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Prepare set of questions for long case viva GDM

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Long Case Viva: Gestational Diabetes Mellitus (GDM)

Suggested case stem

“A 28-year-old G2P1 woman at 32 weeks' gestation is diagnosed with GDM after an oral glucose tolerance test. She has no symptoms, BMI is 31 kg/m², and her previous baby weighed 4.1 kg. Her fasting capillary glucose values remain elevated despite dietary modification.”
Use the following questions in order, progressing from presentation to advanced discussion.

1. Case presentation and diagnosis

  1. Please present the case briefly.
  2. What is your provisional diagnosis?
  3. Define gestational diabetes mellitus.
  4. How will you differentiate GDM from overt diabetes first detected in pregnancy?
  5. What risk factors for GDM are present in this patient?
  6. What additional history will you specifically ask?
    • Previous GDM
    • Previous macrosomia, shoulder dystocia, stillbirth, congenital anomaly
    • Family history of diabetes
    • Symptoms of overt diabetes
    • Dietary history and physical activity
    • Hypertension, polycystic ovarian syndrome, medications
  7. What will you look for on examination?
  8. Which baseline investigations will you order after diagnosing GDM?
  9. How do you screen for GDM in your unit?
  10. At what gestational age is routine screening generally performed?
  11. Who needs early testing in pregnancy?
  12. Describe the one-step 75-g OGTT approach.
  13. Describe the two-step approach using a 50-g glucose challenge test followed by a 100-g OGTT.
  14. What are the diagnostic thresholds for a 75-g OGTT?
  15. What are the diagnostic criteria for overt diabetes in pregnancy?
  16. Why can different institutions use different screening and diagnostic criteria?
Examiner prompt: GDM is glucose intolerance first recognized in pregnancy that is not clearly pre-existing diabetes. Insulin resistance increases with advancing gestation because of placental hormones.
Reference: Creasy & Resnik's Maternal-Fetal Medicine, section “Gestational Diabetes”.

2. Pathophysiology

  1. Explain the pathophysiology of GDM.
  2. Why does GDM commonly become apparent in the second half of pregnancy?
  3. Name placental hormones that contribute to insulin resistance.
  4. Why do some women develop GDM while others do not?
  5. Is GDM primarily a disorder of insulin resistance, insulin deficiency, or both?
  6. How does maternal hyperglycaemia produce fetal macrosomia?
  7. Explain the Pedersen hypothesis.
  8. Why is neonatal hypoglycaemia seen after delivery?
  9. Why is congenital malformation less common in true GDM than in pregestational diabetes?

3. Maternal and fetal complications

  1. What maternal complications are associated with GDM?
  2. What fetal and neonatal complications are associated with poorly controlled GDM?
  3. Why does GDM increase the risk of pre-eclampsia?
  4. Why is polyhydramnios seen in GDM?
  5. What is the mechanism of shoulder dystocia in a fetus of a diabetic mother?
  6. What pattern of fetal overgrowth is characteristic in diabetic pregnancy?
  7. Why can unexplained intrauterine fetal death occur in poorly controlled diabetes?
  8. What are the short-term neonatal complications?
  9. What are the long-term risks for the mother?
  10. What are the long-term risks for the child?
  11. What is the recurrence risk in a future pregnancy?

4. Antenatal management

  1. Outline your management plan for this woman.
  2. Who should form the multidisciplinary team?
  3. What advice will you provide regarding diet?
  4. What advice will you give regarding exercise?
  5. Should all women with GDM lose weight during pregnancy?
  6. How will you teach self-monitoring of blood glucose?
  7. Which glucose values should be monitored: fasting, pre-meal, or post-meal?
  8. What glucose targets do you use in pregnancy?
  9. How often will you review her glucose log?
  10. What is medical nutrition therapy?
  11. When would you start pharmacotherapy?
  12. What factors would make you start medication earlier?
  13. What is the first-line pharmacological treatment when lifestyle measures fail?
  14. How do you initiate and titrate insulin?
  15. Which insulin regimen would you choose for isolated fasting hyperglycaemia?
  16. Which regimen would you choose for predominantly postprandial hyperglycaemia?
  17. What are the advantages of rapid-acting insulin analogues in pregnancy?
  18. Can metformin be used in GDM?
  19. What counseling is needed before starting metformin?
  20. Why is glyburide/glibenclamide used less commonly in many protocols?
  21. What are the adverse effects and dangers of insulin treatment?
  22. How will you educate the patient about recognition and treatment of hypoglycaemia?
  23. Is HbA1c useful for day-to-day monitoring of GDM? Why or why not?
  24. How will you assess adherence to dietary advice and glucose monitoring?
Examiner prompt: Management should be individualized and follow local obstetric-diabetes protocols. NICE guidance covers diagnosis, self-management, pharmacological treatment, delivery planning, and postnatal follow-up for diabetes in pregnancy. See the current NICE diabetes-in-pregnancy guideline.

5. Fetal surveillance and assessment

  1. How will you assess fetal growth in this patient?
  2. What ultrasound findings may suggest poor glycaemic control?
  3. What is the role of serial growth scans?
  4. When would you perform antenatal fetal surveillance with NST/CTG or biophysical profile?
  5. Does every woman with diet-controlled GDM require intensive fetal surveillance?
  6. How would your surveillance differ in insulin-treated GDM?
  7. How will you assess amniotic fluid volume?
  8. How accurate is ultrasound estimation of fetal weight?
  9. What limitations should you explain before making decisions based on estimated fetal weight?
  10. What additional maternal conditions would increase fetal surveillance needs?

6. Timing and mode of delivery

  1. What factors determine timing of delivery in GDM?
  2. How does management differ between diet-controlled and medication-controlled GDM?
  3. When would earlier delivery be considered?
  4. What are the indications for induction of labour in GDM?
  5. Is GDM by itself an indication for elective caesarean delivery?
  6. When would you consider elective caesarean delivery for suspected macrosomia?
  7. How will you counsel regarding the risk of shoulder dystocia?
  8. What intrapartum precautions are necessary?
  9. How will you manage maternal blood glucose during labour?
  10. What glucose target do you aim for intrapartum?
  11. What is your plan if she is fasting for induction or caesarean delivery?
  12. How will you manage insulin during labour?
  13. Does a woman with GDM require continuous electronic fetal monitoring in labour?
  14. How will you manage a prolonged labour in this patient?

7. Immediate neonatal care

  1. What information should be communicated to the neonatal team before delivery?
  2. What are the immediate priorities after birth?
  3. When should the newborn be fed?
  4. How will the neonate be monitored for hypoglycaemia?
  5. List neonatal complications that require observation.
  6. How would you manage neonatal hypoglycaemia?
  7. Why should early breastfeeding be encouraged?
  8. Is delayed cord clamping contraindicated in GDM?

8. Postpartum management

  1. What happens to insulin requirement immediately after placental delivery?
  2. Should insulin or metformin be continued after delivery in a woman with GDM?
  3. When and how should the mother be screened for persistent diabetes postpartum?
  4. Why is a 75-g OGTT preferred for postpartum testing in many guidelines?
  5. How will you interpret the postpartum OGTT?
  6. What advice will you give if the postpartum test is normal?
  7. How frequently should she be screened for type 2 diabetes subsequently?
  8. What contraception advice will you offer?
  9. Does breastfeeding have benefits for the mother with prior GDM?
  10. What preconception counseling is required before the next pregnancy?
  11. What should be documented in the discharge summary?

9. Common examiner extensions

Scenario A: Poor control despite diet

“Her fasting glucose values are persistently high after 1 week of dietary treatment.”
  1. What is your next step?
  2. Which medication/regimen is appropriate for isolated fasting hyperglycaemia?
  3. What hypoglycaemia counseling will you give?
  4. When will you reassess fetal growth and well-being?

Scenario B: Suspected macrosomia

“At 37 weeks, ultrasound estimates fetal weight as 4.3 kg.”
  1. How will you counsel the patient?
  2. What are the limitations of this ultrasound estimate?
  3. Discuss induction versus expectant management.
  4. When would elective caesarean be considered?
  5. Describe management of shoulder dystocia.

Scenario C: Polyhydramnios

“At 34 weeks, she has polyhydramnios and increasing postprandial glucose values.”
  1. What are the possible causes of polyhydramnios?
  2. How will you reassess glucose control?
  3. What fetal assessment is required?
  4. What intrapartum risks does polyhydramnios create?

Scenario D: GDM detected early

“She is diagnosed at 10 weeks with a markedly raised fasting plasma glucose.”
  1. What possibilities must be considered?
  2. How would you assess for overt pre-existing diabetes?
  3. What maternal complication screening may be required?
  4. How do fetal risks differ from those in GDM diagnosed at 28 weeks?

10. Rapid-fire viva questions

  1. Define macrosomia.
  2. Define large for gestational age.
  3. What is shoulder dystocia?
  4. Name three neonatal metabolic complications.
  5. Name three maternal risk factors for GDM.
  6. Why is fasting glucose particularly important?
  7. Why are postprandial glucose levels monitored?
  8. Can a woman with GDM have a vaginal delivery?
  9. Is GDM an indication for caesarean section?
  10. What is the definitive treatment for insulin resistance of pregnancy?
  11. What is the best postpartum test for diabetes after GDM?
  12. What is the major long-term maternal risk?
  13. What is the major preventable neonatal risk during the first hours after birth?
  14. What is the immediate treatment for symptomatic maternal hypoglycaemia?
  15. What should be checked before the woman leaves hospital?

High-yield closing question

“Summarize management of GDM in one minute.”
Expected structure:
  1. Confirm diagnosis and exclude overt diabetes.
  2. Explain maternal-fetal risks and involve obstetric, diabetes, dietetic, and neonatal teams.
  3. Start individualized diet, safe physical activity, and self-monitoring of glucose.
  4. Add insulin, or metformin where appropriate under local protocol, if targets are not met.
  5. Monitor maternal control, fetal growth, liquor, and fetal well-being according to degree of control and treatment.
  6. Plan delivery based on glycaemic control, complications, fetal size, and obstetric indications.
  7. Maintain intrapartum glucose control and arrange neonatal feeding and glucose monitoring.
  8. Stop pregnancy-specific medication after delivery unless overt diabetes is present, perform postpartum diabetes testing, and provide lifelong prevention and screening advice.
For current practice, use your institution's diagnostic cutoffs and delivery protocol, because the one-step and two-step testing strategies differ between national guidelines. The ADA pregnancy standards and ACOG GDM guidance are commonly referenced alongside local policies.

Prepare the most asked questions and answers for GDM for longcase. The important ones

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GDM Long Case: Most Important Viva Questions with Model Answers

1. What is gestational diabetes mellitus?

Answer:
Gestational diabetes mellitus, or GDM, is diabetes or glucose intolerance first diagnosed during pregnancy that is not clearly overt pre-existing diabetes. It usually develops in the second half of pregnancy because placental hormones cause increasing insulin resistance.

2. Why does GDM occur?

Answer:
Pregnancy causes progressive insulin resistance due to placental hormones such as human placental lactogen, progesterone, cortisol, and placental growth hormone. Most women compensate by increasing insulin secretion. GDM occurs when pancreatic beta-cell insulin secretion is inadequate for this increased insulin requirement.

3. What are the risk factors for GDM?

Answer:
  • Previous GDM
  • Previous macrosomic baby, usually birth weight 4 kg or more
  • Obesity or high BMI
  • First-degree family history of type 2 diabetes
  • Previous unexplained stillbirth or recurrent miscarriage
  • Polycystic ovarian syndrome
  • Maternal age above 25 to 35 years, depending on local protocol
  • High-risk ethnicity
  • Glycosuria in pregnancy
  • Hypertension or metabolic syndrome

4. When do you screen for GDM?

Answer:
Routine screening is usually done at 24 to 28 weeks, when insulin resistance increases. High-risk women should be tested at the first antenatal visit. If early testing is normal, it should be repeated at 24 to 28 weeks.

5. What tests are used to diagnose GDM?

Answer:
There are different accepted protocols, so I would use my hospital protocol.

One-step 75-g OGTT, IADPSG/WHO-style criteria

After overnight fasting, measure fasting, 1-hour, and 2-hour plasma glucose after 75 g glucose.
GDM is diagnosed if any one value is abnormal:
ValueCutoff
Fasting≥92 mg/dL or 5.1 mmol/L
1 hour≥180 mg/dL or 10.0 mmol/L
2 hours≥153 mg/dL or 8.5 mmol/L

Two-step approach

  1. 50-g glucose challenge test, non-fasting. Measure plasma glucose at 1 hour.
  2. If positive, perform a fasting 100-g 3-hour OGTT. GDM is diagnosed when at least two values are abnormal using Carpenter-Coustan criteria.

6. What is DIPSI criteria?

Answer:
In the DIPSI method, a woman is given 75 g oral glucose irrespective of fasting status and plasma glucose is checked after 2 hours.
  • A 2-hour value ≥140 mg/dL is diagnostic of GDM.
This may be asked commonly in Indian obstetric viva examinations. State that local and national protocols differ.

7. How will you differentiate GDM from overt diabetes diagnosed in pregnancy?

Answer:
Overt diabetes should be suspected if there is marked hyperglycaemia early in pregnancy or classic diabetic symptoms.
Diagnostic values for overt diabetes include:
  • Fasting plasma glucose ≥126 mg/dL
  • HbA1c ≥6.5%
  • Random plasma glucose ≥200 mg/dL with symptoms
  • Two-hour plasma glucose ≥200 mg/dL on a 75-g OGTT
Such patients should be managed as having pre-existing diabetes rather than simple GDM.

8. What complications can occur in the mother?

Answer:
  • Pre-eclampsia
  • Polyhydramnios
  • Recurrent infections, especially urinary and vaginal infections
  • Induction of labour
  • Operative vaginal delivery or caesarean birth
  • Shoulder dystocia-related maternal trauma
  • Future recurrence of GDM
  • Increased future risk of type 2 diabetes and cardiovascular disease
A previous GDM pregnancy is a major marker of future dysglycaemia. A 2025 systematic review also confirms that recurrence is associated with factors such as obesity and other metabolic risks PMID 41130422.

9. What are the fetal and neonatal complications?

Answer:

Fetal complications

  • Macrosomia or large for gestational age fetus
  • Polyhydramnios
  • Birth trauma, especially shoulder dystocia
  • Intrauterine fetal death in poorly controlled diabetes
  • Prematurity

Neonatal complications

  • Hypoglycaemia
  • Respiratory distress syndrome
  • Hypocalcaemia
  • Polycythaemia
  • Hyperbilirubinaemia
  • Hypertrophic cardiomyopathy
  • Admission to neonatal intensive care unit

10. Explain why macrosomia occurs in GDM.

Answer:
Maternal hyperglycaemia crosses the placenta, but maternal insulin does not. The fetal pancreas responds by producing excess insulin. Fetal insulin acts as a growth hormone, leading to increased deposition of fat and glycogen, especially around the shoulders, trunk, and abdomen. This is the basis of the Pedersen hypothesis.

11. Why does neonatal hypoglycaemia occur?

Answer:
The fetus is exposed to maternal hyperglycaemia and develops hyperinsulinaemia. After birth, the maternal glucose supply suddenly stops, but neonatal insulin levels remain high for some time. This causes neonatal hypoglycaemia.

12. What is your management plan after diagnosing GDM?

Answer:
My management would include:
  1. Explain the diagnosis and maternal-fetal risks.
  2. Refer to a multidisciplinary team: obstetrician, physician/diabetologist, dietitian, diabetes educator, and neonatologist.
  3. Start medical nutrition therapy and advise safe physical activity.
  4. Teach self-monitoring of capillary blood glucose.
  5. Review glucose records frequently.
  6. Add pharmacotherapy if targets are not achieved.
  7. Monitor fetal growth, liquor volume, and fetal well-being as appropriate.
  8. Plan timing and mode of delivery based on glycaemic control, medication requirement, fetal growth, and obstetric factors.
  9. Arrange postpartum glucose testing and long-term diabetes prevention.

13. What dietary advice will you give?

Answer:
I will advise:
  • A balanced, individualized diet planned with a dietitian.
  • Three small-to-moderate meals and two to three healthy snacks.
  • Avoid concentrated sugars, sweetened drinks, and refined carbohydrates.
  • Prefer high-fibre carbohydrates, vegetables, pulses, whole grains, protein, and healthy fats.
  • Do not advise starvation diets or weight-loss diets during pregnancy.
  • Ensure adequate calories for fetal growth.

14. What exercise advice will you give?

Answer:
If there is no obstetric contraindication, I will advise moderate physical activity, such as brisk walking for about 30 minutes on most days. A short walk after meals can reduce postprandial glucose levels.
Exercise is avoided or modified if there is placenta previa after 26 weeks, threatened preterm labour, ruptured membranes, severe hypertension, significant bleeding, or another obstetric contraindication.

15. What glucose targets do you use in GDM?

Answer:
Common targets used in many protocols are:
TimingTarget
Fasting / pre-meal<95 mg/dL or <5.3 mmol/L
1-hour post-meal<140 mg/dL or <7.8 mmol/L
2-hour post-meal<120 mg/dL or <6.7 mmol/L
I would mention that exact targets should follow the local diabetes-in-pregnancy protocol. The current ADA pregnancy guidance supports structured monitoring and postpartum follow-up.

16. When will you start medication?

Answer:
I will start pharmacotherapy when glucose targets are not achieved despite an adequate trial of dietary modification, exercise, and glucose monitoring, or if glucose levels are markedly elevated at diagnosis.
Persistent fasting hyperglycaemia is especially important because it is strongly associated with fetal overgrowth.

17. What is the drug of choice in GDM?

Answer:
Insulin is the preferred and most established treatment when lifestyle measures fail, because it does not cross the placenta in clinically significant amounts and can be titrated precisely.
Metformin may be used in selected women according to local protocol, after counseling that it crosses the placenta and that some women will still require insulin. Glyburide/glibenclamide is generally less preferred in many modern protocols because of concerns about neonatal outcomes and treatment failure.

18. How will you choose insulin therapy?

Answer:
The regimen depends on the glucose pattern:
  • Raised fasting glucose: bedtime basal insulin such as NPH or another locally approved basal insulin.
  • Raised post-breakfast, lunch, or dinner glucose: rapid-acting insulin before the respective meal.
  • Both fasting and postprandial elevation: basal-bolus regimen.
Dose is adjusted according to serial glucose records, maternal weight, gestation, and hypoglycaemic episodes.

19. What fetal surveillance will you do?

Answer:
I will perform:
  • Ultrasound for fetal growth and estimated fetal weight.
  • Assessment of amniotic fluid volume.
  • Repeat growth scans if indicated.
  • Antenatal surveillance, such as NST/CTG or biophysical profile, in women requiring medication, those with poor glycaemic control, hypertension, suspected fetal growth abnormality, reduced fetal movements, or other obstetric complications.
Diet-controlled GDM with good glucose control does not necessarily require the same intensive surveillance as poorly controlled or insulin-treated GDM.

20. How will you manage polyhydramnios in GDM?

Answer:
I will:
  1. Reassess glucose control and adherence.
  2. Repeat ultrasound to assess fetal growth, liquor volume, and fetal anatomy if needed.
  3. Assess fetal well-being.
  4. Watch for maternal discomfort, preterm labour, malpresentation, cord prolapse after membrane rupture, and postpartum haemorrhage.
  5. Plan delivery depending on severity, glucose control, and obstetric findings.

21. When will you deliver a woman with GDM?

Answer:
Timing should be individualized according to glycaemic control, medication use, fetal growth, and complications.
A practical viva answer is:
  • Diet-controlled GDM with good control: expectant management until around 39 to 40 weeks if no obstetric issue.
  • Medication-controlled GDM with good control: delivery is often planned around 39 weeks.
  • Poor control, vascular disease, hypertension, fetal compromise, or previous unexplained stillbirth: consider earlier delivery after balancing prematurity against fetal risks.
Always state: “I will follow the unit protocol and individualize the decision.”

22. Is GDM an indication for caesarean section?

Answer:
No. GDM alone is not an indication for caesarean birth. The mode of delivery depends on standard obstetric indications, estimated fetal weight, previous obstetric history, pelvic assessment, fetal presentation, and the risk of shoulder dystocia.
Elective caesarean may be discussed when estimated fetal weight is very high, commonly 4.5 kg or more in a diabetic pregnancy, though ultrasound weight estimation has limitations.

23. How will you manage blood glucose during labour?

Answer:
I will monitor capillary blood glucose regularly, usually hourly in active labour if insulin-treated or poorly controlled. The aim is to avoid maternal hyperglycaemia, which reduces the risk of neonatal hypoglycaemia.
If needed, insulin with dextrose infusion may be used according to the institutional intrapartum protocol. The woman should not be left fasting without an appropriate glucose and insulin plan.

24. What neonatal care is needed?

Answer:
Before delivery, I will inform the neonatal team. After birth:
  • Encourage skin-to-skin contact and early feeding, ideally within the first hour.
  • Monitor neonatal blood glucose according to neonatal protocol.
  • Observe for hypoglycaemia, respiratory distress, hypothermia, jaundice, polycythaemia, and feeding difficulty.
  • Admit to neonatal care if hypoglycaemia persists or the baby is symptomatic.

25. What is your postpartum plan?

Answer:
After delivery, insulin requirement falls sharply because placental hormones are removed.
For women with GDM:
  • Stop insulin or oral hypoglycaemic agents after birth unless overt diabetes is suspected.
  • Encourage breastfeeding.
  • Perform a 75-g OGTT at 4 to 12 weeks postpartum.
  • If normal, advise lifelong screening for diabetes every 1 to 3 years.
  • Counsel regarding healthy diet, physical activity, weight management, future pregnancy planning, and early GDM testing in subsequent pregnancy.
The ADA recommends a 75-g OGTT at 4 to 12 weeks because HbA1c can be unreliable shortly after pregnancy. See the ADA postpartum recommendation.

One-Minute Summary for Viva

“GDM is glucose intolerance first recognized during pregnancy, usually due to increasing insulin resistance in the second half of gestation. I would confirm the diagnosis using the hospital-approved OGTT criteria and exclude overt diabetes. Management includes dietary advice, safe exercise, self-monitoring of blood glucose, and insulin if targets are not achieved. I would monitor fetal growth, liquor, and fetal well-being according to glycaemic control and treatment requirement. Delivery timing is individualized, with vaginal birth possible in most women. During labour, maternal glucose should be controlled and the neonatal team informed. After delivery, treatment is usually stopped, the baby is monitored for hypoglycaemia, and the mother requires a 75-g OGTT at 4 to 12 weeks and lifelong screening for type 2 diabetes.”

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GDM Long Case Viva Cheat Sheet

Definition

GDM = glucose intolerance/diabetes first recognized during pregnancy that is not clearly overt pre-existing diabetes. Usually presents in the second half of pregnancy due to placental-hormone mediated insulin resistance.

Risk factors

  • Previous GDM or previous baby ≥4 kg
  • Obesity, PCOS, age >25 to 35 years
  • First-degree family history of type 2 diabetes
  • High-risk ethnicity
  • Glycosuria, hypertension, metabolic syndrome
  • Previous unexplained stillbirth or poor obstetric outcome

Screening and diagnosis

  • Routine screen: 24 to 28 weeks
  • High risk: test at booking, repeat at 24 to 28 weeks if initially normal.

DIPSI, frequently asked in Indian viva

  • 75-g glucose orally, non-fasting
  • 2-hour venous plasma glucose ≥140 mg/dL = GDM

75-g OGTT, IADPSG criteria

Diagnosis if any one value is abnormal:
TestDiagnostic value
Fasting≥92 mg/dL
1 hour≥180 mg/dL
2 hours≥153 mg/dL
Overt diabetes in pregnancy: FPG ≥126 mg/dL, HbA1c ≥6.5%, or 2-hour 75-g value ≥200 mg/dL.

Pathophysiology

Placental hormones cause insulin resistance. If maternal beta-cell insulin secretion cannot compensate, maternal hyperglycaemia develops. Maternal glucose crosses placenta but insulin does not → fetal hyperinsulinaemia → macrosomia.
Pedersen hypothesis: maternal hyperglycaemia → fetal hyperglycaemia → fetal hyperinsulinaemia → excessive fetal growth.

Complications

MaternalFetal/neonatal
Pre-eclampsiaMacrosomia/LGA
PolyhydramniosShoulder dystocia, birth trauma
Induction/CSNeonatal hypoglycaemia
Postpartum haemorrhageRDS, hypocalcaemia
Future GDM and type 2 DMPolycythaemia, jaundice
IUFD if poorly controlled

Management: answer in sequence

  1. Counsel regarding maternal and fetal risks.
  2. Multidisciplinary care: obstetrician, physician/diabetologist, dietitian, diabetes educator, neonatologist.
  3. Medical nutrition therapy: small frequent meals, high-fibre complex carbohydrates, avoid sugary drinks and refined sugars. No starvation diet.
  4. Exercise: moderate activity, for example walking, if no obstetric contraindication.
  5. Self-monitoring of blood glucose.
  6. Medication if targets not met despite lifestyle measures.
  7. Fetal growth and well-being surveillance.
  8. Individualize timing/mode of birth.
  9. Postpartum OGTT and lifelong follow-up.

Glucose targets

Use your hospital protocol. Common targets are:
TimeTarget
Fasting/pre-meal<95 mg/dL
1-hour post-meal<140 mg/dL
2-hour post-meal<120 mg/dL

Pharmacotherapy

  • Insulin: preferred medication if lifestyle treatment fails.
  • Raised fasting values: basal insulin, often at bedtime.
  • Raised post-meal values: rapid-acting insulin before the relevant meal.
  • Both elevated: basal-bolus regimen.
  • Metformin: may be used in selected patients according to local protocol after counseling.
  • Glibenclamide/glyburide: less preferred in many current protocols.

Antenatal surveillance

  • Serial ultrasound for growth, estimated fetal weight, and liquor
  • NST/CTG/BPP if insulin-treated, poorly controlled, hypertension, reduced movements, polyhydramnios, or other high-risk features.
  • Diet-controlled, well-controlled GDM usually needs less intensive surveillance.

Delivery

  • Vaginal delivery is possible. GDM alone is not an indication for caesarean section.
  • Diet-controlled, well-controlled: commonly deliver by 39 to 40 weeks.
  • Medication-controlled, well-controlled: often plan birth at about 39 weeks.
  • Consider earlier delivery for poor control, pre-eclampsia, fetal compromise, significant macrosomia, or other obstetric indications.
  • Discuss elective CS if estimated fetal weight is very high, commonly ≥4.5 kg in diabetes, remembering ultrasound weight estimates are imperfect.

Intrapartum

  • Inform neonatal team.
  • Monitor capillary glucose, often hourly in insulin-treated or poorly controlled patients.
  • Avoid maternal hyperglycaemia.
  • Use insulin-dextrose protocol if needed, as per unit policy.
  • Be prepared for shoulder dystocia if macrosomia is suspected.

Neonatal care

  • Early skin-to-skin and feed within 1 hour
  • Monitor neonatal glucose
  • Watch for hypoglycaemia, RDS, jaundice, polycythaemia, and hypocalcaemia.

Postpartum

  • Stop insulin/oral therapy after delivery in usual GDM, unless overt diabetes is suspected.
  • Encourage breastfeeding.
  • 75-g OGTT at 4 to 12 weeks postpartum.
  • If normal: screen for diabetes every 1 to 3 years.
  • Counsel on healthy weight, diet, physical activity, contraception, and early testing in the next pregnancy.

One-minute viva answer

“GDM is glucose intolerance first detected during pregnancy, usually caused by increasing placental-hormone mediated insulin resistance. I will confirm the diagnosis using the unit-approved criteria and exclude overt diabetes. Management includes dietitian-guided nutrition, safe exercise, self-monitoring of glucose, and insulin when targets are not achieved. I will monitor fetal growth and liquor, individualize surveillance and delivery timing, maintain good intrapartum glucose control, and arrange early neonatal feeding and glucose monitoring. After delivery, treatment is usually stopped and a 75-g OGTT is done at 4 to 12 weeks, followed by lifelong type 2 diabetes screening.”
Current ADA pregnancy standards recommend postpartum 75-g OGTT at 4 to 12 weeks and repeat diabetes screening every 1 to 3 years.

Not like this make short Q and A

GDM Long Case: Short Viva Q&A

1. What is GDM?
Diabetes first diagnosed during pregnancy, not clearly pre-existing diabetes.
2. When is GDM screened for?
At 24-28 weeks of gestation.
3. Who needs early screening?
Women with previous GDM, obesity, PCOS, family history of diabetes, or previous macrosomic baby.
4. What is the DIPSI test?
75 g oral glucose, 2-hour plasma glucose measured irrespective of fasting.
≥140 mg/dL = GDM.
5. What are IADPSG 75-g OGTT criteria?
Any one abnormal value:
  • Fasting ≥92 mg/dL
  • 1 hour ≥180 mg/dL
  • 2 hours ≥153 mg/dL
6. Why does GDM occur?
Placental hormones cause insulin resistance.
7. What are the risk factors?
Obesity, previous GDM, family history of diabetes, PCOS, previous baby ≥4 kg, high maternal age.
8. What are the maternal complications?
Pre-eclampsia, polyhydramnios, operative delivery, future type 2 diabetes.
9. What are fetal complications?
Macrosomia, shoulder dystocia, IUFD, preterm birth.
10. What are neonatal complications?
Hypoglycaemia, jaundice, polycythaemia, hypocalcaemia, respiratory distress.
11. Why does macrosomia occur?
Maternal glucose crosses the placenta causing fetal hyperinsulinaemia, which promotes growth.
12. Why does neonatal hypoglycaemia occur?
After birth maternal glucose supply stops, but fetal insulin remains high.
13. What is Pedersen hypothesis?
Maternal hyperglycaemia → fetal hyperglycaemia → fetal hyperinsulinaemia → macrosomia.
14. What is the first step in management?
Dietary modification, exercise, and self-monitoring of blood glucose.
15. What diet advice will you give?
Small frequent meals; avoid sugars and refined carbohydrates; take high-fibre complex carbohydrates.
16. Is exercise allowed?
Yes, if no obstetric contraindication. Walking after meals is useful.
17. What are glucose targets?
  • Fasting: <95 mg/dL
  • 1-hour post-meal: <140 mg/dL
  • 2-hour post-meal: <120 mg/dL
18. When is insulin started?
When glucose targets are not achieved with diet and exercise.
19. What is the preferred drug?
Insulin.
20. Is metformin used?
Yes, in selected women according to local protocol, but insulin is preferred when control is inadequate.
21. What insulin is used for high fasting glucose?
Bedtime basal insulin, commonly NPH or another approved basal insulin.
22. What insulin is used for high post-meal glucose?
Rapid-acting insulin before the relevant meal.
23. What fetal monitoring is required?
Ultrasound for growth and liquor; CTG/NST if poor control, insulin use, or other complications.
24. Is GDM an indication for caesarean section?
No. Caesarean is done only for obstetric indications or very large estimated fetal weight.
25. When is delivery planned?
  • Diet-controlled, well-controlled: 39-40 weeks
  • Medication-controlled, well-controlled: around 39 weeks
  • Poor control or complications: consider earlier delivery.
26. What is done during labour?
Monitor capillary glucose regularly, maintain normal glucose, and inform the neonatal team.
27. What is important after delivery for the baby?
Early feeding within 1 hour and monitoring for neonatal hypoglycaemia.
28. What happens to insulin after delivery?
Usually stopped in GDM because insulin resistance falls after placental delivery.
29. What postpartum test is done?
75-g OGTT at 4-12 weeks postpartum.
30. Why is postpartum follow-up important?
She has a high future risk of type 2 diabetes and GDM in the next pregnancy.

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Ovarian Cancer: Short Viva Q&A

1. What is the most common type of ovarian cancer?
Epithelial ovarian carcinoma, especially high-grade serous carcinoma.
2. At what age is ovarian cancer common?
Usually after menopause, with peak incidence around 60 years.
3. What are the risk factors for ovarian cancer?
Increasing age, nulliparity, infertility, endometriosis, family history, and BRCA1/BRCA2 mutations.
4. What factors reduce the risk?
Oral contraceptive pills, pregnancy, breastfeeding, and risk-reducing salpingo-oophorectomy in high-risk women.
5. What are hereditary ovarian cancer syndromes?
Hereditary breast and ovarian cancer syndrome due to BRCA1/BRCA2, and Lynch syndrome.
6. What symptoms suggest ovarian cancer?
Persistent abdominal distension, bloating, pelvic/abdominal pain, early satiety, reduced appetite, urinary frequency, and unexplained weight loss.
7. Why is ovarian cancer called a silent killer?
Symptoms are vague and often appear late, so many patients present with advanced disease.
8. What may be found on examination?
Adnexal mass, ascites, abdominal distension, pleural effusion, umbilical nodule, or supraclavicular lymphadenopathy.
9. What is the first investigation for suspected ovarian cancer?
Pelvic ultrasound, preferably transvaginal ultrasound.
10. What ultrasound features suggest malignancy?
Solid areas, papillary projections, thick septa, bilateral masses, ascites, irregular surface, and increased vascularity.
11. What is CA-125?
A tumour marker commonly raised in epithelial ovarian cancer.
12. Is CA-125 diagnostic of ovarian cancer?
No. It can also be raised in endometriosis, fibroids, PID, menstruation, pregnancy, liver disease, and other cancers.
13. What is the role of CA-125?
It helps in evaluation of an adnexal mass, monitoring treatment response, and detecting recurrence. It is not a screening test in average-risk women.
14. What imaging is used for staging?
Contrast-enhanced CT scan of chest, abdomen, and pelvis.
15. Is there an effective screening test for ovarian cancer in the general population?
No. Routine CA-125 or ultrasound screening is not recommended for average-risk asymptomatic women.
16. What is the common route of spread?
Transcoelomic spread through the peritoneal cavity.
17. Other routes of spread?
Lymphatic and hematogenous spread.
18. Common sites of metastasis?
Peritoneum, omentum, pelvic and para-aortic lymph nodes, liver surface, pleura, and bowel serosa.
19. What is Krukenberg tumour?
Metastatic ovarian tumour, classically from gastric cancer, often bilateral and containing signet-ring cells.
20. What is the most important prognostic factor?
Stage at diagnosis. In advanced disease, the amount of residual tumour after cytoreductive surgery is also very important.
21. What is the FIGO stage I?
Tumour confined to the ovaries or fallopian tubes.
22. What is FIGO stage II?
Tumour with pelvic extension below the pelvic brim.
23. What is FIGO stage III?
Peritoneal metastasis outside the pelvis and/or retroperitoneal lymph-node involvement.
24. What is FIGO stage IV?
Distant metastasis, for example pleural effusion with positive cytology or parenchymal liver metastasis.
25. How is ovarian cancer definitively diagnosed?
By histopathological examination of tissue obtained at surgery or image-guided biopsy.
26. What is the standard primary treatment?
Staging or cytoreductive surgery followed by platinum-based chemotherapy in most epithelial ovarian cancers.
27. What is cytoreductive surgery?
Surgery aimed at removing all visible tumour, or leaving minimal residual disease.
28. What does standard staging laparotomy include?
Peritoneal washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, peritoneal biopsies, and assessment of lymph nodes and all peritoneal surfaces.
29. What is the standard chemotherapy regimen?
Carboplatin plus paclitaxel.
30. What is neoadjuvant chemotherapy?
Chemotherapy given before surgery, followed by interval debulking surgery.
31. When is neoadjuvant chemotherapy considered?
When primary complete cytoreduction is unlikely, disease is very extensive, or the patient is not fit for major surgery.
32. What is interval debulking surgery?
Cytoreductive surgery after a few cycles of neoadjuvant chemotherapy.
33. Can fertility-sparing surgery be done?
Yes, in selected young women with early-stage, low-grade unilateral tumours, after careful staging and counseling.
34. What is the role of PARP inhibitors?
They are maintenance treatment in selected patients, particularly those with BRCA mutations or homologous recombination-deficient tumours.
35. Why is BRCA testing important?
It guides use of PARP inhibitors and identifies relatives who may need genetic counseling and preventive measures.
36. What is platinum-sensitive recurrence?
Recurrence occurring more than 6 months after completion of platinum-based chemotherapy.
37. What is platinum-resistant recurrence?
Recurrence within 6 months after platinum-based chemotherapy.
38. What is the treatment of recurrent ovarian cancer?
Depends on platinum sensitivity, prior treatment, BRCA/HRD status, performance status, disease distribution, and patient preference.
39. What is the role of follow-up?
To assess symptoms, clinical examination, treatment toxicity, and recurrence. CA-125 may be monitored if initially raised.
40. What are common causes of death in advanced ovarian cancer?
Progressive peritoneal disease, malignant bowel obstruction, malnutrition, infection, thromboembolism, and pleural disease.

One-minute viva answer

“Ovarian cancer is most commonly epithelial, with high-grade serous carcinoma being the usual histological type. It commonly presents late with vague symptoms such as abdominal distension, bloating, early satiety, pelvic pain, ascites, or an adnexal mass. Initial evaluation includes pelvic ultrasound, CA-125, and CT chest-abdomen-pelvis for staging. Definitive diagnosis is histological. Management should be planned by a gynecologic oncology multidisciplinary team and usually consists of maximal cytoreductive surgery and carboplatin-paclitaxel chemotherapy. Neoadjuvant chemotherapy followed by interval debulking is used if primary complete resection is not feasible. Genetic testing, particularly BRCA testing, is important for treatment and family counseling.”
The NCI ovarian cancer guidance supports surgical staging for apparently localized disease, while the ESMO ovarian cancer guideline covers diagnosis, staging, systemic treatment, and follow-up.
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