DIABETES IN
     PREGNANCY
Iris Thiele Isip Tan MD, FPCP, FPSEM
            Clinical Associate Professor
              UP ...
Definitions




             Gestational   Pre-gestational
             diabetes      diabetes
Gestational Diabetes

Definitions


             Any degree of glucose
             intolerance with onset or first
        ...
Pre-gestational Diabetes

Definitions



             Diabetes diagnosed before
             pregnancy
Gestational Diabetes

  Screening and diagnosis
  Rationale for treatment
  Monitoring of blood glucose
  Diet and exercis...
Screening

              Risk factors for GDM
                Increasing maternal age and weight
                Previous ...
Screening


              Screen all pregnant women
              “... women with GDM without
              risk factors a...
Screening

              All women should undergo
              screening at first prenatal visit and
              after 2...
Screening


              50-g glucose             Oral glucose
              challenge test      tolerance test (OGTT)
  ...
75-g OGTT


CHO intake of at least 150 g/day 3 days prior
Fast for 10 to 16 hours
75 grams of anhydrous dextrose powder as...
75-g OGTT


Abstain from tobacco, coffee, tea, food and
alcohol during test

Sit upright and quietly during the test

Slow...
Diagnosis
              >130 mg/dL
              50-g glucose                  Oral glucose
              challenge test  ...
Rationale for treatment
                                      Increased risk for
                              macrosomic ...
Rationale for treatment
                                                Increased risk for
                               ...
Monitoring blood glucose
              Self-monitor blood glucose levels
              both fasting and postprandial,
    ...
Monitoring blood glucose

            5th Int’l Workshop                  NICE                                CDA
        ...
Monitoring blood glucose
              Measure HbA1c in women with
              gestational diabetes who may
            ...
Dietary Management




  Determine if patient is overweight
  Expected pregnant weight =
  ideal body weight (for height) ...
IOM recommendations for weight
gain by pre-pregnancy BMI
                          2009
                                  ...
Dietary Management

Recommended Daily Caloric Intake
 Pregravid BMI Category                      kcal/kg/day
Low (BMI <18...
Dietary Management


                      For considerably overweight
                      women with GDM, reduce energy...
Dietary Management

  3 meals and 3 snacks
  50-60% complex high fiber CHO
  18-20% CHON or at least 75 g
  <30% fats
Dietary Management
Avoid concentrated sweets
No cookies, cakes, pies, soft
drinks, chocolate, table sugar,
fruit juice, ju...
Dietary Management


            Eat small frequent meals
            Eat about every 3 hours
            Include a good s...
Dietary Management


            Eat a very small breakfast
            No more than 1 starch exchange
            (<15 g ...
Dietary Management




            Choose high-fiber foods
            Fresh and frozen vegetables
            Beans and le...
Dietary Management


        Free foods - eat as desired
        cabbage             mushrooms celery
        radish      ...
Dietary Management


                    Monitor urine ketones before
                    breakfast to detect starvation
 ...
Exercise

                  ACOG (expert opinion)
                  minimum of 30 minutes exercise
                  on mo...
Insulin Initiation
                      ADA Protocol
                      Fasting whole BG >95 mg/dL
                   ...
Insulin Initiation

                       Diet therapy alone for at least
                       2 weeks before starting ...
Insulin Regimens

                        Human insulin
                        Insulin analogues




Insulin lispro and a...
Insulin Regimens

ASGODIP Protocol
Intermediate-acting insulin 30 min prebreakfast
Intermediate-acting insulin 30 min pres...
Subsequent visits

Date
                            ASGODIP Protocol
time     CBG   Comments

11/20
                      ...
Maternal
                               surveillance

              Increased frequency of preterm
              birth in ...
Fetal surveillance

                              ASGODIP Protocol
                              Ultrasound at first visit ...
Glycemic control during
                    labor and delivery


ASGODIP Protocol
Infusion of 500 ml 5% dextrose/saline x ...
Glycemic control during
                      labor and delivery


ASGODIP Protocol
After delivery, resume diet
Generally ...
Postpartum
                                           follow-up


Schedule 75-g OGTT after 6 weeks
60-70% chance of develo...
Postpartum
                                   follow-up

     Annual follow-up
     Measure FBS
     Assess weight reducti...
Pre-gestational diabetes

       Preconception care
       Monitoring of blood glucose
       Hypoglycemia
       Special ...
Preconception Care
    Contraceptive advice
    Risks of pregnancy (maternal and
    fetal/neonatal)
    Importance of mai...
Preconception Care
    Prepregnancy Assessment
    History and PE
    Gynecologic evaluation
    Lab evaluation
       HbA...
Preconception Care
Potential Contraindications to Pregnancy
Ischemic heart diease
Active proliferative retinopathy, untrea...
Preconception Care

Shift Type 2 diabetics on OHA to insulin
Maternal HbA1c to assess risk of malformations
 Goal <1% abov...
Monitoring blood glucose


                  No data to suggest that
                  postprandial monitoring has a
     ...
Monitoring blood glucose

                       Self-monitored blood glucose
                       Fasting/overnight/pre...
Hypoglycemia



Attempts to achieve normoglycemia in type 1
DM increase risk of hypoglycemia (DCCT)
 No evidence that hypo...
Diabetic Retinopathy

May accelerate during pregnancy
 Gradual attainment of good metabolic
 control before conception
 Pr...
Diabetic Retinopathy

    Risk factors for progression
    Duration of diabetes
    Retinal status
    Elevated HbA1c
    ...
Hypertension


Type 1 diabetics frequently develop
hypertension in association with
diabetic nephropathy
Type 2 diabetics ...
Hypertension

                 Aggressive monitoring and control to
                 reduce risk of worsening
            ...
Diabetic Nephropathy

 Baseline assessment of renal
 function before conception and
 followed at regular intervals
   urin...
Diabetic Nephropathy


Permanent worsening of renal function
in >40% of women with incipient renal
failure (serum crea > 3...
Diabetic Nephropathy
Proteinuria >190 mg/24 h before or
during early pregnancy triples risk of
hypertensive disorders in s...
Neuropathy

Autonomic neuropathy may complicate
management
   gastroparesis
   urinary retention
   hypoglycemic unawarene...
Cardiovascular disease


 Untreated CAD is associated with a
 high mortality rate
  Successful pregnancies after coronary
...
Key Points

              Screen all pregnant Filipino
              women
              Be aware of the limitations of
  ...
Key Points

                  Counsel diabetic women of
                  child-bearing potential on
                  con...
Key Points

                  Advise regarding possible
                  worsening of diabetic
                  complica...
Thank You
http://www.endocrine-witch.info
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Diabetes in Pregnancy

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Lecture for incoming first year residents of the Department of Medicine, Philippine General Hospital

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Diabetes in Pregnancy

  1. 1. DIABETES IN PREGNANCY Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital
  2. 2. Definitions Gestational Pre-gestational diabetes diabetes
  3. 3. Gestational Diabetes Definitions Any degree of glucose intolerance with onset or first recognition during pregnancy Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop- Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1– B167, 1998
  4. 4. Pre-gestational Diabetes Definitions Diabetes diagnosed before pregnancy
  5. 5. Gestational Diabetes Screening and diagnosis Rationale for treatment Monitoring of blood glucose Diet and exercise Insulin initiation and follow-up Maternal and fetal surveillance Labor and delivery Postpartum follow-up
  6. 6. Screening Risk factors for GDM Increasing maternal age and weight Previous GDM Previous macrosomic infant Family history of diabetes among first-degree relatives Gestational diabetes Ethnic background with a high prevalence of diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  7. 7. Screening Screen all pregnant women “... women with GDM without risk factors appear to be no different from women with GDM Gestational and risk factors.” diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  8. 8. Screening All women should undergo screening at first prenatal visit and after 26th week AOG if negative on previous testing Gestational diabetes AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996
  9. 9. Screening 50-g glucose Oral glucose challenge test tolerance test (OGTT) (GCT) 75-g or 100 g? Gestational “A one-stage definitive diabetes procedure is preferred.” International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  10. 10. 75-g OGTT CHO intake of at least 150 g/day 3 days prior Fast for 10 to 16 hours 75 grams of anhydrous dextrose powder as chilled 25% solution (400 cc) flavored with calamansi Drink within 5 minutes (first swallow is time zero) Terminate test should nausea and vomiting occur Collect samples at 0, 1 and 2 hours
  11. 11. 75-g OGTT Abstain from tobacco, coffee, tea, food and alcohol during test Sit upright and quietly during the test Slow walking is permitted but avoid vigorous exercise
  12. 12. Diagnosis >130 mg/dL 50-g glucose Oral glucose challenge test tolerance test (OGTT) (GCT) 75-g or 100 g? Thresholds ADA ASGODIP for diagnosis 100-g 75-g 75-g Gestational FBS 95 95 - diabetes 1h 180 180 - 2h 155 155 140 3h 140 - -
  13. 13. Rationale for treatment Increased risk for macrosomic or LGA infants GDM Normal 100 75 Gestational 50 % diabetes 25 0 MMC VMMC PoGH CSMC PGH AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996 Isip-Tan unpublished data
  14. 14. Rationale for treatment Increased risk for Cesarean sections GDM Normal 100 80 Gestational diabetes 60 % 40 20 MMC VMMC PoGH PGH AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996 Isip-Tan unpublished data
  15. 15. Monitoring blood glucose Self-monitor blood glucose levels both fasting and postprandial, preferably 1 h after a meal. Gestational diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  16. 16. Monitoring blood glucose 5th Int’l Workshop NICE CDA 90-99 mg/dL 63-106 mg/dL 68-94 mg/dL Fasting (5.0-5.5 mmol/L) (3.5-5.9 mmol/L) (3.8-5.2 mmol/L) 1 h after <140 mg/dL <140 mg/dL 99-139 mg/dL meal (<7.8 mmol/L) (<7.8 mmol/L) (5.5-7.7 mmol/L) 2 h after <120-127 mg/dL 90-119 mg/dL meal (<6.7-7.1 mmol/L) (5.0-6.6 mmol/L) Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007) National Institute for Health & Clinical Excellence (2008) Canadian Diabetes Association (2008)
  17. 17. Monitoring blood glucose Measure HbA1c in women with gestational diabetes who may have developed type 2 diabetes while pregnant Gestational diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  18. 18. Dietary Management Determine if patient is overweight Expected pregnant weight = ideal body weight (for height) + expected weight gain/trimester
  19. 19. IOM recommendations for weight gain by pre-pregnancy BMI 2009 Rates of weight gain* Total weight Prepregnancy BMI 2nd and 3rd trimester gain (lbs) (lbs/week) Underweight 1 <28-40 BMI <18.5 (1-1.3) Normal weight 1 25-35 BMI 18.5-24.9 (0.8-1) Overweight 0.6 15-25 BMI 25.0-29.9 (0.5-0.7) Obese 0.5 11-20 BMI >30.0 (0.4-0.6) * Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
  20. 20. Dietary Management Recommended Daily Caloric Intake Pregravid BMI Category kcal/kg/day Low (BMI <18.5 kg/m2) 36-40 Normal (BMI 18.5-24.9 kg/m2) 30 High (BMI 25-29.9 kg/m2) 24 Obese (BMI >29.9 kg/m2) 12 Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  21. 21. Dietary Management For considerably overweight women with GDM, reduce energy intake by no more than 30% of habitual intake Total cal/day = 1,800-2,000 Not less than 2,000 cal/day if multiple pregnancy International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  22. 22. Dietary Management 3 meals and 3 snacks 50-60% complex high fiber CHO 18-20% CHON or at least 75 g <30% fats
  23. 23. Dietary Management Avoid concentrated sweets No cookies, cakes, pies, soft drinks, chocolate, table sugar, fruit juice, juice drinks, Kool-Aid, Hi-C, nectars, jams or jellies Avoid convenience foods No instant noodles, canned soups, instant potatoes, frozen meals or packaged stuffing Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  24. 24. Dietary Management Eat small frequent meals Eat about every 3 hours Include a good source of protein at every meal and snack (i.e. low- fat meat, chicken, fish, low-fat cheese, nuts, peanut butter, cottage cheese, eggs and turkey) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  25. 25. Dietary Management Eat a very small breakfast No more than 1 starch exchange (<15 g CHO so limit cereal, bread, pancakes, toast, bagels, muffins and Danishes and no fruit or juice Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  26. 26. Dietary Management Choose high-fiber foods Fresh and frozen vegetables Beans and legumes Fresh fruits (except at breakfast) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  27. 27. Dietary Management Free foods - eat as desired cabbage mushrooms celery radish cucumber zucchini lettuce green beans spinach onion green onion garlic broccoli asparagus nopales spinach lemon/lime butter olives sour cream avocado olive oil Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  28. 28. Dietary Management Monitor urine ketones before breakfast to detect starvation ketonuria Individualize! Monitor blood glucose levels, urine ketones, appetite and weight gain
  29. 29. Exercise ACOG (expert opinion) minimum of 30 minutes exercise on most days of the week for a normal pregnancy Exercise is a useful adjunct to treatment Avoid excessive abdominal muscle contraction International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  30. 30. Insulin Initiation ADA Protocol Fasting whole BG >95 mg/dL 1-h postprandial whole BG >140 mg/dL 2-h postprandial whole BG >120 mg/dL Dr. Jovanovic Fasting plasma glucose >90 mg/dL (5 mmol/L) 1-h postprandial whole BG >120 mg/dL (6.7 mmol/L) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  31. 31. Insulin Initiation Diet therapy alone for at least 2 weeks before starting insulin If fasting glucose (on OGTT) >95 mg/dL, start insulin after 1 week of dietary therapy or at diagnosis
  32. 32. Insulin Regimens Human insulin Insulin analogues Insulin lispro and aspart safe and effective Limited experience with insulin glargine and detemir
  33. 33. Insulin Regimens ASGODIP Protocol Intermediate-acting insulin 30 min prebreakfast Intermediate-acting insulin 30 min presupper + rapid- acting insulin Three injections of rapid-acting insulin given 30 minutes before each meal + intermediate-acting OR long-acting insulin at bedtime Initiating dose depending or start on a daily dose of 0.1 to 0.3 u/kg BW.
  34. 34. Subsequent visits Date ASGODIP Protocol time CBG Comments 11/20 Every 2 weeks to check glycemic control after 160 pancakes breakfast WOF obstetric complications after 148 spaghetti (i.e. macrosomia, IUGR, lunch preeclampsia and hydramnios) after 118 dinner
  35. 35. Maternal surveillance Increased frequency of preterm birth in untreated GDM Use of corticosteroids not contraindicated but intensify glucose monitoring and adjust insulin Risk of hypertensive disorders increased Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  36. 36. Fetal surveillance ASGODIP Protocol Ultrasound at first visit to determine age of pregnancy At 20-22 weeks to detect malformations At 32-34 weeks to monitor growth HbA1c values >7.0% or fasting plasma glucose >120 mg/dL (6.7 mmol/L) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  37. 37. Glycemic control during labor and delivery ASGODIP Protocol Infusion of 500 ml 5% dextrose/saline x 4 h CBG q 4 h Short-acting insulin for CBG > 140 mg% Dose equal to mmol of CBG i.e. 12 u for 12 mmol/L Dose equal to 1/20th of mg/dL CBG i.e. 12 u for 240 mg/dL Omit insulin for CBG < 140 mg/dL
  38. 38. Glycemic control during labor and delivery ASGODIP Protocol After delivery, resume diet Generally do not require insulin GDM with high insulin requirements during pregnancy should have CBG monitoring Give insulin only if CBGs persistently high (>200 mg/dL)
  39. 39. Postpartum follow-up Schedule 75-g OGTT after 6 weeks 60-70% chance of developing GDM in subsequent pregnancies 40-60% chance of developing type 2 diabetes in the future Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  40. 40. Postpartum follow-up Annual follow-up Measure FBS Assess weight reduction Review pregnancy plans Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  41. 41. Pre-gestational diabetes Preconception care Monitoring of blood glucose Hypoglycemia Special considerations
  42. 42. Preconception Care Contraceptive advice Risks of pregnancy (maternal and fetal/neonatal) Importance of maintaining blood glucose levels Genetic counseling Personal commitment by women and her family Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  43. 43. Preconception Care Prepregnancy Assessment History and PE Gynecologic evaluation Lab evaluation HbA1c, urinalysis and culture, 24-h urine for Crea Cl and CHON Thyroid panel: FT4 1.0-1.6 and TSH <2.5 uU/L ECG or treadmill Neuropathy testing if indicated Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  44. 44. Preconception Care Potential Contraindications to Pregnancy Ischemic heart diease Active proliferative retinopathy, untreated Renal insufficiency Crea Cl <50 ml/min or serum crea >2 mg/dL or heavy proteinuria (>2 g/24 h) or hypertension (BP >130/80 mm Hg despite treatment) Severe gastroenteropathy Nausea/vomiting, diarrhea Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  45. 45. Preconception Care Shift Type 2 diabetics on OHA to insulin Maternal HbA1c to assess risk of malformations Goal <1% above normal range, lower if possible Monitor every 1 to 2 months Discontinue contraception Stable glycemic control Maternal diabetic complications and coexisting medical problems acceptable Diabetes Care 26:S91-93, 2003
  46. 46. Monitoring blood glucose No data to suggest that postprandial monitoring has a specific role beyond what is needed to achieve HbA1c Pre-gestational diabetes Diabetes Care 26:S91-93, 2003
  47. 47. Monitoring blood glucose Self-monitored blood glucose Fasting/overnight/premeal plasma glucose 60-99 mg/dL 1-h postmeal 100-129 mg/dL A1c at initial visit Monthly until A1c <6.2% achieved then q2-4 months Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  48. 48. Hypoglycemia Attempts to achieve normoglycemia in type 1 DM increase risk of hypoglycemia (DCCT) No evidence that hypoglycemia is an independent risk to the developing embryo Clear risk to the mother Diabetes Care 26:S91-93, 2003
  49. 49. Diabetic Retinopathy May accelerate during pregnancy Gradual attainment of good metabolic control before conception Preconception laser photocoagulation with standard indications Baseline dilated comprehensive eye examination Follow up eye exam during pregnancy Diabetes Care 26:S91-93, 2003
  50. 50. Diabetic Retinopathy Risk factors for progression Duration of diabetes Retinal status Elevated HbA1c Hypertension Valsalva maneuver (increases risk of retinal hemorrhage) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  51. 51. Hypertension Type 1 diabetics frequently develop hypertension in association with diabetic nephropathy Type 2 diabetics commonly have coexisting hypertension Pregnancy-induced hypertension proteinuria in excess of 190 mg/day before conception or in early pregnancy Diabetes Care 26:S91-93, 2003
  52. 52. Hypertension Aggressive monitoring and control to reduce risk of worsening nephropathy, development of retinopathy or clinical atherosclerosis SBP <130 mm Hg Avoid ACE-inhibitors, ARBs, beta- DBP <80 mm Hg blockers and diuretics in women contemplating pregnancy Diabetes Care 26:S91-93, 2003
  53. 53. Diabetic Nephropathy Baseline assessment of renal function before conception and followed at regular intervals urine albumin-to-creatinine ratio 24 h albumin excretion Diabetes Care 26:S91-93, 2003
  54. 54. Diabetic Nephropathy Permanent worsening of renal function in >40% of women with incipient renal failure (serum crea > 3 mg/dL or crea clearance < 50 mL/min) Permanent worsening of renal function does not occur more often in women with less severe nephropathy Diabetes Care 26:S91-93, 2003
  55. 55. Diabetic Nephropathy Proteinuria >190 mg/24 h before or during early pregnancy triples risk of hypertensive disorders in second half of pregnancy Risk of IUGR during later pregnancy if protein excretion > 400 mg/24 h Discontinue ACE inhibitors in women attempting pregnancy who have microalbuminuria Diabetes Care 26:S91-93, 2003
  56. 56. Neuropathy Autonomic neuropathy may complicate management gastroparesis urinary retention hypoglycemic unawareness orthostatic hypotension Peripheral neuropathy especially compartment syndromes i.e. carpal tunnel syndrome may be exacerbated Diabetes Care 26:S91-93, 2003
  57. 57. Cardiovascular disease Untreated CAD is associated with a high mortality rate Successful pregnancies after coronary revascularization in women with diabetes Normal exercise tolerance to maximize probability that patient will tolerate increased cardiovascular demands of gestation Diabetes Care 26:S91-93, 2003
  58. 58. Key Points Screen all pregnant Filipino women Be aware of the limitations of self-monitored blood glucose Do not wait too long to shift to insulin if diet therapy fails Gestational Ensure postpartum OGTT diabetes
  59. 59. Key Points Counsel diabetic women of child-bearing potential on contraception and risks of unplanned pregnancy with poor metabolic control Shift to insulin Pre-gestational Aim for A1c <1% above normal diabetes or better
  60. 60. Key Points Advise regarding possible worsening of diabetic complications during pregnancy Discontinue ACE-inhibitors in albuminuric women attempting pregnancy Pre-gestational diabetes
  61. 61. Thank You http://www.endocrine-witch.info
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