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DR. TARIK Y. ZAMZAMI MD, CABOG, FICS

DR. TARIK Y. ZAMZAMI MD, CABOG, FICS. ASSOCIATE PROFESSOR CONSULTANT OB/GYN KAUH Email.tzamzami@kaau.edu.sa. Gestational Diabetes (GDM). Definition. Prevalence. 1-14 %. Carbohydrate Metabolism. Pregnancy is potentially diabetogenic stat:

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DR. TARIK Y. ZAMZAMI MD, CABOG, FICS

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  1. DR. TARIK Y. ZAMZAMIMD, CABOG, FICS ASSOCIATE PROFESSOR CONSULTANT OB/GYN KAUH Email.tzamzami@kaau.edu.sa

  2. Gestational Diabetes(GDM) Definition

  3. Prevalence 1-14 %

  4. Carbohydrate Metabolism Pregnancy is potentially diabetogenic stat: First half: tendency to hypoglycemia Second half: tendency to hyperglycemia Progressive insulin resistance as pregnancy progresses: HPL Estrogen Progesterone Cortisol

  5. Pathophysiology • Deficiency of insulin receptors prior to pregnancy • Deficient insulin production • HPL block insulin receptors

  6. Detection and diagnosis Risk assessment for GDM should be undertaken at the first prenatal visit

  7. Risks • Maternal • Fetal

  8. Maternal Risks • Hypertensive disorders • Increase cesarean delivery • Developing type II DM after delivery

  9. Fetal risks • Macrosomia • N.hypoglycemia • hypocalcemia • polycythemia • Jaundice • PMR 4.3 folds

  10. Screening

  11. When to screen • High risk patients: .test as soon as possible . If test was –ve repeat at 24-28 wks • Low risk patients: at 24-28 wks

  12. High Risk • Age • Obesity • Family history of DM • Previous large baby • Previous perinatal loss

  13. Low risk • Age < 25 years • Weight normal before pregnancy • Member of an ethnic group with a low prevalence of GDM • No known diabetes in first-degree relatives • No history of abnormal glucose tolerance • No history of poor obstetric outcome

  14. How to screen • One step approach: . using OGTT • Two step approach: . Using 50 gm GCT . If > 140 mg/dl (7.8 mmol/l) perform OGTT

  15. O’sullivan criteria: . F >105 mg/dl (5.8 MMOL/L) . 1 hr > 190 mg/dl (10.6) . 2 hr > 165 mg/dl (9.2) . 3 hr >145 mg/dl (8.1) Carpenter criteria (new): . F > 95 mg/dl (5.3 MMOL/L) . 1 hr > 180 mg/dl (10) . 2 hr > 155 mg/dl (8.6) . 3 hr >140 mg/dl (7.8) Diagnosis of GDM with 100 gm GTT (ADA)

  16. Diagnosis of GDM with 75 gm GTT (WHO) • Fasting > 95 mg/dl (5.3 mmol/L) • 2 hr > 155 mg/dl (8.6 mmol/L)

  17. Diagnosis of Frank DM • Fasting > 126 mg/dl (7 mmol/L) • Random >200 mg/dl (11.1 mmol/L)

  18. Obstetric management • U/S to assess growth pattern • Surveillance fetal well being at term: . Fetal kick counts . CTG . BPP . Amniotic fluid

  19. Monitoring degree of glycemic control • Daily self monitoring (home) • Post-prandial is superior to pre-prandial(glucose profile) • Urine glucose is not reliable • HB A1c is reliable substitute for self monitoring • Urine ketones

  20. Management • Nutritional counseling • An intake of ~1,800 kcal/day • Insulin therapy indicated when medical nutrition therapy (MNT), fails to maintain fasting whole blood glucose levels < 95 mg/dl (5.3 mmol/l) or 2-h postprandial whole blood glucose levels < 120 mg/dl (6.7 mmol/l).

  21. Cont. • Oral glucose-lowering agents are not recommended during pregnancy • Program of moderate exercise • GDM is not of itself an indication for cesarean delivery or for delivery before 38 weeks completed gestation. • Breast-feeding, as always, should be encouraged in women with GDM

  22. LONG-TERM THERAPEUTIC CONSIDERATIONS • Glycemic status should be performed at least 6 weeks after delivery • If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. • Women with IFG or IGT in the postpartum period should be tested at more frequent intervals. Patients should be educated regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal body weight through MNT and physical activity.

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