOT MACROSOMIC
EXPECTANT MANAGEMENT BEYOND THE ESTIMATED DUE DATE
GENERALLY IS NOT RECOMMENDED BECAUSE AFTER 40 OR
MORE WEEKS
BENEFITS OF CONTINUED CONSERVATIVE MANAGEMENT ARE
LIKELY TO BE OUTWEIGHED BY THE DANGER OF FETAL
COMPROMISE
ASSESSMENT OF FETAL LUNG MATURITY BY MEANS OF
AMNIOCENTESIS IN A DIABETIC PREGNANCY IS NO LONGER
REQUIRED WITH DELIVERY AFTER 38 WEEKS*
MODE OF DELIVERY
GDM IS NOT ITSELF AN INDICATION FOR CAESAREAN DELIVERY *
THE RISK OF MACROSOMIA, SHOULDER DYSTOCIA, AND FETAL
INJURY IN LABOR IS INCREASED 3-FOLD IN DIABETIC PREGNANCY.
THESE RISKS SHOULD BE TAKEN INTO ACCOUNT WHEN
PLANNING MODE OF DELIVERY.
USING ULTRASOUND EFW OR ABDOMINAL CIRCUMFERENCE (AC)
TO MAKE DECISIONS REGARDING TIMING AND ROUTE OF
DELIVERY MAY BE ASSOCIATED WITH A LOWER RATE OF
SHOULDER DYSTOCIA
IF EFW IS <4000 KG, VAGINAL DELIVERY IS USUALLY
APPROPRIATE
UNLESS THERE ARE OTHER OBSTETRIC INDICATIONS FOR
CAESAREAN SECTION
IF EFW IS 4000-4500KG
CONSIDER PAST DELIVERY HISTORY, CLINICAL PELVIMETRY,
ULTRASOUND DETERMINED BODY TO HEAD DISPROPORTION,
AND PROGRESSION OF LABOR TO DETERMINE MODE OF
DELIVERY

MODE OF DELIVERY BASED ON EFW
IF FETAL WEIGHT IS ESTIMATED TO BE 4500 KG OR MORE
RISKS AND BENEFITS OF CAESAREAN DELIVERY SHOULD BE DISCUSSED
WITH THE PATIENT
ACOG RECOMMENDS OFFERING CAESAREAN DELIVERY TO DIABETIC
PATIENTS IF THE FETAL WEIGHT IS ESTIMATED TO BE 4500 KG OR MORE

DIABETES MELLITUS SHOULD NOT IN ITSELF BE CONSIDERED A
CONTRAINDICATION TO ATTEMPTING A VAGINAL BIRTH AFTER A
PREVIOUS CAESAREAN SECTION (VBAC)
DELIVERY SHOULD TAKE PLACE IN A HOSPITAL WITH FULL
OBSTETRIC, ANESTHETIC, AND NEONATAL INTENSIVE CARE
FACILITIES

SPECIAL CIRCUMSTANCES
PRE-ECLAMPSIA
MANAGEMENT SHOULD BE AS FOR THE NON DIABETIC
POPULATION WITH PRE-ECLAMPSIA
PRETERM LABOR AND DELIVERY
IF PRETERM LABOR OR DELIVERY BEFORE 36 WEEKS IS
INDICATED, BETAMETHASONE TO PROMOTE FETAL LUNG
MATURITY SHOULD BE ADMINISTERED IF POSSIBLE

ANTENATAL STEROIDS ADVERSELY AFFECT
MATERNAL GLYCEMIC CONTROL AND INCREASE
INSULIN REQUIREMENTS
PATIENT SHOULD BE ADMITTED TO THE ANTENATAL UNIT;
INTENSIVE INSULIN THERAPY AND FREQUENT GLUCOSE
MONITORING ARE REQUIRED TO PREVENT
HYPERGLYCEMIA
TOCOLYTIC DRUGS ARE NOT CONTRAINDICATED IN
DIABETES MELLITUS BUT B-AGONIST DRUGS SHOULD
BE AVOIDED AS THEY CAN CAUSE SEVERE INSULIN
RESISTANCE AND GLUCOSE INTOLERANCE


ANALGESIA AND ANESTHESIA
EFFECTIVE PAIN RELIEF IS IMPORTANT AND ALL
FORMS OF PAIN RELIEF USED IN LABOR CAN BE
ADMINISTERED
PAIN/STRESS FOLLOWING SURGERY AND TRAUMA
IMPAIRS INSULIN SENSITIVITY BY AFFECTING NON-
OXIDATIVE GLUCOSE METABOLISM
HENCE, IT MIGHT BE SURMISED THAT GLUCOSE REGULATION CAN BE
IMPROVED WITH ADMINISTRATION OF ANALGESIA IN STRESSFUL
STATES!
IF GENERAL ANESTHESIA IS USED IN WOMEN WITH DIABETES
MELLITUS, BLOOD GLUCOSE SHOULD BE MONITORED
REGULARLY (EVERY 30 MINUTES) FROM INDUCTION OF
GENERAL ANESTHESIA UNTIL AFTER THE BABY IS BORN AND
THE WOMAN IS FULLY CONSCIOUS

POST-PARTUM MANAGEMENT
POST-DELIVERY
ELEVATED VALUES SHOULD BE CONFIRMED WITH FASTING PLASMA
GLUCOSE (>126 MG/DL OR 7.0 MMOL/L) OR POSTPRANDIAL GLUCOSE
(>200 MG/DL OR 11.1 MMOL/L)
IN SUCH PATIENTS, MNT AND IF NECESSARY PHARMACOLOGICAL
THERAPY, SHOULD BE CONTINUED
ALL TYPES OF INSULIN, GLYBURIDE OR GLYPIZIDE CAN BE SAFELY
USED BY BREASTFEEDING WOMEN
LIMITED DATA SUGGEST THE METFORMIN, WHILE EXCRETED INTO
BREAST MILK, DOES NOT APPEAR TO HAVE HARMFUL NEONATAL
EFFECTS
POSTPUERPERAL RECLASSIFICATION

WOMEN WITH A HISTORY OF GDM SHOULD BE SCREENED FOR
DIABETES MELLITUS 6-12 WEEKS POSTPARTUM USING
NONPREGNANT OGTT CRITERIA
WOMEN WITH A HISTORY OF GDM SHOULD HAVE LIFELONG
SCREENING FOR THE DEVELOPMENT OF DIABETES MELLITUS
OR PREDIABETES AT LEAST EVERY 3 YEARS

TESTING TO DETECT TYPE 2 DIABETES MELLITUS AND
ASSESSING RISK FOR FUTURE DIABETES MELLITUS IN
ASYMPTOMATIC INDIVIDUALS SHOULD BE CONSIDERED IN
ADULTS OF ANY AGE WHO ARE OVERWEIGHT (BMI >25KG/M2)
AND WHO HAVE ONE OR MORE ADDITIONAL RISK FACTORS
FOR DIABETES MELLITUS
IN THOSE WITHOUT THESE RISK FACTORS, TESTING SHOULD
BEGIN AT AGE 45 YEARS.


IF TESTS ARE NORMAL, REPEAT TESTING ARE
CARRIED OUT AT LEAST AT 3-YEAR INTERVALS
TO TEST FOR DIABETES MELLITUS OR TO ASSESS
RISK FOR FUTURE DIABETES MELLITUS, HBA1C, FPG
OR 2 HOURS 75G OGTT IS APPROPRIATE:***
FPG 100-125MG/DL (5.6-6.9 MMOL/L) IMPAIRED FASTING
GLUCOSE (IFG) OR
2 HOURS PLASMA GLUCOSE IN THE 75 G OGTT 140-
199MG/DL (7.8-11.0MMOL/L) IMPAIRED GLUCOSE
TOLERANCE (IGT) OR
HBA1C 5.6-6.4%
IN THOSE IDENTIFIED WITH INCREASED RISK FOR
FUTURE DIABETES MELLITUS, IDENTIFY AND, IF
APPROPRIATE, TREAT OTHER CVD RISK FACTORS

LONG TERM PREVENTION OF DELAY OF
TYPE 2 DIABETES MELLITUS
PATIENTS WITH IGT, IFG, OR AN HBA1C OF 5.7-6.4%
REFERRED TO WEIGHT MANAGEMENT PROGRAM TARGETING WEIGHT LOSS OF 7%
OF BODY WEIGHT
ADVISED INCREASE IN PHYSICAL ACTIVITY TO AT LEAST 150 MINUTES/WEEK OF
MODERATE ACTIVITY
FOLLOW-UP COUNSELLING FOR PREVENTION OF TYPE 2 DIABETES MELLITUS
MAY BE CONSIDERED IN THOSE AT THE HIGHEST RISK FOR DEVELOPING
DIABETES MELLITUS
PREDIABETIC MONITORING = DONE YEARLY

BREASTFEEDING
DIRECT EFFECT OF BREASTFEEDING ON DM RISK IS UNCLEAR
LIMITED STUDIES
REGARDLESS, EXCLUSIVE BREASTFEEDING IS STILL
RECOMMENDED!
CONTRACEPTION
BARRIER METHODS
BARRIER METHODS ARE WELL SUITED FOR WOMEN WITH
PRIOR GDM BECAUSE OF THEIR LACK OF SYSTEMATIC SIDE
EFFECTS OR INFLUENCE ON GLUCOSE TOLERANCE
INTRAUTERINE DEVICE (IUD)
A VERY EFFECTIVE AND REVERSIBLE METHOD WITHOUT
METABOLIC DISTURBANCES
AN IDEAL CONTRACEPTIVE FOR WOMEN WITH PRIOR GDM
NOT CONTRAINDICATED TO PATIENTS WITH GDM

COMBINED ORAL CONTRACEPTIVES (COCS)
METABOLIC EFFECTS OF A GIVEN COC FORMULATION DEPEND ON
NET EFFECT OF THE TYPE AND/OR DOSAGE OF EACH HORMONAL
COMPONENT
SMOKING
MATERNAL AGE >35 YEARS
IN HEALTHY POPULATION
EPID STUDIES ON CURRENT OR PREVIOUS COC-USERS NOT
ESTABLISHED AN INCREASED RISK OF DM
SHORT TERM STUDIES FOUND NO CLINICALLY RELEVANT DAMAGING
EFFECT ON LIPID METABOLISM
WOMEN WITH PRIOR GDM LIKELY FALL IN LOW ABSOLUTE RISK
OF CARDIOVASCULAR AND VENOUS THROMBOTIC EVENTS,
HENCE:
LOW-DOSE COC CAN BE PRESCRIBED TAKING INTO ACCOUNT
THAT:
ABSOLUTE RISKS INCREASE WITH AGE
PERIODIC RISK ASSESSMENT OF CARDIOVASCULAR RISK
FACTORS IN WOMEN WITH PRIOR GDM SHOULD BE DONE

THE MAGNITUDE OF OTHER RISK FACTORS AND FAMILY
HISTORY OF THROMBOSIS INCREASE THE ODDS FOR
ARTERIAL AND VENOUS THROMBOTIC EVENTS BY 2 TO 12
FOLD IN COC USERS

WHEN HYPERTENSION OR MIGRAINES ARE PRESENT IN
WOMEN WITH PRIOR GDM, IT WOULD BE MOST CAUTIOUS NOT
TO PRESCRIBE A COC

IN ALL CASES, THE LOWEST ETHINYL ESTRADIOL WITH NEWER
PROGESTINS SHOULD BE PRESCRIBED AND CLOSE
ATTENTION SHOULD BE PAID TO INCREASES IN BLOOD
PRESSURE AND WEIGHT
ALL WOMEN SHOULD
RECEIVE NUTRITIONAL COUNSELLING
BE ENCOURAGED TO EXERCISE DAILY
ACHIEVE A HEALTHY WEIGHT
RECEIVE APPROPRIATE MEDICAL THERAPY
TO CONTROL BLOOD PRESSURE AND/OR LIPIDS IF LIFESTYLE
INTERVENTIONS FAIL

NON ORAL COMBINATION HORMONAL METHODS (NOT
YET AVAILABLE LOCALLY)
CAN BE ADMINISTERED AS A MONTHLY INJECTION OR AN
INTRAVAGINAL RING
PROGESTIN ONLY ORAL CONTRACEPTIVES (POCS)
TAKEN CONTINUOUSLY AND CONTAIN LOW DOSE
NORETHINDRONE, LEVONORGESTREL OR DESOGESTREL
LONG ACTING PROGESTINS
CAN BE ADMINISTERED INTRAMUSCULARLY (IM)/
SUBCUTANEOUSLY (SQ) OR AS AN IMPLANT
OFFER THE SAME METABOLIC ADVANTAGE AS POC WITH NO
EFFECT ON MATERNAL COAGULATION FACTORS OR BLOOD
PRESSURE


DMPA SHOULD BE USED WITH CAUTION IN BREASTFEEDING
WOMEN AND THOSE WITH ELEVATED TRIGLYCERIDE
LEVELS (>150MG/DL)
CLOSE ATTENTION SHOULD BE PAID TO WEIGHT GAIN,
WHICH ALSO HAS BEEN DEMONSTRATED TO INCREASE THE
RISK OF SUBSEQUENT DIABETES
THE FOOD AND DRUG AUTHORITY (FDA) CAUTIONS DMPA
USE FOR MORE THAN 2 YEARS BECAUSE OF THE
ASSOCIATED DECREASE IN BONE MINERAL DENSITY
LONG ACTING PROGESTIN METHODS ARE NOT A FIRST LINE
CHOICE IN WOMEN WITH PRIOR GDM UNLESS COMPLIANCE
WITH TAKING DAILY MEDICATION IS A PROBLEM
IF ESTROGEN CONTAINING CONTRACEPTIVES ARE
CONTRAINDICATED, THE POC WOULD BE THE FIRST
CHOICE HORMONAL METHOD OR EITHER TYPE OF IUD

SURGICAL STERILIZATION
AN EXCELLENT CHOICE FOR WOMEN WHO ARE NO LONGER
DESIROUS OF SUBSEQUENT CHILDBEARING ESPECIALLY
AMONG PAROUS WOMEN PARTICULARLY THOSE WHO DELIVER
BY CAESAREAN SECTION
INFANTS OF DIABETIC MOTHERS
MONITORING AND MANAGEMENT OF HYPOGLYCAEMIA AFTER
DELIVERY
BLOOD SUGAR MONITORING PROTOCOL
TESTING:
1. CHECK BLOOD SUGAR WITHIN 30 MINUTES OF DELIVERY, AT 1, 2 HOURS
OF LIFE, AND THEREAFTER
2. INFANT WILL NEED 4 STABLE BLOOD SUGARS PRIOR TO DISCONTINUING
BLOOD SUGAR CHECKS.
TREATMENT:
BLOOD SUGAR >45MG/DL NORMAL X 4 (CONSECUTIVELY), NO FURTHER
TESTING REQUIRED!
IF BLOOD SUGAR 30-45MG/DL: STEP-BY-STEP PROCEDURE IS DONE TO
INCREASE BLOOD SUGAR LEVELS
1. BREASTFEEDING
2. FORMULA FEEDING BY CUP OR DROPPER
3. TRANSFER TO NURSERY INTENSIVE CARE UNIT (NICU) AND GIVE IV
GLUCOSE INFUSION OF D10W AT 4ML/KG/HR AND REPEAT BLOOD SUGAR
IN 30 MINUTES
IF BLOOD SUGAR <45 MG/DL REPEATEDLY CONSIDER SWITCHING TO D12.5
OR THE PLACEMENT OF A CENTRAL CATHETER (TO ALLOW FOR THE INFUSION
OF AN ELEVATED CONCENTRATION OF GLUCOSE) SO AS TO AVOID FLUID
OVERLOAD
THANK YOU!

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