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Gestational Diabetes

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Symposium presentation at the annual convention of the Philippine College of Physicians, 6 May 2019. SMX Convention Center.

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Gestational Diabetes

  1. 1. G E S TAT I O N A L D I A B E T E S I R I S T H I E L E I S I P TA N M D , M S C Professor 3, UP College of Medicine Director, UP Manila Interactive Learning Center Chief, UP Medical Informatics Unit S C R E E N I N G M A N A G E M E N T P O S T PA R T U M C A R E
  2. 2. NOTHING TO DISCLOSE I give consent for the audience to tweet this talk and give me feedback (@endocrine_witch). Feel free take pictures of my slides (though it will be on www.slideshare.net/isiptan).
  3. 3. Pregnancy in women with normal glucose metabolism Lower fasting blood glucose Postprandial hyperglycemia & carbohydrate intolerance American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  4. 4. Women with GDM secrete 40-70% less insulin for any degree of insulin resistance vs normal women Buchanan TA et al. What is gestational diabetes? Diabetes Care 2007;30(S2):S105-11
  5. 5. Buchanan TA et al. What is gestational diabetes? Diabetes Care 2007;30(S2):S105-11 Progressive loss of beta cell compensation for insulin resistance (Fig A) leads to progressive hyperglycemia and diabetes (Fig B).
  6. 6. S C R E E N I N G
  7. 7. http://www.asean-endocrinejournal.org/ index.php/JAFES/article/view/98/186
  8. 8. UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186 pregnant women should be screened for gestational diabetes. ALL
  9. 9. UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186 Increased risk of perinatal morbidity Macrosomia Birth injuries Shoulder dystocia Hypoglycemia
  10. 10. Increased risk of maternal morbidity Cesarean section Preeclampsia Pregnancy-induced hypertension Type 2 diabetes UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186
  11. 11. UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186 ALL pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes.
  12. 12. Risk Factors for Gestational Diabetes 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) First-degree relative with type 2 diabetes (PPV 6.7%)4 First-degree relative with type 1 diabetes (PPV 15%)4 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) 1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21. 2 Schytte T, Jorgensen LG, Brandslund I, et al. The clinical impact of screening for gestational diabetes. Clinical Chemistry and Laboratory Medicine 2004;42(9):1036–42. 3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8. 4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.
  13. 13. Risk Factors for Gestational Diabetes 1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21. 3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8. 4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32. 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 CHO metabolism 5 Toulis KA, Goulis DG, Kolibiankis EM, Venetis CA, et al. Risk of gestational diabetes mellitus in women with polycystic ovary syndrome: a systematic review and a meta-analysis. Fertil Steril 2009;92(2):667–77.
  14. 14. UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186 Test high-risk women at the soonest possible time. Test routinely at 24 to 28 weeks gestation for women with no risk factors. Test even beyond 28 weeks gestation for women at risk.
  15. 15. 75-g OGTT to screen for gestational diabetes Any one value meeting the threshold is considered gestational diabetes UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186 FBS 92 mg/dL 1h 180 mg/dL 2h 153 mg/dL
  16. 16. Consume at least 150 g carbohydrate for 3 days preceding OGTT No walking during OGTT Water is allowed during fasting
  17. 17. Preexisting pregestational diabetes Diagnosed using standard criteria for diabetes in the first semester GDM diagnostic criteria were not derived from data in the first half of pregnancy American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  18. 18. M A N A G E M E N T
  19. 19. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 Lifestyle change is essential and may suffice Add medications if needed to achieve glycemic targets 
 70-85% can be managed with lifestyle modification alone with old GDM criteria Possibly more with lower thresholds of new criteria
  20. 20. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 Provide adequate calorie intake for Fetal/neonatal and maternal health Glycemic goals Appropriate gestational weight gain
  21. 21. Calorie needs not different from pregnant women without GDM Dietary reference intake for all pregnant women: minimum of 175 g carbohydrate, 71 g protein and 28 g fiber American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  22. 22. Non-caloric sweeteners in moderation Avoid concentrated sweets (cookies, cakes, pies, soft drinks, chocolate, juice drinks, jams or jellies) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  23. 23. Eat small frequent meals (every 3 hours) Include a good source of protein at every meal and snack (low-fat meat, chicken, fish, low-fat cheese, nuts, peanut butter, cottage cheese, eggs) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  24. 24. Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009) 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)
  25. 25. Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009) Choose high-fiber food Vegetables Beans & legumes Fresh fruit (except at breakfast)
  26. 26. http://www.diabetesforecast.org/2015/adm/diabetes- plate-method/what-is-the-plate-method.html
  27. 27. Monitor urine ketones before breakfast to detect starvation ketonuria. Three meals and three snacks
  28. 28. Fasting <95 mg/dL 1h postprandial <140 mg/dL 2h postprandial <120 mg/dL American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 G LY C E M I C TA R G E T S
  29. 29. Hernandez TL. Patterns of Glycemia in Normal Pregnancy: Should the Current Therapeutic Targets be Challenged? Diabetes Care 2011;34(7):1660-8 MEAN PATTERN OF GLYCEMIA IN NORMAL PREGNANCY (12 studies) vs 140 mg/dL vs 120 mg/dL
  30. 30. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 Insulin is recommended as first-line agent.
  31. 31. I N S U L I N T I M E T O O N S E T P E A K T I M E D U R AT I O N P R E G N A N C Y C AT E G O RY Regular 30 min 3 h 8 h B Aspart 10-15 min 40-50 min 3-5 h B Lispro 10-15 min 30-90 min 3-5 h B Glulisine 10-15 min 55 min 3-5 h C NPH 1-2 h 4-8 h 10-20 h B Detemir 1-2 h None 24 h B Glargine U -100 1-2 h None 24 h No human pregnancy data (previously C) Glargine U-300 >6 h None 24 h No human pregnancy data Degludec 1 h None 42 h (steady state) C Blum AK. Insulin use in pregnancy: an update. Diabetes Spectr 2016;29(2):92-97.
  32. 32. MEAN PATTERN OF GLYCEMIA IN NORMAL PREGNANCY (12 studies) Hernandez TL. Patterns of Glycemia in Normal Pregnancy: Should the Current Therapeutic Targets be Challenged? Diabetes Care 2011;34(7):1660-8
  33. 33. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 Metformin and glibenclamide cross the placenta and are not recommended.
  34. 34. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13 Discontinue metformin once pregnancy is confirmed for women with PCOS. No benefit in preventing spontaneous abortion or GDM
  35. 35. CBG q 4h D5-containing IVF Short- or rapid- acting insulin for CBG >140 mg/dL
  36. 36. P O S T PA RT U M C A R E
  37. 37. Breastfeeding may reduce diabetes risk after GDM pregnancy.
  38. 38. Entire cohort n=522 Gunderson EP et al. Diabetes Care 2012;35:50–56 Glucose tolerance categories among infant-feeding groups of women with history of GDM at 6-9 weeks’ postpartum Normal PreDM DM Entire cohort n=522
  39. 39. Obese women only n=241 Gunderson EP et al. Diabetes Care 2012;35:50–56 Normal PreDM DM Obese women only n=241 Glucose tolerance categories among infant-feeding groups of obese women with history of GDM at 6-9 weeks’ postpartum
  40. 40. 75-g OGTT 4-12 weeks postpartum OGTT is recommended over HbA1c American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  41. 41. Lifetime maternal risk for diabetes is 50-70% after 15-25 years Test every 1-3 years if postpartum OGTT is normal; frequency depends on risk factors American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  42. 42. Both metformin & intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes & a history of GDM. American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13
  43. 43. G E S TAT I O N A L D I A B E T E S I R I S T H I E L E I S I P TA N M D , M S C Professor 3, UP College of Medicine Director, UP Manila Interactive Learning Center Chief, UP Medical Informatics Unit S C R E E N I N G M A N A G E M E N T P O S T PA R T U M C A R E @endocrine_witch

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