Gestational diabetes

1. By
Dr. Lamiaa Gamal

2. Diabetes
during
pregnancy
Type 1
diabetes
7.5%
Type 2
diabetes
5%
Gestational
diabetes
87.5%
Prediabetes

3. Rare diagnosis during pregnancy
Presented by Unexpected coma
Early pregnancy screening test for
women admitted to blood sugar control

4. TYPE 2 DIABETES
Q: Is it type 2 Diabetes or gestational diabetes?
A: the International Association of Diabetes and
Pregnancy Study Groups now recommend that
high-risk women who are found to have diabetes at
their initial prenatal visit, according to standard
diagnostic criteria, receive a diagnosis of overt
diabetes rather than gestational diabetes

5. Type 2 Diabetes is better prognosis than
type 1 Diabetes
 better glycemic control
 fewer large for gestational age infants
 fewer preterm deliveries
 fewer neonatal care admissions

6. PREDIABETES
 People who are at increased risk of
developing diabetes
 Impaired fasting glucose (IFG)
 Impaired glucose tolerance (IGT)

7. IMPAIRED FASTING GLUCOSE (IFG)
A condition in which the fasting blood
sugar level is elevated (100-125 mg/dL)
after an overnight fast but is not high
enough to be classified as diabetes

8. IMPAIRED GLUCOSE TOLERANCE (IGT)
A condition in which the blood sugar
level is elevated (140-199 mg/dL after a
2-h OGTT) but is not high enough to be
classified as diabetes

9. GESTATIONAL DIABETES
is defined as any degree of glucose intolerance
with onset or first recognition during the present
pregnancy and can in some cases inadvertently
include women with pre-existing, undiagnosed DM.

10. PREVALENCE
1.5
89
0
10
20
30
40
50
60
70
80
90
100
deaths DALYs
Frequency of deaths and DALYS due to Diabetes in 2012
million
http://www.who.int/nmh/publications/ncd-status-report-2014/en/

11.  The global prevalence of diabetes was
estimated to be 9% in 2014.
 The prevalence of diabetes was highest in the
WHO Region of the Eastern Mediterranean
Region (14% for both sexes) and lowest in the
European and Western Pacific Regions (8% and
9% for both sexes, respectively).

12.  Gestational diabetes is known to occur in at
least 1-5% of all pregnancies
 IDF estimates that 21.4 million or 16.8% of
live births to women in 2013 had some form
of hyperglycaemia in pregnancy.
 An estimated 16% of those cases were due
to diabetes in pregnancy and would require
careful monitoring during the pregnancy
and follow-up post-partum.
http://www.idf.org/diabetesatlas

15. REGIONAL DIFFERENCES IN THE PREVALENCE (%) OF
HYPERGLYCAEMIA IN PREGNANCY
North America
and
Caribbean Region
10.4%
(lowest)
South-east Asia Region
25%
(highest)

16. A staggering 91.6% of cases of
hyperglycaemia in pregnancy were in
low- and middle-income countries, where
access to maternal care is often limited.

17. The prevalence of hyperglycaemia in pregnancy
increases rapidly with age and is highest in
women over the age of 45 (47.7%),
although there are fewer pregnancies in that
age group.
This explains why just 23% of global cases of
hyperglycaemia in pregnancy occurred in
women over the age of 35, even though the risk
of developing the condition is higher in these
women

18. 2
8
15
0
2
4
6
8
10
12
14
16
white women Hispanic, black, and
Asian populations
Native Americans from
the southwestern United
States
Gestational diabetes and race
%

19.  High recurrence risk with future pregnancies has
been reported to be as high as 68%.
 One-third will develop overt diabetes mellitus
within 5 years of delivery, with higher-risk
ethnicities having risks nearing 50%.
 Black women have been shown to have lower
rates of macrosomia, despite similar levels of
glycemic control
 Hispanic women have higher rates of macrosomia
and birth injury than women of other ethnicities,
even with aggressive management

20. RISK FACTORS FOR GESTATIONAL DIABETES
• Body mass index more than 30 kg/m²
• Previous macrosomic baby weighing 4.5 kg
or more
• Previous gestational diabetes
• Family history of diabetes (first-degree
relative with diabetes)

21. • Certain ethnic groups
• age > 25 years
• essential or pregnancy related hypertension
• unexplained stillbirth/miscarriages and glycosuria
• Polycystic ovarian syndrome

22. PATHOGENESIS
(NORMAL PREGNANCY)
Meal
Rise of blood
glucose
insulin, glucagon, somatomedins, and adrenal
catecholamines
Glucose supply to
mother and fetus

23. DURING NORMAL PREGNANCY
 Interprandial hypoglycemia (plasma
glucose mean = 65-75 mg/dL).
 Levels of placental steroid and peptide
hormones (e.g, estrogens, progesterone,
and chorionic somatomammotropin) rise
linearly throughout the second and third
trimesters.
 By the third trimester, 24-hour mean
insulin levels are 50% higher than in the
nonpregnant state.

24. Diabetogenic
potency
Peak
elevation
(weeks)
Hormone
Weak10Prolactin
Very weak26Estradiol
Moderate26Human chorionic
sommatomamotropin (hcs)
Very strong26Cortisol
Strong32Progesterone
Adapted from jovanovic –peterson L, Peterson C: Review of gestational diabetes mellitus and low calorie diet
and physical exercise as therapy. Diabetes Metab Rev 12:287-308, 1996

25. DURING DIABETESInadequate maternal insulin secretion
Fetal hyperinsulinemia
recurrent postprandial hyperglycemic episodes
energy expenditure due to the
conversion of excess glucose into fat
depletion in fetal oxygen levels
Fetal hypoxia
surges in adrenal catecholamines
Hypertension, Cardiac remodeling and hypertrophy, Stimulation of
erythropoietin, red cell hyperplasia, and Increased hematocrit
excess nutrient storage
Macrosomia

26. MATERNAL MORBIDITY
• Half the patients with preexisting
retinopathy experienced
deterioration during pregnancy
• All the patients had partial
regression following delivery and
returned to their prepregnant state
by 6 months postpartum
Diabetic
retinopathy
• pregnancy does not measurably
alter the time course of diabetic
renal disease, nor does it
increase the likelihood of
progression to end-stage renal
disease
Renal disease

27. • Chronic hypertension 1 in 10
diabetic pregnancies
• Preeclampsia is more frequent
among women with diabetes
(approximately 12%) versus the
non-diabetic population (8%)
• The rate of preeclampsia has
been found to correlate with the
level of glycemic control
Elevated
blood
pressure
• Increased risk of developing type 2
diabetes
• 5 percent of women who have gestational
diabetes develop type 2 diabetes within 6
months of delivery, about 60 percent will
develop type 2 diabetes within 10 years
Diabetes

28. OTHER ASSOCIATED MORBIDITIES
 Preterm labour
 Premature rupture of membranes
 Increased ceserean section
 Obstructed labour and birth traumas

29. Cumulative incidence of type 2 diabetes in
women with a history of gestational diabetes

31. MATERNAL MORTALITY
World Health Organization 2014

32. FETAL MORBIDITY
Miscarriage
• Patients with long-standing (>10 y) and poorly
controlled diabetes (HbA1C exceeding 11%) have
been shown to have a miscarriage rate of up to
44%
Birth defects
• General population 1-2%
• With overt diabetes, the likelihood of a structural
anomaly is increased 4- to 8-fold

33. Growth restriction
• underlying maternal vascular disease(
diabetes-associated retinal or renal
vasculopathies and/or chronic hypertension(
Obesity
• Approximately 30% of fetuses of women with
diabetes mellitus in pregnancy are large for
gestational age (LGA). In preexisting
diabetes mellitus, this incidence appears to
be slightly higher (38%).

34. Macrosomia
• a birth weight above the 90th percentile for
gestational age or greater than 4000 g.
• Macrosomia occurs in 15-45% of babies born to
diabetic women, a 3-fold increase from
normoglycemic controls
Metabolic syndrome
• By age 10-16 years, offspring of diabetic pregnancy
have a 19.3% rate of impaired glucose intolerance
• The childhood metabolic syndrome includes
childhood obesity, hypertension, dyslipidemia, and
glucose intolerance

35. Cardiovascular risk factors
• higher levels of biomarkers for endothelial
damage and inflammation, as well as
higher leptin levels, BMI, waist
circumference, and systolic blood pressure
and decreased adiponectin levels
Neurocognitive development
• both GDM and low socioeconomic status
were at even greater risk for ADHD and
also at increased risk for compromised
neurobehavioral functioning

36. PERINATAL MORTALITY CAUSES:
 Congenital malformations
 Respiratory distress syndrome (RDS)
 Extreme prematurity

37. PERINATAL MORBIDITY IN DIABETIC PREGNANCY
Morbidity Gestational Diabetes Type 1 Diabetes Type 2 Diabetes
Hyperbilirubinemia 29% 55% 44%
Hypoglycemia 9% 29% 24%
Respiratory distress 3% 8% 4%
Transient tachypnea 2% 3% 4%
Hypocalcemia 1% 4% 1%
Cardiomyopathy 1% 2% 1%
Polycythemia 1% 3% 3%

39. SCREENING OF GDM
High risk
group
• During the 1st trimester (
1st prenatal visit)
Routine
• Between 24-28 weeks of
gestation

40. Screen women with GDM for
persistent diabetes 6-12 weeks
postpartum using
oral glucose tolerance test
(OGTT) and
nonpregnancy diagnostic
criteria

41. Continue to screen women with
history of GDM for diabetes or
pre diabetes
at least every 3 years

42. Women with GDM history and pre
diabetes should receive
lifestyle interventions or
metformin
for diabetes prevention

43. There is no uniform approach for GDM
diagnosis. Two options:
 “One-step”: 2-h 75-g OGTT
(International Association of Diabetes and
Pregnancy Study [IADPSG] consensus)
OR
 “Two-step”: 1-h 50-g (non fasting) screen
followed by 3-h 100-g OGTT for those who
screen positive
(National Institutes of Health [NIH] consensus)

44. ONE STEP
Perform OGTT in the morning after an overnight
fast of at least 8 h
GDM diagnosis: when any of the following plasma
glucose values are exceeded
Fasting: ≥92 mg/dL (5.1 mmol/L)
1 h: ≥180 mg/dL (10.0 mmol/L)
2 h: ≥153 mg/dL (8.5 mmol/L)

45. TWO STEP
 Perform a 50-g GLT (non fasting), with plasma
glucose measurement at 1 h (Step 1), at 24–28
weeks of gestation in women not previously
diagnosed with overt diabetes
 If the plasma glucose level measured 1 h after
the load is ≥140 mg/dL* (7.8 mmol/L), proceed
to 100-g OGTT (Step 2); the 100-g OGTT should
be performed when the patient is fasting
 The diagnosis of GDM is made when the plasma
glucose level measured 3 h after the test is ≥140
mg/dL (7.8 mmol/L).

47. DIAGNOSTIC CRITERIA OF DIABETES MELLITUS
According to the American Diabetes Association’s
"Standards of Medical Care in Diabetes—2010:
 Hemoglobin A1C (HbA1C) >= 6.5%
 Fasting plasma glucose = >126 mg/dL
 A 2-hour plasma glucose level >= 200 mg/dL
during a 75-g OGTT
 A random plasma glucose level >= 200 mg/dL in a
patient with classic symptoms of hyperglycemia
or hyperglycemic crisis

48. POST DIAGNOSTIC TESTING
1st TRIMESTER
• HbA1C
• Blood urea nitrogen (BUN)
• Serum creatinine
• Thyroid-stimulating hormone
, Free thyroxine levels
• Spot urine protein-to-
creatinine ratio
• Capillary blood sugar levels
• Ultrasonographic
assessment for pregnancy
dating and viability

49. 2nd TRIMESTER
• Spot urine protein-to-
creatinine study in women
with elevated value in first
trimester
• Repeat HbA1C - Capillary
blood sugar levels
• Detailed anatomic
ultrasonogram at 18-20 weeks
and a fetal echocardiogram if
the maternal
glycohemoglobin value was
elevated in the first trimester

50. 3rd TRIMESTER
•blood glucose, blood pressure
follow up
• Growth ultrasonogram to
assess fetal size every 4-6
weeks from 26-36 weeks in
women with overt
preexisting diabetes;
perform a growth
ultrasonogram for fetal size
at least once at 36-37 weeks
for women with gestational
diabetes mellitus

51. FETAL BIOPHYSICAL TESTS
Various fetal biophysical tests can ensure that the
fetus is well oxygenated, including:
 Fetal heart rate testing
 Fetal movement assessment
 Ultrasonographic biophysical scoring
 Fetal umbilical Doppler Ultrasonographic
studies.

52. MANAGEMENT
• avoid single large meals and foods
with a large percentage of simple
carbohydrates
• Supplemental calcium and vitamin
D at 24 to 28 weeks gestation may
improve metabolic profile of women
with GDM
Diet
• Aim for at least 30 minutes
most days of the week
Physical
activity

53. • to achieve glucose profiles
similar to those of non diabetic
pregnant women
Insulin
• these 2 drugs to be effective,
and no evidence of harm to the
fetus has been found, although
the potential for long-term
adverse effects remains a
concern
Glyburide
and
metformin

54. • For natal complications and
associated shoulder dystocia
Obstetric
care
• Treatment of hypoglycemia
• Early breast feeding
Management
of neonate

55. BREAST FEEDING
 breast-fed infants have a much lower risk of
developing diabetes than those exposed to cow's
milk proteins.
 Studies of breastfeeding women with diabetes
indicate that lactation, even for a short duration,
also has a beneficial effect on overall maternal
glucose and lipid metabolism.

56. BREAST FEEDING
 For postpartum women who had gestational
diabetes mellitus during their pregnancies,
breastfeeding may offer a practical low-cost
intervention that helps reduce or delay the risk
of subsequent diabetes.
 A study by Gunderson et al found that a higher
intensity of lactation among exclusively or
mostly breastfeeding (< 6 oz formula per 24 h) -
mothers improved insulin sensitivity and
glucose metabolism.

57. A 2013 systematic review and meta-analysis of
randomized trials for the US Preventive Services
Task Force found that appropriate management
of GDM(nutritional therapy, self blood glucose
monitoring, administration of insulin if target
blood glucose concentrations are not met with
diet alone) resulted in reductions in:
●Preeclampsia (three trials)
●Birth weight >4000 grams (five trials)
●Shoulder dystocia (three trials)
http://www.uptodate.com/contents/gestational-diabetes-mellitus-glycemic-control-and-maternal-prognosis

58. PREVENTION
 patients who lose weight before pregnancy
and follow an appropriate diet may lower
their risk of gestational diabetes mellitus.
 marked weight loss and attention to diet are
not likely to be successful.
 12-week standard exercise program during
the second half of pregnancy had no benefit
in preventing gestational diabetes in healthy
women with normal BMI.
 breastfeeding should be recommended.