1. 2 Mar 2012
GESTATIONAL DIABETES
MANAGEMENT
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Wednesday, 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 above
Wednesday, 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
6. Risky
Cesearean Section Preeclampsia
Increased
risk of
maternal
morbidity
Pregnancy-induced hypertension Type 2 diabetes mellitus
http://www.flickr.com/photos/ulybug/512369383/
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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 above
Wednesday, 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 baby
Wednesday, 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
CPG
Wednesday, 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
CPG
Wednesday, 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 baby
Wednesday, 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 above
Wednesday, 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.
Testing
Wednesday, 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 above
Wednesday, 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) FBS
Wednesday, November 21, 12
17. ★ Capillary blood glucose
★ RBS
★ Fructosamine
★ FBS
★ Hba1c
★ Urine glucose
NOT to be used
for diagnosis of GDM
Use
OGTT
Wednesday, 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 & Diabetes
Wednesday, 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
samples
Wednesday, 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) FBS
Wednesday, 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 test
Wednesday, 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
OGTT
Wednesday, 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
OGTT
Wednesday, 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 test
Wednesday, 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 above
Wednesday, 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 exceeded
Wednesday, 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 above
Wednesday, 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 exceeded
Wednesday, 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):751-3
Wednesday, 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 Diabetes
Wednesday, November 21, 12
34. “Non-c aloric sweeteners may
be used in moderation.”
ADA GDM Position Statement 2004
Wednesday, 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 lbs
Wednesday, 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
Text
Wednesday, 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
IOM
Wednesday, 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 lbs
Wednesday, 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 2004
Wednesday, 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 2007
Wednesday, 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 above
Wednesday, 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 2007
Wednesday, 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 above
Wednesday, November 21, 12
47. Q11
Can we give Metformin
for GDM?
a) Yes
b) No
Wednesday, 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
OHA
Wednesday, 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
Insulin
Wednesday, November 21, 12
50. Q11
Can we give Metformin
for GDM?
a) Yes
b) No
Wednesday, 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 above
Wednesday, 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 above
Wednesday, 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 above
Wednesday, 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
ASGODIP
Wednesday, 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)
ASGODIP
Wednesday, 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 above
Wednesday, 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 limited
Wednesday, 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 plans
Wednesday, 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 2004
Wednesday, 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 2008
Wednesday, 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 limited
Wednesday, November 21, 12
63. Thank You
http://www.endocrine-witch.net
@endocrine_witch
Image from http://wthr.frumph.net/
Wednesday, November 21, 12