CURRENT CONCEPTS IN MANAGEMENT OF GDM - PowerPoint PPT Presentation

1 / 40
About This Presentation
Title:

CURRENT CONCEPTS IN MANAGEMENT OF GDM

Description:

CURRENT CONCEPTS IN MANAGEMENT OF GDM Dr SANJAY KALRA, D.M. [AIIMS] Diabetes and pregnancy One of the most challenging aspects of diabetes practice Seemingly easy ... – PowerPoint PPT presentation

Number of Views:274
Avg rating:3.0/5.0
Slides: 41
Provided by: bhartihos
Category:

less

Transcript and Presenter's Notes

Title: CURRENT CONCEPTS IN MANAGEMENT OF GDM


1
CURRENT CONCEPTS IN MANAGEMENT OF GDM
Dr SANJAY KALRA, D.M. AIIMS
2
OUR VISIONTo be a globally-acknowledged centre
of excellence for clinical care,
education training, and research
in diabetology and endocrinology.
3
Diabetes and pregnancy
  • One of the most challenging aspects of diabetes
    practice
  • Seemingly easy Practically difficult
  • Needs a lot of commitment on part of doctor,
    patient and family
  • Success can be achieved if we try together

Lets begin by staying awake for the next 30
minutes
4
Women and diabetes
  • Diabetes no longer means
  • Abstinence
  • Amenorrhea
  • Inability to conceive
  • Inability to deliver healthy children
  • Death during pregnancy

5
Diabetes and fertility
  • Delayed menarche in T1
  • Menstrual abnormalities
  • Premature Ovarian Failure
  • PCOD
  • Only 1 diabetic pregnancy out of 35 000
    deliveries in London in 1920s

6
Classification
  • Type 1
  • Type 2
  • GDM any degree of glucose intolerance, with
    onset or first recognition during pregnancy
  • 2-12 in various studies
  • 17 in Indian studies
  • 22/170 13 in Karnal

7
Total Deliveries - 170
8
HIGHEST G 10 Highest A 4,4,4
History of Diabetic Cases
9
Metabolism in normal pregnancy
  • Decreased FBG nadir at 12 wks, partly due to
    increased renal clearance
  • Increased PPBG facilitated anabolism for
    foetus
  • Increased insulin levels, both F and PP peak at
    18-20 wks
  • beta-cell hypertrophy and hyperplasia
  • Decreased insulin sensitivity by 50, in late
    2nd and 3rd trimesters
  • Enhanced lipolysis spares glucose for
    utilization by foetus accelerated starvation
    due to placental hormones
  • Due to progesterone, hPL, leptin, TNF-?, other
    inflammatory and stress-related markers
    Radaelli, 2004

10
Diabetes and pregnancy
  • Placental structure and function is affected
  • Early IUGR as high BG inhibits trophoblast
    proliferation
  • Hypertension, renal disease more frequent
  • High glycogen content in placenta

11
Diabetes and embryogenesis
  • Early fetal loss due to apoptosis of blastocyst,
    modulated by regulatory gene Bax, which is
    stimulated by high BG
  • Malformation rate 3X higher 4-10
  • High BG reduces total cell mass and number of
    blastocysts, esp in inner cell layer
  • Cardiac 4x
  • Anencephaly 5x
  • Spina bifida 3x
  • Caudal regression syn 212x
  • Arthrogryposis 28x
  • Cleft lip/palate 1.5x
  • Ureteric duplication 23x
  • Renal agenesis 5x
  • Pseudohermaphroditism 11x
  • Anorectal atresia 4x

12
Diabetes and fetal growth
  • Maternal diabetes
  • Incr nutrient transfer to foetus
  • Foetal hyper-insulinemia wk 9 onwards
  • Incr IGF-1 because of changes in IGFBP-1 affinity
  • Incr adipose tissue
  • Accel skeletal maturation
  • Incr hepatic glycogen content
  • Organomegaly liver, spleen, heart
  • Delayed pulmo maturation
  • Delay in switch from HbF to HbA
  • Polycythemia

13
Stillbirths in diabetes
  • Fetal hypoxia as O2 is diverted to non-visceral
    tissues, acidosis
  • Hypokalemia
  • Placental dysfunction
  • Hypoglycemia
  • Oxidative stress
  • Impaired O2 delivery to foetus as GHb has higher
    O2 affinity

14
Diabetes in future life
  • LGA
  • IUGR
  • Maternal history
  • T2 more common than T1
  • Programming effect of intrauterine environment on
    insulin sensitivity

15
Screening for GDM
  • WHO FBG and 2h PPBG or 2h post-75 g glucose BG
  • 1 h post- 50 g glucose load BG GCT
  • ADA FBG, 1 h, 2 h, 3 h post- 75 or 100 g glucose
    BG
  • One-step or two-step protocol
  • At first visit reassess at 24 28 weeks

16
Screening for GDM
  • 1 hr GCT
  • 140 mg
  • 130 mg
  • 75 g GTT
  • 2 h 155 mg
  • 100 g GTT
  • 1 h 180 mg
  • 2 h 155 mg
  • 3 h 140 mg

Any time of day No regards to meals
All venous samples. Normal meals x 3 days No
smoking Patient seated 8 14 hrs fasting
17
Diagnosis of GDM
18
Treatment
  • Medical nutrition therapy
  • Exercise
  • Insulin
  • Glibenclamide
  • Metformin

19
Treatment of Diabetic Cases
20
MNT
  • 6 meal pattern
  • Substantial night snack light breakfast
  • Encourage complex carbohydrates, fruits
  • 30 cal/kg/day 1500 cal for a 50 kg lady
  • Avoid starvation/ketosis
  • Increase intake in 3rd trimester
  • Weight reduction if BMI gt 27

21
Exercise
  • Upper limb exercises
  • Avoid resistance exercises
  • Walking swimming Breathing exercises
  • Avoid jogging
  • Pelvic floor exercises

22
INSULIN
  • Be dynamic
  • Choose regime acc to BG profile
  • Usually FBG is easy to control, PPBG is difficult
  • Prefer human insulin use analogs only if esential
  • Basal-bolus regime
  • Regular- regular- premixed
  • Premixed 50 premixed 30
  • Premixed b.d.
  • Premixed o.d.
  • NPH o.d.

23
Treatment of Diabetic Cases
6 to 120 U/day dose variation
24
OHAs
  • GLIBENCLAMIDE does not cross placental barrier
  • Recent reports suggest no increase in foetal
    malformation rate
  • Risk of maternal hypoglycemia
  • Stop as soon as patient comes to you
  • METFORMIN used extensively in South Africa in
    pregnancy
  • Being used extensively for PCOD, infertility
  • Reports suggest beneficial results in ist
    trimester continuation rate
  • Stop as soon as pregnancy is diagnosed/at 12
    weeks

25
First trimester
  • Early USG for dating, to r/o CMF
  • CRL may lag behind dates is associated with 7x
    CMF
  • Tight glycemic control F 95, 1hPP 140, 2hPP 120
    mg
  • Prefer basal-bolus regime may use analogues
  • Preempt hypoglycemia if nausea, vomiting are
    present check ketones
  • Supplement folic acid till 12 wks

26
Blood glucose goals
  • FBG lt 95 in whole blood, lt 105 in plasma
  • 1 h PP lt 140, 155
  • 2 h PP lt 120, 130 ADA
  • Mean FBG 56 , MBG 74.7, 1 h PP lt 105 mg
    Paretti, 2001 in healthy 3rd trimester
  • MBG lt 86 IUGR
  • MBG gt 105 LGA
  • MBG gt 110 neonatal metabolic and respiratory
    complications Langer,1998
  • Desired BG 63 100 mg Tamas, 1981

27
Second trimester
  • Monitor glucose, HbA1c/fructosamine
  • Insulin dose may double by end of
    2nd trimester
  • highest glucose levels between BF and lunch
  • Monitor B.P., renal and retinal problems
  • Encourage upper limb exercise
  • USG at 18-20 wks
  • Fetal echo at 20-24 wks
  • Doppler at 20 wks -ve predictive value for PIH
    is 90 ve 30
  • USG for foetal growth, liquor volume regularly
    after 26 wks
  • Watch for candidiasis, UTI, carpal tunnel
    syndrome

28
Screening for chr anomalies
  • Amniocentesis
  • Triple marker test gestational age, mothers
    age, blood uE3, AFP,hCG from 16-22 wks
    identifies 60-70 abn pregnancies
  • AFP, uE3 levels are lower in diabetic
    pregnancies
  • USG increased fetal nuchal lucency at 10-14 wks
    may point to Downs

29
Third trimester
  • Insulin req increases till 34-36 wks, then
    plateaus or falls
  • USG for FAC, liquor volume. Estimated foetal
    weight may be inaccurate
  • Watch for PIH, preterm labour, IUGR, IUD
  • asymmetrical growth restriction is a feature of
    nephropathy/retinopathy, PIH
  • is due to uteroplacental insufficiency which
    spares brain growth at expense of reduced liver
    glycogen and SC fat
  • is ass with IUD, intrapartum hypoxia, NEC

30
Third trimester
  • Delaying delivery beyond 38 wks increases risk of
    perinatal death
  • May have to deliver at 36-37 wks
  • Give betamethasone, ritodrine under insulin cover
  • NST/ CTG
  • Biophysical profile
  • Umbilical artery resistance index
  • Aspirin reduces risk of PIH by 15 may be
    offered to all diabetics

31
Maternal Complication
32
Labour and delivery
  • Insulin requirements are low in labour
  • Give GIK infusion may use 10 dextrose 100
    ml/hr 40 cals/hr
  • Watch for ketosis
  • Insulin req falls further after delivery
  • Intermittent CTG
  • LSCS vs NVD
  • Epidural
  • Paediatrician must be present
  • Breastfeeding
  • 24 hr milk 50 g carbohydrates

33
Time and Method of Delivery
34
The neonate
  • Hypoglycemia
  • Polycythemia
  • Hyperviscosity syndrome
  • NEC
  • RDS
  • TTN
  • Transient HCMP
  • Hypocalcemia
  • Hypomagnesemia
  • Hyperbilirubinemia
  • Prematurity
  • Congenital malformations

35
Birth Weight
Max birth weight 4.25 kg at 41 wks gestation
36
Neonatal Complication
37
Gender ratio
  • Distt Karnal 800 females for 1000 males
  • Diabetic pregnancies 12 daughters, 11 sons

38
Post partum management
  • GTT at 6 wks
  • Contraception
  • Counselling for future pregnancies
  • 5-10 may develop T1DM GAD ve
  • T2DM in obese, pts with high insulin req, wt gain
    postpartum, maternal h/o DM

39
Post partum follow up at 6 weeks
40
Management
  • Specialized diabetes antenatal care
  • Education
  • Self-monitoring
  • 10-30 need insulin esp at 30 wks
  • Serial USG for FAC
  • Induction of labour on obstetric grounds
  • May need GIK infusion if labour is long
  • Stop insulin after delivery
Write a Comment
User Comments (0)
About PowerShow.com