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Gestational diabetes

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Gestational diabetes

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Gestational diabetes

  1. 1. By Dr. Lamiaa Gamal
  2. 2. Diabetes during pregnancy Type 1 diabetes 7.5% Type 2 diabetes 5% Gestational diabetes 87.5% Prediabetes
  3. 3. Rare diagnosis during pregnancy Presented by Unexpected coma Early pregnancy screening test for women admitted to blood sugar control
  4. 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. 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. 6. PREDIABETES  People who are at increased risk of developing diabetes  Impaired fasting glucose (IFG)  Impaired glucose tolerance (IGT)
  7. 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. 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. 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. 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. 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. 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
  13. 13. REGIONAL DIFFERENCES IN THE PREVALENCE (%) OF HYPERGLYCAEMIA IN PREGNANCY North America and Caribbean Region 10.4% (lowest) South-east Asia Region 25% (highest)
  14. 14. 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.
  15. 15. 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
  16. 16. 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 %
  17. 17.  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
  18. 18. 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)
  19. 19. • Certain ethnic groups • age > 25 years • essential or pregnancy related hypertension • unexplained stillbirth/miscarriages and glycosuria • Polycystic ovarian syndrome
  20. 20. PATHOGENESIS (NORMAL PREGNANCY) Meal Rise of blood glucose insulin, glucagon, somatomedins, and adrenal catecholamines Glucose supply to mother and fetus
  21. 21. 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.
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. • 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
  26. 26. OTHER ASSOCIATED MORBIDITIES  Preterm labour  Premature rupture of membranes  Increased ceserean section  Obstructed labour and birth traumas
  27. 27. Cumulative incidence of type 2 diabetes in women with a history of gestational diabetes
  28. 28. MATERNAL MORTALITY World Health Organization 2014
  29. 29. 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
  30. 30. 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%).
  31. 31. 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
  32. 32. 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
  33. 33. PERINATAL MORTALITY CAUSES:  Congenital malformations  Respiratory distress syndrome (RDS)  Extreme prematurity
  34. 34. 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%
  35. 35. SCREENING OF GDM High risk group • During the 1st trimester ( 1st prenatal visit) Routine • Between 24-28 weeks of gestation
  36. 36. Screen women with GDM for persistent diabetes 6-12 weeks postpartum using oral glucose tolerance test (OGTT) and nonpregnancy diagnostic criteria
  37. 37. Continue to screen women with history of GDM for diabetes or pre diabetes at least every 3 years
  38. 38. Women with GDM history and pre diabetes should receive lifestyle interventions or metformin for diabetes prevention
  39. 39. 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)
  40. 40. 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)
  41. 41. 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).
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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.
  47. 47. 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
  48. 48. • 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
  49. 49. • For natal complications and associated shoulder dystocia Obstetric care • Treatment of hypoglycemia • Early breast feeding Management of neonate
  50. 50. 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.
  51. 51. 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.
  52. 52. 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
  53. 53. 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.

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