Transcript Preconception Care and Management of Gestational Diabetes

Preconception Care and Management
of Gestational Diabetes
Mahmud Rajabalee
M.B.BCh (Ainshams, Cairo)
DIS (France)
Learning objectives
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To realize the importance of preconception
care of women with diabetes to prevent
adverse pregnancy outcomes
To describe how to achieve optimal glycemic
control in the preconception period and
throughout pregnancy
To point out the need for postpartum followup of patients with gestational diabetes
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
Case Study
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31 year old woman G1P0 presents to the
clinic at 6 weeks’ gestation
Known type 2 diabetes on Glibenclamide and
Metformin
HbA1C is 8.1%
She expresses concerns about the impact on
her health and her future newborn
How should she be managed?
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
Prevalence of Diabetes & IGT in the
child bearing period
Diabetes
 20-29 years: 2.2 %
 30-39 years: 8.9 %
 40-49 years: 15.4 %
IGT
 20-29 years: 5.9%
 30-39 years: 11.8%
 40-49 years: 15.9%
Prevalence of Diabetes and IGT in the
childbearing period
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20-29 years: 8.1%
30-39 years: 20.7%
40-49 years: 31.3%
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
Preconception Care
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Elevated maternal glucose or HbA1C levels
during embryogenesis is associated with
high rates of spontaneous abortions and
major malformations in newborns
Unfortunately, unplanned pregnancies occur
in about two-thirds of women with diabetes
Preconception Care of Women With Diabetes Diabetes Care 27: 76S-78S.
Preconception Care
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Counselling about the risk of malformations
Use of effective contraception
Preconception Care Program
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Multidisciplinary team
Internist
Obstetrician
Diabetes educators
The patient is the most active member
Preconception Care Program
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Patient education about the effects of
diabetes on pregnancy outcomes
Appropriate use of contraception
Diabetes self-management skills
Follow up
Preconception Care : goals of
treatment
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Optimal HBA1C :
Medical nutrition therapy (MNT)
Self-monitoring of blood glucose (SMBG)
Self-administration of insulin and selfadjustment of insulin doses
Education about hypoglycaemia
Physical activity
Preconception Care : Initial visit
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Medical & obstetric history
Duration and type of diabetes (1 or 2)
H/O acute complications
H/O chronic complications
Diabetes management : Insulin regimen, oral
hypoglycaemic, SMBG, diet, physical activity
Preconception Care: Physical
Examination
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Blood pressure, including orthostatic
Fundoscopy
Cardiovascular examination
Neurological examination
Preconception Care : Laboratory
evaluation
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HbA1C measurement
Serum creatinine
Albumin/creatinine ratio or 24 hour albumin
excretion rate.
Protein excretion >190 mg/24 hours: at a 3fold increased risk for hypertensive disorders
during pregnancy
Preconception Care : Laboratory
evaluation
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Those with protein excretion >400 mg/24
hours are at risk for intrauterine growth
retardation during later pregnancy
ACE inhibitors should be stopped
TSH and/or FT4 in women with type 1
diabetes
Preconception Care : Management
plan
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Counselling about
The risk and prevention of congenital
anomalies
fetal and neonatal complications of maternal
diabetes
effects of pregnancy on maternal diabetic
complications
Preconception Care : Management
plan
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Counselling about
risks of obstetrical complications that occur
with increased frequency in diabetic
pregnancies
the need for effective contraception until
glycemia is well controlled
Preconception Care : Selection of
antihyperglycemic therapy
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Insulin is the gold standard: efficacy, does
not cross placenta
Oral hypoglycemic currently not
recommended
Preconception Care: Goals for SMBG
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Pre-meals capillary plasma glucose 4.4 – 6.1
mmol/L
2 hours postprandial capillary plasma glucose <
8.6 mmol/L
Follow-up: 1 to 2 months’ intervals
Preconception Care: Special
considerations
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Hypoglycemia
Retinopathy: glycemic control, laser
photocoagulation
Preconception Care: Special
considerations
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Hypertension
frequent concomitant or complicating
disorder
pregnancy induced hypertension occurs
more frequently
Aggressive control
ACE inhibitors, B-blockers and diuretics
avoided
Preconception Care: Special
considerations
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Nephropathy
renal function: serum creatinine and urinary
protein excretion
- potential impact of pregnancy on proteinuria
- impact of renal insufficiency on fetal growth
and development.
Preconception Care: Special
considerations
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Nephropathy
Incipient renal failure (Creatinine clearance <
50 ml/min)
→ permanent worsening of
renal function in > 40%
Less severe nephropathy → transient
worsening of renal function
Preconception Care: Special
considerations
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Neuropathy
autonomic neuropathy: gastroparesis, urinary
retention, hypoglycemic unawareness, or
orthostatic hypotension
Peripheral neuropathy, especially carpal
tunnel syndrome, may be exacerbated by
pregnancy.
Preconception Care: Special
considerations
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Cardiovascular disease
Untreated CAD is associated with a high
mortality rate during pregnancy
Exercise tolerance should be normal
Preconception Care: Special
considerations
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At the earliest possible time after conception,
pregnancy should be confirmed by laboratory
assessment (urinary or serum B-hCG).
The woman should be reevaluated by the
health care team
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
Management of Gestational Diabetes
(GDM)
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Definition & Prevalence
glucose intolerance that is first detected
during pregnancy
prevalence is 7% worldwide.
Gestational diabetes mellitus. Diabetes Care 2004; 27 Suppl 1:S88.
GDM: Detection & Diagnosis
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Risk assessment at the first prenatal visit
High risk patients:
obesity
personal history of GDM
strong family history of diabetes
ethnic group with a high prevalence of
diabetes
GDM: Detection & Diagnosis
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Women at high risk of GDM should have
glucose testing at the first antenatal visit
If not found to have GDM at that initial
screening, retested at between 24 and 28
weeks gestation
GDM: Detection & Diagnosis
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Two-step approach
An initial screening: plasma glucose 1 hour
after a 50-g oral glucose load (glucose
challenge test – GCT).
A value above 7.8 mmol/L identifies 80% of
women with GDM.
Confirmed with an OGTT using 75 or 100 g
glucose load.
GDM: Detection & Diagnosis
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Diagnosis of GDM with
a 100-g oral glucose
load
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Diagnosis of GDM with
a 75-g oral glucose
load
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Fasting
1-h
2-h
3-h
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Fasting
1-h
2-h
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5.3 mmolL
10.0
8.6
7.8
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5.3 mmolL
10.0
8.6
GDM: Detection & Diagnosis
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One-step approach
Cost-effective in high-risk populations
GDM: Obstetrics and Perinatal
considerations
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Increase in the risk of
intrauterine fetal death during the last 4–8
weeks of gestation
Fetal macrosomia and its associated risk of
shoulder dystocia and birth trauma
Neonatal hypoglycemia, jaundice,
polycythemia, and hypocalcemia
Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS,
Robinson JS. Effect of treatment of gestational diabetes mellitus
on pregnancy outcomes. N Engl J Med 2005;352:2477-2486.
GDM: Obstetrics and Perinatal
considerations
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Increased frequency of
Maternal hypertensive disorders
Need for cesarean delivery
- Fetal growth disorders
- Alterations in obstetric management due to
the knowledge that the mother has GDM
GDM: Long term considerations
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Women with GDM are at increased risk of
developing diabetes, usually type 2, after
pregnancy
Offspring of women with GDM are at
increased risk of obesity, glucose intolerance,
and diabetes in late adolescence and young
adulthood
GDM: Therapeutic strategies
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Medical Nutrition Therapy (MNT)
Goals:
achieve normoglycemia
prevent ketosis
provide adequate weight gain
contribute to fetal wellbeing
GDM: Therapeutic strategies
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Medical Nutrition Therapy (MNT)
Calorie allotment
BMI of 22 to 27: 30 kcal/kg per day
BMI 27 to 29: 24 kcal/kg per day
BMI > 30: 12 to 15 kcal/kg per day
BMI less than 22: 40 kcal/kg per day
GDM: Therapeutic strategies
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Medical Nutrition Therapy (MNT)
Carbohydrate intake: 35 to 40%
Protein: 20%
Fat: 40%
GDM: Therapeutic strategies
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Medical Nutrition Therapy (MNT)
Calorie distribution: 3 meals and 3 snacks
Overweight: snacks are eliminated.
Breakfast: 10% of total calories
Lunch: 30%
Dinner: 30%
Snacks: 30%
GDM: Therapeutic strategies
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Glucose monitoring:
SMBG: Fasting and 2 hours postprandial
Goals: FPG < 5.3 mmol/L
2 hours postprandial < 6.5 mmol/L
HbA1C every 4 weeks
American College of Obstetricians and Gynecologists. Gestational Diabetes.
ACOG practice bulletin #30, American College of Obstetricians and
Gynecologists, Washington, DC 2001.
GDM: Therapeutic strategies
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Insulin
15% requires insulin
When diet fails to maintain SMBG at the
following levels:
- Fasting plasma glucose 5.3 mmol/L
- 2 hours postprandial plasma glucose 6.5
mmol/L
GDM: Therapeutic strategies
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Insulin
Premixed insulin is not appropriate
If FPG is high, an intermediate acting insulin
is given at bedtime.
if the postprandial blood glucose high, short
acting insulin is given before the meals
GDM: Therapeutic strategies
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Insulin
if both fasting and postprandial blood glucose
high, an intermediate acting insulin is given
before breakfast and at bedtime and a short
acting insulin is given tid before meals
GDM: Therapeutic strategies
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Insulin dose
varies in different populations because of
varied rates of obesity and ethnic
characteristics.
Intermediate acting: 40% of total daily dose
Regular Insulin: 60% of total daily dose
GDM: Therapeutic strategies
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Insulin dose
No absolute rule
Dose distribution is modified according to
- individual requirements
- amount she will eat at each meals.
Morning sickness should be taken in
consideration.
GDM: Therapeutic strategies
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Insulin dose
greater in obese women
may need to be increased progressively as
pregnancy advances to term
SMBG guides the doses and timing of the
insulin regimen
GDM: Therapeutic strategies
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Insulin dose
The evening dose of intermediate acting
insulin is modified according to the fasting
capillary blood glucose
The pre-meals short acting insulin dose is
modified according to the postprandial
capillary blood glucose.
GDM: Therapeutic strategies
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Short acting insulin analogues
Insulin lispro and aspart, currently used in
pregnancy
Acceptable safety profiles
Minimal transfer across the placenta
No evidence of teratogenesis
GDM: Therapeutic strategies
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Short acting insulin analogues
improve postprandial glucose excursions
lower risk of delayed postprandial
hyperglycemia.
Long acting insulin analogues (Insulin
Gargline and Detemir) not recommended for
use in pregnancy at present.
GDM: Therapeutic strategies
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Oral hypoglycemic agents
Concerns:
Transplacental passage → fetal
teratogenesis, prolonged neonatal
hypoglycemia
Most restrospective studies have not
demonstrated an ↑ risk of maformed infants
GDM: Therapeutic strategies
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Metformin
decreases hepatic glucose output
improving peripheral glucose uptake, thus
reducing insulin resistance
may be a more logical alternative to insulin
for women with GDM who are unable to cope
with the increasing insulin resistance of
pregnancy
The Metformin in Gestational Diabetes
(MiG) trial
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Prospective randomized multicenter trial
Testing the hypothesis that metformin
compared with insulin, is associated with:
- similar perinatal outcomes,
- improved markers of insulin sensitivity in
the mother and baby
- improved treatment acceptability
A Trial in Progress: Gestational Diabetes: Treatment with metformin compared with insulin (the
Metformin in Gestational Diabetes [MiG] trial)
Janet A Rowan. Diabetes Care. Alexandria: Jul 2007. Vol. 30 pg. S214, 6 pgs
The Metformin in Gestational Diabetes
(MiG) trial
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Women with GDM at 20-33 weeks
The MiG trial will address the efficacy and
detailed safety of metformin
Long-term follow-up of offspring will examine
whether treatment influences later health
Comparison of glyburide & Insulin in
women with GDM
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404 women with GDM
randomly assigned between 11 & 33 weeks to
receive glyburide or insulin
primary end point: achievement of the desired
level of glycemic control
Secondary end points: maternal and neonatal
complications
Langer O, Conway DL, Berkus MD, Xenakis EM-J, Gonzales O. A
comparison of glyburide and insulin in women with gestational
diabetes mellitus. N Engl J Med 2000;343:1134-1138.
Comparison of glyburide & Insulin in
women with GDM
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no significant differences in % of infants who
had
Macrosomia
Lung complications
Hypoglycemia
Admitted to a neonatal intensive care unit
Fetal anomalies
Comparison of glyburide & Insulin in
women with GDM
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Same degree of glycemic control
Cord-serum insulin concentrations were
similar in the two groups
Glyburide was not detected in the cord
serum of any infant in the glyburide group.
Comparison of glyburide & Insulin in
women with GDM
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Conclusion
In women with GDM, glyburide is a clinically
effective alternative to insulin
As the study was conducted after the period
of organogenesis the effects on the incidence
of congenital anomalies could not be
assessed.
GDM: Therapeutic strategies
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Physical exercise
Decreases insulin resistance.
Women without medical or obstetrical
contraindications should be encouraged to
start or continue a program of moderate
exercise to lower glucose concentrations
GDM: Therapeutic strategies
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Timing and mode of delivery
GDM is not of itself an indication for cesarean
delivery or for delivery before 38 completed weeks of
gestation.
Prolongation of gestation past 38 weeks increases
the risk of fetal macrosomia without reducing
cesarean rates, so that delivery during the 38th week
is recommended unless obstetric considerations
dictate otherwise.
GDM: Therapeutic strategies
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Intrapartum blood glucose control
Maternal hyperglycemia should be avoided
during labor
maternal glucose concentrations should be
maintained between 4.0 – 7.0 mmol/L.
Insulin infusion is rarely needed during labor
(except in type 1 diabetes)
GDM: Therapeutic strategies
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Intrapartum blood glucose control
At delivery of the placenta, insulin infusion is
stopped
When the patient resumes oral feeds, S/C
insulin is resumed if required
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
GDM Postpartum monitoring
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OGTT 6 weeks postpartum using criteria
used for the general population
If normal, reassessment of glycemia yearly
IFG or IGT: diabetic diet and exercise
program.
Offspring followed closely for the
development of obesity and/or abnormalities
of glucose tolerance.
Case Study
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31 year old woman G1P0 presents to the
clinic at 6 weeks’ gestation
Known type 2 diabetes on Glibenclamide and
Metformin
HbA1C is 8.1%
She expresses concerns about the impact on
her health and her future newborn
How should she be managed?
Outline
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Case study
Prevalence of diabetes & IGT in the child
bearing period
Preconception care of women with diabetes
Management of gestational diabetes
Postpartum monitoring
Conclusion
Conclusion
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A multidisciplinary team work is essential for
preconception care and management of
GDM
Maternal glycemic control is crucial to
improving pregnancy outcomes
Management is simple and just requires
awareness and organisation