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 <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 <5.8 and 2-hour glucose <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.

Transcript

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