Transcript GESTATIONAL DIABETES MELLITUS

DR Akinyemi Olaleye
MBBS, FWACS, DGE
Review basic physiology of gestational diabetes
Review fetal and maternal implications
Review current recommendations for screening for
GDM
Review recommendations from the 5th International
Workshop-Conference on Gestational Diabetes
Mellitus
Review use of insulin analogs in pregnancy
Review use of oral antihyperglycemic agents in
pregnancy
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Definition: metabolic disorder
◦ Abnormality in carbohydrate metabolism
◦ Relative or absolute insulin lack.
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20th century witness remarkable outcome.
Before this life expectancy was short
Survivors had infertility.
Those who got pregnant had disastrous
outcome. MM=30-60%, PM=60%.
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In 1921 banting and best discovered insulin.
Fertility was restored
MM improved remarkably.
PM remained high
◦ Fetal macrosoma, and IUFD were the causes.
◦ Early delivery & C/S were the antidote.
◦ Late IUFD was still a problem.
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1930 White classification.
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1930 White classification, fetal risk was
proportional to severity of mat diabetes,this
permitted individualized timing of delivery
and perinatal survival =85%.
TODAY, refinement in management has
reduced PM to near that of normal pregnancy,
except for cong. abnormality.
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Overt DM,
chronic,10% .Type
1or type 2
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Gest. DM. 90%.
Carbohydrate
intolerance of varying
severity with onset or
first recognition in
preg.
Change in glucose
metabolism
Type 2 unmasked in
preg.
Defined as carbohydrate intolerance that
begins or is first recognized during
pregnancy
 Important because it impacts maternal
health care both during and after pregnancy
 Incidence varies, but most often reported as
5-7% of pregnant women; may be greater in
some high-risk populations
 Underlying risk factors include increased
maternal age, obesity, h/o GDM in prior
pregnancy, h/o large babies
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Normal pregnancy
12
24
Gestational Age
(weeks)
36
Insulin Output
Insulin Resistance
OVERVIEW
Insulin Output
Insulin Resistance
OVERVIEW Cont
Gestational diabetes
12
24
Gestational Age
(weeks)
36
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Reduced insulin sensitivity.
Increased fasting insulin
Increased diabetogenic hormones(human
placental lactogen, placental insulinase,
cortisol, oestrogens and Progesterone)
Increased insulinase
In diabetics, insulin requirement increases in
preg.
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More difficult to control
Proliferative retinopathy may worsen but the
course of background retinopathy and
nephropathy does not change,instead it is
nephropathy assoc with HT and proteinuria
that worsen pregnancy outcome.
No other long term effect of preg on DM.
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Spont.abortion
Cong. Abnormality
Fetal death
Macrosomia, Obstructed labour, instrumental
delivery, shoulder dystocia
Perinatal mortality
Preterm delivery
polyhydramnios
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Infections ( candidiasis, UTI)
PIH.
Preterm labour.
OVERVIEW Cont
Maternal hyperglycemia
Fetal hyperglycemia
Fetal hyperinsulinemia
Pederson
Hypothesis
(1952)
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May be assymptomatic
SYMPTOMS & SIGNS: polyuria, polydipsia
SCREENING
◦ FBS,2HPP. RBS
◦ 50% glucose oral challenge, 1hr glucose 140mg/dl.
130mg/dl
◦ Universal or selective.
◦ Timing of screening.
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75g glucose OGTT (WHO)
100g OGTT (ACOG) 3hr monitoring
Do risk assessment at first visit, with no
screening for low risk
Low-risk ethnicity (Caucasian, European)
Age < 25
BMI < 25
No known diabetes in first degree relative
No h/o glucose intolerance
No h/o obstetric complications usually associated
with GDM
4th International WorkshopConference on Gestational
Diabetes Mellitus, ADA, ACOG
High risk patients should be screened as early
as possible and repeated at 24-28 weeks if
screening negative.
.Strong family history of diabetes
.Prior history of GDM
.Morbid obesity
.Other manifestations of glucose intolerance
. glycosuria
4th International WorkshopConference on Gestational
Diabetes Mellitus, ADA, ACOG
Recommended screening is 2-step approach,
with 50-g 1-hr GCT followed by 2-hr or 3-hr
100-g OGTT
Threshold value for 1-hr GCT is 130 or 140 –
either is acceptable
Threshold values for 2-hr OGTT are 95, 180,
155, 140, respectively; 2 values must be
abnormal to diagnose GDM
4th International WorkshopConference on Gestational
Diabetes Mellitus, ADA, ACOG
WHO advocates universal screening utilizing a
one-step 2-hr 75-g OGTT
Patient is diagnosed with GDM if fasting > 126
or 2-hr > 140
5th International Workshop-Conference on
Gestational Diabetes Mellitus did not change
recommendations set forth by 4th International
Workshop-Conference on Gestational Diabetes
Mellitus
Summary for IADPS
To diagnose overt diabetes (preexisting) at any
point in pregnancy
Measure of glycemia
Threshold
Fasting glucose
> 126 mg/dl
A1C
> 6.5%
Random glucose
> 200 mg/dl
International Association of
Diabetes and Pregnancy Study
Groups, 2009
Diagnosis of GDM (75gOGTT)
Glucose measure
Glucose threshold
FPG
92 mg/dl
1-hr plasma glucose
180 mg/dl
2-hr plasma glucose
153 mg/dl
*one or more of these values must be met or exceeded
for diagnosis of GDM
International Association of
Diabetes and Pregnancy Study
Groups, 2009
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First prenatal visit
◦ Measure FBS, A1C, or random glucose on only high-risk
women
 If results indicate overt diabetes as per Table above, treat and
f/u as for preexisting diabetes
 If results are not diagnostic of overt diabetes and FPG > 92 but
< 126, diagnose as GDM; if FPG < 92, test for GDM at 24-28
weeks
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24-28 weeks
◦ 2-hr 75-g OGTT after overnight fast on all women not
previously found to have overt diabetes or GDM
◦ Overt diabetes if FPG > 126
◦ GDM if one or more values equals or exceeds thresholds
◦ Normal if all values on OGTT less than thresholds
International Association of
Diabetes and Pregnancy Study
Groups, 2009
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Screening/diagnosis
◦ WHO endorses universal screening with single step,
arguing that the 2-step process introduces
additional barrier to care
◦ Discussions continue around use of fasting, random
glucose, or A1C at initial visit, but no consensus at
present
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Pre pregnancy clinic
Combined management
Early booking and dating
More frequent visits
Admit for stabilization
Dietary control (fasting<105mg/dl)(2hr pp
<120)
Mild exercise
Preferably use insulin(oral hypoglyceamics)
Various insulin regime(Post prandial
surveillance)
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Medical management of GDM includes
following:
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Dietary therapy.
Exercise
Self-monitoring of glucose at home
If diet and exercise fail, oral hyperglycemic agent
or insulin
 metformin safe
 Short-acting insulin analogs should be standard, and
long-acting analogs not far behind.
 Counsel on hypoglycemic symptoms
◦ Goal: Euglycemia!!
.Avoid sugar and foods high in sugar
.High fiber diet with correct caloric intake
.30-35 kcal/day with no patient receiving less than
1800 or more than 2800 calories/day
Diet composed of:
1. Carbohydrate 45%
2. Protein 25%
3. Fats 30%
If euglycemia is not achieved with diet within 1-2
weeks, use S/C insulin is recommended.
Emphasize complex carbohydrates, such as starchy
vegetables (such as potatoes, corn, beans and
peas), grains, fruit and other starchy foods .
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Physical activity increases insulin receptor
sensitivity by counteracting the hormonal
changes that accompany pregnancy.
Performing 15 to 20 minutes of armchair
exercises daily during routine sedentary
activities, such as watching television or
reading.
Taking a walk up and down a street.
Can help a pregnant woman reduce
hyperglycemia without increasing the risk of
inducing uterine contractions.
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Alpha fetoprotein
USS at 20 weeks
Value of antenatal testing.
Timing& mode of delivery
Insulin management in labour.
Avoid prolong labour
1-2hourly glucose measurement.
Intraprtum monitoring.
SHOULDER DYSTOCIA
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Fetal surveillance with GDM
◦ Increased surveillance of fetal well-being
suggested if oral agent or insulin necessary, or
abnormal fetal growth evident on ultrasound
◦ Optimal timing of delivery remains uncertain, but
would consider delivery by 39 weeks if evidence
of poor glucose control and/or abnormal fetal
growth noted
◦ Allow usual indications for delivery management
if diet controlled with normal growth and wellbeing
. Oral hypoglycaemics are contraindicated during
early pregnancy, labour and early puerperium as
they are not adequate for controlling diabetes,
have teratogenic effects and may result in
neonatal hypoglycaemia.
 - Doses of insulin tend to increase in the first
half of pregnancy, then stabilize and finally rise
in the last quarter, to be decreased again
postpartum.
 - Twice daily ( before breakfast and before
dinner)
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injections of a combination of short and intermediate
acting insulin sufficient otherwise a subcutaneous insulin
pump is used.
- Mono component insulin Actrapid" (short acting) and "
Mixtard“ (intermediate acting).
- The total first dose of insulin is calculated by starting
with a low dose of 20 units combined insulin then increase
it according to the blood sugar .
OR according to the patient’s weight as follow:
In the first trimester ............patient’s
weight x 0.7
In the second trimester.........patient’s
weight x 0.8
In the third trimester............patient’s
weight x 0.9
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In higher doses, 2/3 the dose is given in the
morning with the same ratio and 1/3 the
dose is given in the evening in a ratio 1:1.
Day of delivery, reduce insulin dosage by 25%
and avoid intermediate acting or
5% glucose infusion in a rate of 125 ml/hour
+ short acting insulin 1-2 units/hour.
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MACROSOMIA : early feeding, RBS, HB,
b1b2.
RDS
Hypoglycaemia
Hypocalaemia
Hyperbilirubin
Polycytaemia
Perinatal mortality=2-4%( cong abn,unexp
IUFD)
cardiac hypertrophy.
1-3% inheritance.
◦ Assess fasting and/or 2-hr PP in first day or two
after delivery – no further treatment necessary if
normal (majority of GDM)
◦ If fasting and/or 2-hr PP abnormal, continue oral
agent or insulin
◦ Screen for Type 2 diabetes at 6-week postpartum
visit
◦ Counsel patients regarding dietary and behavioral
changes necessary to minimize risk of developing
overt diabetes later in life.
◦ Contraception.
Time
Test
Purpose
Post-delivery (1-3 d)
Fasting or random glucose
Detect persistent, overt
diabetes
Postpartum visit
75-g 2-h OGTT
PP classification of glucose
metabolism per ADA
1 year postpatum
75-g 2-h OGTT
Assess glucose metabolism
Annually
Fasting plasma glucose
Assess glucose metabolism
Tri-annually
75-g 2-h OGTT
Assess glucose metabolism
Prepregnancy
75-g 2-h OGTT
Assess glucose metabolism
5th Annual Workshop-Conference on GDM
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Gestational Diabetes should be considered a
pre-diabetes condition
Women with gestational diabetes have a 7fold future risk of type 2 diabetes vs.women
with normoglycemic pregnancy
Lancet, 2009, 373(9677): 1773-9
THANK
YOU