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Gestational diabetes mellitus


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Gestational diabetes mellitus

  2. 2. INTRODUCTION • 3-10% of pregnancies: abnormal maternal glucose regulation • 90% due to gestational diabetes mellitus • Definition: glucose intolerance of variable degree with onset or first recognition during pregnancy • Rising prevalence of diabetes: women have some form of diagnosed diabetes particularly type II DM among women of childbearing age--- resulted in increasing number of pregnant women with pre-existing diabetes • Type II- 8% of cases of diabetes mellitus in pregnancy and pre-existing diabetes mellitus now affects 1% of all pregnancies.
  3. 3. Pathophysiology • GDM characterised by hyperinsulinaemia and insulin resistance resulting in abnormal carbohydrate intolerance. • In first trimester and early second trimester, increased insulin sensitivity occurs due to relatively higher levels of estrogen • in late second and early third trimesters, increased insulin resistance and rreduced sensitivity due to a number of antagonistic hormones especially, placental lactogen, leptin, progesterone, prolactin, cortisol and adiponection
  4. 4. IMPLICATIONS OF DIABETES IN PREGNANCY DOUBLE risk of serious injury at birth TRIPLE likelihood of Caesarean delivery QUADRUPLE incidence of Neonatal Intensive Care Unit admission
  5. 5. Effects of Pregnancy on Diabetes • Difficult to stabilise blood glucose during pregnancy due to altered carbohydrate metabolism and impaired insulin action • Insulin requirement increases as pregnancy advances • Accelerated starvation----rapid activation of lipolysis with short period of fasting • Ketoacidosis can be precipitated durring – hyperemesis gravidarum – infection – fasting of labour – Iatrogenically induced by sympathomimetics and corticosteroids used in preterm labour • Accelerates vascular changes
  7. 7. Hyperglycaemia in 1st trimester Impaired organogenesis Congenital abnormalities Chronic maternal hyperglycemia Fetal hyperinsulinaemia Fetal hyperglycaemia Increased fetal oxygen demand Glycosylated Hb carries less oxygen molecule and O2 binds more avidly and releases O2 less Decreased Oxygen tension (hypoxaemia) Increase in anaerobic metabolism increased lactate and acidaemia Abortion/ IUD Increased erythropoiesis Polcythaemia and hyperviscosity RBC breakdown and neonatal hyperbilirubinaemia
  8. 8. Maternal hyperglycaemia Fetal hyperglycaemia Fetal osmotic diuresis Polyhydramnios Polyhydramnios Fetal macrosomia Fetal hyperinsulinaemia fetal hypoglycaemia Increased IGF Obstructed labour Shoulder Dystocia Erb's palsy/ Birth Asphyxia Decreased cortisol production Respiratory distress syndrome decreased surfactant synthesis in lung
  9. 9. Maternal Complications of GDM During Pregnancy Abortion Preterm labour (due to infection or polyhydramnios) Pre-eclampsia Polyhydramnios Maternal distress due to oversized fetus and polydramnios Microangiopathy Nephropathy, retinopathy, neuropathy Large vessel disease Coronary artery disease Thromboembolic disease Infection Hypo and hyperglycaemia During labour Prolonged labour Shoulder dystocia Perineal injuries PPH Operative interference Increased risk of Caesarean delivery Puerperium Puerperal sepsis Lactational failure
  10. 10. Fetal Complications 1st trimester • Congenital abnormalities – Cardiac : ASD, VSD – NTD – Sacral agenesis/ CRS – PCKD – Renal agenesis – Duodenal atresia – Tracheoesophageal fistula 2nd Trimester • Macrosomia Delivery • Birth asphyxia • Shoulder dystocia After delivery • RDS • Hypoglycaemia • Polycythaemia • neonatal jaundice
  11. 11. Fetal and Neonatal Complications of diabetes in pregnancy • Shoulder dystocia leading to brachial plexus injury and clavicular fracture---majority resolve and heal within a few months
  12. 12. GESTATIONAL DIABETES PRE-EXISTING DIABETES No increased risk of congenital anomalies increases risk of fetal macrosomia Increases risk of having Caesarean section Increased risk for metabolic syndrome and type II diabetes later in life (>50% women with gestational diabetes develop type II DM) Babies born to women with gestation diabetes are at inceased risk for obesity, glucose intolerance and diabetes in adolescence Higher risk of congenital malformations and miscarriages Recurrent urinary tract infections Vulvovaginal infections with poor control Associated with risk of (PPPPRIM) Pre-eclampsia, Polyhydraminos, PPROM, Preterm labour, Risk of operative deliveries IUGR Macrosomia Ketoacidosis in type I, progression of microvascular complications Caesarean section rates invariably increased due to fetal macrosomia, poor blood sugar control, polyhydramnios or associated with failure of induction
  13. 13. Risk Factors • Age >25years • BMI >25kg/m² • Increased weight gain during pregnancy • Previous history of large for gestational age infants • History of GDM during previous pregnancies • previous stillbirth with pancreatic islet hyperplasia on autopsy • Ethnic group ( East Asian, Pacific Island ancestry) • Elevated fasting or random blood glucose levels during pregnancy • Family history of diabetes in first degree relatives • History of metabolic X syndrome • History of type I or type II Diabetes Mellitus • Unexplained fetal loss
  14. 14. Signs Elevated serum glucose: severely elevated blood glucose level on random glucose testing excludes the need for screening GLycosuria is od uncertain significance during pregnancy Ketonuria Elevated glycosylated haemoglobin Ultrasound features such as greater than normal abdominal circumference DIAGNOSIS Symptoms Asymtomatic Insidious onset Polyuria, polyuria, polyphagia Vague symptoms of fatige and abdominal discomfort and weight loss Women with established diabetes may have symptoms such as retinopathy or neuropathy
  15. 15. SCREENING AND DIAGNOSTIC INVESTIGATION • NORMAL • Random blood glucose level 11.1mmol/L • Fasting blood glucose level 7.0mmol/L • ABNORMAL • Random bood glucose level ≥ 11.1mmol/L • Fasting blood glucose level ≥ 7.0mmol/L
  16. 16. Glucose Challenge test • 24-28 weeks gestation • 50g glucose drink given to the patient and blood is drawn after 1 hour to measure blood glucose levels • of the test result is positive i.e blood glucose level ≥ 7.2mmol/L (some clinicians use cut off as 7.8mmol/L), then the patient has to undergo the 3 hour 100g oral glucose tolerance test Normal Serum or plasma glucose level 7.2mmol/L Some clinician use a cut off of 7.8mmol/L Abnormal Serum or plasma glucose level ≥ 7.2mmol/L or ≥ 7.8mmol/L
  17. 17. • Advantages • 2 step approach identifies approximately 80% of women with gestational diabetes using of 7.8mmol/L and approximately 90% women with cut off 7.2mmol/L • Disadvantages • False positives common • Sensitivity of Glucose tolerance screening varies with patient ethnicity
  18. 18. Indications • Glycosuria on one occasion before 20th week and • 2 or more occasions thereafter • Glycosuria occuring at anytime during pregnancy with • a positive family history of diabetes or past history of having a baby 4kg or more. • Following positive screening test • If FBG is more than 126mg/dL and if confirmed on repeat testing, there is no need to do MGTT
  19. 19. 75g Oral Glucose Tolerance test- Modified Oral Glucose Tolerance (MGTT) • Patient consume at least 150g carbohydrate for 3 days prior to test • Patient should rest, no smoking, no drugs, no signs and symptoms of infection • Fasting for 12hours is recommended and maternal venous blood is drawn to measure the fasting blood glucose level • A 75g glucose in 300ml drink is given to the patient and blood is drawn at intervals to measure glucose levels. • Only a fasting and 120min sample are needed
  20. 20. WHO Croteria for 2 hours 75g glucose tolerance test whole blood venous (mmol/L) whole blood capillary (mmol/L) Plasma venous (mmol/L) Plasma capillary (mmol/L) Fasting >6.1 >6.1 >7.0 >7.1 2hrs >6.7 >7.8 >7.8 >8.9 Category Normal IGT Diabetes Mellitus Fasting <5.6 5.6-7.8 >7.8 2hrs <7.8 7.8-11.1 >11.1
  21. 21. Other Screening Tests Glycosylated haemoglobin • Blood sample • Reflection f patients glycaemic control over the previous 2-3 months • Ordinarily decreased during pregnancy • Risk of fetal malforrmation correlates with degree of hyperglycaemia during the first 6-8 weeks of gestation if HbA1c is 1% or more above normal • Normal: 4.7-6.3% in non pregnant women, 4.5-5.7% in pregnant women 4.4-5.6% in late pregnancy Advantage: does not require fasting plasma glucose
  23. 23. Antenatal care • All diabetic women are managed in a multidisciplinary combined obstetric and diabetic clinic with specialist obstetrician, diabetologist, specialist midwife, paediatrician and dietician • All women should recieve dietary instruction, with individual recommendations based on weight and height • Patient should recieve nutrition counselling from a registered dietician • Daily calories should be made up approximately 40% carbohydrate, 20% proteins and 40% fats. • This should improve blood glucose levels
  24. 24. Antenatal Care Multidisciplinary approach Dietary instruction with individual instruction based on height and weight Nutrition counselling from registered dietician Daily calories should be made up approximately 40% carbohydrate, 20% proteins and 40% fats. A daily intake of 2000 to 2200 : 30 kcal/kg for women with an ideal prepregnancy weight In women who are obese (BMI: >30kg/m²), calorie reduction by approximately one third (to approximately 25kcal/kg/d) may be acceptable, although caloric restriction during pregnancy must be viewed with caution. Non caloric sweetener used in moderation Increased fibre intake for constipation Vitamins and supplements Avoid alcohol Moderate exercise
  25. 25. Role of Ultrasound • Preferably done in first trimester to confirm gestational age by dates • Repeated at 18 to 20 weeks gestation to evaluate the fetus for congenital anomalies • Particularly important in patients with pre-existing type 1 and 2 diabetes and elvated first trimester HbA1c (>6.5%) • Should be done at 30 to 32 weeks and 36-38 weeks of gestation to evaluate fetal size, amniotic fluid index, and to hlp ascertain the mode of delivery
  26. 26. Tests of fetal wellbeing • Daily fetal movement counting: 32 weeks gestation and continue until delivery • Amniotic fluid index and biophysical profile: – these tests are usually conducted twice weekly and are institued at 32 to 34 weeks of gestation in women on insulin and can be done from 34-36 weeks of gestation in women whose diabetes is controlled by diet – Some clinician mahe patients with diet controlled gestational diabetes as they would a patient with a normal pregnancy without any additional testing.
  27. 27. Blood glucose monitoring • Maternal metabolic surveillance should be directed at maintaining glycaemic control and detecting hyperglycaemia • Target for blood glucose levels are usually • 5.6mmol/L for fasting blood glucose • 7.2mmol/L for 1hr postprandial blood glucose or • 6.7mmol/L for 2hr postprandial blood glucose to reduce macrosomia • Ideally daily self monitoring of blood glucose four times daily is recommended to establish glycaemic control. However in practice it is done fortnightly
  28. 28. • In patients requiring insulin therapy, glucose levels should be checked at least 4 times a day • a glucose level measured first thing in the morning can rule out fasting hyperglycaemia and additional 1 or 2 hour postprandial values can ensure adequate glycaemic control • In patients with diet controlled gestational diabetes, testing 4 times daily may be done once a fortnight • Urine ketones need to be checked periodically during pregnancy
  29. 29. SUMMARY Diagnosis Consult about diet and lifestyle Do blood sugar profile after 1-2 weeks If range between 4-7 mmol/l consider diet therapy If >7mmol/l or type 1 diabetes or U/S show fetal macrosomia, start insulin (actrapid 4-6U tds). Can admit patient for education therapy Antenatal visit fortnightly till 32 weeks, weekly after 32 weeks During check up, monitor BSP and detect any complications of DM Fetus: 11-14weeks correct dating Morphological scanning in 2nd trimester between 18- 22weeks Serial scan for big baby, IUD, polyhydramnios (accelerated growth rate of abdominal circumference indicate macrosomia HbA1c should check for every trimester (especially 1st trimester) Maintain below 7% Check for urinary tract infection and vaginal candidiasis
  31. 31. • Human insulin is treatment of choice when blood glucose is not adequately controlled by diet • Insulin therapy is indicated when diet does not maintain blood glucose levels at 5.8mmol/L for fasting blood glucose, 8.6mmol/L for 1 hr or 7.2mmol/L for 2hour postprandial blood glucose (Obs today) • Insulin therapy also recommended if blood glucose levels are not controlled adequately by diet alone after two week trial
  32. 32. • Regular insulin is the preferred short acting insulin for pregnant patients. • NPH insulin is the preferred intermediate acting insulin for pregnant patients • Therapy is based preferably by self monitoring of blood glucose levels • A patient newly started on insulin will begin at doses of 50-75% of the calculated dose • Insulin dose should be individualised and adjusted according to the patient's blood glucose levels Give actrapid 4-6U TDS Monitor for 2 weeks If still elevated increase until 12 U tds If still cannot control add intermittent acting insulin (monotard) If total of >30U per day, it indicate moderate-severe poor control of DM.
  33. 33. Adverse effects • Hypoglycaemia • Lipoatrophy or lipohypertrophy • Flushing • Rash • Urticaria • Acute edema • Hepatomegaly in high doses
  34. 34. Sulfonylureas Insulin secretagogues GLipizide, glyburide Increase insulin secretion, decrease hepatic glucose production with resultant reversal or hyperglycaemia and indirect improvement of insulin sensitivity Meglitinides Biguanides Decrease insulin resistance Alpha glucosidase inhibitors eg acarbose) decrease intestinal absorption of starch and glucose Thiazolidinediones Eg rosiglitazone and pioglitazone
  35. 35. Oral Antidiabetic agents • Has not been recommende in the part because of concerns of potential teratogenicity and transport of glucose across the placenta • Glyburide: does not cross the placenta in significant amounts and recent trials have said it is safe to use • American College of Obstetricians and Gynecologists and ADA recommend not to prescribe it until further studies support its safetly and efficacy • Include: Sulfonyl ureas (insulin secretagogues)
  36. 36. Time and mode of delivery • All pregnant women advised during the antenatal care about the potential risks of pregnancy progressing beyond term • Gestational diabetes – GDM on diet with no complications can be delivered at 40 weeks – GDM on insulin should be delivered by induction of labour at 38-39 weeks • Pre-existing diabetes – Diabetes itself not an indication for Caesarean Section – Pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean if indicated, after 38 completed weeks – Pregnant women with ultrasound features of macrosomic fetus (fetal weight more than 4.5kg) and poorly controlled blood sugar are delivered by elective caesarean section.
  37. 37. Diabetes and C-section • Preoperative considerations • Patient should take their evening dose of NPH insulin the night before the procedure • Do not take the morning dose of insulin • If necessary, intravenous insulin infusion can be aded to maintain normoglycaemia
  38. 38. • Intraoperative consideration • Maintain normoglycaemia • Postoperative considerations: • Reassess glycaemic control after delivery
  39. 39. • Postpartum Management • Blood glucose levels usually decline rapidly after delivery • Blood glucose levels should be reassessed at 6 weeks after delivery, if not before, an then at 3 year intervals if levels are normal. • If impaired fasting glucose or impaired glucose tolerance are observed postpartum, the patient should be tested annually for diabetes. • All women with gestational diabetes should be counselled regarding diet, weight loss (if needed), and exercise in order to decrease the longterm risk of type 2 • patient with pre-existing diabetes should be transitioned to appropriate treatment postpartum (eg oral agent or adjusted insulin dosage) • Contraception
  40. 40. • After 6 weeks or more following delivery, can diagnose Diabetes Mellitus if symptoms of diabetes mellitus are present Random blood glucose 11.1mmol/L Fasting blood glucose 7.0mmol/L 2hour post prandial 75g glucose tolerance test 11.1mmol/L
  41. 41. Resources • Obstetrics Today- 2nd edition Prof Sachichitanantham and Dr Kavitha Nagandla • DC Dutta • Medscape