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Gestational diabetes Q & A

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Screening and management of gestational diabetes

Screening and management of gestational diabetes

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  • 1. 2 Mar 2012 GESTATIONAL DIABETES MANAGEMENT Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Clinical Associate Professor, UP College of MedicineWednesday, November 21, 12
  • 2. Q1 Which of the following women will you screen for gestational diabetes? a) 25 y.o. G1P0 whose mother has diabetes b) 38 y.o. G3P0 with recurrent first- trimester abortions c) 27 y.o. G2P1 d) All of the aboveWednesday, November 21, 12
  • 3. Unite for Diabetes CPG 2010 All pregnant women should be screened for GDM.Wednesday, November 21, 12
  • 4. Risky Filipino women are at increased risk for diabetes in pregnancy. ASGODIP Data n/N Low risk 35/853 High risk 136/350 171/1203 Overall 14.2% Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy: Preliminary Data on Prevalence. PJIM 1996:34:67-68.Wednesday, November 21, 12
  • 5. Risky Macrosomia Shoulder Dystocia Increased risk of perinatal morbidity Birth injuries Hypoglycemia http://www.flickr.com/photos/mikewade/3267336862/ http://www.flickr.com/photos/jessicafm/280232106/ http://www.flickr.com/photos/clairity/1385780317/ http://www.flickr.com/photos/tessawatson/379265818/Wednesday, November 21, 12
  • 6. Risky Cesearean Section Preeclampsia Increased risk of maternal morbidity Pregnancy-induced hypertension Type 2 diabetes mellitus http://www.flickr.com/photos/ulybug/512369383/ http://www.flickr.com/photos/j2dread/4501366303/ http://www.flickr.com/photos/78428166@N00/4921825364/Wednesday, November 21, 12
  • 7. International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes “... women with GDM without risk factors appear to be no different from women with GDM and risk factors.”Wednesday, November 21, 12
  • 8. Q1 Which of the following women will you screen for gestational diabetes? a) 25 y.o. G1P0 whose mother has diabetes b) 38 y.o. G3P0 with recurrent first- trimester abortions c) 27 y.o. G2P1 d) All of the aboveWednesday, November 21, 12
  • 9. Q2 Which of the following factors best predict risk of GDM? a) prior history of GDM b) glucosuria c) family history of diabetes d) prior macrosomic babyWednesday, November 21, 12
  • 10. Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3 Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4) Family history of diabetes (OR 7.1 [95%CI 5.6, 8.9]1; OR 2.74 [95%CI 1.47, 5.11]3) Prior macrosomic baby (OR 5.59 [95%CI 2.68, 11.7])3 Age >25 years old (OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37 [95%CI 1.45, 7.85]3) Risk Factors for GDM UNITE CPGWednesday, November 21, 12
  • 11. Diagnosis of polycystic ovary syndrome (OR 2.89 [95%CI 1.68, 4.98])5 Overweight or obese before pregnancy (BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/ m2 OR 2.65 [95%CI 1.36, 5.14]3 Macrosomia in current pregnancy (PPV 40% 4) Polyhydramnios in current pregancy (PPV 40% 4) Intake of drugs affecting carbohydrate metabolism Risk Factors for GDM UNITE CPGWednesday, November 21, 12
  • 12. Q2 Which of the following factors best predict risk of GDM? a) prior history of GDM b) glucosuria c) family history of diabetes d) prior macrosomic babyWednesday, November 21, 12
  • 13. Q3 For pregnant women, when should testing be done? a) Test high-risk women at the soonest possible time b) Women without risk factors should be tested between 24-28 wks AOG c) Testing for gestational diabetes should still be carried out in women at risk even beyond 24-28 wks AOG d) All of the aboveWednesday, November 21, 12
  • 14. ASGODIP (Veterans Memorial Medical Center) AOG tested % 21-30 31-40 <20 weeks weeks weeks n=19 n = 74 n = 60 Negative 95 92 85 for GDM Positive 5 8 15 for GDM Bihasa MTG et al. Screening for gestational diabetes: Report from ASGODIP participating hospital: Veterans Memorial Medical Center. PJIM 1996:34:57-61. TestingWednesday, November 21, 12
  • 15. Q3 For pregnant women, when should testing be done? a) Test high-risk women at the soonest possible time b) Women without risk factors should be tested between 24-28 wks AOG c) Testing for gestational diabetes should still be carried out in women at risk even beyond 24-28 wks AOG d) All of the aboveWednesday, November 21, 12
  • 16. Q4 Which test should be used to screen for GDM? a) 75-g OGTT b) 100-g OGTT c) 50-g GCT d) FBSWednesday, November 21, 12
  • 17. ★ Capillary blood glucose ★ RBS ★ Fructosamine ★ FBS ★ Hba1c ★ Urine glucose NOT to be used for diagnosis of GDM Use OGTTWednesday, November 21, 12
  • 18. One- step 50-g glucose Oral glucose challenge tolerance test (OGTT) test (GCT) 75-g or 100 g “A one-stage definitive procedure is preferred.” International Diabetes Federation (2009) Global Guideline on Pregnancy & DiabetesWednesday, November 21, 12
  • 19. OGTT 100-g OGTT high glucose load often unpalatable 100-g OGTT duration 75-g OGTT 100-g more 3 hours international cumbersome; standard in 4 blood non-pregnant samplesWednesday, November 21, 12
  • 20. CPG Philippine Diabetes CPG has endorsed the use of the 75-g OGTT.Wednesday, November 21, 12
  • 21. Q4 Which test should be used to screen for GDM? a) 75-g OGTT b) 100-g OGTT c) 50-g GCT d) FBSWednesday, November 21, 12
  • 22. Q5 Which of the following is true of the OGTT procedure? a) Low CHO intake for past 3 days b) Fast for 10 to 16 h c) Slow walking is not permitted d) Supine position during testWednesday, November 21, 12
  • 23. 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 OGTTWednesday, November 21, 12
  • 24. 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 OGTTWednesday, November 21, 12
  • 25. Q5 Which of the following is true of the OGTT procedure? a) Low CHO intake for past 3 days b) Fast for 10 to 16 h c) Slow walking is not permitted d) Supine position during testWednesday, November 21, 12
  • 26. Q6 Which of the following results is/are consistent with GDM? a) 75-g OGTT: FBS 90 1h 190 2h 150 b) 75-g OGTT: FBS 98 1h 190 2h 150 c) 100-g OGTT: FBS 98 1h 190 2h 150 3h 140 d) All of the aboveWednesday, November 21, 12
  • 27. CPG Thresholds ADA IADPSG for diagnosis 100-g 75-g 75-g* FBS 95 95 92 1h 180 180 180 2h 155 155 153 3h 140 - - * Requires only 1 threshold value exceededWednesday, November 21, 12
  • 28. Q6 Which of the following results is/are consistent with GDM? IADPSG a) 75-g OGTT: FBS 90 1h 190 2h 150 ADA b) 75-g OGTT: FBS 98 1h 190 2h 150 c) 100-g OGTT: FBS 98 1h 190 2h 150 3h 140 ADA d) All of the aboveWednesday, November 21, 12
  • 29. CPG Thresholds ADA IADPSG for diagnosis 100-g 75-g 75-g* FBS 95 95 92 1h 180 180 180 2h 155 155 153 3h 140 - - * Requires only 1 threshold value exceededWednesday, November 21, 12
  • 30. OGTT ACOG recommends against IADPSG consensus Diagnosis of GDM based on the 1-step screening and diagnosis test outlined in the IADPSG guidelines is not recommended at this time because there is no evidence that diagnosis using these criteria leads to clinically significant improvement in maternal or newborn outcomes, and it would lead to a significant increase in healthcare costs. ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3Wednesday, November 21, 12
  • 31. Q7 Which of the following is TRUE of dietary management for GDM? a) Do NOT prescribe less than 1500 cal/day for multiple pregnancy b) For overweight women, reduce energy intake by no more than 30% of habitual intake c) Monitor urine ketones at bedtime to detect starvation ketonuria d) Non-caloric sweeteners are NOT allowed.Wednesday, November 21, 12
  • 32. Diet 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)Wednesday, November 21, 12
  • 33. Diet 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 DiabetesWednesday, November 21, 12
  • 34. “Non-c aloric sweeteners may be used in moderation.” ADA GDM Position Statement 2004Wednesday, November 21, 12
  • 35. Q7 Which of the following is TRUE of dietary management for GDM? a) Do NOT prescribe less than 1500 cal/day for multiple pregnancy b) For overweight women, reduce energy intake by no more than 30% of habitual intake c) Monitor urine ketones at bedtime to detect starvation ketonuria d) Non-caloric sweeteners are NOT allowed.Wednesday, November 21, 12
  • 36. Q8 For a woman with normal BMI, what is the allowed weight gain in pregnancy? a) <28-40 lbs b) 25-35 lbs c) 15-25 lbs d) 11-20 lbsWednesday, November 21, 12
  • 37. Weight gain during pregnancy 12.5 kg British cohort of >3800 primigravidae eating without restriction Product of conception Fetus, placenta, amniotic fluid Maternal tissue expansion Uterus, breasts, blood volume Maternal fat reserve TextWednesday, November 21, 12
  • 38. Rates of weight gain* Prepregnancy Total weight 2nd and 3rd BMI gain (lbs) trimester (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 IOMWednesday, November 21, 12
  • 39. Q8 For a woman with normal BMI, what is the allowed weight gain in pregnancy? a) <28-40 lbs b) 25-35 lbs c) 15-25 lbs d) 11-20 lbsWednesday, November 21, 12
  • 40. Q9 Which of the following is TRUE of self-monitoring of blood glucose? a) For women on dietary intervention alone, monitor BG 6x a day. b) For women treated with insulin, postprandial monitoring is superior to pre-prandial. c) If on insulin, test BG before breakfast to detect hypoglycemia. d) Daily SMBG does not appear to be superior to intermittent office monitoring.Wednesday, November 21, 12
  • 41. “For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.” ADA GDM Position Statement 2004Wednesday, November 21, 12
  • 42. Diet only Monitor BG 4x a day (prebreakfast and 1 h after the first bite of food at each meal) AACE 2007Wednesday, November 21, 12
  • 43. Q9 Which of the following is TRUE of self-monitoring of blood glucose? a) For women on dietary intervention alone, monitor BG 6x a day. 3x a day b) For women treated with insulin, postprandial monitoring is superior to pre-prandial. c) If on insulin, test BG before breakfast to detect hypoglycemia. Test at night d) Daily SMBG does not appear to be superior to intermittent office monitoring.Wednesday, November 21, 12
  • 44. Q10 What are the targets for SMBG? a) Between 60 to 90 mg/dL for fasting and less than 120 mg/dL 1 hour after the first bite of food at each meal (postprandial) b) Not more than 95 mg/dL for fasting and less than 120 mg/dL 2 hours postprandial c) 90 mg/dL for fasting and less than 140 mg/dL 2 hours postprandial d) None of the aboveWednesday, November 21, 12
  • 45. 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 2007Wednesday, November 21, 12
  • 46. Q10 What are the targets for SMBG? a) Between 60 to 90 mg/dL for fasting and less than 120 mg/dL 1 hour after the first bite of food at each meal (postprandial) b) Not more than 95 mg/dL for fasting and less than 120 mg/dL 2 hours postprandial c) 90 mg/dL for fasting and less than 140 mg/dL 2 hours postprandial d) None of the aboveWednesday, November 21, 12
  • 47. Q11 Can we give Metformin for GDM? a) Yes b) NoWednesday, November 21, 12
  • 48. ★ Use of Metformin or glibenclamide during pregnancy NOT an approved indication ★ Discuss with patients ★ Obtain and document informed consent. Canadian Diabetes Association 2008 METFORMIN: Off-label use OHAWednesday, November 21, 12
  • 49. 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 InsulinWednesday, November 21, 12
  • 50. Q11 Can we give Metformin for GDM? a) Yes b) NoWednesday, November 21, 12
  • 51. Q12 When and how should insulin be started in GDM? a) Consider insulin when diet and exercise fail to maintain glucose targets in 1-2 weeks b) Ultrasound shows incipient fetal macrosomia (AC >70th percentile) c) Start daily insulin at 0.1-0.3 u/kg BW d) All of the aboveWednesday, November 21, 12
  • 52. 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 PP whole BG >120 mg/dL (6.7 mmol/L) Insulin Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)Wednesday, November 21, 12
  • 53. Q12 When and how should insulin be started in GDM? a) Consider insulin when diet and exercise fail to maintain glucose targets in 1-2 weeks b) Ultrasound shows incipient fetal macrosomia (AC >70th percentile) c) Start daily insulin at 0.1-0.3 u/kg BW d) All of the aboveWednesday, November 21, 12
  • 54. Q13 Which of the following is true of management during labor? a) Give dextrose-containing IV fluids b) Give short-acting insulin for CBG>140 mg/dL c) Check CBG q hourly. d) All of the aboveWednesday, November 21, 12
  • 55. Protocol for Spontaneous Delivery Infusion of 500 ml 5% dextrose/saline x4h CBG q 4h Give short-acting insulin for CBG >140 mg/dL L - Do se equal to mmol of CBG i.e. 12 u for 12 mmol/ u for - Dose equal to 1/20th of mg/dL of CBG i.e. 12 240 mg/dL Omit insulin for CBG <140 mg/dL ASGODIPWednesday, November 21, 12
  • 56. After delivery Resume diet GDMs with high insulin requirements during pregnancy should have glucose profiles Give insulin if BG persistently high (>200 mg/dL) ASGODIPWednesday, November 21, 12
  • 57. Q13 Which of the following is true of management during labor? a) Give dextrose-containing IV fluids b) Give short-acting insulin for CBG>140 mg/dL c) Check CBG q hourly. d) All of the aboveWednesday, November 21, 12
  • 58. Q14 Which of the following is true of postpartum follow-up? a) Schedule 75-g OGTT 6 weeks after follow-up b) Measure FBS every 3 years c) Advise patient not to get pregnant again d) Breastfeeding should be limitedWednesday, November 21, 12
  • 59. Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009) Annual follow-up Measure FBS Assess weight reduction Review pregnancy plansWednesday, November 21, 12
  • 60. Ff-up 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 2004Wednesday, November 21, 12
  • 61. Ff-up 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 2008Wednesday, November 21, 12
  • 62. Q14 Which of the following is true of postpartum follow-up? a) Schedule 75-g OGTT 6 weeks after follow-up b) Measure FBS every 3 years c) Advise patient not to get pregnant again d) Breastfeeding should be limitedWednesday, November 21, 12
  • 63. Thank You http://www.endocrine-witch.net @endocrine_witch Image from http://wthr.frumph.net/Wednesday, November 21, 12