Transcript Slide 1

Gestational Diabetes Mellitus
Dr. R V S N Sarma., M.D., M.Sc., (Canada)
Consultant Physician & Chest Specialist
Visit us at: www.drsarma.in
GDM
Gestational Diabetes Mellitus
Is it physiological?
Is it a disease?
Should we screen for gdm?
Does it require treatment?
Recent RCTs settled the issues
Crowther et al. NEJM 2005;352
GDM
GDM
Glucose Intolerance in Pregnancy
Prevalence
of GDM 3 to 18 %
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GDM - Definition
GDM
• Distinguish GDM from Pre-gestational DM
• Abnormal Glucose Tolerance
• Onset (begins) with pregnancy or
• Detected first time during pregnancy
• No h/o of pre pregnancy DM or IGT
• Hb A 1 c is usually < 7.5 in GDM
• In DM + Pregnancy it is > 7.5
• GDM is a forerunner of T2DM
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Pathogenesis of GDM
GDM
• Pregnancy is Diabetogenic condition
• A Wonderful Metabolic Stress Test
• Placental Diabetogenic Hormones
– Progesterone, Cortisol, GH
– Human Placental Lactogen (HPL), Prolactin
• Insulin Resistance (IR), ↑  cell stimulation
• Reduced Insulin Sensitivity up to 80%
• Impaired 1st phase insulin, Hyperinsulinemia
• Islet cell auto antibodies (2 to 25% cases)
• Glucokinase mutation in 5% of cases
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GDM
Fundamental Defect in GDM
• The hormones of pregnancy cause IR
• They also cause direct hyperglycemia
• But, the basic defect is
• The maternal pancreatic  cells are unable
to compensate for this increased demand
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Normal Glucose Tolerance
GDM
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Abnormal GT in GDM
GDM
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GDM
Risk Stratification for GDM
• High Risk Group (Indians mostly)
– BMI  30; PCOD; Age > 35 years
– F h/o DM; Ethnic predisposition; Acanthosis
– Previous h/o GDM, IGT, Macrosomic baby
• Low Risk Group
– Age < 25, BMI < 23, No F h/o DM or IGT
– No bad obstetric history; No ↑ risk ethnicity
• Intermediate Risk Group
– Not falling in the above two classes
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Adopted from ADA guidelines
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Whom to Screen for GDM ?
GDM
• Low Risk Group
– No screening required for GDM
• Intermediate Risk Group
– Screen around 24–28 weeks of gestation
• High Risk Group
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As soon as possible after conception
Must - before 24–28 weeks of gestation
Better do a full 3 hr OGTT for GDM
If negative – screening in 2nd & 3rd trimester
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Adopted from ADA guidelines
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Indian Scenario
GDM
• Since the pregnant mothers without any of
the risk factors are so very few in India
• Since we boast of being in the DM capitol
• We need to screen all pregnant women
• And identify early the GDM problem
• We have enough tough maternal problems
• Let us at least treat a treatable problem
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GDM – Two Step Screening
GDM
• Two Step Screening
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Do a Random Glucose Challenge Test (GCT)
50 grams of oral glucose any time of day
1 hour post test for plasma glucose (1 hr PG)
Result > 180 mg% - Dx of GDM confirmed
Result > 140 mg% - Dx of GDM suspected
140 to 180 – We need OGTT (100 g) to confirm
• One Step Screening
– OGTT – 3 hours after 100 g of oral glucose
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Glucose Challenge Test (GCT)
GDM
< 140
140 to 180
180+
No GDM
repeat 24 wk
Need to do
OGTT – 3 hr
GDM
confirmed
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Please be specific
GDM
• Do not use the ‘loose’ word ‘Blood Sugar’
• Be specific to measure ‘Plasma Glucose’
• Always venous sample for OGTT
• No capillary blood testing for OGTT
• NaF to be added as anticoagulant to blood
• Centrifuge to separate plasma immediately
• Plasma glucose to be estimated a.s.a.p
• Glucometer can be used for monitoring
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OGTT –100g –3 hour Test
GDM
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Test sample timing
Plasma Glucose value
Fasting (mg%)
95
1 hour (mg%)
180
2 hour (mg%)
155
3 hour (mg%)
140
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Some Questions
GDM
When to order for USG ?
• Scan for anomalies at 20-weeks
• Growth scans from 26-28 weeks
Breast feed or not after delivery ?
• Must give breast feeding
• This reduces maternal glucose
intolerance
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GDM – Fetal Morbidity
GDM
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Macrosomia of the baby
CPD – Shoulder Dystocia
Intrapartum Trauma – Feto-maternal
Congenital Anomalies, HCM
Neonatal Hypoglycemia
Neonatal Hypocalcemia
Neonatal Hyperbilirubinemia
Respiratory Distress Syndrome (RDS)
Polycythemia (secondary) in the new born
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Macrosomia
GDM
• Birth weight > 4000 g - 90th percentile GA
• ↑ Intrapartum feto-maternal trauma
• Increased need for C- Section
• 20 – 30% of infants of GDM – Macrosomic
• Maternal factors for Macrosomia
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Uncontrolled Hyperglycemia
Particularly postprandial hyperglycemia
High BMI of mother
Older maternal age, Multiparity
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Macrosomic Newborn (4.2kg)
GDM
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Shoulder Dystocia
GDM
Erb’s palsy
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Macrosomia
GDM
GDM
Non DM
P value
Birth Weight
3512 g
3333 g
< 0.05
LGA
40.4%
13.7%
< 0.001
Macrosomia
32.0%
11.0%
< 0.01
Neonatal Hypoglycemia
GDM
• Due to fetal hyperinsulinemia
• Neonatal plasma glucose < 30 mg%
• Poor glycemic control before delivery
• Increases perinatal morbidity
• Congenital anomalies – 3 to 8 times more
• More if periconception hyperglycemia
• Assoc. maternal fasting hyperglycemia
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Minor Adverse Health Effects
Normal
Birth Wt (g)
3303±64
GDM
GDM
DM
P
3649±51
3849±72
<0.01
Macrosomia(%)
8
36
47
<0.01
C-S
5
10
14
<0.01
Hypoglycemia
2
28
52
<0.01
Hypocalcemia
0
4
7
<0.01
Hyperbilirubinemia 15
23
21
<0.01
7
11
<0.01
Polycythemia
0
Cord C-Pep
1.18±0.1
2.07±0.12
2.98±0.22 <0.01
Cord Glu
100±3.6
103±2.9
114±5.5
<0.01
Major Adverse Health Effects
Normal
GDM
DM
CNS
6.4%
18.4%
Congenital heart disease
7.5%
21.0%
Respiratory disease
2.9%
7.9%
Intestinal atresia
0.6%
2.6%
Anal atresia
1.0%
2.6%
Renal & Urinary defect
3.1%
11.8%
Upper limb deficiencies
2.3%
3.9%
Lower limb deficiencies
1.2%
6.6%
Upper + Lower spine
0.1%
6.6%
Caudal digenesis
0.1%
5.3%
Neonatal Complications
GDM
DM
GDM
T. hypoglycemia(%)
52
28
3
<0.01
P. hypoglycemia(%)
6
2
0
<0.01
Hypocalcemia(%)
5
5
0
<0.01
Hyperbilirubinemia(%) 21
23
15
<0.01
5
2
0
<0.01
11
7
0
<0.01
RDS(%)
5
2
0
<0.01
IUGR(%)
2
1
0
<0.05
Trans tachypnea(%)
Polycythemia(%)
Normal p-value
GDM
Congenital Anomalies - DM Control
Maternal HbA1c levels
< 7.2
Nil
7.2-9.1
14%
9.2-11.1
23%
> 11.2
25%
Critical periods - 3-6 weeks post conception
Need pre-conceptional metabolic care
Late effects on the offspring
GDM
• Increased risk of IGT
• Future risk of T2DM
• Risk of Obesity
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Maternal Morbidity
GDM
• Hypertension; Insulin Resistance
• Preeclampsia and Eclampsia
• Cesarean delivery; Pre term labour
• Polyhydramnios – fluid > 2000 ml
• Post-partum uterine atony
• Abruptio placenta
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Risk of T2DM after GDM
GDM
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IGT and T2DM after delivery in 40% of GDM
R.R of T2DM for all with GDM is 6 (C.I. 4.1 – 8.8)
Must be counseled for healthy life style
Re-evaluate with 75 g OGTT after 6 wk, 6 months
More risk - if GDM before 24 wks of gestation
High levels of hyperglycemia during pregnancy
If the mother is obese and has +ve family h/o
GDM in previous pregnancies and age > 35 yrs.
High risk ethnic group (like Indians)
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A Delicate Balance !
GDM
• Plasma Glucose values in pregnancy
hang on a delicate balance
• If the Mean Plasma Glucose (MPG) is
– Less than 87 mg% - IUGR of fetus
– More than 104 mg% - LGA of fetus
• It is imp. to screen for hypothyroidism
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Women with T2DM
GDM
• T2DM patients must plan their pregnancy
• Preconception Hb A1c  7.00; MAU estimate
• OADs should be discontinued; Folic acid +
• Start on Insulin and titrate for euglycemia
• Nutrition and weight gain counseling
• ACEi and ARB must be substituted
• Screening for retinopathy; nephro (eGFR <90)
• Must avoid hypoglycemia and ketosis
• SMBG must be trained and started
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GDM – Glycemic Targets
GDM
Recommended values for
Glycemic Targets
Pre-pregnancy Hb A1c
 7.00 (if possible  6.00)
Pregnancy values
Range
FPG
1 hr PPG
100 – 140
2 hr PPG
90 – 120
Hb A1c
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70 - 95
 6.00
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GDM and MNT
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GDM
Two weeks trial of Medical Nutrition Therapy
Pre-pregnancy BMI is a predictor of the efficacy
If target glycemia is not achieved initiate insulin
MNT – extra 300 calories in 2 and 3rd trimesters
Calories – 30 kcal/kg/day = 1800 kcal for 60 kg
If BMI > 30; then only 25 kcal/kg/day
3 meals and 3 snacks – avoid hypoglycemia
50% of total calories as CHO, 25% protein & fat
Low glycemic, complex CHO, fiber rich foods
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Diet therapy in GDM
GDM
• Small, frequent meals
• Avoid eating for two
• Avoid fasts and feasts
• Avoid health drinks
• Eat a bedtime snack
Tips for diet management
GDM
• Small breakfast
• Mid morning snack
• High protein lunch
• Mid afternoon snack
• Usual dinner
• Bed time snack
GDM and Exercise
GDM
• Recumbent bicycle
• Upper body egometric exercises
• Moderate exercises
• Mother to palpate for uterine contractions
• Walking is the simplest and easiest
• Continue pre pregnancy activity
• Do not start new vigorous exercise
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GDM and Insulins
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GDM
In 10 to 15% of GDM, MNT fails –Start on insulin
Good glycemic control – No increased risk
Human Insulins only – Not Analogs
Daily SMBG up to 7 times!
Insulin Glargine (Lantus) – Not to be used at all
Insulin Lispro tested and does not cross placenta
Insulin Aspart not evaluated for safty
CSII may be needed in some cases
Oral drugs not recommended (SU?, Metformin?)
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Insulin Regimen
GDM
• If MNT fails after 2 - 4 weeks of trial
• Initiate Insulin + Continue MNT
• Dose: 0.7, 0.8 and 0.9 u/kg – 1, 2 & 3 trim.
• Eg. 1st trim – 64 kg = 0.7 x 64 = 45 units
• Give 2/3 before BF = 30 units of 30:70 mix
• Give 1/3 before supper = 15 u of 50:50 mix
• Increase total dose by 2-4 units based on BG
• After BG levels stabilize – monitor till term
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GDM and Delivery
GDM
• Delivery until 40 weeks is not recommended
• Delivery before 39th week – assess the
pulmonary maturity by phosphatase test on
amniocentesis fluid
• C - Section may be needed (25 -30%)
• Be prepared for the neonatal complications
• Assess the mother after delivery for glycemia
• May need to continue insulin for a few days
• Pre-gestational DM–Insulin (30% less) or OAD
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punarapi jananam punarapi maranam
Once again is the birth, sure follows the death
punarapi jananee jaTarae sayanam |
Yet again, is the slumber in the uterine filth
iha samsaarae bahu dustaarae
he! what to say of this miserable troth
kripayaa paarae paahi muraarae ||
O! lord, save us from this cyclical myth
Jagad Guru Adi Sankaracharya’s Bhaja Govindam
Punarapi Garbham
Yet another conception
Punarapi Prasavam
GDM
Yet another child-birth
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Punarapi Jananee
Once again for the mom
Sisuvau KaTinam
GDM
and the babe, the miseries
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Iha Madhu maehae
This Diabetes you see
Bahu Dustarae
GDM
Terrible to the core
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Kripaya Nivaaare
Please put an end to this
Nipunarae vidyae
GDM
O! Doctor, the expert !
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Punarapi Jananam
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GDM
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