Gestational Diabetes Yannis Dimitropoulos ST3 in Diabetes and Endocrinology Torbay Hospital Buckfast Abbey Diabetes and En...
What we will Cover <ul><li>Definition and Aetiology of Gestational Diabetes  </li></ul><ul><li>Importance of diagnosis and...
GESTATIONAL DIABETES(GDM) <ul><li>A carbohydrate intolerance of variable severity with its onset/first recognition in preg...
Why does Gestational Diabetes Mellitus happen? <ul><li>Increasing prevalence of obesity in the population of women of chil...
Deterioration of  β  cell function  and insulin resistance in Type 2 diabetes 0 20 40 60 80 100 Age ß-cell function (%) – ...
Deterioration of  β  cell function  and insulin resistance in  Gestational DM   0 20 40 60 80 100 Age ß-cell function (%) ...
Why is it important to treat Gestational Diabetes?
Pedersen Hypothesis (1954) <ul><li>Maternal hyperglycaemia leads to foetal hyperglycaemia which evokes an exaggerated resp...
Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) 2005 <ul><li>Randomized double-blind intervention tri...
ACHOIS Results Outcome Intervention  Routine Group Infants Number Number  Total number 506 524 Birth weight 3335g 3482g Ma...
Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) 2008 <ul><li>Observational multi -centre study (25.505 patients with ...
Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) 2008 <ul><li>There were  no obvious glucose thresholds at which risks...
 
International Association of Diabetes and Pregnancy Study Groups (IADPSG) Consensus panel (2008) <ul><li>The panel recomme...
NICE Guidelines 2008
CEMACH: adverse outcomes in pregnant women with type 1 and type 2 diabetes, 2002/3 and 2007
NICE -Risks of Gestational Diabetes in Pregnancy <ul><li>Foetal macrosomia </li></ul><ul><li>Birth trauma (to mother and b...
NICE -Risk Factors for Screening for GDM <ul><li>BMI> 30kg/m ² </li></ul><ul><li>Previous macrosomic baby 4.5kg or above <...
The Torbay Hospital Antenatal Diabetes Clinic referral process <ul><li>If previously diagnosed with GDM, Obstetric Clinic ...
Low  vs. High Risk GDM management <ul><li>Low Risk:  </li></ul><ul><li>If macrosomia or polyhydramnios on USS, refer to Di...
The Torbay Hospital Diabetes Antenatal Clinic <ul><li>Multi –disciplinary: </li></ul><ul><li>Diabetes in Pregnancy Special...
The Torbay Hospital Diabetes Antenatal Clinic <ul><li>CBS values and patterns are reviewed in association with dietary, es...
The Torbay Hospital Diabetes Antenatal Clinic <ul><li>Intra-partum management plan is outlined in the multi-disciplinary “...
REFERENCES <ul><li>ACHOIS Trial NEJM June 2005 Vol. 352 no 24, pp. 2477-2486 </li></ul><ul><li>HAPO Study NEJM May 2008 Vo...
<ul><li>Thank you! </li></ul>
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Gestational diabetes

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  • Type 2 diabetes is typically not diagnosed until Beta cell function has been significantly impaired. After diagnosis, beta cell function deteriorates linearly with time. Extrapolating back a graph of time vs. function from the UKPDS suggests that beta cell dysfunction begins many years before it results in a clinical presentation of type two diabetes.
  • Type 2 diabetes is typically not diagnosed until Beta cell function has been significantly impaired. After diagnosis, beta cell function deteriorates linearly with time. Extrapolating back a graph of time vs. function from the UKPDS suggests that beta cell dysfunction begins many years before it results in a clinical presentation of type two diabetes.
  • Women with at least one risk factor for GDM GTT 24-34 weeks – FPG &lt;7.8 and 2-hr 7-8 - 11 1000 randomly assigned to ‘Intensive’ versus ‘Routine’ care ‘ Routine care’ – patients and physicians were not aware of the diagnosis of GDM
  • 23,316 pregnant women at 15 centres in 9 countries with 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Blinded if fasting glucose &lt;5.8 and 2-hour glucose &lt;11.1 mmol/l
  • Reviewed the evidence from HAPO, ACHOIS and all other available smaller randomized trials.
  • NICE implies oral treatments as good as insulin.
  • Gestational diabetes

    1. 1. Gestational Diabetes Yannis Dimitropoulos ST3 in Diabetes and Endocrinology Torbay Hospital Buckfast Abbey Diabetes and Endocrinology Training Day 07/05/2010
    2. 2. What we will Cover <ul><li>Definition and Aetiology of Gestational Diabetes </li></ul><ul><li>Importance of diagnosis and treatment of Diabetes in pregnancy </li></ul><ul><li>Aims and modalities of treatment according to best available evidence </li></ul>
    3. 3. GESTATIONAL DIABETES(GDM) <ul><li>A carbohydrate intolerance of variable severity with its onset/first recognition in pregnancy </li></ul><ul><li>This includes GDM that reverts to normal carbohydrate tolerance post-partum, but also all undiagnosed DM1, DM2 and rare monogenic Diabetes first detected during pregnancy </li></ul>
    4. 4. Why does Gestational Diabetes Mellitus happen? <ul><li>Increasing prevalence of obesity in the population of women of childbearing age augments insulin resistance. </li></ul><ul><li>Increasing maternal age also portends increased insulin resistance </li></ul><ul><li>Insulin resistance increases further during pregnancy </li></ul>
    5. 5. Deterioration of β cell function and insulin resistance in Type 2 diabetes 0 20 40 60 80 100 Age ß-cell function (%) – 10 –8 –6 –4 –2 0 2 4 6 – 12 30 40 50 60 70
    6. 6. Deterioration of β cell function and insulin resistance in Gestational DM 0 20 40 60 80 100 Age ß-cell function (%) – 10 –8 –6 –4 –2 0 2 4 6 – 12 30 40 50 60 70
    7. 7. Why is it important to treat Gestational Diabetes?
    8. 8. Pedersen Hypothesis (1954) <ul><li>Maternal hyperglycaemia leads to foetal hyperglycaemia which evokes an exaggerated response to Insulin which causes increased neonatal fat deposition and abdominal girth with increased birth weight. </li></ul><ul><li>The above was further supported by recent studies (HAPO study associations with neonatal anthropometrics, 2009) </li></ul>
    9. 9. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) 2005 <ul><li>Randomized double-blind intervention trial: 1000 women with GDM randomly assigned to ‘Intensive’ versus ‘Routine’ care </li></ul><ul><li>Intensive care: </li></ul><ul><li>Diet and monitoring (2 weeks) </li></ul><ul><li>Treat with insulin if 2 X FPG >5.5 and/or 2 X 2-hr post-prandial glucoses >7 (>8 if after 35/40) </li></ul><ul><li>All treated with multiple Insulin injections </li></ul><ul><li>Significant reduction in the rate of perinatal complications in the intervention group (1%) compared to the routine care group (4%). </li></ul>
    10. 10. ACHOIS Results Outcome Intervention Routine Group Infants Number Number Total number 506 524 Birth weight 3335g 3482g Macrosomia (>4kg) 49 (10%) 110 (21%) Death (Neonatal/Stillbirth) 0 5 Stillbirth 0 3 Shoulder dystocia 7 16 Bone fracture 0 1 Nerve palsy 0 3 Jaundice 44 48
    11. 11. Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) 2008 <ul><li>Observational multi -centre study (25.505 patients with GDM) showing continuous graded associations of maternal blood glucose levels below those diagnostic of Diabetes with: </li></ul><ul><li>Primary outcomes: </li></ul><ul><li>-increased birth weight (strong association) </li></ul><ul><li>-increased cord-blood serum C-peptide levels (strong association) </li></ul><ul><li>-C-section (weaker association) </li></ul><ul><li>-Neonatal hypoglycaemia (weaker association) </li></ul><ul><li>Secondary outcomes: </li></ul><ul><li>-Premature (<37/40) delivery, </li></ul><ul><li>-Shoulder dystocia/birth trauma, </li></ul><ul><li>-Admission to NICU </li></ul><ul><li>-Preeclampsia and Hyperbilirubinaemia </li></ul>
    12. 12. Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) 2008 <ul><li>There were no obvious glucose thresholds at which risks increased. </li></ul><ul><li>The results were applicable to all centres and were independent of other risk factors. </li></ul>
    13. 14. International Association of Diabetes and Pregnancy Study Groups (IADPSG) Consensus panel (2008) <ul><li>The panel recommends testing of FBG, HbA1c or RPG on all high-risk pregnant women. </li></ul><ul><li>Diagnostic of overt Diabetes: </li></ul><ul><li>FPG ≥ 7.0, HbA1c ≥ 6.5%, RPG ≥ 11.1 </li></ul><ul><li>(Treat as established pregnant diabetic) </li></ul><ul><li>Diagnostic of GDM: FPG ≥ 5.1 but <7.1 </li></ul><ul><li>If results not diagnostic of Diabetes (FPG < 5.1) then 75g OGTT at weeks 24-28 for all pregnant women at risk </li></ul><ul><li>Overt Diabetes if FPG ≥ 7.0 </li></ul><ul><li>GDM if FPG ≥ 5.1 </li></ul><ul><li>1hr PG ≥ 10 </li></ul><ul><li>2hr PG ≥ 8.5 </li></ul>
    14. 15. NICE Guidelines 2008
    15. 16. CEMACH: adverse outcomes in pregnant women with type 1 and type 2 diabetes, 2002/3 and 2007
    16. 17. NICE -Risks of Gestational Diabetes in Pregnancy <ul><li>Foetal macrosomia </li></ul><ul><li>Birth trauma (to mother and baby) </li></ul><ul><li>IOL or caesarean section </li></ul><ul><li>Transient neonatal morbidity </li></ul><ul><li>Neonatal hypoglycaemia </li></ul><ul><li>Perinatal death </li></ul><ul><li>Obesity and/or Diabetes developing later on in baby’s life </li></ul><ul><li>increased risk of the mother developing GDM with following pregnancies and Diabetes later in life </li></ul>
    17. 18. NICE -Risk Factors for Screening for GDM <ul><li>BMI> 30kg/m ² </li></ul><ul><li>Previous macrosomic baby 4.5kg or above </li></ul><ul><li>Foetal abdominal circumference >97 th centile on USS </li></ul><ul><li>Previous Gestational Diabetes </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>History of PCOS </li></ul><ul><li>Family history of Diabetes (first degree) </li></ul><ul><li>Family origin with a high prevalence of Diabetes </li></ul><ul><li>(South Asian, Afro-Caribbean, Middle Eastern, Chinese) </li></ul>
    18. 19. The Torbay Hospital Antenatal Diabetes Clinic referral process <ul><li>If previously diagnosed with GDM, Obstetric Clinic review with dating scan (12/40) for OGTT at earliest opportunity or proceed directly to CBS monitoring if previous Insulin-treated GDM. </li></ul><ul><li>For all others with risk factors OGTT at 28/40 </li></ul><ul><li>Refer to Diabetes ANC if: </li></ul><ul><li>Fasting blood glucose >5.5 mmol/l </li></ul><ul><li>Low-risk GDM if 2hr glucose 7.8-8.5 mmol/l </li></ul><ul><li>High-risk GDM if 2hr glucose >8.5 mmol/l </li></ul>
    19. 20. Low vs. High Risk GDM management <ul><li>Low Risk: </li></ul><ul><li>If macrosomia or polyhydramnios on USS, refer to Diabetes ANC directly. </li></ul><ul><li>If USS normal, review by midwife for diet and lifestyle advice. CBS monitoring for 1 week and review by Diabetes Specialist Midwife. If CBS <5.5 fasting and <7.0 post-prandial, for repeat 1 week CBS monitoring at 33/40 and repeat growth scan at 36/40. </li></ul>
    20. 21. The Torbay Hospital Diabetes Antenatal Clinic <ul><li>Multi –disciplinary: </li></ul><ul><li>Diabetes in Pregnancy Specialist Nurse </li></ul><ul><li>Specialist Diabetes Dietician </li></ul><ul><li>Consultant Diabetologist (and/or SpR) </li></ul><ul><li>Diabetes Specialist Midwife </li></ul>
    21. 22. The Torbay Hospital Diabetes Antenatal Clinic <ul><li>CBS values and patterns are reviewed in association with dietary, especially carbohydrate intake. </li></ul><ul><li>Further patient education regarding the significance of monitoring blood sugars in pregnancy and the effect of dietary intake on CBS readings. </li></ul><ul><li>In some cases, a further week of monitoring with tight dietary control </li></ul><ul><li>Progression to Insulin treatment if CBS still high. </li></ul><ul><li>Patients may need a full basal Bolus type regime with TDS short-acting Novorapid and Insulatard nocte ab initio or insulin at certain times of the day to begin with. Insulin requirements gradually increase up to week 37/40, then decline. </li></ul><ul><li>For selected cases, Metformin or Glibenclamide are used. </li></ul><ul><li>The aims of the treatment are: </li></ul><ul><li>fasting values <5.5mmol/l </li></ul><ul><li>post-meal values <7.0mmol/l </li></ul>
    22. 23. The Torbay Hospital Diabetes Antenatal Clinic <ul><li>Intra-partum management plan is outlined in the multi-disciplinary “Diabetes in Pregnancy” notes by week 32/40. </li></ul><ul><li>For all DM1, DM2 and GDM patients on Insulin, Sliding-scale Insulin is usually started whilst in established labour and stopped post-vaginal delivery. </li></ul><ul><li>Sliding-scale Insulin may be continued for a short period of time in cases of C-Section. </li></ul><ul><li>Post-natal issues </li></ul><ul><li>Advice regarding GDM risk in future pregnancies, the importance of weight-control and screening prior to future planned pregnancies. Post-partum 6/52 FPG </li></ul>
    23. 24. REFERENCES <ul><li>ACHOIS Trial NEJM June 2005 Vol. 352 no 24, pp. 2477-2486 </li></ul><ul><li>HAPO Study NEJM May 2008 Vol. 358, no 19, pp. 1991-2003 </li></ul><ul><li>HAPO study associations with neonatal anthropometrics 2009 </li></ul><ul><li>CEMACH: adverse outcomes in pregnant women with type 1 and type 2 diabetes, 2002/3 and 2007 </li></ul><ul><li>IADPSG Consensus Panel statement 2008 </li></ul><ul><li>NICE guideline: Diabetes in Pregnancy March 2008 </li></ul><ul><li>South Devon Healthcare NHS Foundation Trust clinical guideline 0485: Diabetes in Pregnancy (reviewed 2009) </li></ul><ul><li>Effects of treatment in women with GDM: systematic review and meta-analysis BMJ April 2010 vol. 340: p. 796 </li></ul><ul><li>Medical Management of Diabetes in Pregnancy. Rob Dyer, Kath Williams, Jane Hogg and Sarah Thorne Torbay 2010 </li></ul>
    24. 25. <ul><li>Thank you! </li></ul>
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