Title: Gestational Diabetes
1Gestational Diabetes
- By Lisa Tang, MD
- August 10, 2005
2Case Presentation
- Mrs. N.M. is 24 y.o. G1P0 overweight woman at 8
wks by LMP who recently found out she was
pregnant, presented to the ED with two weeks hx
of polydipsia and polyuria. - Random blood sugar was 239. UA noted for 3
glucose. Pt was discharged from the ED and
arranged to have follow up for prenatal visit.
3Case Presentation-cont
- PMH
- None
- Meds
- None
- Allergies
- NKDA
- FH
- No FH of DM
- SH
- From Mexico, has been in the U.S. x 6 yrs
- Unplanned but desired pregnancy
- FOB in Mexico
- Good social support -lives with her parents
- High school education
- Used to smoke, 1 pack/wk x 3 yrs, quitted in 7/04
- Denies EtOH, and drugs
4Gestational Diabetes (GDM)Epidemiology
- Diabetes Mellitus
- Complicates 3-5 of all pregnancies.
- Affects more than 200,000 women in the U.S. per
year. - Is a major cause of perinatal morbidity and
mortality as well as maternal morbidity.
5Gestational Diabetes (GDM)Epidemiology-cont
- GDM
- Represents approximately 90 of all cases of
diabetes. - Is especially common in populations with a higher
rate of type 2 DM - -African Americans
- -Asian Americans
- -Hispanic Americans
- -Native Americans
6Definition
- CHO intolerance of variable severity that begins
or is first recognized during pregnancy. (1) - Applies regardless of whether insulin is used for
treatment or the condition persists after
pregnancy. (1) - Does not exclude the possibility that
unrecognized glucose intolerance may have
antedated the pregnancy. (1)
7Modified Whites Classification of Diabetes in
Pregnancy (6)
- Class A
- Abnormal GTT at any age or of any duration
treated only by diet therapy
- A1
- -Diet Controlled GDM
- A2
- -Insulin-treated GDM
8Pathophysiology
- Caused by placental production of human placental
lactogen (HPL) and progesterone. - Other hormones that may contribute include
prolactin and cortisol.
9Pathophysiology-cont
- Early in pregnancy, relatively higher levels of
estrogen enhance insulin sensitivity. - As placenta develops, estrogen decreases as HPL
and progesterone rise, resulting in increased
insulin resistance at the end organs. - Insulin resistance is most marked in the third
trimester at which time GDM most often occurs.
10Pathophysiology-cont
- Insulin
- is the major fetal growth hormone .
- produces excessive fetal growth particularly in
fat, the most insulin-sensitive tissue.
11Growth Abnormalities(1)Two Extremes Of Growth
Abn
12Early Complications
- Congenital malformations in infants of mothers
with chronic DM (1) - Leading cause of perinatal mortality in
pregnancies complicated by DM occurring in 6-12
of all infants - Result of poor glucose control during the
critical weeks of organogenesis, 5-8 wks of
gestation
13Infant of a Diabetic Mother with Sacral Agenesis
- Cardiovascular anomalies ASD, VSD
- Skeletal anomalies sacral agenesis
- CNS anomalies
- Genitourinary anomalies renal agenesis,
polycystic kidneys
14Late Complications
- The fetus is likely
- to weigh gt 4000 gram and be disproportionately
large with increased risk of shoulder dystocia. - to be at greater risk of intrauterine fetal death
during the last 4-6 weeks of gestation. - to be at higher risk of respiratory distress
syndrome.
15Screening
- Controversial whether all patients should be
screened for GDM. - The U.S. Preventive Services Task Force
concludes that the evidence is insufficient to
recommend for or against universal screening for
GDM screening for high risk women may be
beneficial. (2) - The American Diabetes Association has proposed
that screening be limited to women with RF for
GDM.
16Screening-cont
- Women (at low risk) with ALL of the following
characteristics need not be screened with a
laboratory blood glucose test. - Less than 25 years of age
- Normal body weight with BMI lt 25
- No first degree relative with DM
- Not a member of an ethnic group at increased risk
for type 2 DM women of Hispanic, African, Native
American, South or East Asian or Pacific Islands
ancestry - No hx of abnormal glucose metabolism
- No hx of poor obstetric outcome
17Screening-cont
- For women who do not meet the above criteria,
screening should be conducted at 24 -28 wks of
gestation with use of a 50 g one hour oral
glucose load - An abnormal one hour screening test with a venous
plasma glucose of gt140 mg/dL necessitates a full
diagnostic 100 g three hours oral glucose
tolerance test (GTT)
18Screening-cont
- Women at high risk for GDM have the following
characteristics - Personal past hx of GDM
- A strong FH of type 2 DM
- Marked obesity
- They should be tested as soon as possible and if
initial screen is negative, be retested at 24-28
wks of gestation.
19Dx of GDM with Use of a 100 gram Oral Glucose
Load
20Management
- The goal is to prevent adverse pregnancy
outcomes. - A multidisciplinary approach is used.
- Patient is seen every 1-2 wks until 36 wks
gestation and then weekly. - Patient is asked to keep an accurate diary of
their blood glucose concentration.
21Dietary Therapy
- Refer to a dietitian
- Recommend a complex, high fiber CHO diet
- Avoid concentrated sweets
22When Dietary Therapy Fails
- Insulin
- Oral Hypoglycemic Agents
- -Glyburide
- -Metformin
23Insulin Regimen
- Pt should check their fasting glucose and a 1
hour or 2 hour postprandial glucose level after
each meal, for a total of four determinations
each day. - If the fasting value is gt 95 mg/dL, or 1 hr value
gt 130-140 mg/dL or 2 hr value gt 120 mg/dL,
insulin therapy needs to be initiated.
24Insulin Regimen
25Alternative to Insulin TherapyGlyburide
- 2nd generation sulfonylurea
- Does not cross the placenta
- Some physicians are using glyburide in lieu of
insulin given its ease of use. - Both the ACOG and ADA do not endorse the use of
glyburide in the tx of GDM until additional RCTs
support its safety and effectiveness.
26Alternative to Insulin TherapyMetformin
- Is used as a tx for infertility in PCOS.
- Is a category B drug
- Hasnt been well studied for use in pregnancy.
- Both the ACOG and ADA do not endorse the use of
metformin in the tx of GDM until additional RCTs
support its safety and effectiveness.
27Antepartum Testing
- First trimester u/s and a fetal echo to assess
congenital cardiac anomalies. - Second trimester u/s to assess fetal growth.
- Twice weekly testing NSTs and amniotic fluid
volume determination beginning at 32 wks
gestation to assess fetal well-being.
28Delivery
- Early delivery may be indicated for
- women with poor glycemic control
- pregnancies complicated by fetal abnormalities
- Otherwise, pregnancies are allowed to go to term.
29Intrapartum
- The goal is to maintain normoglycemia in order to
prevent neonatal hypoglycemia. - Check patients glucose q1-2 hours.
- Start insulin drip to maintain a glucose level of
between 80 - 110 mg/dL. - Observe infant closely for hypoglycemia,
hypocalcemia, and hyperbilirubinemia after birth.
30Postpartum Care
- After delivery
- Measure blood glucose.
- -fasting blood glucose concentrations should
be lt105 mg/dL and one hour postprandial
concentrations should be lt 140 mg/dL. - Administer one half of the pre-delivery dose
before starting regular food intake.
31Postpartum Care-cont
- Follow up
- Per American Diabetes Association, a 75 g two
hours oral GTT should be performed 6-8 wks after
delivery.
32Postpartum Care-cont
- Follow up
- If the pts postpartum GTT is normal, she should
be re-evaluated at a minimum of 3 years interval
with a fasting glucose. - All pts should be encouraged to exercise and lose
wt. - All pts should be evaluated for glucose
intolerance or DM before a subsequent pregnancy.
33Management of Mrs. N.M
- First Trimester
- Ht 60 inches
- Current Wt 179 lbs Pre-pregnancy Wt 155 lbs
- Routine prenatal labs wnl
- HgbA1C 8.8
- 19 wks u/s normal, with EDD 5/13/2005
- Fetal echo was done at 20 wks with BPD and FL c/w
stated GA. No obvious structural or functional
fetal heart dz.
34Management of Mrs. N.M-cont
- Initial prenatal visits issues addressed
- Diabetic teaching-including how to use a
glucometer and how to inject insulin. Pt was
educated about the signs of hypoglycemia and was
told to eat small snacks if that happen. - Self monitoring and diet modification
- Exercise pt began to walk daily x 30 mins
35Management of Mrs. N.M-cont
- Second Trimester
- Level II U/S was done. Result was normal with a
single IUP, posterior placenta and no e/v of
placenta previa. SizeDate - Insulin regimen consisted of NPH and Lispro was
initiated. - HgbA1C 5.0
36Management of Mrs. N.M-cont
- Third Trimester
- Biweekly antenatal testing began.
- Insulin regimen was adjusted according to
increased needs. - HgbA1c 5.3
- Two more u/s were done with normal fetal growth.
37Delivery
- Pt had NSVD on 5/7/2005 at 39 wks of gestation.
- She delivered a healthy boy, B.M. with wt 2895 g
(6 lb 6 oz) and Apgar 8, 9. - Delivery was complicated by 1st deg lac.
- Blood sugar was monitored q2 and insulin drip per
protocol was used.
38Postpartum
- Insulin regimen was decreased to ½ of her
previous regimen. - Given that Mrs. N.M.s RF and elevated HgbA1c at
presentation, she most likely has pre-existing DM
Type II.
39Now
- On metformin 500 mg po daily the first week, then
BID after - Mrs. N.M. is breastfeeding.
- Her mother has been helping her out with child
care. - Baby boy, B.M. is growing appropriately and
meeting all his developmental milestones.
40Take Home Message
- As obesity increases in the U.S., the rate of
gestational diabetes will rise. - All pregnant women should be screened for GDM,
whether by pts hx, clinical risk factors, or a
lab screening test to determine blood glucose
levels. (3) - It is important that multidisciplinary approach
be used to improve pregnancy outcome.
41Questions?
42Bibliography
- Gabbe, Steven MD and Graves, Cornelia R MD,
Management of Diabetes Mellitus Complicating
Pregnancy, Obstetrics Gynecology
2003102(4)857-868 - Turk, David K MD, MPH, Ratcliffe, Stephen D, MD,
and Baxley, Elizabeth G. MD, Management of
Gestational Diabetes Mellitus, Am Fam Physician
2003681767-72,1775-6 - ACOG Practice Bulletin No 30 Gestational
Diabetes. Volume 98 No 3 September 2001 - Jovanovic, Lois MD, Screening and Diagnosis of
Gestational Diabetes Mellitus, Up to Date version
13.2 - Jovanovic, Lois MD, Treatment and Course of
Gestational Diabetes Mellitus, Up to Date version
13.2 - Barss, Vanessa MD and Blatman, Robert N. MD,
Obstetrical Management of Pregnancy Complicated
by Diabetes Mellitus, Up to Date version 13.2 - USPSTF Guidelines Screening for Gestational
Diabetes Recommendations and Rationale - ADA Position Statement Gestational Diabetes
Mellitus