1. Post Partum

2. Objectives • Discuss the immediate care of the infant • Discuss the importance of breast feeding • Discuss follow up screening of the mother • Discuss risk of IGT or diabetes in future • Discuss follow up education for mother

3. After delivery – the infant • Watch for signs of hypoglycemia • Check blood glucose – heel prick • Within 1st hour after delivery • After each of 1st4 feeds • Less than 2.6 mmol/L or 44 mg/dl defined as hypoglycemia • Treatment of hypoglycemia • Topfeeding/glucose in water/ IV dextrose Seshiah, Balaji, 2006

4. After delivery – the infant • Usual care • Vital signs • Apgar scores • Pre-warmed incubator • Start breast feeding within 30 minutes for better latching • Watch for jaundice – check bilirubin • If macrosomic, check calcium and magnesium on day 2 Seshiah, Balaji, 2006

5. After delivery - mother • Exogenous insulin not required after placenta is delivered • Blood glucose usually returns to normal • Check fasting within 48 hours to rule out type 1 or type 2 diabetes

6. Breast feeding • Encourage for all • Protects infant from over or undernutrition during early childhood • May lower risk of • Obesity • Hypertension • Cardiovascular disease • Diabetes Gunderson, 2007

7. Post partum period • Encourage mother to achieve healthy weight. • Healthy eating • Adequate intake to sustain breast feeding • Regular activity

8. Future pregnancies • Should be planned • Education regarding birth control is needed • Encourage achieving healthy weight prior to conceiving again • Check blood glucose levels well ahead of conception allowing time to normalize if necessary

9. Contraception • Any method of contraception can be safely used in a woman with history of GDM • Intrauterine devices are commonly used • Progesterone-only oral contraceptives are the best choice within the first 6 weeks post partum • They have the lowest risk of thrombosis • Preferred during breastfeeding

10. Glucose tolerance testing • Should be done 6-12 weeks post partum • Fasting glucose testing is not sufficient to identify all who have IGT or type 2 diabetes • Only 34% of women with IGT or type 2 had elevated fasting glucose levels • 44% of those with type 2 had fasting less than 5.5 mmol/L (100 mg/dL) • OGTT should be done Metzger, Buchanan, Coustan et al. 2007

11. CVD risk • Women with GDM may have many of characteristics of metabolic syndrome • Hypertension, dyslipidemia, obesity, IGT should all be evaluated and treated Metzger, Buchanan, Coustan et al. 2007

12. Postpartum education is key • OGTT at 6-12 weeks • Managing risk factors • Obesity • Hypertension • Dyslipidemia • Birth control • Preconception screening • Annual screening for diabetes – 35-60% risk of type 2 within 10 years Metzger, Buchanan, Coustan et al. 2007

13. References • Gunderson EP. Breastfeeding after gestational diabetes pregnancy. Diabetes Care. 2007;30(suppl 2):S161-168. • Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. • Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28.