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Screening, Diagnosis, Management, Followup of GDM & T2DM

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Title: Screening, Diagnosis, Management, Followup of GDM & T2DM


1
GESTATIONALDIABETES MELLITUS Preexisting
(Overt) Diabetes(Screening, Diagnosis,
Management and Follow-up)
  • Dr Malleswar Rao Kasina, MD,DGO

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White classification
  • Based on maternal and obstetric risk factors,
    graded from A (best) to F (worst) designed to
    predict pregnancy outcomes

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  • 1971 and further updated in 1980 to incorporate
    ischemic heart disease and renal transplantation

8
Introduction
  • Gestational diabetes mellitus (GDM)
  • Diabetes diagnosed in the second or third
  • trimester of pregnancy that is not clearly
  • overt diabetes.
  • (American Diabetes Association, 2017)

9
DEFINITION MAGNITUDE
  • A carbohydrate intolerance of varying degrees
    severity with onset or first recognition during
    pregnancy with a probable resolution after the
    end of pregnancy
  • Not the same as Type 1 or Type 2 Diabetes
  • Varies worldwide among different racial and
    ethnic groups within a country
  • Prevalence in India
  • Chennai 0.56 (Ramachandran A, 2002)
  • Mysore Parthenon Study 6 ( Fall C,2000)

10
DEFINITION OF GDM
  • GDM is defined as any degree of glucose
    intolerance with onset or first recognition
    during pregnancy.
  • and disappear after 6 weeks post partum
  • After 6 weeks post partum , if MGTT
  • NORMAL GDM
  • ABNORMAL TYPE 2 DM

Source American Diabetes Association 2009
11
ETIOLOGY
  • Pregnancy ? pro-diabetic state
  • Pregnancy ? marked insulin resistance ? increased
    insulin requirement ? GDM
  • Complicates 4 of all pregnancies
  • 60 to 80 of women with GDM are obese
    experience insulin resistance GDM

12
MECHANISM OF INSULIN RESISTANCE
  • The pancreas releases 1.52.5 times more insulin
    in order to respond to the resultant increase in
    insulin resistance.Normal patient meets the
    demand
  • In GDM
  • Post receptor defect. Inadequate insulin release

13
Pregnancy Pathophysiology
  • Glucose is a teratogen at high levels
  • Crosses placenta readily while insulin cannot
  • Insulin resistance occurs because hormonal
    changes associated with pregnancy partially block
    the effects of insulin
  • Insulin resistance causes glucose to be shunted
    from mother to the fetus to facilitate fetal
    growth and development

14
  • Subsequent increase in insulin resistance causes
    maternal glucose levels to increase 80 of
    non-pregnant women

  • Increased insulin resistance

  • Decreased insulin secretion

  • Increased maternal glucose

  • GDM
  • GDM disappears after pregnancy
  • Useful physiologic process out of balance

15
PATHOPHYSIOLOGY
  • lt 20 weeks of POG
  • Anabolic phase
  • Increase in Insulin sensitivity
  • gt 20 weeks of POG
  • Catabolic phase
  • Increase in Insulin resistance

16
Pathophysiology
  • Early in pregnancy, maternal estrogen and
    progesterone increase and promote pancreatic
    ß-cell hyperplasia and increased insulin release
  • As pregnancy progresses, increased levels of
    human placental lactogen, cortisol, prolactin,
    progesterone, and estrogen lead to insulin
    resistance in peripheral tissues.
  • Table 1 describes the diabetogenic potency and
    time of peak effect of these hormones. The timing
    of these hormonal events is important in regard
    to scheduling testing for GDM

Hormone  Peak elevation (weeks) Diabetogenic potency
ProlactinEstradiolHPLCortisolProgesterone 1026262632 Weak Very weakModerateVery strongStrong
Adapted from Jovanovic-Peterson L, Peterson C Review of gestational diabetes mellitus and low-calorie diet and physical exercise as therapy. Diabetes Metab Rev 12287-308, 1996. Adapted from Jovanovic-Peterson L, Peterson C Review of gestational diabetes mellitus and low-calorie diet and physical exercise as therapy. Diabetes Metab Rev 12287-308, 1996. Adapted from Jovanovic-Peterson L, Peterson C Review of gestational diabetes mellitus and low-calorie diet and physical exercise as therapy. Diabetes Metab Rev 12287-308, 1996.
17
  • GDM results when there is delayed or insufficient
    insulin secretion in the presence of increasing
    peripheral resistance

18
Discussion
  • What are the risk factors for gestational
    diabetes?
  • What risk factors do you see most often in your
    setting?

19
Risk factors for GDM
Low risk
  • High risk
  • Obesity
  • Diabetes in 1st degree relative
  • Previous
  • history of GDM or glucose intolerance
  • complicated pregnancy
  • infant with macrosomia gt 3.5 kg
  • Older age
  • High risk ethnic group South Asian, East Asian,
    Indigenous American or Australian, Hispanic
  • PCOS
  • Age less than 25 years
  • No previous poor pregnancy outcomes
  • No diabetes in 1st degree relatives
  • Normal prepregnancy weight and weight gain during
    pregnancy
  • No history of abnormal glucose tolerance

Perkins, Dunn, Jagastia, 2007
20
Is Hypertension a risk factor?
  • Hypertension prior to pregnancy or during 1st
    trimester doubled the risk of GDM independent
    of maternal weight
  • Hence all women with hypertension should be
    screened for GDM

Hedderson, Ferrara, 2008
21
Why diagnose and treat GDM?
  • Short term risks for the mother
  • Development of gestational hypertension,
    worsening essential hypertension or development
    of preeclampsia
  • Operative delivery - related to macrosomia
  • Polyhydramnios
  • Premature labour
  • Long term risks for the mother
  • Development of type 2 diabetes in next 10 years
    (30-60 depending on population)
  • Development of cardiovascular disease

CDA, 2013 Metzger, Buchanan, et al. 2007
22
Why diagnose and treat GDM?
  • Short term risks for the baby
  • Macrosomia
  • Neonatal hypoglycemia
  • Jaundice
  • Preterm birth
  • Birth injury
  • Hypocalcemia/ hypomagnesimia
  • Respiratory distress syndrome
  • Long term risks for the baby
  • Obesity
  • Type 2 diabetes

23
Screening
  • Whom to screen
  • When to screen
  • How to screen

24
Venous or capillary
  • The venous plasma is the gold standard
  • Where laboratory facilities or technicians are
    not available, capillary glucose estimations may
    be done using a hand held glucose meter.
  • The glucose meter must be standardized with a lab
    and calibrated against the lab on a regular
    basis.

25
Screening for GDM
  • Indians fall into the high-risk category for
    developing GDM
  • therefore universal screening is recommended in
    pregnancy

26
When ??
  • offer universal screening to ALL antenatal
  • women at 24 28 wks of gestation
  • and an early screening at booking if there
  • are additional risk factors identified by history
  • o Previous unexplained loss at term
  • o Previous baby weight gt 4 kg
  • o Previous Pregnancy with GDM
  • o Strong F/H

27
Diagnosis of Diabetes in non-pregnant women
menOGTT is not recommended for routine clinical
use.The FPG is the preferred test to diagnose
diabetes in children non-pregnant adults.Use
of the A1C for the diagnosis of diabetes is not
recommended at this time. ADA recommendations.
American Diabetes Association Criteria for
Glycemic abnormalities
28
When to screen to rule out unidentified
pre-existing diabetes?First trimester
  • Screening in 1st trimester
  • Fasting plasma glucose gt126 mg/dl (7 mmol/L)
  • or
  • HbA1c gt6.5
  • or
  • Random gt200mg/dl (11.1 mmol/L)
  • or
  • 2hr value in OGTT gt200mg/dl (11.1 mmol/L)
  • If overt diabetes is detected, it must be treated
    appropriately.

ADA, 2015
29
Fasting and postprandial venous plasma sugar
during pregnancy
Fasting 2h postprandial Result
lt100 mg/dl lt 120mg/ dl Not diabetic
gt125 mg/ dl gt200 mg/ dl Diabetic
100-125 mg/dl 120-200 mg/dl Border line indicates glucose tolerance test to diagnose GDM (These values are not called as IFG and IGT)
30
When to screen for GDM?24-28 Weeks (One Step
Strategy)
  • Screening should be done at 24-28 weeks
  • Diagnosis based on a 75 gm glucose load given in
    fasting state
  • GDM diagnosed when one or more of the following
    is present
  • Fasting 92 - 125 mg/dl (5.0 6.9 mmol/L)
  • 1 hour post 75 gm load gt180 mg/dl (10 mmol/L)
  • 2 hour post 75 gm load gt153mg/dl (8.5 mmol/L)
  • If woman tests negative, screening at 32 weeks
    also may be necessary in presence of high risks

World Health Organization, 2013
31
DIAGNOSIS
  • TWO-STEP STRAREGY
  • 50-75g oral glucose challenge
  • Single serum glucose measurement _at_ 1 hr
  • lt7.8 mmol/L(lt140mg/dL) ? normal
  • gt7.8 mmol/L(gt140mg/dL)
  • 100-g oral glucose challenge
  • Serum glucose measurements in fasting state, I,
    II III hrs
  • Normal values
  • Fasting ? lt 5.8 mmol/L (lt105mg/dL)
  • I hr ? lt 10.5 mmol/L (lt190mg/dL )
  • II hr ? lt 9.1 mmol/L (lt165mg/dL)
  • III hr ? lt 8.0 mmol/L (lt145mg/dL)

32
  • Overnight fast of at least 8 hours
  • At least 3 days of unrestricted diet and
    unlimited physical activity
  • gt 2 values must be abnormal
  • Urine glucose monitoring is not useful in
    gestational diabetes mellitus
  • Urine ketone monitoring may be useful in
    detecting insufficient caloric or carbohydrate
    intake in women treated with calorie restriction

33
Is there any place to monitor glycosylated
hemoglobin (HbA1c) in pregnant women with
gestational diabetes? Especially in relation to
predicting fetal morbidity such as macrosomia/
shoulder dystocia?
The NICE guideline on diabetes in pregnancy
(National Collaborating Centre) recommends that
HbA1c should not be used routinely for assessing
glycaemic control in the second and third
trimesters of pregnancy. Do not use routine
measurement of HbA1c for management
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SCREENING
  • Essentially all Indian women have to be screened
  • for gestational diabetes mellitus as they belong
  • to a high risk ethnicity
  • LOW RISK GROUPS
  • lt25 yrs of age
  • BMI lt25kg/sq.m
  • No H/O maternal macrosomia
  • No H/O diabetes
  • No H/O D.M in first degree relative
  • Not members of high risk ethnic groups
  • Member of an ethnic group with a low prevalence
  • of GDM
  • No H/O abnormal glucose tolerance
  • No H/O poor obstetric outcome

36
  • Intermediate risk
  • At least one of the criteria in the list
  • High risk
  • Marked obesity
  • Prior GDM
  • Glycosuria
  • Strong family history
  • Must be done between 24 28 weeks of pregnancy
  • Most GDM cases revert to normal after delivery

37
Value of Screening During Current Pregnancy
  • Increased screening, identification and treatment
    can decrease the morbidity and mortality of GDM
  • Decreased macrosomia, cesarean birth and birth
    trauma due to a gt 4000g infant
  • Decreased neonatal hypoglycemia, hypocalcaemia,
    hypomagnesiemia, hyperbilirubinemia,
    polycythaemia
  • Identify women at future risk for diabetes and
    those with insulin resistance

38
  • Women are generally screened for GDM with glucose
    challenge test in the late second trimester
  • If result is abnormal ? oral glucose tolerance
    test
  • Abnormal glucose challenge test but no GDM?
    increased risk of future cardiovascular disease
  • They have a lower risk than women who actually
    did have gestational diabetes
  • In women with glucose intolerance during
    pregnancy, type 2 diabetes and vascular disease
    may develop in parallel, which is consistent with
    the "common soil" hypothesis for these conditions

39
  • Retesting
  • Negative initial test but risk factors present
  • Obesity
  • gt33 years of age
  • Positive 1 hour screen followed by a negative
    OGGT
  • 3/4 glucosuria
  • Low risk ? no screening for no risk ethnic
    population.
  • Average risk ? at 24-28 weeks
  • High risk ? as soon as possible

40
Management ApproachMulti-Disciplinary
  • Once diagnosed as Gestational diabetes the
    patients are under the care of a team for
    monitoring of maternal sugar and fetal well
    being. The team -
  • Endocrinologist
  • Dietician
  • Obstetrician
  • Pediatrician
  • Sonologist

41
MANAGEMENTExercise
  • . Jovanovic-Peterson and associates studied 19
    women with GDM, assigning 9 to dietary treatment
    and 10 to diet plus 20 minutes of monitored
    exercise 3 times a week for 6 weeks.
  • They found a significantly lower OGTT and fasting
    blood glucose in patients assigned to the
    exercise group beginning 6 weeks after initiating
    therapy.
  • What type of exercise??
  • Non weight bearing (ex swimming, cycling, brisk
    walking)

42
Diet control
  • ADA has recommended dietary therapy to start with
    2,0002,500 kcal/day (35 kcal/kg present
    pregnancy weight), with 5060 carbohydrates
    (complex, high fiber), 1020 protein, and 2530
    fat (lt10 saturated). New ADA recommendations
    specify a protein level of 1020 of calories but
    now allow greater flexibility in the levels of
    carbohydrate and fat.

43
  • Gestational diabetes diet
  • Water foods are the main concentration. That
    means plants vegetables, fruits, grains
    legumes
  • Only low-fat and non-fat dairy products
  • Only the leanest cuts of meat with all
  • excess fat trimmed
  • Avoid saturated fats
  • Strongly avoid Trans fats
  • Avoid fast foods, processed foods, microwave
    foods, high-sugar foods, alcohol high-sodium
    foods
  • Drink plenty of fresh water every day
  • Eat 5 or 6 small meals everyday
  • Eat your meals at the same times every day

44
Medical nutrition therapy
  • Approximately 30 kcal/kg of ideal body weight
  • gt40-45 should be carbohydrates
  • 6-7 meals daily( 3meals, 3-4 snacks)
  • Bed time snack to prevent ketosis
  • Calories guided by fetal well being/maternal
    weight gain/blood sugars/ ketones
  • Energy requirements during the first 6 months of
    lactation require an additional 200 calories
    above the pregnancy meal plan

45
Maintain a healthy weightWeekly Rate Of Weight
Gain
Time Frame Expected Weight Gain
In the first trimester of pregnancy (the first 3 months) Three to six pounds for the entire three months
During the second and third trimester (the last 6 months) Between ½ and 1 pound each week
If you gained too much weight early in the pregnancy Limit weight gain to ¾ of a pound each week (3 pounds each month) to help get your blood sugar level under control
A weight gain of two pounds or more each
week
is considered high.
46
Maintain a healthy weightThings to Keep in Mind
  1. A weekly rate of weight gain may go up and down
    throughout the pregnancy.
  2. A physician can assess whether weight gain is
    appropriate or not.
  3. A weight loss can be dangerous during any part of
    the pregnancy, therefore any weight loss needs to
    be reported to a health care provider right away.
  4. If weight gain slows or stop, and does not
    increase again after one-to-two weeks, it should
    be reported to a health care provider
    immediately. Adjustments in your treatment plan
    may be necessary.

47
Keep daily records of your diet, physical
activity, and glucose levels
  • Keep track of the following
  • Blood sugar level
  • Food
  • Physical wellness
  • Physical activity
  • Weight gain

48
Insulin
  • The ACOG ADA criteria for initiating insulin
    therapy include a fasting plasma glucose
    level gt95mg/dL and 2-hour plasma postprandial
    levels 120mg/dL.
  • Total insulin doses can be calculated and given
    with split dosing by three injections. If insulin
    is required, the target plasma glucose levels to
    reduce risk of fetal macrosomia are

fasting 1hour 2 hours 2-6 am
lt95mg/dL Not gt 140mg/dL lt 120mg/dL lt95mg/dL
49
ANTENATAL MANAGEMENT OF GDM
  • GROWTH SCAN
  • Scan at 28 and 34 weeks for growth
  • Scan at 36 weeks for EBW and serial growth scans
  • PLOT GROWTH CHART
  • MONITORING
  • 2 weekly BSP till 36 weeks (if within normal
    range)
  • Weekly BSP if abnormal or escalation of treatment
    (till normal)
  • Weekly BSP after 36 weeks
  • TIMING OF DELIVERY
  • Offer induction of labour at 38 weeks if on
    treatment
  • Offer induction of labour at 40 weeks if not on
    treatment
  • Earlier if evidence of macrosomia/polyhydramnios
    or poor control at term

Each visit Review BP Screen for PE
50
Antepartum Management
  • At 28 weeks Inj Betnesol 12 mg 2 doses
  • All patients on diet therapy before 32 weeks are
    followed by fortnight visit and weekly visits
    thereafter
  • Patients on insulin therapy are always monitored
    by weekly visit

51
Antepartum Management(contd)
  • As per ACOG recommendations for GDM patients
    weekly fetal surveillance was started from 32nd
    week of gestation for
  • Clinical Examination
  • Growth profile
  • Biophysical profile
  • Non stress test

52
Know your blood sugar level
keep it under control
Time of Blood Sugar Test Healthy Target Levels (in mg/dl)
Fasting glucose level No higher than 95
One hour after eating No higher than 140
Two hours after eating No higher than 120
  • Although your glucose levels change during the
    day, there is a healthy range that is normal. If
    your glucose level is outside of the healthy
    target range, speak with your health care
    provider.

53
Know your blood sugar level
keep it under control
Measuring your blood sugar will give you information about For example
The amount of food you can eat Can you have that extra ½ bagel for breakfast?
Foods that affect your glucose level Does your body process different foods differently?
Times when your glucose level is high or low You might have high blood sugar in the morning after breakfast other women may have high blood sugar after dinner.
Times that physical activity is more likely to keep your glucose level in target Does walking for 20 minutes after breakfast or dinner help to keep your glucose level within the healthy range?
  • Knowing your glucose levels at specific times of
    the day may become very important if insulin
    therapy becomes necessary.
  • Insulin resistance can increase as a pregnancy
    progresses indicating a need for additional
    insulin to control glucose levels.

54
Know your blood sugar level
keep it under control
  • You may have to test four times a day
  • In the morning before eating breakfast,

    referred to as the Fasting glucose level
  • 1 or 2 hours after breakfast
  • 1 or 2 hours after lunch
  • 1 or 2 hours after dinner
  • You may also have to test your glucose level
    before you go to bed at night. This is referred
    to as your nighttime or nocturnal glucose test.

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treatment
  • The total first dose of insulin is calculated
    according to the patients weight as follow
  • In the first trimester ? weight x 0.7
  • In the second trimester ? weight x 0.8
  • In the third trimester ? weight x 0.9

56
Gestational DiabetesINSULIN
  • If fasting hyperglycemia start with NPHhs
  • initial dose 6-8 U
  • if only pc hyperglycemia use Humalog
  • 2-4u ac the specific meal
  • adjust 2u/time 1 formula /time
  • BG target ac lt5.3 (90mg.)
  • 2 h pc lt6.7 ( 120 mg)

57
OHA
  • 1) Gilbenclamide (sulphonylurea) MOA enhance
    insulin secretion by beta cells. Older
    sulphonylurea medications such as tolbutamide and
    chlorpropamide can cause fetal hyperinsulinaemia.
    Glibenclamide has minimal passage across the
    placenta.
  • Study A trial published in 2000 randomized
    404 women with gestational diabetes to receive
    either glibenclamide or insulin treatment.
  • Results no difference in the glycaemic
    control achieved between the two groups and no
    significant differences in rates of macrosomia or
    metabolic neonatal complication.
  • 2) Metformin MOA increase insulin sensitivity.
  • Study MiG trial randomized 751 women to
    insulin or metformin treatment with insulin
    supplementation if required.
  • ResultsThere was no difference in
    peri-natal morbidity between the two groups. 46
    of the metformin group received supplemental
    insulin to meet glucose targets.

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Fetal monitoring
  • Baseline ultrasound fetal size
  • At 18-22 weeks ? major malformations fetal
    echocardiogram
  • 26 weeks onwards ? growth and liquor volume
  • III trimester ? frequent USG for accelerated
    growth (abdominal head circumference)

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FETAL ASSESSMENT
  • EXCLUDE MACROSOMIA AT TERM (DOCUMENT IN NOTES)
  • NO ROLE FOR DOPPLER UNLESS EVIDENCE OF IUGR
  • POLYHYDRAMNIOS OR MACROSOMIA IS AN INDICATION FOR
    INSULIN/EARLY DELIVERY

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Gestational Diabetes
  • Fetal Risks
  • no increase in congenital anomalies
  • increased risk of stillbirth if fasting pc
    hyperglycemia
  • macrosomia
  • birth trauma-shoulder
  • dystocia and related
  • complications

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Insulin Management during Labor Delivery
  • Usual dose of intermediate-acting insulin is
    given at bedtime
  • Morning dose of insulin is withheld
  • I.V infusion of normal saline is begun
  • Once active labor begins or glucose levels fall
    below 70 mg/dl, infusion is changed from saline
    to 5 dextrose
  • delivered at a rate of 2.5 mg/kg/min
  • Glucose levels are checked hourly using a
    portable meter allowing for adjustment in
    infusion rate
  • Regular (short-acting) insulin is administered by
    iv infusion if glucose levels exceed 140 mg/dl

64
  • Maternal hyperglycemia in labor fetal
    hyperinsulinaemia, worsen fetal acidosis
  • Maintain sugars 80-120 mg/dl (capillary?70-110mg/
    dl )
  • Feed patient the routine GDM diet
  • Maintain basal glucose requirements
  • Monitor sugars 1-4 hrly intervals during labour
  • Give insulin only if sugars more than 120 mg/dl
  • Maternal complication
  • Fetal complication
  • Glycemic monitoring SMBG and targets
  • Fetal monitoring ultrasound
  • Planning on delivery
  • Long term risks

65
Related to fetus
  • Macrosomia (gt 4kg, 2030 of infants whose
    mothers have GDM)
  • FBS gt 105 mg/ dl
  • Maternal hyperglycemia
  • Fetal hyperglycemia
  • Fetal hyperinsulinemia
  • Excessive Fetal growth adiposity

66
Macrosomic baby
Normal baby
67
Timing and mode of delivery
  • Timing
  • -Uncomplicated, well controlled DM not requiring
    insulin with normal fetal growth- 38 to 40 weeks
  • -GDM requiring insulin therapy- 38 weeks/earlier
    if indicated
  • Mode Of Delivery
  • Studies have documented an increase in the rate
    of shoulder dystocia when macrosomia is
    suspected. Consequently, estimated fetal weight
    plays an important role in the decision-making
    process for route of delivery. When it is
    suspected that the fetus is macrosomic, cesarean
    delivery should be considered. Providers must
    remember that ultrasonography has a range of
    error of 1015 in estimating fetal weight at
    term.

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postnatal care
  • IF GDM, NO NEED FOR POST DELIVERY MONITORING
  • STOP INSULIN POST DELIVERY (ENSURE SHE HAS GDM
    NOT DM)
  • UNLESS ITS HIGH REQUIREMENT OF INSULIN ANTENATALLY

70
POST NATAL CARE
  • 6 WEEKS FBS (NICE) (LOW RISK)
  • HIGH RISK PATIENTS DO MOGTT
  • YEARLY FBS
  • OGTT NEXT PREGNANCY AT 16-18WEEKS

71
Should I breastfeed having gestational diabetes?
  • Yes, women with gestational diabetes should
    breastfeed their babies, if possible.
  • Breastfeeding is not only beneficial to the baby,
    but it is also beneficial to the
    mother.
  • Breastfeeding allows the body to use extra
    calories stored during pregnancy, allowing for
    weight loss.
  • A weight loss after having the baby not only
    enhances overall health, but also helps to reduce
    the risk of developing type 2 diabetes later in
    life.

72
Breastfeeding is also believed to help lower
fasting blood glucose levels in mothers.
73
Could GDM hurt my baby in other ways?
  • Gestational diabetes usually does not cause birth
    defects or deformities.
  • Most developmental or physical defects happened
    during the first trimester of pregnancy, between
    the 1st and 8th week, and gestational diabetes
    typically develops around the 24th week of
    pregnancy.

74
Women with gestational diabetes typically have
normal blood sugar levels during the first
trimester, allowing the body and body Systems
of the fetus to develop normally.
75
The future ..
  • women who exhibit glucose intolerance during
    pregnancy have an increased risk of developing
    type 2 diabetes within 15 years .
  • Children born out of these
  • childhood obesity / adult onset diabetes

76
Pearls
  • Look for unrecognized DM2 or GDM at 1st prenatal
    visit if risk factors
  • New criteria for diagnosing GDM  2-hr, 75 g OGTT
  • Increased no. of women with GDM
  • Rx hyperglycemia in pregnancy to prevent maternal
    fetal complications
  • Lifestyle modifications diet exercise (during
    after pregnancy)
  • Pharmacologic options Metformin(MFM), Glyburide,
    Insulin
  • Screen for DM2 or pre-diabetes at 6-12 wks
    post-partum

77
Preexisting (overt) Diabetes
  • Preconception Counselling
  • risk of NTD 1-2
  • Folic Acid 1-4 mg /day
  • BG 3.5-5.3 (65-95 mg/dL)prior to meals
  • switch to MDI (Multiple Daily Insulins) regimen
    (insulin ac meals and HS)
  • keep track of cycles

78
Preexisting Diabetes
  • Normoglycemia prior to conception
  • Ideally HBA1C 6 or less
  • Team approach
  • Glucose monitoring qid
  • ACE contraindicated should be D/C at conception
    or use Diltiazem instead
  • Baseline HBA1C, 24h urine for protein Creatinine
    Clearance , opthalmology review
  • Switch from OHA to insulin

79
Pre existing Diabetes
  • Assess for end organ disease
  • 1. Assess for nephropathy
  • Including risk of PIH.
  • 2. Assess Rx.retinopathy It
  • may PROGRESS.
  • 3. Assess for neuropathy generally
  • remains stable during pregnancy
  • 4. Assess and treat
  • Vasculopathy.CAD is a relative
  • C/I for pregnancy

80
Preexisting Diabetes
  • Maternal Risks
  • PIH /PET
  • polyhydramnios
  • preterm labour
  • operative delivery 50
  • birth trauma
  • infection
  • increase in insulin requirements
  • DKA

81
Preexisting Diabetes
  • Fetal Risks
  • congenital anomalies 3X inc. risk
  • unexplained stillbirth
  • shoulder dystocia
  • macrosomia
  • IUGR

82
Preexisting Diabetes
  • Neonatal Risks
  • hypoglycemia
  • hypocalcemia
  • hyperbilirubinemia/polycythemia
  • idiopathic RDS
  • delayed lung maturity
  • prematurity
  • predisposition to diabetes

83
Preexisting Diabetes
  • Congenital anomalies
  • 3x the general population risk
  • approaches the gen. pop.risk (2-3) if optimal
    control in periconception period
  • related to glycemic control during embryogenesis

84
Preexisting Diabetes
Congenital anomalies
  • CVS
  • ASD/VSD, CoA Transposition, Cardiomegaly
  • CNS
  • Anencephaly,
  • NTD,
  • Microcephaly
  • GI duodenal atresia, anorectal atresia,
    situs inversus
  • GU renal agenesis
  • Polycystic kidneys
  • MSK
  • caudal regression
  • syndrome

85
Preexisting Diabetes
  • Maternal Surveillance
  • Blood pressure
  • Renal function
  • Urine culture
  • Thyroid function
  • BG control HB A1C
  • q trimester
  • monthly

86
Preexisting Diabetes
  • Fetal Surveillance
  • U/S for dating/viability 8 weeks
  • Fetal anomaly detection
  • nuchal translucency 11-14w
  • maternal serum screen
  • anatomy survey 18-20 w
  • Fetal echo 22 w

87
  • Multidose Insulin
  • breakfast 25 H
  • lunch 15 H
  • supper 25 H
  • hs 35 NPH
  • Indicates insulin as a
  • of total daily dose

Gabbe Obstet Gynecol 2003
88
Peripartum Management
  • Withhold subcutaneous insulin from onset of
    labour or induction
  • IV D10 _at_50cc/h
  • IV short acting insulin in
  • NS usually starting at
  • 0.5-1u/h
  • 10u insulin in 100 cc NS(1U10cc)

89
Timing of Delivery
  • GDM Diet controlled
  • Same as non diabetic
  • Offer induction at 41 weeks
  • if undelivered
  • GDM on Insulin/Type II/Type I
  • If suboptimal control deliver following
  • confirmation of lung maturity if lt39
  • weeks
  • Otherwise deliver by 40 weeks
  • Generally do not allow to go postterm

90
Mode of Delivery
  • Macrosomic infants of diabetic
  • mothers have higher rates
  • of shoulder dystocia than non
  • diabetic mothers
  • Ultrasound estimates of fetal
  • weight become significantly
  • inaccurate after 4000g
  • Reasonable to recommend
  • C/S delivery if EFW is gt4500g

91
Oral Hypoglycemic agents
  • Traditionally not
  • recommended in pregnancy
  • Recent RCT of oral
  • glyburide vs insulin for GDM
  • 440 patients
  • BG measured 7x daily
  • Treatment started after 11 weeks gestation

92
Oral Hypoglycemic agents
  • Glyburide Insulin
  • Achieved N BG 82 88
  • LGA infants 12 13
  • Macrosomia 7 4
  • C Section 23 24
  • Hypoglycemia 9 6
  • Preeclampsia 6 6
  • Anomalies 2 2

Langer NEJM 2000
93
Newborn baby
94
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