Gestational diabetes mellitus


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Gestational diabetes mellitus

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Gestational diabetes mellitus

  1. 1. Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. Outline •Physiological changes •Definition •Prevalence •Adverse outcome •Screening •Diagnosis •Medical management •Obstetric management •Conclusion Aboubakr Elnashar
  3. 3. Physiological changes Pregnancy is a state of physiological insulin resistance & relative G intolerance 1. GT: decreases progressively with increasing gestation {anti-insulin hormones secreted by the placenta; h pl lactogen, glucagon, cortisol}. 2. Increased insulin requirements : Development of GDM Aboubakr Elnashar
  4. 4. 3· Glucose handling is altered: FBG: decrease G levels following a meal or glucose load: increase compared to the non-pregnant state. The renal tubular threshold for glucose: falls: glycosuria Glycosuria is not a reliable diagnostic tool 4. Starvation: early breakdown of triglyceride: liberation of fatty acids & ketone bodies. Aboubakr Elnashar
  5. 5. COH intolerance with onset or first recognition during the present pregnancy (American Diabetes Association, 2002) So includes pre-existing but previously un recognized diabetes. D in pregnancy Pre- existing IDDM NIDD Gestational Preexisting TrueAboubakr Elnashar
  6. 6. •Depend on: population studied diagnostic tests employed 4.0- 14.0% Aboubakr Elnashar
  7. 7. Severe forms of GDM are linked to adverse outcome (Hyde et al, 2005). The perinatal mortality & morbidity are increased in untreated GDM (large randomized Australlian study) Aboubakr Elnashar
  8. 8. . Maternal problems •Pregnancy Anxiety Abnormal wt gain PET Birth trauma (secondary to macrosomia) Increased rate of CS •Later Increased rate of T2DM, hypertension, CVD Problems in offspring •Fetal ?Malformation IUFD Macrosomia Shoulder dystocia/hypoxia- acidosisl/Erb's palsy Iatrogenic prematurity •Neonatal Hypoglycaemia Polycythaemia Hyperbilirubinaemia Hypocalcaemia Cardiomyopathy •Adult Obesity Increased rate of T2DM, hypertension, CVD, ?Breast cancerAboubakr Elnashar
  9. 9. Abnormal fetal growth •Macrosomia: B. wt > 4000 g regardless of gest age or sex, or organ wt Aboubakr Elnashar
  10. 10. •Etiology: -Maternal hyperglycaemia: Fetal hyperinsulinaemia: stimulate f growth (Pederson hypothesis). -Mat obesity -Mat hyper-triglyceridemia -Recent studies: The relation between mat glycaemic control & f wt is v weak. Only a minority (25%) of infants of mothers with hyperglycaemia become macrosomic. Aboubakr Elnashar
  11. 11. •The growth response of the fetus to hyperglycaemia is dependent upon whether the fetus has gene defect or not. Gene HNF4A, which is associated with diabetes Genetic test for HNF4A of the baby with low blood-sugar & family history of diabetes: Early diagnosis of maturity-onset diabetes of the young. Aboubakr Elnashar
  12. 12. Fetal malformation •Pre-existing DM: Higher rate: cardiac, skeletal, NTD. Etiology: poor glycaemic control at the time of conception •GDM: Normal rate {euglycaemic at the time of conception}. Recent studies: Higher rate Aboubakr Elnashar
  13. 13. Risk of major malformation (%) Normal population 2 Preexisting DM 10 GDM 4 (Schaefer et al, 1997; Aberg et al, 2001; Sheffield et al, 2002)Aboubakr Elnashar
  14. 14. Etiology: Unknown •FBS at time of diagnosis of GDM is high (Schaefer et al. 1997) •Some cases are (undiagnosed) pre-existing T2DM & occult hyperglycaemia at the time of organogenesis Aboubakr Elnashar
  15. 15. Fetal death & occult GDM Perinatal mortality rate: 10-fold higher (Rudge et al, 2000) Occult GDM (GDM pass undetected) contributes to a large proportion of unexplained late IUFD (Robson et aI, 2001) Aboubakr Elnashar
  16. 16. Long-term health problems for offspring obesity, diabetes & CVD (Sattar & Greer, 2002) •Genetic predisposition: GDM is transmitted through the maternal line (Knowler et al, 1985) Aboubakr Elnashar
  17. 17. Maternal long-term health problems •T2DM: General population: 8%. GDM: 30% (Kaufmann et al, 1995). GDM is a transient form of T2DM. •CVD & premature death. Aboubakr Elnashar
  18. 18. Aboubakr Elnashar
  19. 19. Controversy: •Advantage and disadvantage of detecting GDM •What ? •When? •WHO? •Recommendations? Aboubakr Elnashar
  20. 20. Advantage 1.GDM is associated with macrosomia and adverse effects on pregnancy. So prevention of this adverse effects 2. A small proportion are in fact unrecognized preexisting D. , are at risk of all complications of D. Aboubakr Elnashar
  21. 21. 3. GDM is associated with increased risk (50%) of T2D within 10-15 ys. Prevention or delay development of T2DM (de Soares et al, 1997). by Medical or life-style intervention resulted in reduction of DM • In Finland (Tuomilehto et al, 2001) Individuals with impaired glucose tolerance: dietary modification: 50% reduction of risk DM (11% Vs 23%). • In Washington (The Diabetes Prevention Research Croup, 2002) individuals at high risk of T2DM: life-style modification reduced risk of DM by 58% Metformin reduced it by 31%. Prevention of microvascular complication by early diagnosis & careful follow upAboubakr Elnashar
  22. 22. Disadvantages Increase CS rate Aboubakr Elnashar
  23. 23. What? Ideal screening test: Sensitive Specific Simple cheap convenient. Aboubakr Elnashar
  24. 24. Screening tests Random blood glucose (RBG): Within 2 h: 125 mg/dl 2-6 h: 100 mg/dl Fasting blood glucose (FBG): 86 mg/dl 1-h 50 g glucose challenge test (GCT) 140 mg/dl 2-h 50 g glucose challenge test . 75 g glucose tolerance test (GTI) Glycated haemoglobin or Fructosamine: no role in diagnosis of GDM, useful in monitoring of effective glycemic controlAboubakr Elnashar
  25. 25. •GCT: High sensitivity (69%), Specificity (91%),with a cut off of 140 mg/dl (7.8 mmol/l). Poorly tolerated (induce nausea). Time consuming Expensive. Aboubakr Elnashar
  26. 26. •FBG: High sensitivity (81%) Good specificity (76%) with a cut off of 86 mg/dl (4.8 mmol/l) (Perucchini et al, 1999) Easier, Cheaper More acceptable . Can be applied to all pregnant women more than once during pregnancy. Suitable for screening Aboubakr Elnashar
  27. 27. When? •The latter in pregnancy: higher detection rate {GT deteriorates with increasing gestation} •The earlier in pregnancy the GDM is diagnosed: the greater the potential to treat hyperglycemia & improve outcome. Aboubakr Elnashar
  28. 28. WHO?. •Universal: screening all pregnant The only approach that will detect virtually all cases (Griffin et al,2000 ). •Selective: screening high-risk women For reasons of cost and convenience, Disadvantage: missing up to 50% . Aboubakr Elnashar
  29. 29. •Risk factors for selective screening Maternal age >30 Family history of T2DM Non-white ethnic origin Obesity Smoking Increased wt gain in early childhood PCOS Previous large infant (> 97th centile) Previous unexplained still-birth Aboubakr Elnashar
  30. 30. Recommendations •Diabetes UK: Routine screening Urine testing at every ANC visit RBG at booking, at 2l W and if glycosuria. 75 g GTT if FBG > (110mg/dl)6.1 mmol/L or RBG> (125mg/dl) 7.0 mmol/L within 2 h of food •Scottish Guidance Network: Routine screening Urine and RBG at every ANC visit Aboubakr Elnashar
  31. 31. •American Diabetic Association: Selective screening Age> 25' years' Overweight before pregnancy Ethnic group with high prevalence GDM Diabetes in first-degree relative History of abnormal glucose tolerance' History of poor obstetric outcome' . With 50 g GCT. confirm with 100 g GTT •National institute for Clinical Excellence: No routine screening Aboubakr Elnashar
  32. 32. •Society of Obstetricians and Gynecologists of Canada: Routine screening at 24-28 w with 50 g GCT with cut off 7.8 mmol/l . No screening as no definitive evidence to support Selective screening: as early as possible with repeat at 24-28 w Aboubakr Elnashar
  33. 33. Aboubakr Elnashar
  34. 34. The 75 g OGTT using recent WHO criteria is now used almost universally throughout the world as the gold standard test for diagnosing GDM (Piercy, 2006) . Fasting venous & capillary blood glucose are similar. After a meal or a glucose challenge, capillary are higher than venous levels. It is not necessary for both values to be abnormal Plasma glucose Mg/dl Fasting 100 2-h 145 Aboubakr Elnashar
  35. 35. No need for GTT FBS 125mg/dl (7.0 mmol/l) or Random venous plasma glucose 200 mg/dl (11.1 mmol/l) if confirmed on a subsequent day Aboubakr Elnashar
  36. 36. I. Diet II.Exercise III.Insulin IV.Hypoglycemic drugsAboubakr Elnashar
  37. 37. I. Diet •The first line therapy for 1-2 w •3 meals & 4 snacks with last snack at bed time {minimize the overnight hypoglycemia & starvation ketosis (during pregnancy, there is accelerated starvation)} (Maternal Nutrition of the National Research Council, 1995) •Caloric needs acc to BMI (The American Diabetes Association, 2003) < 30 kg/m2: 30 Kcal/kg >30 kg/m2: 25 Kcal/kg Aboubakr Elnashar
  38. 38. •Carbohydrates 40% Protein 30%, Fat 30% (Garner, 1995). •Concentrated sweets & added sugars should be eliminated. •Complex CHO with high fiber contents are preferable {slower glucose rise after ingestion} (American Diabetes Association, 2003). Aboubakr Elnashar
  39. 39. II. Exercise •Reduce insulin requirement by as much as 50%. The effect appears after 4 w. •1h after mealtimes. •For 20-30 min •Upper extremity or lower extremity ms excerises while recumbent do not increase uterine contractions (Durak et al, 1990 ;de Veciana and Mason, 2000). Gentle aerobic exercise Walking (Homko et al, 1998). Aboubakr Elnashar
  40. 40. Aboubakr Elnashar
  41. 41. III. Insulin Aboubakr Elnashar
  42. 42. Rapidly acting analogues (Lispro, Aspart): has been approved during pregnancy (Metzger et al, 2007, Mathiesen et al, 2007) 1. Superior than regular insulin in controlling postprandial hyperglycemia (Heinemann et al, 1998) 2. Rapid onset of action: Given immediately before eating: improves compliance & patient satisfaction 3. Category C medication Aboubakr Elnashar
  43. 43. Long acting analogues (glargine, detemir) Has not been approved in pregnancy Aboubakr Elnashar
  44. 44. Indications: 1. 2. Failed dietary treatment 3. AC >95th centile between 29 & 33 W Despite good glycemic control Reduce macrosomia from 45% to 14% (Buchanan et al, 2004) whole blood glucose mg/dl Plasma glucose mg/dl Fasting 95 105 1h postprandial 140 155 2 h postprandial 120 135 Aboubakr Elnashar
  45. 45. IV. Oral hypoglycaemics •Not recommended for use in pregnancy. 1. Early agents crossed the placenta & stimulated fetal insulin secretion: fetal macrosomia & hyperinsulinaemic hypoglycaemia in neonates. 2. Major congenital malformations in animals (Greene, 2000) Aboubakr Elnashar
  46. 46. •Advantage 1. Ease of administration 2. Ease of storage, 3. Convenience: No injections. No infection Continued 4. Cost. Recent studies evaluating its use in pregnancy Aboubakr Elnashar
  47. 47. Glyburide: Micronase, 5 mg Upjon 2nd generation sulfonyl urea in vitro studies: minimal maternal-fetal transfer (Garcia et al, 2003) Glyburide Vs Insulin (Langer et al, 2000). 404 women with GDM that required treatment, were randomly assigned between 11& 33 w to receive 5-20 mg/d glyburide or insulin •No significant differences: Macrosomia N. Hypoglycemia Admission to the NICU Fetal anomalies •Glyburide was not detected in the cord serum effective & safe alternative to insulin Aboubakr Elnashar
  48. 48. Metformin the only available biguanide. In contrast to glyburide, metformin does cross the placenta. Mechanism: Mainly by decreasing gluconeogenesis & by increasing peripheral utilization of glucose. At therapeutic doses, hypo glycaemia does not occur when used in isolation but it may exert a hypoglycaemic action when given in overdose. Side effects: 1. lower incidence of wt gain & weight loss may occur. 2. Gastrointestinal side-effects are common initially but usually settle within a few days. 3. Vitamin B12 deficiency 4. Lactic acidosis, extremely rare & only occurs in vascular disease, renal patients,PET Aboubakr Elnashar
  49. 49. 3 studies The accumulated experience is smaller with less than 200 women treated. Some disappointing outcome data. •Favorable PNMR but the comparison was with untreated patients for whom the PNMR was 146/1000. Increase in neonatal jaundice (Coetzee & Jackson, 1979) •Met, tolbutamide, insulin: Glycaemic control was comparable to insulin-treated patients in both groups but Met was associated with a 3-fold increase in the incidence of PET and' an increased PNMR compared with those on tolbutamide and insulin (Hellmuth et al, 2001) •Met Vs insulin: both similar ability to control hyperglycaemia but Met was associated with a higher CS and more neonatal hypoglycaemia (Hauge et al, 2003) These outcomes may well reflect small study sizes but the safety of Met is not established and it is advocated that it should not be used for this purpose outside of well designed research studies (Dornan & Hollis, 2001; Glueck et al, 2002) Aboubakr Elnashar
  50. 50. Antenatal 1. Glycemic control 2. Fetal wellbeing 3. F. wt: 4. Delivery: Intrapartum Postpartum 1. Glycemic control 2. Assessment 3. Breast feeding 4. Contraception 5. Prevention Aboubakr Elnashar
  51. 51. A. Antenatal Goals: Maintain Euglycemia Prevent macrosomia Glycemic control <32 w: Significant reduction >32W: No reduction (Sameshima et al, 2000). Aboubakr Elnashar
  52. 52. I. Glycemic control. a. Blood glucose: • Objective: Capillary blood glucose Mg/dl(mmol/L) Fasting <100(5.5) 1 Hour <140 (7.8) 2 Hours <125 (7.0) Aboubakr Elnashar
  53. 53. • Preprandial OR postprandial?: In non-pregnant: Preprandial is preferred In pregnancy: Post prandial is preferred (Konje, 2004) 1. The fetus is more sensitive to hyperglycemia than to nadirs of glucose values 2. F & preprandial BG values are often normal even before treatment 3. Postprandial monitoring: improved glycaemic control decreased rate of macrosomia, CS, neonatal hypoglycaemia (de Veciana et al, 1995). Aboubakr Elnashar
  54. 54. •1h or 2h post prandial?: No agreement (Ahn & Hibbard, 2005), but most authorities advocate 2h postprandial Aboubakr Elnashar
  55. 55. • Frequency: weekly up to 7 times daily Mild: Twice daily Severe: 4 readings (Fasting, 2 h after breakfast, lunch & dinner) • Self-tested blood glucose, using hand-held digital read- out devices Aboubakr Elnashar
  56. 56. Cap Bl sugar FBS 2hPP 60 – 90 NO NO 91 – 120 1 Unit 121 – 150 2 Units 1 Unit 151 – 200 4 Units 2 Units 201 – 250 8 Units 4 Units 251 – 300 10 Units 8 Units 301 – 350 12 Units 10 Units 351 – 400 14 Units 12 Units > 400 Call Doctor 14 Units Aboubakr Elnashar
  57. 57. b. Glycosylated hemoglobin A1C: -Retrospective assessment of glycemic control. Evaluates blood glucose over the life span of the RBC i.e. 120 days. -Due to enhanced erythropoiesis during pregnancy, it is done every 6 w Excellent control: <7% Fructosamine: Not useful {low sensitivity} Aboubakr Elnashar
  58. 58. II. Fetal wellbeing: Indications: Insulin is required Poorly controlled diabetics Hypertension History of IUFD Tests: no reliable test. A combination of tests must be employed. Kick chart, NST, CST, FBP, Doppler Regimen Twice weekly NST with once weekly AFI or FBP Kick chart: At least 10 kicks/2h Aboubakr Elnashar
  59. 59. III. F. wt: Screening for macrosomia •Both cl & US are inaccurate (±10-20%). •Clinical is more accurate than US (Sherman et al, 1998) •US: huge variation in sensitivity (24-88%) & specificity (60-98%) (Reece et al, 1995). •Novel methods (cheek-to-cheek diameter, fetal thigh SC tissue at the level of the femoral diaphysis, thigh soft tissue/FL ratio, upper arm soft tissue thickness, EFW derived from a formula incorporating AC, FL & upper arm soft tissue thickness): Not superior to clinical & routine US (Chauhan et al, 2000) • The best single measurement: Serial measurements of AC Aboubakr Elnashar
  60. 60. IV. Delivery: • Time: In a well controlled GDM, delivery should be considered at 38-40w There is very little evidence to support either induction of labor at 38w or expectant management (Cochrane Syst Rev 2000) Induction at 38w in insulin requiring GDM showed lower rate of: macrosomia (10% Vs 23%), CS (25% Vs 30%) and Shoulder dystocia (0% Vs 3%) (Kjos et al, 1993). Delivery before 38W: Poor glucose control Poor compliance Co morbidities e.g. hypertension Corticosteroids: <36 w Aboubakr Elnashar
  61. 61. •Mode: Elective CS: Estimated F wt>4500 g (ACOG,2003 ) 4000 & 4500g (Inzucchi, 1999). Aboubakr Elnashar
  62. 62. B. Intrapartum •The target glucose level: 75-145 mg/dl (4-8 mmol/l) •On diet: Bl glucose/h On insulin: <20 U/d: No need for insulin (Piercy, 2006) >20 U/d: IV dextrose & insulin Sliding scale Aboubakr Elnashar
  63. 63. C. Postpartum 1.Glycemic control Stop Insulin: Most patient will have normal glucose level. Insulin be reinstituted as needed . Aboubakr Elnashar
  64. 64. 2. Postpartum Assessment •Unrecognized pre GDM is suspected when: 1-Initial fasting >125 mg/dl, 2-GDM during first trimester •75 g OGTT 6 w following delivery (ACOG, 2003) •FBG: if abnormal: OGTT Aboubakr Elnashar
  65. 65. 3. Breast feeding: should be encouraged (Gange et al, 1992). . Reduces the insulin requirement by 25% . Breast- feed babies have a much lower risk of developing DM (Jovanovic,1998) Aboubakr Elnashar
  66. 66. 4. Contraception •Copper IUCD, Mirena: not associated with PID (Kimmerle et al, 1993 ; Kjos et al,1994) •DMPA: Deterioration of CHO tolerance increase risk of diabetes •NORPLANT: No deterioration (Fahmy et al, 1991 ; Konje et al,1992; Singh et al,1992) Aboubakr Elnashar
  67. 67. GDM: Low-dose COCs •didn't influence development of Diabetes (Kjos et al,1998) •Non smoker, <35 years, healthy: no hypertension, nephropathy, retinopathy, or other vascular disease. Progestin-only Pill with breast feeding: 3 fold risk of diabetes (Kjos et al,1998) Should be prescribed with caution, if at all. Aboubakr Elnashar
  68. 68. 5. Prevention of GDM 1.Preconceptual counseling. The risk of future DM Life style advice regarding diet & exercise Avoid obesity Obese to lose weight It may also prevent miscarriage, fetal malformation 2. Metformin before & during pregnancy in women with PCOS {high rate of GDM}. l0-fold reduction (Glueck et al.,2002) Significant reduction in first trimester miscarriage (Glueck et al, 2002; Jakubowicz et al, 2002) Increased live birth rate with no increase in fetal abnormalities or teratogenicity Aboubakr Elnashar
  69. 69. The differences between the results for the prevention and treatment of GDM are of interest. May reflect different responses because of different pathophysiologies of prediabetes and GDM. It seems that prevention may be better than control. Aboubakr Elnashar
  70. 70. Aboubakr Elnashar
  71. 71. •GDM may be associated with a higher rate of fetal malformation, macrosomia; birth trauma & neonatal hypoglycaemia. •Longer term health risks to the mother have been confirmed. •GDM is not itself without risk; the incidence of CS is increased. •Early screening should be done in women with identified risk factors. •Fasting blood glucose is both highly sensitive & simple to implement. Aboubakr Elnashar
  72. 72. •The goal of therapy is maintaining euglycemia & preventing macrosomia. •Glycemic control: FBS <100 mg/dl, 2 h postprandial <125 mg/dl & HbA1c <7%. •Management with diet in first instance, followed by insulin in resistant cases. •Induction of labour should be considered by 38w in insulin requiring GDM. • 75 g OGTT 6 w after delivery is recommended. Aboubakr Elnashar
  73. 73. Thank You Prof. Aboubakr Elnashar Aboubakr Elnashar