Postpartum care in GDM and Pre-conception counseling Dr Amrita Jaipuriar

1. Postpartum care in GDM and Pre-conception counseling Dr Amrita Jaipuriar

2. Immediate Postpartum Period Maternal risks • Late Postpartum Period • Postpartum hemorrhage • Genital tract trauma • Infections • Hypoglycemia • Metabolic syndrome • Future obesity • Type 2 Diabetes • Hypertension • Cardiovascular disorder

3. Neonatal risks • Perinatal death • Hypoglycemia • Respiratory distress • Preterm birth • Birth trauma& shoulder dystocia • Congenital malformation • Hypoxic ischemia • Macrosomia • Polycythemia / Jaundice • Hypocalcemia & Hypomagnesemia

4. Immediate postpartum period is critical for early initiation of preventive health care for both mother and baby

5. Immediate neonatal Care • Essential new born care for every newborn • Early breast feeding to avoid hypoglycemia • Monitoring for hypoglycemia (cut off < 45 mg/dl) • to be started after one hour of delivery • every 4 hours (prior to next feed) • till four stable glucose values are obtained • Evaluate neonate for Respiratory distress syndrome, convulsions, hyperbilirubinemia

6. Recognition of Neonatal Hypoglycemia Most of the times asymptomatic Stupor, tremors, jitteriness, convulsions Tachypnoea , apneic spells, lethargy, limp, eye rolling Difficulty in feeding, sweating episodes, high pitched or weak cry

7. Managing a Newborn with hypoglycemia • Immediate breast feeding without delay • If unable to suck, give expressed milk • If no breast milk secretion/production, baby should be given any formula or top feed • Dissolve one TSF table sugar in 100 ml of normal cow’s milk • Once feed has been given, check blood glucose again after one hour • If blood glucose is >45 mg/dl, 2 hourly feeding (breast feeding is the best option but if not available, formula feed can be given) should be ensured

8. Managing a Newborn with hypoglycemia (contd.) • If Neonatal plasma glucose < 20 mg/dl: • IV bolus 10% dextrose @ 2 ml/kg • Followed by 10% dextrose drip @ 100 ml/kg/d • Check blood sugar 30 min after starting infusion • If hypoglycemia persists refer to NICU

9. Danger signs for referral of Neonate • Failure to maintain IV line & blood glucose is < 20 mg/dl • Two values of plasma glucose < 20 mg/dl in spite of 10% dextrose drip • Neonate not able to suck and blood glucose is < 20 mg/dl • Seizures

10. Optimal control in antenatal period reduces the complications !! • Minimizes risks of complications in the newborn • Reduces malformations, macrosomia, birth trauma, respiratory distress

11. Breast feeding • Early breastfeeding should be encouraged • Prevents hypoglycemia in newborn and promotes bonding between mother and baby • Protects against infant and maternal complications: • - Childhood obesity • - Type 2 DM in baby • - Helps in postpartum weight loss in mother • Treatment with insulin or oral hypoglycemic drugs may be started even in breastfeeding women as secretion of these drugs is negligible in breast milk and does not affect the quality of milk nor the health of newborn

12. Infections • Mothers with GDM are at increased risk of infection especially if delivery was prolonged or required operative intervention • Detect early signs of UTI, puerperal sepsis, and surgical site infection (episiotomy and caesarean delivery) • Large-sized babes of diabetic mothers do not suckle well. This may lead to milk retention and increased risk of breast engorgement and abscess formation

13. Contraception • Safe, effective and reversible method of postpartum contraception • With adequate spacing, her metabolic parameters can return to normal • Thus there is reduced risk of GDM, spontaneous abortions or congenital malformations in the next pregnancy

14. Balance between Risk due to type of contraceptives vsRisk of Unplanned Pregnancy in women with Hyperglycemia

15. Contraceptive options for women with prior GDM

16. Barrier Methods

17. Intrauterine Devices

18. Combined Oral Contraceptives

19. Progestin Only Oral Contraceptives

20. POP should not be the first choice for women during lactation • There is underlying Insulin resistance & B cell dysfunction in DM & Prior GDM patients • POP causes exogenous administration of unopposed progestin • In a large cohort study it was found (JAMA 280: 1998) • Adjusted 3 fold increase for development of Type II DM during first 2 years compared with low dose COC – Risk is time related, risk increases with duration of POC exposure • With use < than 4 month - no increase risk • With 4-8 month use 3 fold increase risk of DM • With > 8 month use 5 fold increase risk of DM

22. Surgical Sterilization

23. Post delivery follow up • Usual post partum care • Maternal glucose levels usually returns to normal after delivery • FPG & 2 hr PPPG is performed on 3rd day of delivery • 75 g GTT performed after 6 weeks - Cut off for normal blood glucose values are : • FPG < 100 mg/dl • 75 g OGTT 2 hour PPPG • Normal < 140 mg/dl • IGT 140-199 mg/dl • Diabetes equal or > 200 mg/dl • Test normal - Women is counselled about life style modifications, weight monitoring & exercise • Test positive women should consult physician

24. A sticker of red dot can alert care giver about GDM offspring and follow up for contraception & discussion about life style changes

26. Importance of testing and procedure

28. Pre-conception counseling

29. Peri-conception Folic acid 5 mg/day oral

30. Thank you