Gestational Diabetes
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  • Excellent presentation. Very comprehensive from the physiological, epidemiological and clinical perspective. It translates the metabolic facets and the endocrine physiology into practical clinical management. It will help our medical community and practitioners very much. Thank you for sharing your expertise.
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  • Slide 1
  • Slide 3 Etiologic Classification of Diabetes Mellitus Diabetes mellitus is best described as a group of metabolic diseases character-ized by hyperglycemia. The hyperglycemia may be the result of defects in insulin secretion or insulin sensitivity, or both. Two major forms of diabetes are recognized in the most recent classification scheme, which was developed by The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, an international group, and has been adopted by both the American Diabetes Association and the World Health Organization. Type 1 diabetes includes almost all cases that are marked by destruction of the pancreatic islet  -cells. Type 2 diabetes includes those cases that result from insulin resistance accompanied by a defect in insulin secretion. Other specific forms of diabetes, which affect far fewer patients than the two major forms, include genetic defects of  -cell function, genetic defects in insulin sensitivity, diseases of the exocrine pancreas, endocrinopathies, drug- or chemical-induced infections, uncommon immune-mediated conditions, and other genetic conditions. Gestational diabetes mellitus is a fourth type in this new classification system. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus . Diabetes Care . 1997;20:1183-1197.
  • Slide 1
  • Slide 1
  • Slide 8 Diagnosed and Undiagnosed Diabetes in the US : Estimated Cases Among Adults, 1997 Using the data collected in the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994, and applying the new diagnostic criteria for diabetes (see Slides 4 and 5), estimates for the prevalence of diabetes (diagnosed and undiagnosed) were developed for the 1997 adult US population. It was estimated that 10.2 million adults (aged  20 years) had diagnosed diabetes (fasting plasma glucose [FPG]  126 mg/dL) and 5.4 million had undiagnosed diabetes (FPG  110 mg/dL and <126 mg/dL). Thus, in the US in 1997, approximately 35% of adults with diabetes had undiagnosed disease. Harris M, Flegal K, Cowie C, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. Diabetes Care . 1998;21:518-524.
  • Slide 4 Glucose Tolerance Categories Either the fasting plasma glucose (FPG) test or the 2-hour plasma glucose (PG) determination during the oral glucose tolerance test (OGTT) may be used to determine glucose tolerance status. According to the most recent diagnostic criteria established by The Expert Committee on the Diagnosis and Class-ification of Diabetes Mellitus, an FPG value  126 mg/dL (  7.0 mmol/L) or a 2-hour plasma glucose value  200 mg/dL (  11.1 mmol/L) are the new cutoff points for the diagnosis of diabetes. The cutoff points for the intermediate stage of hyperglycemia denoted by the terms impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) have been adjusted to conform to the new diagnostic criteria for diabetes mellitus. IFG is now defined by FPG  110 mg/dL (  6.1 mmol/L) and <11.1 mmol/L). The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care . 1997;20:1183-1197.

Gestational Diabetes Presentation Transcript

  • 1. CLINICAL MANAGEMENT OF DIABETES DURING PREGNANCY Antenatal, Intrapartum and Postpartum Perspectives Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates
  • 2. BACKGROUND: WHAT IS DIABETES?
    • A defect in body energy regulation and utilization
    • Causes:
      • Insulin deficiency
      • Insulin resistance
    • End result: Elevated blood sugar
    • Impact of elevated blood sugar:
      • Pregnancy complications
      • Multi-organ dysfunction
      • Excess mortality
  • 3. Epidemiology and Diagnosis
  • 4. Classification of Diabetes Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197. Genetic defects in b-cell function, Pancreatic disease, Endocrinopathies, Drug- or chemical- induced, and other rare forms Other types Insulin resistance with b-cell dysfunction Gestational Insulin resistance and relative insulin deficiency Type 2 b-cell destruction with lack of insulin Type 1
  • 5. INSULIN PHYSIOLOGY: REGULATION OF BLOOD SUGAR
  • 6. TYPE 1 DIABETES: INSULIN DEFICIENCY  - cell destruction with lack of insulin
  • 7. TYPE 2 DIABETES: INSULIN RESISTANCE Insulin Resistance
  • 8. GESTATIONAL DIABETES: INSULIN DEFICIENCY AND INSULIN RESISTANCE Insulin Resistance Insulin Deficiency
  • 9. Gestational Diabetes Screening
    • High risk
      • Marked obesity
      • Previous unexplained fetal demise
      • Personal history of GDM
      • Glucosuria
      • Strong family history of diabetes
    • Low risk
      • Age <25 years
      • Normal weight before pregnancy
      • Ethnicity with low prevalence
      • No known first degree relatives with diabetes
      • No history of abnormal glucose tolerance
      • No history of poor obstetric outcome
  • 10. Gestational Diabetes Screening
    • Universal screening is advisable
    • 1 hour 50 gm glucose load (GCT)‏
      • Venous plasma glucose cut-offs
        • 140 mg/dl
        • 135 mg/dl
        • 130 mg/dl
  • 11. SCREENING THRESHOLDS FOR GESTATIONAL DIABETES MELLITUS WITH THE 50-g ORALGLUCOSE-CHALLENGE TEST 90% 20-25% 130 80% 14-18% 140 SENSITIVITY PATIENTS SCREENING POSITIVE THRESHOLD
  • 12. Diagnosis of Gestational Diabetes
    • Three Hour 100 gm glucose tolerance test (GTT)‏
    • Not necessary if GCT is >200mg/dl on screening
    • Two abnormal values required for the diagnosis of gestational diabetes
    • Currently two diagnostic criteria acceptable
  • 13. Competing Criteria
    • NDDG, 1979
    • FBS 105
    • 1 hour 190
    • 2 hour 165
    • 3 hour 145
    • Carpentar and Coustan, 1982
    • FBS 95
    • 1 hour 180
    • 2 hour 155
    • 3 hour 140
  • 14. Diabetes Trends Among Adults in the U.S. Source: CDC, Behavioral Risk Factor Surveillance System. 1990 2000 1997-1998 No Data Less than 4% 4% to 6% Above 6%
  • 15.  
  • 16. Pathophysiology
  • 17. PRINCIPLE DANGERS
    • GESTATIONAL DIABETES:
      • Fetal hyperinsulinemia
    • PREGESTATIONAL DIABETES:
      • Fetal Anomalies
  • 18. Normal Glucose Regulation in Pregnancy
    • The pregnant patient has a tendency to develop HYPOGLYCEMIA between meals
      • Related to fetal demand
    • Placental steroids cause increased tissue insulin resistance
      • They are “DIABETOGENIC”
    • Insulin production INCREASES in normal pregnancy
      • By 30%
  • 19. RECALL: PATHOLOGIC CHANGES IN GDM Insulin Resistance Insulin Deficiency
  • 20. Effects of Hyperglycemia in GDM Fetal hyperglycemia fetal hyperinsulinemia abnormal fetal growth impaired fetal well-being
  • 21. Fetal Hyperinsulinemia
    • Promotes storage of excess nutrients
      • Net Effect: macrosomia
    • Increased catabolism of excess nutrients and increased energy usage
      • Net Effect: Decreased fetal oxygen storage and episodic fetal hypoxia
    • Episodic fetal hypoxia leads to increased catecholamines causing:
      • Fetal hypertension
      • Cardiac remodelling and hypertrophy
      • Increased erythropoietin, RBC’s, hematocrit
      • Poor fetal circulation and hyperbilirubinemia
      • Stillbirth (?)‏
  • 22. The Impact of Fetal Macrosomnia
    • Increased hyperbilirubinemia
    • Increased hypoglycemia
    • Increased acidosis
    • Increased birth trauma
    • Macrosomic children are more likely to develop glucose intolerance in adulthood
  • 23. Congenital Anomalies and Diabetic Control
    • Risk for Congenital Anomalies at various levels of Hemoglobin A1C
    • Critical periods - 3-6 weeks post conception
    • Importance of pre-conceptional metabolic care
  • 24. Congenital Anomalies with Pregestational Diabetes
    • Cardiac defects x18 8.5%
    • CNS defects x16 5.3%
        • Anencephaly x 13
        • Spina Bifida x 20
    • All Anomalies x 8 18.4%
    • Background major defects 3-4%
  • 25. Perinatal Risks for All Diabetic Pregnancies: Mortality/Morbidity
    • Miscarriage
    • IUGR
    • Macrosomia
    • Birth Injury
    • Stillbirth
  • 26. Neonatal Risks for All Diabetic Pregnancies: Morbidity and Mortality
    • Polycythemia and hyperviscosity
    • Neonatal hypoglycemia
    • Neonatal hypocalcemia
    • Hyperbilirubinemia
    • Hypertrophic and congestive cardiomyopathy
    • RDS
    • Childhood impaired glucose tolerance
  • 27. Maternal Complications
    • Chronic hypertension
    • Pre-eclampsia
    • Diabetic ketoacidosis
    • Maternal hypoglycemia
    • Maternal trauma
    • Higher C Section rate
    • Retinal disease/renal disease not affected significantly by pregnancy
  • 28. CARE FOR THE PATIENT WITH DIABETES
  • 29. Pre-Pregnancy Management
    • Preconceptional care
      • PRECONCEPTION CARE BEGINS AT THE END OF A PREGNANCY WITH GDM
      • Tight glucose control (HbA1c)‏
      • Assessment and treatment of associated medical problems
        • Hypertension,
        • Renal disease,
        • Retinal disease
        • Heart disease
      • Folic acid
      • Assessment of family, financial and personal resources to help achieve a successful pregnancy
  • 30. FIRST PERINATAL VISIT or UPON HOSPITALIZATION
    • Review routine prenatal lab tests
    • Baseline 24 hour urinalysis for protein and creatinine clearance
    • Baseline retinal exam - for Type 1 Diabetics
    • EKG - for Type 1 Diabetics
    • Thyroid function tests - for Type 1 Diabetics
    • Hemoglobin A1C
    • Fetal echocardiogram for pregestational diabetics
  • 31. Antepartum Gestational Diabetes Care
    • Dietary advice
    • Glucose monitoring (5 times per day)‏
    • Insulin therapy if necessary
      • Oral Hypoglycemic agents
    • Frequent visits to monitor glucose control
    • Ultrasound monitoring of fetal growth
    • Mode of Delivery:
      • Based on obstetric issues
    • Timing of Delivery:
      • Based on glucose control
  • 32. What is an ADA diet?
    • Avoidance of large meals with high percentage of simple carbohydrates
    • Three small meals with three snacks are preferred
    • Low glycemic index foods release calories from the gut slowly and improve metabolic control
    • Caloric content:
      • 35 calories/Kg Ideal body weight (or 15 calories/pound IBW)‏
      • No less than 1800 calories and no more than 2800 calories
      • “ Eyeball Technique”
        • Small patient 1800 calories
        • Medium patient 2200 calories
        • Large patient 2400 calorie
  • 33. What is a “Low” Glycemic Index
    • Glycemic Index (GI):
    • Compares equal quantities of carbohydrate in foods
    • Is a measure of the effect on blood glucose levels over a 2 hr period
    • Provides a measure of carbohydrate quality .
    • Expressed as a percentage
    Time GI = 30 GI = 100 BGL BGL
  • 34. ‘ Traditional’ starchy foods have a lower GI
    • Barley
    • Legumes/beans
    • Multigrain ‘Specialty’ breads
    • Mueslix
    • Porridge oats
    33 30’s 40’s 50’s 50’s Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
  • 35. “ Sugary” foods have a intermediate-low GI
    • Soft drinks
    • Flavoured milk (low fat)
    • Yogurt (sweetened)
    • Ice cream (low fat)
    60’s 34 30-40 50’s Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
  • 36. Modern starchy foods have a high GI
    • Potatoes
    • Cornflakes
    • Rice crispies
    • Wholegrain bread
    • Crackers
    • Rice (most types)‏
    85 77 85 70 81 83 Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
  • 37. HOME GLUCOSE MONITORING
    • Fasting and 2 hour post-prandial
    • Pre-meal values only if sliding scale short acting insulin coverage is used
    • Early AM value if hypoglycemia suspected
    • Assure that glucose meter is calibrated
  • 38. INDICATIONS FOR HOSPITALIZATION
    • Persistent nausea and vomiting
    • Significant maternal infection
    • DKA
    • Poor control/compliance
    • Preterm labor
  • 39. Intensive Inpatient Management: The APA Hybrid Protocol
    • For poorly controlled diabetic patients admitted for rapid control.
    • Empiric insulin with the patient’s current standing dose:
    • Targets adequate glycemic control
      • Fasting values: Less than 100 mg/dl
      • 2 hour postparandial values: Less than 120 mg/dl
      • Avoidance of hypoglycemia, ketonuria, and hyperglycemia
  • 40. Intensive Inpatient Management: The APA Hybrid Protocol
    • Begin 2200 to 2400 calorie ADA diet.
    • Obtain fingerstick every 2 hours for 12-24 hours
    • Administer HUMALOG INSULIN for sliding scale
    • Retake blood sugar at 2 hours after EACH sliding dose noted below and repeat sliding scale dose of insulin based on FSG.
    • Adjust Insulin after 24 hours
  • 41. Intensive Inpatient Management: The APA Hybrid Protocol 2 hours 14 Units 220-260 2 hours 16 Units >260 2 hours 12 Units 200-220 2 hours 10 Units 180-200 2 hours 6 Units 161-180 2 hours 4 Units 140-1600 4-6 hours Hold Humalog insulin < 140 Recheck Blood sugar Administer the following dosage of humalog insulin Blood sugar value
  • 42. Patient CH – Before Hybrid Approach Patient CH – After Hybrid Approach
  • 43. Intrapartum management
    • ABSOLUTE REQUIREMENTS:
      • Dextrose containing intravenous fluids
      • Insulin
    • Hourly glucose monitoring
    • Continuous fetal heart rate monitoring
    • Continuous tocodynametry
    • Manage labor as normal
  • 44. THE APA INSULIN DRIP PROTOCOL
    • INTRAVENOUS FLUID MAINLINE: D5W @ 125 cc/hr
    • INSULIN DRIP:
      • Initially Check Fingerstick every hour
      • MIX 100 Units Regular insulin in 500 cc NS (0.2 U/cc)‏
      • TITRATE INFUSION AS FOLLOWS:
    • After Fingerstick has been between 80-140 x >2 hours, decrease frequency of fingersticks to every 2 hours then every 4 hours.
    2.5 U/hr 12.5 cc/hr* FS> 220 2.0 U/hr 10 cc/hr* FS= 181-220 1.5 U/hr 7.5 cc/hr FS= 141-180 1.0 U/hr 5.0 cc/hr FS=101-140 0.5 U/hr 2.5 cc/hr FS= 80-100 0 U/hr Turn off drip FS= <80 Units per hour Drip Rate Fingerstick Value
  • 45. HYPOGLYCEMIA DURING AN INSULIN DRIP
    • For Glucose <60
      • Turn off Insulin drip for 30 minutes
      • Continue D5W (or D5LR) at 100 – 125 cc/hr
      • Recheck Glucose after 30 minutes
      • If blood glucose on recheck is still <60
        • Give 25 ml of D50 IV (or 10-12 grams glucose)
      • Recheck Blood Glucose every 30 minutes
        • Restart insulin when glucose >101 mg/dl
  • 46. INSULIN DRIP FOR THE INSULIN RESISTANT PATIENT
    • Method for poorly controlled, morbidly obese or noncompliant patients with gestational diabetes
    • 50% of total daily insulin dosage divided by 24 hours provides initial rate for insulin drip.
    • EXAMPLE:
      • Ms. Jones current insulin regimen
        • AM: 80units NPH 45 units Regular insulin
        • PM: 60 units NPH, 55 units Regular insulin
      • Total daily dosage= 240 units per day.
      • ½ of 240 units = 120 units
      • 120 units / 24 hours = 5 units per hour as initial dosage.
  • 47. Management - Postpartum
    • Use pre pregnancy insulin levels when on diet and monitor.
    • If GDM monitor sugars only
    • Immediate postpartum goal is fingerstick < 200
    • GDM – Repeat GTT at 6 weeks postpartum
    • GDM - long term risk of NIDDM
    • Contraception
  • 48. THANK YOU !
  • 49. EXTRA SLIDES
  • 50.  
  • 51. INSULIN SECRETION
    • Rising blood glucose levels.
    • After the uptake of glucose by the GLUT2 transporter there is
    • Glycolytic phosphorylation of glucose causing
    • A rise in the ATP:ADP ratio, which then
    • Inactivates the potassium channel that
    • Depolarizes the membrane, causing
    • Calcium channel to open up allowing calcium ions to flow inward. The rise in levels of calcium leads to the
    • Release of insulin from their storage granule.
    1 2 3 4 5 6 7 8
  • 52. INSULIN ACTION
    • Insulin-mediated glucose uptake begins when
    • Insulin binds to the insulin receptor and
    • Induces a signal transduction cascade which
    • Allows the glucose transporter (GLUT4) to transport glucose into the cell.
    1 2 3
  • 53. Diagnosed and Undiagnosed Diabetes in the US: Estimated Cases Among Adults, 1997 Data from Harris, et al. Diabetes Care. 1998;21:518-524. 0 2 4 6 8 10 12 Undiagnosed Diagnosed 10.2 5.4 Millions of Cases
  • 54. Glucose Tolerance Categories: NONPREGNANT Patients Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197. FPG 126 mg/dL 110 mg/dL Impaired Fasting Glucose Normal 2-Hour PG on OGTT 200 mg/dL 140 mg/dL Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus
  • 55. FOLIC ACID
    • All women of reproductive age should consume at least 0.4 mg of folic acid
    • High risk women should consume 4 mg/day
    • This reduces the risk of neural tube defects
    • Newer evidence suggests a lower risk of facial clefting and congenital heart disease as well