Gestational diabetes mellitus (GDM) in the second or third trimester of pregnancy, resolves after the birth of the baby. increasing levels of placental hormones, HPL and increasing maternal insulin resistance, especially after 20 weeks

-Gestational diabetes is usually asymptomatic , risk factors increasing maternal age family history of type 2 diabetes or GDM certain ethnic groups previous unexplained stillbirth previous macrosomia obesity (three-fold risk of GDM) smoking (two-fold risk of GDM change in weight between pregnancies: an inter-pregnancy gain of more than three BMI points doubles the risk of GDM)

-to differentiate between GDM and types 1 and 2 diabetes that present for the first time in pregnancy (the lafer two of which do not resolve following the baby's birth). - The lifetime risk of developing type 2 diabetes after gestational diabetes is seven-fold -referral to a dietician with adherence to a diet restricting sugar and fat, - encouragement of 30 minutes exercise a day, -self-monitoring of blood glucose and insulin therapy if necessary.

Pre-conception care risk of congenital malformations which are associated with hyperglycaemia. -If the HbA1c is > (7.5%) at the initial visit to the midwife, this risk increase in spontaneous miscarriage - taking a daily dose of 5 mg of folic acid prior to conception -any medication should be reviewed and ACE inhibitors discontinued.

Type 1 diabetes Insulin might need to be changed and the regimen intensified to obtain optimal control. NovoRapid® is the only insulin licensed for use in pregnancy.

Type 2 diabetes some anti-diabetic drugs may be teratogenic to early fetal development. Women with type 2 diabetes may also be on statins and ACE inhibitors, which should be discontinued. insulin by subcutaneous injection should be commenced and contraception continued until the woman achieves optimal diabetic control. The BMI weight reduction should be encouraged prior to conception

Pre-conception management Aim to maintain HbA1c < (6.1%) to reduce the risk of congenital malformations. advise women with HbA1c > (10%) to avoid pregnancy. Reinforce self-monitoring of blood glucose. Offer HbA1c testing monthly. retinal assessment at the first pre-conception appointment and then annually if no retinopathy is found.

Assess nephropathy risk including : 1-microalbuminuria estimation 2- serum creatinine/epidermal growth factor receptor (eGFR). Discontinue statins before pregnancy or as soon as pregnancy is confirmed.

Antenatal management multigravidae silently develop type 2 diabetes conceive their fourth or fifth child present late for the initial appointment with the midwife due to being familiar with pregnancy -at risk of developing complications associated with hyperglycaemia

Complications for the pregnancy encompass: pre-eclampsia macrosomic baby, due to hyperglycaemia, with risk of shoulder dystocia IUGR polyhydramnios retinopathy and nephropathy risk of iatrogenic preterm birth leading to the baby being admitted to the neonatal unit.

die in the first few months of life a major congenital malformation. the risks to the fetus/baby born to a woman with diabetes are that they are: stillborn die in the first few months of life a major congenital malformation. -these risk reduced if there is good blood glucose control before and after pregnancy. -a detailed medical history -a referral to endocrine/obstetric clinic.

- multidisciplinary team of obstetrician, physician, dietician and specialist nurse/midwife will provide care. - diabetes screening present at the first appointment with the following risk factors for developing GDM: BMI >30 kg/m2 previous macrosomic baby ≥4.5 kg or above previous GDM first-degree relative with diabetes

education in monitoring their blood sugar glucose levels using the necessary equipment and reagent strips, which need prescribing. They will require education in self-administration of insulin and in balancing insulin requirements based on their blood glucose readings. Dietary assessment and advice is essential so that the insulin dose can be adjusted according to a woman's normal eating habits. preventing both hyperglycaemia and hypoglycemia recognizing the signs and symptoms of hypoglycemia.

blood glucose levels will change throughout pregnancy due to altered hormone levels and the developing fetus having its own metabolic demands. the woman carries glucose tablets/gel and a ready-to-use intramuscular device at all times in case of hypoglycemic episodes. -hypoglycaemia occurring during weeks 8–16 is attributed to nausea and vomiting of pregnancy, A supplement of 5 mg folic acid should be taken daily for the first 12 weeks of pregnancy to reduce the risk of congenital malformations in the fetus.

Urinalysis should be undertaken at each visit to test for glucose, ketones as well as the protein. Women with type 1 diabetes should be offered ketone testing strips and be advised to test for ketonuria if they have symptoms of hyperglycaemia or become unwell. Blood pressure should be recorded at each visit with the midwife being alert for signs of pre-eclampsia, especially with GDM. Women should be discouraged from fasting, especially for long periods (e.g. as with religious observances). Women should test their blood glucose levels on waking and one hour postprandial after every meal during pregnancy.

If taking insulin, women should also test their blood glucose level before going to bed. Women with type 2 diabetes are likely to be commenced on insulin: if taking metformin pre-pregnancy, some centres may decide to continue its use until 32 weeks due to emerging evidence of its safety An ultrasonic scan is undertaken at 7–9 weeks' gestation to confirm viability and gestational age, followed by a further scan at 18–20 weeks to assess the four chambers of the fetal heart for any anomalies, estimate liquor volume and to ascertain fetal growth.

Monthly scans are undertaken to assess fetal growth and their results recorded, observing for signs of macrosomia (dimensions above the 95th centile for the period of gestation). Weekly tests of fetal wellbeing, including CTG or biophysical profiles an indication to intervene earlier: e.g. induction at 38 weeks or caesarean section.

Intrapartum management preterm, steroids are given to the woman to improve fetal lung maturation and additional insulin may be required. If the fetus is macrosomic, the woman should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section. Blood glucose levels should be monitored hourly through labour and birth

For women with type I diabetes an IVI of insulin and dextrose should be commenced from the onset of established labour. For women with type 2 and GDM an IVI of insulin and dextrose should be commenced if blood glucose levels high The neonatal team are ready

Care of the baby at birth A pediatrician should be present at the birth if the woman is receiving insulin. Observe for signs of respiratory distress, hypoglycemia, hypothermia, cardiac decompensation and neonatal encephalopathy. A baby should be admitted to a neonatal intensive care unit (NICU) only if a significant complication is apparent. The woman should hold her baby after the birth and prior to any transfer to the NICU. Blood glucose testing of the baby should be carried out after birth and at intervals according to local protocols.

The baby should feed within 30 minutes of birth and then every 2–3 hours . Blood glucose levels should be assessed in babies who show signs of hypoglycaemia : *abnormal muscle tone * level of consciousness * apnoea * seizures) who is likely to treat with IV dextrose. The baby should not be transferred home until at least 24 hours old, is maintaining blood glucose levels and is feeding well.

Postnatal care of the woman with diabetes Type 1 diabetes: insulin should be reduced immediately after birth and blood glucose levels monitored. observed for signs of hypoglycemia. As placental hormone levels fall, the insulin sensitivity improves, such that the insulin infusion rate is likely to need reducing in the early postnatal period. The woman will usually return to her pre-pregnancy insulin levels, unless she is breastfeeding, when the insulin requirements are reduced by 30% advised that breastfeeding affects glycaemic control

Type 2 diabetes insulin should cease immediately oral diabetic agents the woman may safely take if breastfeeding

GDM: insulin ceases immediately and blood glucose monitoring can stop. A fasting blood glucose test should be undertaken at 6 weeks The woman should be advised of the risk of developing diabetes in future pregnancies and the need for pre-pregnancy screening. informed of the importance of using contraception to prevent pregnancies A healthy lifestyle with regular exercise, smoking cessation and maintaining a BMI within normal limits should also be emphasized to the woman. A follow-up appointment at 6 weeks with the diabetes team