Dr Pallavi Shinde

Department of Gynaecology and Obstetrics

GESTATIONAL
DIABETES MELLITUS
 DIABETES
• Type -1 – insulin dysfunction
• Is characterized by young age onset and absolute insulinemia.
Genetic predisposition with the presence of autoantibodies

• Type -2 – Insulin resistance

• Is characterized by late age onset, overweight woman and
peripheral tissue, insulin resistance

• Gestational diabetes
 INTRODUCTION

• Diabetes during pregnancy is a medical

complication associated with high perinatal mortality
and morbidity.
• It is of two types
• Pregestational diabetes
• Gestational diabetes
 SCREENING
• Low risk – the absence of risk factors as mentioned above –
blood glucose testing not required

• Average risk – some risk factors ----perform a screening test

• High risk –blood glucose test is by using oral glucose

challenge test – after 24 and 28 weeks of pregnancy
 DEFINITION
• Gestation diabetes is defined as impaired glucose
tolerance of variable degree with onset or first recognition
during the present pregnancy
• in normal individuals insulin secretion is proportional to
the insulin requirement thus there is no diabetes
• But when women become pregnant there is insulin resistance as a result of
anti-insulin hormones produces by the placenta
• however the maternal beta cell of the pancreas are able to compensate by
increasing insulin production to match the need as a result there is no glucose
intolerance in the pregnant women
 EFFECTS OF PREGNANCY ON DIABETES
• Pregnancy induces a progressive change in maternal
carbohydrate metabolism
• Pregnancy is a diabetic state
• HPL diminishes the action of insulin on peripheral tissue
leading to insulin resistance
• High levels of estrogen, progesterone, and free active
cortisol oppose the glucose-lowering effect of
insulin-producing insulin resistance.
• Placenta secretes insulinase
 EFFECTS OF DM ON PREGNANCY
• Maternal complication

• During pregnancy – spontaneous abortion if

uncontrolled diabetes infection ( urinary tract
infection ), preterm delivery, preeclampsia,
polyhydramnios
• During labor – prolonged labour, uterine inertia,
shoulder dystocia
• In puerperium – PPH, sepsis, failing lactation,
postpartum endometritis
 INTRODUCTION
• The incidence of diabetes mellitus is increasing
worldwide . The incidence of female having diabetes
mellitus during pregnancy
• Diagnostic criteria
• 1- strong family history of diabetes
• 2-elderly gravida , where in the age of female is above 35
years
• 3- obesity
• 4- history of delivery of baby weighing more than 4 kg
• 5- polyhydramnios
• 6- recurrent vaginal candidiasis
• 7-persistent glycosuria
• 8- polyuria , polyphagia and polydipsia may be present

• Supportive measure
• 1- appropriate lifestyle modification can be advised to
the patient as it goes a long way in maintaining the sugar
level
• 2-regular walk and exercise helps in improving the
glycaemic index
• Medication , breathing technique and yoga help to relax
mentally and physically
• Patient needs to avoid fasting and follow proper diet as
advised by dietician
• Adequate rest is advised
• Avoid mental stress
• Regular check ups and follow ups have to be advised
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY
• In normal conditions insulin secretion is proportional to the insulin requirement.
• Thus no diabetes
• When a woman becomes pregnant there is insulin resistance as a result of anti-
insulin hormones produced by the placenta.
• Beta cells of the pancreas - Increase the level of insulin – compensate insulin
level
• Which influence cell receptor to use the glucose
• Now cells need glucose for energy
• If any issue related to insulin production or dysfunction
• Beta cells of the pancreas ----- influence cell receptor ……use the glucose for
energy – beta cell dysfunction
 GDM RISK ASSESSMENT
• Should be ascertained at the first prenatal visit
• Low risk – Blood glucose testing not routinely required if all the following are
present
• Member of an ethnic group with a low prevalence of GDM
• No known diabetes in first degree relatives
• Age <25 years
• Weight normal at birth
• No history of abnormal glucose metabolism , no history of poor obstetrical
outcome
 GDM RISK ASSESSMENT
• High risk – perform blood glucose testing as soon as feasible, if one or
more of these are present
• Severe obesity
• Strong family history of GDM-impaired glucose metabolism or
glucosuria
• If GDM is not diagnosed blood glucose testing should be repeated at
24 to 28 weeks or at any time there are symptoms or signs suggestive
of hyperglycaemia
 RISK FACTORS

• MOMMA
• M- maternal age group < 25 yrs.
• O – overweight or obese ( BMI)
• M- macrosomia
• M- multiple pregnancy
• A- a history of DM
• In some women however the pancreas is unable to increase
insulin resistance secretion enough to overcome insulin
resistance that develops resistance that developed in pregnancy
resulting in glucose intolerance this is gestational diabetes .
• Onset on usually in the second or third trimester
• Remember GDM represents the first recognition of chronic
pancreatic beta cell dysfunction. GDM is stage in the
evolution of type 2 DM
• Difficult to distinguish pregestational type 2 DM and denovo GDM
• Fasting hyperglycemia
• Blood glucose greater than 200 mg /dl on OGT
• Acanthosis nic grans
• HbA1C> 6%
• A systolic BP >110mm of Hg
• BMI .> 30Kg /m2
• Fetal anomalies
• Clue for type 1
• Lean
• DKA during pregnancy, severe hyperglycemia requiring large doses of insulin
 FETAL COMPLICATION

• Diabetic embryopathy - congenital malformation

• Stillbirth
• Diabetic fetopathy
• Respiratory distress syndrome.
• Respiratory distress –
• Diabetic baby is more prone to develop RDS .
Pulmonary maturity is delayed in diabetics because of
fetal hyperinsulinemia. Which block cortisol action on
pulmonary fibroblast leading to pulmonary maturation

• Fetal microsomia –maternal hyperglycemia leads to

fetal hyperinsulinemia that in turn causes fetal
hyperinsulinemia.
• Fetal hyperinsulinemia result in excessive fetal ( liver ,
muscle )growth and adipose deposition ( microsomia )
• HYPOTHERMIA –
• Diabetic baby prone to hypothermia because
macrosomia baby has large body surface area
resulting in excessive loss of heat from the body
and because the subcutaneous fat in these
neonate is yellow fat ( allow heat loss)
 GDM RISK ASSESSMENT

• The test should be performed in the morning

after an overnight fast of at least 8 hr but not
more than 14 hr and after at least 3 days of
unrestricted diet (>150 g carbohydrate ) and
physical activity .
 ORAL GLUCOSE LOAD
Time 100g glucose

Fasting 95mg/dl

1 hour 180mg/dl

2 hour 155mg/dl

3 hour 140mg/dl
• Effect of pregnancy on diabetes
• Very difficult to stabilize blood glucose levels during pregnancy
• The insulin antagonism is probably due to the combined effect of
HPL estrogen, progesterone, free cortisol, and degeneration of
insulin by the placenta
• Insulin requirement during pregnancy increases as pregnancy
advances
• As more glucose leaks out in urine due to renal glycosuria,
control of insulin dose cannot be made by urine tests and
repeated blood glucose estimation is mandatory
• Ketoacidosis can be precipitated during hyperemesis in
early pregnancy, infection, and fasting of labour .
• It can be iatrogenic ally increased by B sympathomimetic
and corticosteroids used in the management of preterm
labor,
• Insulin requirements fall significantly in the puerperium
• Vascular changes especially retinopathy nephropathy
coronary artery diseases and neuropathy may be worsened
during pregnancy .
 MATERNAL AND FETAL EFFECTS
• Maternal
• A – during pregnancy
• Abortion
• Preterm labour
• UTI
• Increased incidence of preeclampsia
• Polyhydramnios
• Maternal distress
• Diabetes retinopathy, microaneurysm hemorrhages and proliferative retinopathy
• Diabetes nephropathy
• During labour
• Prolongation of labour due to big baby
• Shoulder dystocia
• Perineal injuries
• Postpartum haemorrhages
• Operative interferences
• Puerperium
• Puerperal sepsis
• Lactation failure
 MATERNAL AND FETAL EFFECT
• Fetal hazards
• Fetal macrosomia ( 30 -40%) result from Maternal hyperglycemia of fetal islet –
increased secretion of fetal insulin – stimulate carbohydrate utilization and
accumulation of fat.
• Elevation of maternal free fatty acid in diabetes leads to increased transfer to the
fetus –acceleration of triglyceride synthesis
• Congenital malformation (6-10% ) due to the severity of diabetes affecting
organogenesis
 FETAL EFFECT

• Birth injuries
• Growth restriction
• Unexplained fetal death
• Neonatal complication
 FETAL EFFECTS
• Birth injuries
• Growth restriction
• Unexplained death
• Neonatal fetal death
• Hypoglycemia
• Respiratory distress syndrome
• Polycythemia
• Cardiomyopathy
• Perinatal mortality increased 2-3 times due to hypoglycemia RDS, polycythemia and
jaundice .
 MANAGEMENT

• Diet
• 30 kcal /kg/d based on prepregnant body weight for non obese women
• Obese women with BMI > 30 kg/m may benefit from a 30 % caloric restriction.
• Weekly test for ketonuria because maternal ketonemia has been linked with
impaired psychomotor development is offspring.
• There are no guarantees when it comes to preventing
gestational diabetes — but the more healthy habits you can
adopt before pregnancy, the better. If you've had
gestational diabetes, these healthy choices may also
reduce your risk of having it again in future pregnancies or
developing type 2 diabetes in the future.

• Eat healthy foods. Choose foods high in fiber and low in fat
and calories. Focus on fruits, vegetables and whole grains.
Strive for variety to help you achieve your goals without
compromising taste or nutrition. Watch portion sizes.
• Keep active. Exercising before and during pregnancy
can help protect you from developing gestational
diabetes. Aim for 30 minutes of moderate activity on
most days of the week. Take a brisk daily walk. Ride your
bike. Swim laps. Short bursts of activity — such as
parking further away from the store when you run
errands or taking a short walk break — all add up.
• Start pregnancy at a healthy weight. If you're planning to
get pregnant, losing extra weight beforehand may help
you have a healthier pregnancy. Focus on making lasting
changes to your eating habits that can help you through
• Pathophysiology and Risk Factors
• Gestational diabetes occurs when the body is unable to produce enough insulin
to meet the needs of the pregnancy. Insulin is a hormone that promotes the
uptake of glucose from the blood and its subsequent storage as glycogen.

• In pregnancy, there is progressive insulin resistance. This means that a higher

volume of insulin is needed in response to a normal level of blood glucose. On
average, insulin requirements rise by 30% during pregnancy.

• A woman with a borderline pancreatic reserve (Table 1) is unable to respond to

the increased insulin requirements, resulting in transient hyperglycemia. After
the pregnancy, insulin resistance falls – and the hyperglycemia usually resolves
• The main investigation for gestational diabetes is the oral glucose tolerance test
(OGTT). In this test, a fasting plasma glucose is measured, then a 75g glucose
drink is given – with a repeat plasma glucose measurement after 2 hours.

• GDM is diagnosed if:

• Fasting glucose > 5.6mmol/L
• 2hrs postprandial glucose > 7.8mmol/L
• 24 – 28 weeks’ gestation – if risk factors are present
(Table 1), or in cases of previous gestational diabetes.
• Any point during pregnancy – if 2+ glycosuria on one
occasion, or 1+ on two occasions. Alternatively, pre-
and postprandial blood sugar monitoring can be
performed.
 MANAGEMENT

• The aim of treatment is to provide good glycaemic control for the duration of
the pregnancy. Lifestyle advice should be given regarding diet and exercise –
as this alone can sometimes be sufficient. Capillary glucose measurements
should be taken four times a day.

• The medical management of gestational diabetes involves careful monitoring

and control of blood glucose. The medications used to reduce blood glucose
include:

• Metformin – suitable in pregnancy and breast feeding.

• Glibenclamide – used if metformin is not tolerated (often due to GI side effects)
and insulin has been declined.
• Insulin
• Consider starting at diagnosis if the fasting glucose >7.0mmol/L.
• Or introduce later in pregnancy if
• (i) pre-meal glucose > 6.0mmol/L
• (ii) post-meal glucose >7.5mmol/L
• (iii) fetal AC (abdominal circumference) >95th centile
• In the UK, the obstetric care of any patient with gestational diabetes is
consultant-led throughout the pregnancy. Additional growth scans should be
performed at 28, 32 and 36 weeks, to monitor for the complications of
gestational diabetes (e.g accelerating or large growth, polyhydramnios).
 INSULIN DOSE

• GDM patients – dose of insulin calculated by blood glucose level

• 120-160 mg/dl – 4unit
• 160-200mg/dl – 6 unit
• >200 mg/dl – 8 unit
 POSTNATAL CARE
• All anti-diabetic medication should be stopped immediately after delivery. The
blood glucose should be measured before discharge to check that it has
returned to normal levels.

• Around 6-13 weeks post-partum, a fasting glucose test is recommended. If this

is normal, yearly tests should be offered because of the increased risk of
developing diabetes in the future (50% of mothers with gestational diabetes
will go onto develop Type 2 Diabetes in later life).

• In subsequent pregnancies, an OGTT should be offered at booking and at 24 –

28 weeks’ gestation.
• Glucose Challenge Test
• You may have the glucose challenge test first. Another
name for this blood test is the glucose screening test. In
this test, a health care professional will draw your blood
1 hour after you drink a sweet liquid containing glucose.
You do not need to fast for this test. Fasting means having
nothing to eat or drink except water. If your blood
glucose is too high—140 or more—you may need to
return for an oral glucose tolerance test while fasting. If
your blood glucose is 200 or more, you may have type 2
diabetes.
 ORAL GLUCOSE TOLERANCE TEST (OGTT)
• The OGTT measures blood glucose after fast for at least 8 hours. First, a health
care professional will draw the patient’s blood. Then the patient will drink the
liquid containing glucose. Lab technicians will need your blood drawn every
hour for 2 to 3 hours for a doctor to diagnose gestational diabetes.

• High blood glucose levels at any two or more blood test times—fasting, 1 hour, 2
hours, or 3 hours—mean you have gestational diabetes. Your health care team
will explain what your OGTT results mean.

• Your health care professional may recommend an OGTT without first having the
glucose challenge test.
 ROLE OF HOMOEOPATHY

• Diabetes mellitus is a systemic disorder and there fore constitutional remedy is the
best treatment for diabetes mellitus
• Homoeopathic remedies along with supportive measure can help in preventing or
minimizing the complication of diabetes and also help in maintaining level within the
normal limit
•
 MIASMATIC ANALYSIS

• Persons of tubercular constitution are prone to develop condition like diabetes .

• Usually syco –psora are more prone to develop condition loke diabetes while pseudo
psora provides fertile soil for diabetes insipidus
• In obese individual if symptoms of polydipsia and polyuria are worse during the day
it ay be syco psoric miasm
• Diabetes mellites along with polyhydramnios have syco psora background
• Strong tubercular state ( syco-psora or pseudo ) provides a fertile soil
• To develop diabetes mellitus , in elderly gravida
• Symptoms of polyuria worse at night are usually of pseudo-
psoric or syphilitic origin
• Diabetes mellitus with marked prostration is usually pseudo-
psoric as seen in medicine like actea ac -, pho acid , natrum
m
• After birth
• You can usually see, hold and feed your baby soon after you've given
birth. It's important to feed your baby as soon as possible after birth
(within 30 minutes) and then at frequent intervals (every 2-3 hours) until
your baby's blood sugar levels are stable.

• Your baby's blood sugar level will be tested starting 2 to 4 hours after
birth. If it's low, your baby may need to be temporarily fed through a tube
or a drip.

• If your baby is unwell or needs close monitoring, they may be looked after
in a specialist neonatal unit.
 THERAPEUTICS
Aceticum Acidum
Suited to pale ,lean ,females with lax ,flabby muscles
Wasting and debility
Intense burning thirst
Profuse urination and sweat
Burning ,dry skin
Tendency to dropsy
For anemia and vomiting of pregnancy
Debility after use of anesthesia
 ARSENIC ALBUM

• Debility , exhaustion and emaciation with loss of appetite

• Unquenchable thirst for sips of water at short interval
• Tendency for diabetes gangrene , peripheral neuritis ,dysuria .
• Ulcer on heels , offensive discharge with burning pain
• Aggravation from heat
• Icy coldness of the body
• This remedy is helpful in diabetes with sign and symptoms of peripheral neuropathy
.
 HELONIAS

• For diabetes nephropathy

• Constant aching and tenderness over the kidney region
• Aching and burning across the lumbar region , she can trace the outline of kidney
• Sensation of prolapse
• Consciousness of the womb ,
• This remedy is useful in diabetes nephropathy with congestion or heaviness in the
loins
 LACTICUM ACIDUM

• Good drugs for morning sickness ,diabetes , and rheumatism

• Voracious appetite , thirsty , copious salivation and waterbrash
• Patient passes large quantities of urine frequently , presence of sugar in urine .
• Sweaty feet
• Nausea > eating
• This remedy benefits in case of diabetes with morning sickness and rheumatism
 LYCOPODIUM

• Debility in the morning , lack of vital heat , poor circulation and cold extremities
• Pain in back before urination which ceases after the flow , red sediment in the urine
• Bulimia with bloating
• Craving of upper parts of the body
• Emaciation of upper part of body
• The remedy is useful in diabetes with renal involvement and haematuria .
 NATRUM MURIATICUM

• It is suited to female who are emaciated ,especially around the neck and mammary
glands
• Great debility and weakness felt in the morning in the bed
• Thirsty patient with polyuria
• Sweating while eating , great hunger with emaciation
• This remedy is useful in diabetes along with hypothyroidism
 PHOSPHORUS

• For diabetes retinopathy and neuropathy

• Thrombosis of retinal vessels , degenerative changes in the retinal cells , atrophy of
the optic nerve .
• Thirst for icy cold water
• Hungry soon after eating
• Burning of the feet and back
• Wounds heals and break open again , they bleed profusely even if small
• Ascending sensory and motor paralysis from ends of the fingers and toes
• Haematuria

• Wonderful effect on diabetes retinopathy and neuropathy

 PHOSPHORIC ACID

• Mentally debility followed by physical debility .

• Nervous exhaustion
• Urine is profuse ,frequent , and milky .proceeded by anxiety and followed by
burning .
• Phosphaturia seen in the patient
• Thirst for cold milk , craving for juicy and sour things
• Formation of various parts
• Diabetes with milky urine and phosphaturia
 SYZYGIUM JAMBOLANUM

• Prickly heat in upper parts of the body , small red , pimples which itch violently .
• Great thirst , weakness and emaciation.
• The specific gravity for diabetes , it may also be used in the form of mother tincture .