Based on the information provided:- The patient's blood glucose levels are increasing despite medical nutrition therapy and lifestyle modifications. - Insulin is recommended as first-line pharmacologic treatment for gestational diabetes when targets are not met with lifestyle changes alone.- Regular insulin or NPH insulin are standard first-line insulin regimens for gestational diabetes.Therefore, the most appropriate next step would be to initiate insulin therapy using regular or NPH insulin as the initial treatment (options A, B, D are not recommended/supported for gestational diabetes). Specifically, starting with regular insulin before meals may help control the patient's pre-meal blood glucose levels (option C
•Download as PPTX, PDF•
11 likes•1,375 views
In this interactive lecture Dr. Vicky Guanzon joins me in discussing the updates on the Diagnosis and Treatment of Diabetes in Pregnancy. Delivered at the L'Fischer Hotel in Bacolod City on August 6, 2015.
Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Viewers also liked (20)
Similar to Based on the information provided:- The patient's blood glucose levels are increasing despite medical nutrition therapy and lifestyle modifications. - Insulin is recommended as first-line pharmacologic treatment for gestational diabetes when targets are not met with lifestyle changes alone.- Regular insulin or NPH insulin are standard first-line insulin regimens for gestational diabetes.Therefore, the most appropriate next step would be to initiate insulin therapy using regular or NPH insulin as the initial treatment (options A, B, D are not recommended/supported for gestational diabetes). Specifically, starting with regular insulin before meals may help control the patient's pre-meal blood glucose levels (option C
Similar to Based on the information provided:- The patient's blood glucose levels are increasing despite medical nutrition therapy and lifestyle modifications. - Insulin is recommended as first-line pharmacologic treatment for gestational diabetes when targets are not met with lifestyle changes alone.- Regular insulin or NPH insulin are standard first-line insulin regimens for gestational diabetes.Therefore, the most appropriate next step would be to initiate insulin therapy using regular or NPH insulin as the initial treatment (options A, B, D are not recommended/supported for gestational diabetes). Specifically, starting with regular insulin before meals may help control the patient's pre-meal blood glucose levels (option C (20)
More from Jeremy F. Robles MD, FPCP, FPSEM
More from Jeremy F. Robles MD, FPCP, FPSEM (9)
Recently uploaded
Recently uploaded (20)
Based on the information provided:- The patient's blood glucose levels are increasing despite medical nutrition therapy and lifestyle modifications. - Insulin is recommended as first-line pharmacologic treatment for gestational diabetes when targets are not met with lifestyle changes alone.- Regular insulin or NPH insulin are standard first-line insulin regimens for gestational diabetes.Therefore, the most appropriate next step would be to initiate insulin therapy using regular or NPH insulin as the initial treatment (options A, B, D are not recommended/supported for gestational diabetes). Specifically, starting with regular insulin before meals may help control the patient's pre-meal blood glucose levels (option C
- 1. Detection and Treatment of Diabetes in Pregnancy Ma. Luz Vicenta V. Guanzon, MD, FPCP, FPSEDM Jeremy F. Robles, MD, FPCP, FPSEDM PHILIPPINE SOCIETY OF ENDOCRINOLOGY, DIABETES & METABOLISM Course in Endocrinology, Diabetes & Metabolism in Bacolod August 6, 2015
- 2. Gestational Diabetes • Condition of Carbohydrate Intolerance with onset or first recognition in pregnancy • Incidence increasing with advancing maternal age and obesity epidemic • Adverse outcomes: • Maternal: gestational hypertension and preeclampsia • Neonatal: hyperinsulinemia, macrosomia, shoulder dystocia, caesarian delivery, hypoglycaemia and later life risk for obesity and type 2 diabetes mellitus Int J Mol Sci. 2015 Jun; 16(6): 13442–13473
- 3. Gestational Diabetes • Gestational Diabetes >>> (26-70%) Type 2 diabetes Mellitus within 10 - 15 years of delivery • Universal screening for GDM in most developed nations (including the Philippines). Selective screening in low risk or poor resource poor setting • RCT’s demonstrated improved maternal and neonatal outcomes with subsequent treatment of GDM • Inflammation and biomarkers provide insights & context to pathophysiology & risk prediction Int J Mol Sci. 2015 Jun; 16(6): 13442–13473
- 4. The vicious cycle of obesity and reproductive complications Int J Mol Sci. 2015 Jun; 16(6): 13442–13473
- 5. Inflammation and insulin resistance in obesity, pregnancy and GDM Int J Mol Sci. 2015 Jun; 16(6): 13442–13473
- 6. Case • 38 yo patient consulted the clinic for advise because she recently found out that she was pregnant. She has a strong familial history of Diabetes with both with her mom & dad currently on insulin therapy. • She is on her 1st pregnancy. Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks. She weighs 90 kg with a BMI of 30 kg/m2.
- 7. Risk Factors for Gestational Diabetes
- 8. Risk Factors for GDM Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282
- 10. Screening * 2011 UNITE FOR DIABETES (PHILIPPINES) • All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C, Level 4) • High-risk women should be screened at the soonest possible time (Grade B, Level 3) • Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B, Level 3) • Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Grade C, Level 3)
- 12. Diagnosis of GDM Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282
- 14. Diagnosis of GDM Glucose Levels 2011 POGS 2011 UNITE/ IADPSG 2015 ADA 1 step approach 2 step approach Step 1: >/=130-140 mg/dL (7.8 mmol/L), proceed to a 100-g OGTT Fasting >/=92 mg/dL (5.1 mmol/L) >/=92 mg/dL (5.1 mmol/L) >/=95 mg/dL (5.1 mmol/L) >/=105 mg/dL (5.8 mmol/L) 1 hour - - - >/=180 mg/dL (10.0 mmol/L) >/=180 mg/dL (10.0 mmol/L) >/=190 mg/dL (10.6 mmol/L) 2 hours >/=140 mg/dL (7.8 mmol/L) >/=153 mg/dL (8.5 mmol/L) >/=155 mg/dL (8.6 mmol/L) >/=165 mg/dL (9.2 mmol/L) 3 hours - - - - - - >/=140 mg/dL (7.8 mmol/L) >/=145 mg/dL (8.0 mmol/L) Needs at least 1 Needs at least 1 Needs at least 2 Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS. Those with glucosuria, elevated CBG or HbA1c should undergo OGTT.
- 15. Diagnosis of Overt Diabetes in Pregnancy Parameter Consensus threshold FBS > or = 7.0 mmol/l or 126 mg/dl HbA1c > or = 6.5% (DCCT/UKPDS standardized) RBS > or =11.1 mmol/l (200 mg/dl) If a random plasma glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be confirmed by FPG or A1C using a DCCT/ UKPDS-standardized assay. Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS. Those with glucosuria, elevated CBG or HbA1c should undergo OGTT.
- 16. Case • Patient took a 75 gm OGTT test with the following results: FBS = 120mg/dl ; 2nd hr glucose 180mg/dl • She was diagnosed to have Gestational Diabetes. • Counselling for GDM was initiated, the discussion included self monitoring of blood glucose and lifestyle modification
- 17. Case Monitoring day 1 (mg/dl) pre - breakfast 130 1 hr post BF 180 pre - lunch 135 1 hr post lunch 150 pre - dinner 120 1 hr post dinner 115 bedtime 120 • 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day • Patient was referred to the Dietary Department for instructions and counselling • Management plans were discussed with the patient
- 18. Case • Patient was asked to be admitted for monitoring of blood sugar and initiation of therapy • 7 point monitoring for blood sugars was started pre- meals, 1 hour post meals and bedtime • Patient was referred to the Dietary Department for instructions and counselling
- 19. Treatment Targets of Gestational Diabetes
- 20. Treatment Targets for GDM Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282
- 22. Medical Nutrition Therapy • All women with GDM should receive nutritional counselling for Medical Nutrition Therapy (MNT) • Individualized MNT: • adequate calories & nutrients for pregnancy • consistent with maternal blood glucose goals • Noncaloric sweeteners may be used in moderation. * 2015 American Diabetes Association
- 23. Medical Nutrition Therapy • MNT is a primary therapy for 30-90% of women with GDM ( decrease A1c by 1%) • Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain, normoglycemia and absence of ketosis. • Nutrition therapy + SMBG = positive impact on maternal & infant outcomes * 2007 Diabetes Care (Reader DM)
- 24. Weight Gain During Pregnancy * 2013 American College of Obstetricians and Gynecologists (12.5-13 kg) (11.5-16 kg) (7-11.5 kg) (5- 9 kg) (0.5kg) (0.4 kg) (0.3 kg) (0.2 kg) Recommended Daily Allowance (RDA) +340 kcal/day for 2nd trimester +452 kcal/day for 3rd trimester
- 25. Case • Patient had a BMI of 28 kg/m2 prior to getting pregnant. • Based on IOM weight recommendation we expect her to gain 7 - 11.5 kg in this pregnancy. Recommended weight gain in the 2nd and 3rd trimester would be 0.3 kg per week • Remember to add +340 kcal/day for 2nd trimester and +452 kcal/day for 3rd trimester to the total caloric requirement
- 26. Medical Nutrition Therapy • Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal) • <1500 kcal/day increase ketonuria & ketonemia • Caloric requirement per day using pre gravid wt: • 25 - 30 kcal/kg for overweight patients • 30 - 35 kcal/kg for normal weight patients • 35 - 40 kcal/day for under weight patients * 2007 Diabetes Care (Reader DM)
- 27. Medical Nutrition Therapy • 175 g carbohydrate/day for pregnant • Limit carbohydrate intake 35-45% (main nutrient that affects post prandial glucose levels) • Low glycemic index (<55) produce lower post meal glucose elevations ( decrease A1c by 0.4% ) • No specific glucose benefit with high fiber diet. * 2007 Diabetes Care (Reader DM)
- 28. Caloric Distribution of Meals • 40-45% of total calories for Carbohydrates • 20-25% of total calories for Protein • 35-40% of total calories Fat Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009
- 29. Dietary Recommendations for Gestational Diabetes • Breakfast matters - eat smaller amounts • Avoid fruit juice • Strictly limit sweets and desserts • Use artificial sweeteners ( equal or splenda) • Keep food records * http://www.ucsfhealth.org/
- 30. Dietary Recommendations for Gestational Diabetes • Distribute between 3 meals and 2-3 snacks / day • Eat reasonable portions of starch • Drink one cup of milk at a time • Limit fruit portions • Do not eat fruit that has been canned in syrup. * http://www.ucsfhealth.org/
- 31. Case • Caloric Distribution were as follows: • 10% Breakfast ; 30% Lunch ; 30% Dinner • 10% snacks x 3 • Meal Distribution were as follows: • Carbohydrates 45% ; Protein 25 % ; Fat 30%
- 32. Physical Activity • Exercise is an adjunct to MNT • Monitor fetal activity & blood glucose levels • Limit physical activity to 15 - 30 mins • GDM patients to walk briskly or do arm exercises while seated in a chair for at least 10 min after each meal accomplishes this goal DIABETES CARE, VOLUME 30, SUPPLEMENT 2, JULY 2007
- 33. Pharmacologic Treatment of Gestational Diabetes
- 34. Pharmacologic Treatment of GDM Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282 If targets not achieved with lifestyle modifications within 2 weeks initiate pharmacotherapy
- 35. Medication with limited &/or no data in Gestational Diabetes Management Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282 Agent Summary of Available data Therapeutic considerations Alpha glucosidase inhibitors limited to no human data available Not recommended for use currently DPP IV inhibitors limited to no human data available GLP-1 receptor agonists no human data available Meglitinides no human data available animal studies - fetal adverse SGLT-2 inhibitors no human data available animal studies - fetal adverse Thiazolidinediones no human data available animal studies - fetal adverse
- 36. Insulin therapy for Gestational Diabetes
- 38. Glucose Homeostasis in Pregnancy
- 39. Insulin therapy in GDM Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282 • Many guidelines continue to recommend insulin as the first-line therapy • Regular insulin is the standard against which rapid analogs are compared • Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared
- 41. Question? Due to the concern that her glucose values are increasing, what would you recommend as the next step to help manage her blood glucose? A. Exenatide B. Glyburide C. Insulin D. Pioglitazone
- 42. Question? Which of the type of insulin would be most appropriate for the initial treatment for the patient? A. Regular insulin B. Rapid acting analog insulin C. Neutral protamine hagedorn D. Long acting analog insulin
- 43. Case day 1 (mg/dl) Insulin coverage day 2 (mg/dl) Insulin coverage day 3 (mg/dl) Insulin coverage pre - breakfast 130 - - - 120 rapid insulin 4 units sc 95 rapid insulin 4 units sc 1 hr post BF 180 - - - 115 - - - 120 pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin 4 units sc 122 rapid insulin 6 units sc 1 hr post lunch 150 - - - 160 - - - 118 pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin 4 units sc 115 rapid insulin 4 units sc 1 hr post dinner 115 - - - 110 - - - 120 bedtime 120 - - - 110 5 units intermediate insulin sc 116 5 units intermediate insulin sc
- 44. Case day 1 (mg/dl) Insulin coverage day 2 (mg/dl) Insulin coverage day 3 (mg/dl) Insulin coverage pre - breakfast 130 - - - 120 rapid insulin 4 units sc 95 rapid insulin 4 units sc 1 hr post BF 180 - - - 115 - - - 120 pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin 4 units sc 122 rapid insulin 6 units sc 1 hr post lunch 150 - - - 160 - - - 118 pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin 4 units sc 115 rapid insulin 4 units sc 1 hr post dinner 115 - - - 110 - - - 120 bedtime 120 - - - 110 5 units intermediate insulin sc 116 5 units intermediate insulin sc
- 45. Case day 1 (mg/dl) Insulin coverage day 2 (mg/dl) Insulin coverage day 3 (mg/dl) Insulin coverage pre - breakfast 130 - - - 120 rapid insulin 4 units sc 95 rapid insulin 4 units sc 1 hr post BF 180 - - - 115 - - - 120 pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin 4 units sc 122 rapid insulin 6 units sc 1 hr post lunch 150 - - - 160 - - - 118 pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin 4 units sc 115 rapid insulin 4 units sc 1 hr post dinner 115 - - - 110 - - - 120 bedtime 120 - - - 110 5 units intermediate insulin sc 116 5 units intermediate insulin sc
- 46. Case day 1 (mg/dl) Insulin coverage day 2 (mg/dl) Insulin coverage day 3 (mg/dl) Insulin coverage pre - breakfast 130 - - - 120 rapid insulin 4 units sc 95 rapid insulin 4 units sc 1 hr post BF 180 - - - 115 - - - 120 pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin 4 units sc 122 rapid insulin 6 units sc 1 hr post lunch 150 - - - 160 - - - 118 pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin 4 units sc 115 rapid insulin 4 units sc 1 hr post dinner 115 - - - 110 - - - 120 bedtime 120 - - - 110 5 units intermediate insulin sc 116 5 units intermediate insulin sc
- 47. Case • Patient was discharged with the following insulin regimen: • Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc) • Intermediate acting insulin 5 units at bedtime • Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )
- 48. Case • Patient was asked to follow up after 2 weeks • Her blood sugar level levels remained controlled with her insulin regimen. She continued her diet and had light exercises • Succeeding follow up was unremarkable. Blood sugars remained controlled throughout pregnancy with minor insulin adjustments.
- 49. Insulin therapy in GDM • Insulin requirements progressively increases throughout pregnancy: 0.7 unit/kg up to week 12 0.8 unit/kg for weeks 13 to 26 0.9 unit/kg for weeks 26 to 36 1.0 unit/kg for weeks 36 to term. Obese patients may require 1.5 to 2.0 units/kg to overcome the combined insulin resistance & obesity. Uptodate 2015
- 50. Post Partum Management Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282 • Maternal and infant blood glucose should be monitored very closely. • Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline • Breastfeeding is encouraged; metformin, glyburide, glipizide, and insulin are considered preferred therapies in breastfeeding women
- 51. Question? How will you follow up your Gestational Diabetes patient? A. Follow- up after 2 weeks B. Follow- up after 2 months C. Follow- up after 2 years D. No need for follow-up
- 52. Kelly KW, Carroll DG, Meyer A. Drugs in Context 2015; 4: 212282 • Post partum follow up should be done between 6 weeks to 6 months. • Interval periodic screening for high risk patients done yearly & 2-3 year interval for low risk patients. • Various screening methods may be utilized for follow up ( OGTT, FBS, HbA1c ) Post Partum Management
- 53. • Randomized trials have shown that medical nutritional therapy, self-monitoring of blood glucose levels, & insulin therapy, when needed improves perinatal outcome in GDM patients • Medical nutritional therapy is the initial approach • Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity Key points
- 54. • Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone • Glyburide & metformin oral medications are alternatives to patients who refuse or cannot comply with insulin • Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus. Key points
- 55. Detection and Treatment of Diabetes in Pregnancy The Filipino Endocrinologist teaching the Filipino Doctor. www.endo-society.org.ph PHILIPPINE SOCIETY OF ENDOCRINOLOGY, DIABETES & METABOLISM Course in Endocrinology, Diabetes & Metabolism in Bacolod August 6, 2015
Editor's Notes
- Women with adverse lifestyle factors and excess weight are more likely to develop polycystic ovarian syndrome (PCOS) and subfertility. They are likely to enter pregnancy overweight and are at increased risk for excess gestational weight gain (GWG). Obesity and excess GWG results in a three-fold increased risk of adverse pregnancy outcomes including gestational diabetes mellitus (GDM), and may have epigenetic impacts including long term metabolic syndrome and cardiovascular disease for mother and baby. Post-partum weight retention contributes to prevalent obesity and type 2 diabetes mellitus (T2DM) long-term and to risks in subsequent pregnancies [10].
- A proposed model of inflammation and insulin resistance in obesity, pregnancy and GDM. Women who are obese have features of chronic low-grade inflammation, manifest by increased tumour necrosis factor alpha (TNF-α), interleukin-6 (IL-6), interleukin-12 (IL-12), and high sensitivity C-reactive protein (hsCRP). Obesity is characterised by insulin resistance, and down-regulation of adiponectin and up-regulation of leptin, resistin and retinol-binding protein-4 (RBP4) contribute to this. Pregnancies occurring in obese women are characterised by further inflammation and a Th-2 predominant immune response, which may contribute to pregnancy complications. Foetal and placental hormones, production of abnormal growth factors and tissue remodelling may contribute to inflammation and increasing insulin resistance. GDM develops when beta cell dysfunction coexists, and may be characterised by further abnormalities in adipokine and cytokine profiles, increased free fatty acids (FFA), triglycerides (TG), low vitamin D and endothelial dysfunction.
- POGS locally advocate universal screening for type 2 diabetes mellitus in the first pre natal visit.
- HAPO findings indicating that associations between maternal glycemia and adverse outcomes are continuous across the range of glucose concentrations below levels diagnostic of diabetes. HAPO data show strong linear associations of risks for 90th percentiles of birth weight, cord C-peptide, and percent body fat with each of three measures of maternal glucose (FPG, 1-h, and 2-h post–75-g load) Among the HAPO cohort, 11.1% had only one elevated result, 3.9% had two elevated results, and 1.1% had elevation of all three results. The total incidence of GDM was 17.8%; the FPG plus 1-h plasma glucose levels identified a large majority of these individuals.
- No limit is placed on the timing of initial assessment for detection of overt diabetes in pregnancy. However, if enrolment is at 24 weeks’ gestation or later and overt diabetes is not found, the initial test should be followed by a 75-g OGTT.
- Glucose Homeostasis in Pregnancy In order to better evaluate the potential long-term implications of GDM, we first considered the physiology of glucose homeostasis in pregnancy, underlining those modifications that are more likely to lead to the development of GDM. Pregnancy is characterized by a complex endocrine–metabolic adaptation process including impaired insulin sensitivity, increased β-cell response, moderately increased blood glucose levels (particularly following the ingestion of a meal), and changes in the levels of circulating free fatty acids, triglycerides, cholesterol and phospholipids.[7] These changes do not reflect a pathological condition; rather, they represent a necessary and indispensable adaptation to meet the energy demands of the fetus and to prepare the maternal organism for delivery and lactation. In fact, the insulin resistance developing in pregnancy is likely to be a physiological event favoring glucose supply to the fetus. The reduced insulin-mediated utilization of glucose switches the maternal energy metabolism from metabolizing carbohydrates to lipid substrates (i.e., free fatty acids), redirecting carbohydrates toward the fetal tissues.[8] The insulin resistance that develops during pregnancy is similar to that observed in T2DM, with impaired insulin action mainly as a result of postreceptor alterations involving glucose transport and intracellular metabolism in insulin-sensitive tissues.[9] The degree of insulin resistance seems to be influenced by obesity and inheritance. In fact, in obese women (BMI > 30; or weight > 150% of ideal body weight) the incidence of GDM is 1.4- to 20-fold higher than that in normal weight subjects.[10] Despite insulin resistance, glucose homeostasis is maintained in normal pregnancies by a concomitant compensatory increase in insulin secretion. The intolerance to carbohydrates develops as soon as β-cell secretion is no longer sufficient to compensate for insulin resistance (Figure 1). Although the specific mechanism(s) of the alteration of insulin secretion and action remain uncertain, a substantial contribution is made by endocrine modifications that accompany pregnancy. Changes in β-cell function occur in parallel with the development of the feto–placental unit and the local production of hormones, such as estrogens, progesterone, cortisol, human chorionic somatotropin, placental lactogen, prolactin and growth hormone (Table 1). These hormones have been shown to induce insulin resistance both in vitro and in vivo.[12] Moreover, the increase of TNF-α, an inflammatory marker, is the strongest predictor of impaired insulin action during pregnancy, far stronger than gestational hormones such as human placental lactogen and steroids.[13] In women with GDM, the impaired insulin-mediated glucose utilization and the inadequate increase in first-phase insulin secretion are the initial alterations of glucose homeostasis that cause the plasma glucose excursion after meal ingestion and post-oral glucose tolerance test (OGTT) hyperglicemia. The loss of early insulin release in these women is likely to contribute to the glucose intolerance and postprandial hyperglycemia, and is considered to be a marker of glucose homeostasis impairment. Xiang et al. estimated that women with GDM have a 67% reduction in pancreatic β-cell effect as compared with normal pregnant women.[14]