Clinical Practice Guideline: Gestational Diabetes

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Lecture at the 2010 Philippine Society of Endocrinology & Metabolism Annual Convention

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Clinical Practice Guideline: Gestational Diabetes

  1. 1. Clinical Practice Guideline Gestational Diabetes Iris Thiele Isip Tan MD, FPCP, FPSEM MS Health Informatics (cand.) Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital 18 March 2010
  2. 2. AACE A AD IDF CDA P DI HAPO GO NICE AS IADPSG Disclosure None ... Where guidelines disagreed, I picked the one I agreed with ☺
  3. 3. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Referred for rapid weight gain of 5 kg in the last 4 weeks Her mother has type 2 diabetes S c re e n fo r G DM?
  4. 4. There is not sufficient high-level evidence to make a recommendation for, or against, screening for GDM. US Preventive Services Task Force 2008 UK National Health Service 2002 Canadian Task Force on Periodic Health Examination 1994 “Screening, diagnosis and treatment of gestational diabetes is cost-effective.” UK National Institute for Health and Clinical Excellence 2008
  5. 5. No consensus on GDM screening Who? When? How?
  6. 6. International Association of Diabetes 1998 and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care Mar 2010; 33(3):676-82. cilitate Umbrella organization to fa collaboration “This report represents the opinions of individual members of the IADPSG Consensus Panel and does not necessarily reflect the position of the organizations they represent.”
  7. 7. Overt Dia be te s First prenatal visit in Preg na ncy Measure FPG, A1c or FPG >7 mmol/L A1c >6.5% random plasma glucose RPG >11.1 mmol/L in all or only on high-risk women IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682. If results not diagnostic of overt diabetes and FPG 5.1-6.9 mmol/L (92-125 mg/dL) → GDM FPG <5.1 mmol/L → 75-g OGTT at 24-28 wks AOG
  8. 8. 75-g OGTT thresholds FPG 5.1 mmol/L (92 mg/dL) 1-h PG 10.0 mmol/L (180 mg/dL) Be nefit o f e a r ly te s t ing? 2-h PG 8.5 mmol/L (153 mg/dL) IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682. 75-g OGTT at 24-28 wks Overt diabetes if FPG >7.0 mmol/L (126 mg/dL) GDM if one or more values equals or exceeds thresholds Normal if all values on OGTT less than thresholds
  9. 9. First prenatal visit Screen women at very high risk using standard* diagnostic testing. * FPG, HbA1c, 75-g OGTT or random plasma glucose ADA Standards of Medical Care 2010 Very high risk Severe obesity Prior history of GDM or delivery of LGA infant Presence of glycosuria Diagnosis of PCOS Strong family history of Type 2 diabetes
  10. 10. Greater than low risk women Test for GDM at 24-28 weeks AOG Low risk women No testing required ADA Standards of Medical Care 2010 Low risk (must fulfill all) Age < 25 years Weight normal before pregnancy Ethnic group with low DM prevalence No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetrical outcome
  11. 11. 1996 IADPSG ADA ASGODIP First 50-g GCT FPG, HbA1c or FPG, HbA1c, 75-g prenatal random plasma OGTT or random (low risk) or visit glucose plasma glucose 75-g OGTT (high risk) Further GCT ➝ 100-g OGTT If GCT <130 75-g OGTT if FPG testing <5.1 mmol/L 100-g OGTT (1-step) If 2-h OGTT 24-28 wks <140 100-g OGTT Thresholds FPG >7 mmol/L .0 FPG 95 mg/dL 75-g OGTT 2h Overt diabetes 1-h 180 mg/dL 140 mg/dL 75-g OGTT any value 2-h 155 mg/dL FPG 5.1 mmol/L (92 mg/dL) 3-h 140 mg/dL 1-h 10 mmol/L (180 mg/dL) at least 2 2-h 8.5 mmol/L (153 mg/dL)
  12. 12. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Referred for rapid weight gain of 5 kg in the last 4 weeks Her mother has type 2 diabetes FBS or 75-g OGTT?
  13. 13. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG 75- g OGT T: Fa stin g 102 ⤳ GDM 1 h PG 192 by FBS 2 h PG 155 criterion
  14. 14. Diet prescription in GDM? “Initiate MNT immediately once diagnosed.” AACE 2007
  15. 15. “All women with GDM should receive nutritional counseling by a registered dietitian when possible.” ADA GDM Position Statement 2004 Choose where possible CHO from low GI sources Lean proteins including oily fish Balance of poly- and monounsaturated fats NICE 2008
  16. 16. If pre-pregnancy BMI >27, restrict caloric intake to <25 kcal/kg/day ... ... and take moderate exercise (>30 min daily). NICE 2008 Obese women (BMI >30): 30-33% calorie restriction (to ~25 kcal/kg actual weight/day) Restrict CHO to 35-40% of calories. ion Statement 2004 ADA GDM Posit
  17. 17. Monitor urine ketones before breakfast to detect starvation ketonuria 3 meals and 3 snacks 50-60% complex high fiber carbohydrates 18-20% protein or at least 75 g <30% fats ASGODIP 1996
  18. 18. “Non-caloric sweeteners may be used in moderation.” ADA GDM Position Statement 2004
  19. 19. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Ht 165 cm Wt 90 kg TC R = 90 x 25 kc al/kg = 2250 kc al/day 3 me als an d 3 sna cks CH O (50%) 281 g CH ON (20%) 112 g fats (30%) rest Ur ine keton es at ff- up
  20. 20. Blood glucose monitoring? “SMBG is essential during pregnancy.” Canadian Diabetes Association 2008
  21. 21. “Daily SMBG appears to be superior to intermittent office monitoring of plasma glucose.” ADA GDM Position Statement 2004 “For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.” ADA GDM Position Statement 2004
  22. 22. Both preprandial and postprandial testing are recommended. If on insulin, test at night because of increased risk of nocturnal hypoglycemia. Canadian Diabetes Association 2008
  23. 23. Patients should intensively monitor BG AACE 2007 Insulin therapy Diet only Monitor BG 6x a day Monitor BG 4x a day (before each meal* and (prebreakfast and 1 h 1 h after the first bite of after the first bite of food food at each meal) at each meal) * to determine insulin dosage correction
  24. 24. “Urine glucose monitoring is not useful in GDM.” ADA GDM Position Statement 2004 “Urine ketone monitoring may be useful in detecting insufficient or caloric or CHO intake in women treated with caloric restriction.” ADA GDM Position Statement 2004
  25. 25. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM MNT started Monitor CBG 3x a day, alternate between - prebreakfast and 1 h after breakfast & lunch - 1 h after meals
  26. 26. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM After 2 weeks Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130- 150 mg/dL
  27. 27. How long can we wait before declaring diet therapy a failure?
  28. 28. Consider insulin when ... Diet and exercise fail to maintain glucose targets during a period of 1-2 weeks Ultrasound suggests incipient fetal macrosomia (AC >70th percentile) NICE 2008
  29. 29. Glucose targets Between 60 to 90 mg/dL (fasting) and less than 120 mg/dL (1 hour after the first bite of food at each meal) AACE 2007
  30. 30. “HbA1c should not be used routinely for assessing glycemic control in the second and third trimesters of pregnancy.” NICE 2008
  31. 31. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130-150 mg/dL Start insulin to bring down postprandial CBGs
  32. 32. Can we give Metformin in GDM? Ho w ab ou t Gli ben cla mide?
  33. 33. Off-label use Use of metformin or glibenclamide during pregnancy not an approved indication Discuss with patients Canadian Diabetes Association 2008
  34. 34. Option of giving metformin or glibenclamide Obtain and document informed consent. “... tailored to glycemic profile of, and acceptability to, the individual woman.” Me tfo rm in in Ges tat ion al Dia betes (M iG) Stu dy NICE 2008
  35. 35. Combination therapy MiG study Women taking metformin (who had insulin added) required lower insulin dose ? metformin + glibenclamide IDF 2009
  36. 36. Insulin remains the agent of choice “In poorly resourced areas of the world, the theoretical disadvantages of using oral glucose- lowering agents ... far less than the risks of non- treatment.” IDF 2009
  37. 37. Recommended insulin regimens? Prandial, basal bolus, split-mixed? Analogues?
  38. 38. Initiate a basal-bolus regimen if a patient cannot maintain glucose targets with diet alone. NPH insulin (basal) and rapid-acting insulin at meals Subcutaneous insulin infusion with an insulin pump AACE 2007
  39. 39. Insulin regimens in GDM Intermediate-acting insulin 30 min prebreakfast and presupper + rapid-acting insulin 3 injections of rapid-acting insulin given 30 min before each meal + intermediate- acting OR long-acting insulin at bedtime ASGODIP 1996
  40. 40. Insulin therapy in GDM Initiating dose depends on the blood glucose May start daily insulin dose 0.1-0.3 u/kg BW ASGODIP 1996
  41. 41. Which type of insulin and which regimen? Discuss with patient. “ ... rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy ...” NICE 2008
  42. 42. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM Ht 165 cm Wt 90 kg Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130-150 mg/dL Start prandial (regular) insulin i.e. 4-6 units premeals tid
  43. 43. How often to follow-up?
  44. 44. Subsequent Visits Every 2 weeks for Glycemic control: check 2-h PPBG Obstetric complications: macrosomia, IUGR, preeclampsia, and hydramnios ASGODIP 1996
  45. 45. Ultrasound At first visit to determine age of pregnancy At 20-22 wks to detect malformations At 32-34 wks to monitor growth ASGODIP 1996
  46. 46. Management during labor and delivery
  47. 47. Protocol for Spontaneous Delivery Infusion of 500 ml 5% dextrose/saline x 4 h CBG q 4h Give short-acting insulin for CBG >140 mg/dL - Dose equal to mmol of CBG i.e. 12 u for 12 mmol/L - Dose equal to 1/20th of mg/dL of CBG i.e. 12 u for 240 mg/dL Omit insulin for CBG <140 mg/dL ASGODIP 1996
  48. 48. Maternal hyperglycemia is the main cause of neonatal hypoglycemia Insulin is still required before active labor; SC or IV to maintain BG 70-90 mg/dL Infuse glucose 2.5 mg/kg/ min Measure CBG q hourly Double the glucose infusion for the next hour if BG <60 mg/dL Give regular insulin SC or IV for BG >120 mg/dL AACE 2007
  49. 49. After delivery Resume diet GDMs with high insulin requirements during pregnancy should have glucose profiles Give insulin if BG persistently high (>200 mg/dL) ASGODIP 1996
  50. 50. Postpartum follow-up
  51. 51. Reclassify at least 6 weeks after delivery Reassess q 3 years if normal BG postpartum Test for diabetes annually if with IFG or IGT postpartum ADA GDM Position Statement 2004
  52. 52. All patients with prior GDM should be educated re: lifestyle modifications Maintain normal body weight: MNT and physical activity Women with IFG or IGT postpartum: intensive MNT and individualized exercise program ADA GDM Position Statement 2004
  53. 53. Planning subsequent pregnancies Plan future pregnancies in consultation with health care provider Assess glucose tolerance prior to conception to assure normoglycemia at time of conception Canadian Diabetes Association 2008
  54. 54. “As always, solutions of an immediate problem raise questions for the future.” Robert G. Moses, MD
  55. 55. ht tp:/ w w. slide sh are.net/i sip ta n /w Thank You h ttp://www.endocrine-witch.info

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