Transcript Endometriosis

Diabetes in Pregnancy
Max Brinsmead MB BS PhD
February 2013
Types and Incidence
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KNOWN DIABETIC (Before pregnancy)
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Insulin dependent – Type 1 or Juvenile Onset
Diabetes
NIDM – Type 2 or Maturity Onset Diabetic
Together account for <1% of pregnancies
GESTATIONAL DIABETES
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Diagnosed during a pregnancy
May or may not resolve after pregnancy
Comprise 2 – 9% of pregnancies depending on the
population
Glucose Metabolism in Pregnancy
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Pregnancy is a diabetogenic stress
Results from antagonism of insulin by placental
hormones
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The diabetogenic stress increases as pregnancy
advances
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HPL, Sex steroids and corticosteroids
But reverses quickly after placenta delivers
BUT…
Facilitated transfer of glucose to the parasitic
fetus  fasting hypoglycaemia
The Effect of Diabetes on Pregnancy
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 Maternal blood sugar will
 Fetal blood sugar and…
  Fetal insulin
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This causes…
 Fetal growth which 
 Dystocia  Caesarean or shoulder difficulties 
 Brachial plexus palsy
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BUT
Fetal brain growth is reduced
 Lung maturation is delayed
 And the neonate is at risk of hypoglycaemia &
hypocalcaemia
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Effect of Diabetes on Pregnancy (2)
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 Fetal blood sugar will cause
 Fetal glycosuria
 Polyhydramnios
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There is risk of intrauterine death
?due to hypoxia
 ?due to ketoacidosis
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There is Rate of maternal Pre eclampsia
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?due to placental bed vasculopathy
There are Risks of Prematurity
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Some of which is due to intervention on behalf of
the mother
Extra Risks for Type 1 Diabetics
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First trimester hyperglycaemia causes…
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Rates of congenital malformation (CNS & Heart)
If there is diabetic vasculopathy then the
inevitable kidney damages causes…
Rates of pre eclampsia
 Risk of fetal growth retardation
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The Effect of Pregnancy on Diabetes
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Insulin antagonism  Insulin requirements
Pregnancy is a state of lipidolysis so IDDM patients
are at risk of ketoacidosis
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Especially during labour
Will be complicated by nausea, vomiting & slow
gastric emptying
And altering energy expenditure
A desire for tight glucose control and a parasitic
fetus puts the mother at risk of serious
hypoglycaemia
Retinopathy and nephropathy may deteriorate
rapidly
Insulin requirements change rapidly after delivery
Principles of Management
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Family Planning
Preconception care
Stringent blood glucose control before
pregnancy
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Meticulous blood glucose control throughout
pregnancy
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Monitor HBA1c
Multidisciplinary care from Physician, Dietition, Nurse
Educator and Obstetrician
Watch for known complications
Timely delivery
Appropriate mode of delivery
Family Planning
Controversies in Gestational Diabetes
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Selective or universal testing
At least 50% missed unless all screened
 Can obstetric outcomes be changed?
 These questions answered by the 2005 ACHOIS
study
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Glucose challenge or GTT
75G one hour test is best for screening
 IADPSP recommends universal 1-step testing with
75g 2 hr test
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Criteria for diagnosis
Criteria for the use of insulin
Role of oral hypoglycaemic drugs
The Effect of Treatment of Gestational Diabetes
on Pregnancy Outcomes Crowther et al NEJM June 2005
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The ACHOIS study
RCT of approx. 1,000 pregnant women with
gestational diabetes; standard care vs blood glucose
control by diet +/- insulin
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Risk of Perinatal Risk (i.e. death, shoulder dystocia,
fracture and N palsy) reduced from 4% to 1%;
RR=0.33 (CI 0.14 – 0.75)
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Rate of Induction Labour; RR1.36 (CI 1.15 – 1.62)
Rate of NICU admissions; RR 1.13 (CI 1.03 – 1.23)
No difference in rate of Caesareans
Rates of depression and stress in mothers in
the puerperium
Cost Effectiveness of Treatment for Gestational
Diabetes Moss et al BMC Preg & Childbirth Oct 2007
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From the ACHOIS study
For every 100 women with abnormal GTT in
pregnancy (mild gestational diabetes) offered
treatment there was $60,000 additional costs
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From pregnancy multidisciplinary care
Induction of labour (10 additional women)
Neonatal care admission (9 additional babies)
However saved 1 baby from perinatal death and
2 from neonatal complications
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Estimated saving $80,000
Hyperglycaemia and Adverse Pregnancy
Outcome Study Metzger et al NEJM May 2008
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The HAPO study
A prospective study of 25,505 women in 19 centres
All had a 2-hour 75-g GTT at 24 – 34 weeks
Those with Fasting GLUC > 5.7 or 2 hr >11.0 were
identified and removed
Remainder followed without knowledge of the GTT
result (a blinded prospective study)
Found significant positive associations between
fasting, 1-HR and 2-HR GLUC and
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LGA babies
Primary CS rates
Risk of neonatal hypoglycaemia
An RCT of Treatment for Mild Gestational
Diabetes Landon et al NEJM October 2009
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The MFMU trial
958 women in a number of US centres
All had an abnormal 3 Hr GTT but the fasting GLUC
was <5.3
Randomly assigned to treatment or observation
Treatment
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Reduced mean fetal birthweight by 106g
Fewer babies <4 Kg (7.1% vs 14.5%
Less shoulder dystocia (1.5% vs 4.0%)
Fewer Cesareans (26.9% vs 33.8%)
Reduced risk of preeclampsia and gestational
hypertension (8.6% vs 13.6%)
All these were significant differences
Criteria for Selective Testing
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First degree affected relative
Age >35 years
Ethnic origin
Obesity BMI >30
Poor obstetric history esp. “unexplained
stillbirth”
Previous fetal macrosomia (>4.5Kg)
Clinical suspicion
Polyhydramnios
 Macrosomia
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Previous Gestational Diabetes
Criteria for the Diagnosis
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May begin with Fasting and 2 hr
Postprandial GLUC
If Fasting >7.8 or
 2 hr PP >11.0 then…
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This patient requires insulin ASAP
Best test is the WHO 75G GTT
Diabetes is Fasting GLUC >5.4 or…
 2 hr PP >7.8
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IADPSP criteria
Fasting ≥ 5.1
 1 hr ≥ 10.0
 2 hr ≥ 8.5
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Management of Gestational Diabetes
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Diet
Abstinence from all simple sugars
 Reduce fats and oils
 Regular meals with complex CHO (low glycaemic
index)
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Exercise
Self-tested blood glucose 4x  once daily
Aim for Fasting GLUC <5.0
 And 2 hr PP 5.9 – 6.4
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Metformin or Insulin if targets not met
Cease any insulin at delivery
Repeat 75g GTT after 8 – 12 weeks
Role for Oral Hypoglycaemics
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Use Metformin or Glibenclamide
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Achieves the same outcomes as insulin if
target GLUC are met
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Better than insulin at controlling maternal
weight
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7 – 46% will go on to require insulin
An RCT of Metformin vs Insulin for Gestational
Diabetes Rowan et al NEJM May 2008
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From Auckland New Zealand
751 women randomised to Metformin or Insulin
46% of those assigned to Metformin required
supplemental insulin
Outcomes the same (Composite RR 0.99 CI 0.80-1.23)
but women preferred Metformin
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Respiratory distress
Prematurity
Jaundice
Birth Trauma
Low Apgar
Birthweight
Maternal outcomes
Management of Insulin Dependent Diabetes
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Before Pregnancy
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Multidisciplinay care
Self-tested blood glucose 4x daily
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Aim for Fasting GLUC <5.0
And 2 hr PP 5.9 – 6.4
Prenatal diagnosis
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Normalise HBa1c
Folic acid 5 mg daily
Check kidney and retina
1st trimester screening by serum biochemistry + ultrasound
Routine morphology at 18w
Cardiac ultrasound at 22w
Scan for growth and umbilical Dopplers
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28 & 36w
Delivery of the Pregnant Diabetic
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Timing for Type 1 diabetics is often a juggle
between difficult sugar control and fetal
maturity
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Low threshold for Caesarean especially if
fetal macrosomia is suspect
Most gestational diabetics induced at term
i.e. >37 completed weeks
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?role for Betamethasone for the fetal lungs
but wait for spontaneous or induced Cx ripening
Monitor GLUC in labour
May require dextrose and insulin by infusion
for those who are insulin-dependant
Monitor the fetus in labour
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