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Clinical Practice Guideline
Gestational Diabetes
 Iris Thiele Isip Tan MD, FPCP, FPSEM
            MS Health Informatics (cand.)
Clinical Associate Professor, UP College of Medicine
 Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital
                                          18 March 2010
AACE




          A
         AD
IDF           CDA

     P
  DI
                                   HAPO
  GO


          NICE
AS




                                       IADPSG

              Disclosure
              None ...

              Where guidelines disagreed, I
              picked the one I agreed with ☺
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Referred for rapid
weight gain of 5 kg in
the last 4 weeks

Her mother has
type 2 diabetes


S c re e n fo r G DM?
There is not sufficient
                                            high-level evidence to
                                            make a recommendation
                                            for, or against, screening
                                            for GDM.
                                                 US Preventive Services Task Force 2008
                                                       UK National Health Service 2002
                                                                Canadian Task Force on
                                                      Periodic Health Examination 1994




“Screening, diagnosis
and treatment of
gestational diabetes is
cost-effective.”
         UK National Institute for Health
           and Clinical Excellence 2008
No consensus on GDM screening

      Who? When? How?
International Association of Diabetes
                             1998
                                       and Pregnancy Study Groups
                                       Recommendations on the Diagnosis
                                       and Classification of Hyperglycemia
                                       in Pregnancy. Diabetes Care
                                       Mar 2010; 33(3):676-82.
                            cilitate
Umbrella organization to fa
collaboration
                                       “This report represents
                                       the opinions of
                                       individual members of
                                       the IADPSG Consensus
                                       Panel and does not
                                       necessarily reflect the
                                       position of the
                                       organizations they
                                       represent.”
Overt Dia be te s   First prenatal visit
                    in Preg na ncy
                                       Measure FPG, A1c or
FPG >7 mmol/L
 A1c >6.5%
                                       random plasma glucose
RPG >11.1 mmol/L                       in all or only on high-risk
                                       women
                                                             IASDPG Consensus Panel
                                                Diabetes Care Mar 2010; 33(3):676–682.



If results not diagnostic of
overt diabetes and
   FPG 5.1-6.9 mmol/L
   (92-125 mg/dL) → GDM
   FPG <5.1 mmol/L →
   75-g OGTT at
   24-28 wks AOG
75-g OGTT thresholds
                                    FPG 5.1 mmol/L (92 mg/dL)
                                    1-h PG 10.0 mmol/L
                                    (180 mg/dL)
Be nefit o f e a r ly te s t ing?    2-h PG 8.5 mmol/L
                                    (153 mg/dL)
                                                        IASDPG Consensus Panel
                                           Diabetes Care Mar 2010; 33(3):676–682.


 75-g OGTT at 24-28 wks
     Overt diabetes if FPG >7.0
     mmol/L (126 mg/dL)
     GDM if one or more values
     equals or exceeds
     thresholds
     Normal if all values on
     OGTT less than thresholds
First prenatal visit
                             Screen women at very
                             high risk using standard*
                             diagnostic testing.
                             * FPG, HbA1c, 75-g OGTT or random
                             plasma glucose
                                          ADA Standards of Medical Care 2010


Very high risk
  Severe obesity
  Prior history of GDM or
  delivery of LGA infant
  Presence of glycosuria
  Diagnosis of PCOS
  Strong family history of
  Type 2 diabetes
Greater than low risk
                                        women
                                        Test for GDM at 24-28
                                        weeks AOG
                                        Low risk women
                                        No testing required
                                                  ADA Standards of Medical Care 2010

Low risk (must fulfill all)
  Age < 25 years
  Weight normal before pregnancy
  Ethnic group with low DM prevalence
  No known diabetes in first-degree
  relatives
  No history of abnormal glucose
  tolerance
  No history of poor obstetrical
  outcome
1996

               IADPSG              ADA            ASGODIP
First                                             50-g GCT
              FPG, HbA1c or    FPG, HbA1c, 75-g
prenatal      random plasma    OGTT or random     (low risk) or
visit         glucose          plasma glucose     75-g OGTT
                                                  (high risk)

Further                        GCT ➝ 100-g OGTT If GCT <130
          75-g OGTT if FPG
testing   <5.1 mmol/L          100-g OGTT (1-step) If 2-h OGTT
24-28 wks                                          <140
                                  100-g OGTT
Thresholds FPG >7 mmol/L
                 .0               FPG 95 mg/dL    75-g OGTT 2h
              Overt diabetes      1-h 180 mg/dL   140 mg/dL
     75-g OGTT any value          2-h 155 mg/dL
     FPG 5.1 mmol/L (92 mg/dL)    3-h 140 mg/dL
     1-h 10 mmol/L (180 mg/dL)          at least 2
     2-h 8.5 mmol/L (153 mg/dL)
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Referred for rapid
weight gain of 5 kg in
the last 4 weeks

Her mother has
type 2 diabetes


FBS or 75-g OGTT?
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG



75- g OGT T:
Fa stin g 102 ⤳ GDM
1 h PG 192 by FBS
2 h PG 155 criterion
Diet prescription
in GDM?

“Initiate MNT immediately
once diagnosed.”
                   AACE 2007
“All women with GDM
                               should receive
                               nutritional counseling by
                               a registered dietitian
                               when possible.”
                                      ADA GDM Position Statement 2004




Choose where possible
 CHO from low GI sources
 Lean proteins including
 oily fish
 Balance of poly- and
 monounsaturated fats
                   NICE 2008
If pre-pregnancy BMI >27,
                                    restrict caloric intake to
                                    <25 kcal/kg/day ...

                                    ... and take moderate
                                    exercise (>30 min daily).
                                                        NICE 2008


Obese women (BMI >30):
30-33% calorie
restriction (to ~25 kcal/kg
actual weight/day)
Restrict CHO to 35-40%
of calories.   ion Statement 2004
          ADA GDM Posit
Monitor urine ketones
before breakfast to detect
starvation ketonuria

3 meals and 3 snacks
  50-60% complex high
  fiber carbohydrates
  18-20% protein or at
  least 75 g
  <30% fats
                 ASGODIP 1996
“Non-caloric sweeteners
may be used in
moderation.”
       ADA GDM Position Statement 2004
31/F obese pregnant
 (pre-pregnancy BMI 30)
 20 weeks AOG

Ht 165 cm Wt 90 kg
TC R = 90 x 25 kc al/kg =
2250 kc al/day

3 me als an d 3 sna cks
CH O (50%) 281 g
CH ON (20%) 112 g
fats (30%) rest

Ur ine keton es at ff- up
Blood glucose
 monitoring?
 “SMBG is essential
 during pregnancy.”
   Canadian Diabetes Association 2008
“Daily SMBG appears to
                                          be superior to intermittent
                                          office monitoring of
                                          plasma glucose.”
                                                  ADA GDM Position Statement 2004




“For women treated with
insulin, limited evidence
indicates that
postprandial monitoring
is superior to preprandial
monitoring.”
        ADA GDM Position Statement 2004
Both preprandial and postprandial
testing are recommended.

If on insulin, test at night because of
increased risk of nocturnal hypoglycemia.

                            Canadian Diabetes Association 2008
Patients should
intensively monitor BG
                   AACE 2007



                               Insulin therapy
Diet only                      Monitor BG 6x a day
Monitor BG 4x a day            (before each meal* and
(prebreakfast and 1 h          1 h after the first bite of
after the first bite of food    food at each meal)
at each meal)
                               * to determine insulin
                               dosage correction
“Urine glucose monitoring
                                          is not useful in GDM.”

                                                 ADA GDM Position Statement 2004




“Urine ketone
monitoring may be useful
in detecting insufficient
or caloric or CHO intake
in women treated with
caloric restriction.”
        ADA GDM Position Statement 2004
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Diagnosed GDM

MNT started
Monitor CBG 3x a day,
alternate between
- prebreakfast and 1 h
after breakfast & lunch
- 1 h after meals
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Diagnosed GDM


After 2 weeks
Preprandial CBGs
70-80 mg/dL
1h Postprandial CBGs
130- 150 mg/dL
How long can we wait before
declaring diet therapy a failure?
Consider insulin
when ...




                   Diet and exercise fail to
                   maintain glucose targets
                   during a period of 1-2 weeks
                   Ultrasound suggests incipient
                   fetal macrosomia (AC >70th
                   percentile)
                                        NICE 2008
Glucose targets
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
“HbA1c should not be
used routinely for
assessing glycemic
control in the second
and third trimesters of
pregnancy.”
                  NICE 2008
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Diagnosed GDM
Preprandial CBGs
70-80 mg/dL
1h Postprandial CBGs
130-150 mg/dL
Start insulin to bring
down postprandial CBGs
Can we give
Metformin in GDM?

Ho w ab ou t
Gli ben cla mide?
Off-label use


Use of metformin or
glibenclamide during
pregnancy not an
approved indication
Discuss with patients




    Canadian Diabetes Association 2008
Option of giving
                                           metformin or
                                           glibenclamide


                                           Obtain and document
                                           informed consent.


                                           “... tailored to glycemic
                                           profile of, and
                                           acceptability to, the
                                           individual woman.”
Me tfo rm in in Ges tat ion al Dia betes
(M iG) Stu dy                                                 NICE 2008
Combination
therapy

MiG study
Women taking
metformin (who had
insulin added) required
lower insulin dose

? metformin +
glibenclamide
                   IDF 2009
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
Recommended
insulin regimens?

Prandial, basal bolus,
split-mixed? Analogues?
Initiate a basal-bolus
regimen if a patient
cannot maintain
glucose targets with
diet alone.
NPH insulin (basal) and
rapid-acting insulin at meals
Subcutaneous insulin
infusion with an insulin pump

                       AACE 2007
Insulin regimens
in GDM
 Intermediate-acting insulin
 30 min prebreakfast and
 presupper + rapid-acting
 insulin
 3 injections of rapid-acting
  insulin given 30 min before
  each meal + intermediate-
  acting OR long-acting
  insulin at bedtime

                                ASGODIP 1996
Insulin therapy
in GDM

Initiating dose depends
on the blood glucose

May start daily insulin
dose 0.1-0.3 u/kg BW




                          ASGODIP 1996
Which type of insulin
and which regimen?
Discuss with patient.



“ ... rapid-acting insulin
analogues (aspart and
lispro) have advantages
over soluble human
insulin during
pregnancy ...”


                    NICE 2008
31/F obese pregnant
(pre-pregnancy BMI 30)
20 weeks AOG

Diagnosed GDM
Ht 165 cm Wt 90 kg
Preprandial CBGs
70-80 mg/dL
1h Postprandial CBGs
130-150 mg/dL
Start prandial (regular)
insulin i.e. 4-6 units
premeals tid
How often to
follow-up?
Subsequent Visits
Every 2 weeks for
  Glycemic control: check
  2-h PPBG
  Obstetric complications:
  macrosomia, IUGR,
  preeclampsia, and
  hydramnios


                    ASGODIP 1996
Ultrasound

 At first visit to determine
 age of pregnancy
 At 20-22 wks to detect
 malformations
 At 32-34 wks to monitor
 growth


                              ASGODIP 1996
Management
during labor and
delivery
Protocol for
Spontaneous Delivery

 Infusion of 500 ml 5%
 dextrose/saline x 4 h
 CBG q 4h
 Give short-acting insulin for
 CBG >140 mg/dL
  - Dose equal to mmol of CBG
  i.e. 12 u for 12 mmol/L
  - Dose equal to 1/20th of mg/dL of
  CBG i.e. 12 u for 240 mg/dL
  Omit insulin for CBG <140
  mg/dL                                ASGODIP 1996
Maternal hyperglycemia
is the main cause of
neonatal hypoglycemia
 Insulin is still required before
 active labor; SC or IV to
 maintain BG 70-90 mg/dL
 Infuse glucose 2.5 mg/kg/
 min
  Measure CBG q hourly
  Double the glucose infusion
  for the next hour if BG <60
  mg/dL
  Give regular insulin SC or IV
  for BG >120 mg/dL                 AACE 2007
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 1996
Postpartum
follow-up
Reclassify at least 6
weeks after delivery


Reassess q 3 years if
normal BG postpartum

Test for diabetes annually
if with IFG or IGT
postpartum



       ADA GDM Position Statement 2004
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
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
“As always, solutions of an
immediate problem raise questions
for the future.”
                    Robert G. Moses, MD
ht tp:/ w w. slide sh are.net/i sip ta n
       /w

                      Thank You
     h ttp://www.endocrine-witch.info

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Clinical Practice Guideline: Gestational Diabetes

  • 1. Clinical Practice Guideline Gestational Diabetes Iris Thiele Isip Tan MD, FPCP, FPSEM MS Health Informatics (cand.) Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital 18 March 2010
  • 2. AACE A AD IDF CDA P DI HAPO GO NICE AS IADPSG Disclosure None ... Where guidelines disagreed, I picked the one I agreed with ☺
  • 3. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Referred for rapid weight gain of 5 kg in the last 4 weeks Her mother has type 2 diabetes S c re e n fo r G DM?
  • 4. There is not sufficient high-level evidence to make a recommendation for, or against, screening for GDM. US Preventive Services Task Force 2008 UK National Health Service 2002 Canadian Task Force on Periodic Health Examination 1994 “Screening, diagnosis and treatment of gestational diabetes is cost-effective.” UK National Institute for Health and Clinical Excellence 2008
  • 5. No consensus on GDM screening Who? When? How?
  • 6. International Association of Diabetes 1998 and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care Mar 2010; 33(3):676-82. cilitate Umbrella organization to fa collaboration “This report represents the opinions of individual members of the IADPSG Consensus Panel and does not necessarily reflect the position of the organizations they represent.”
  • 7. Overt Dia be te s First prenatal visit in Preg na ncy Measure FPG, A1c or FPG >7 mmol/L A1c >6.5% random plasma glucose RPG >11.1 mmol/L in all or only on high-risk women IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682. If results not diagnostic of overt diabetes and FPG 5.1-6.9 mmol/L (92-125 mg/dL) → GDM FPG <5.1 mmol/L → 75-g OGTT at 24-28 wks AOG
  • 8. 75-g OGTT thresholds FPG 5.1 mmol/L (92 mg/dL) 1-h PG 10.0 mmol/L (180 mg/dL) Be nefit o f e a r ly te s t ing? 2-h PG 8.5 mmol/L (153 mg/dL) IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682. 75-g OGTT at 24-28 wks Overt diabetes if FPG >7.0 mmol/L (126 mg/dL) GDM if one or more values equals or exceeds thresholds Normal if all values on OGTT less than thresholds
  • 9. First prenatal visit Screen women at very high risk using standard* diagnostic testing. * FPG, HbA1c, 75-g OGTT or random plasma glucose ADA Standards of Medical Care 2010 Very high risk Severe obesity Prior history of GDM or delivery of LGA infant Presence of glycosuria Diagnosis of PCOS Strong family history of Type 2 diabetes
  • 10. Greater than low risk women Test for GDM at 24-28 weeks AOG Low risk women No testing required ADA Standards of Medical Care 2010 Low risk (must fulfill all) Age < 25 years Weight normal before pregnancy Ethnic group with low DM prevalence No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetrical outcome
  • 11. 1996 IADPSG ADA ASGODIP First 50-g GCT FPG, HbA1c or FPG, HbA1c, 75-g prenatal random plasma OGTT or random (low risk) or visit glucose plasma glucose 75-g OGTT (high risk) Further GCT ➝ 100-g OGTT If GCT <130 75-g OGTT if FPG testing <5.1 mmol/L 100-g OGTT (1-step) If 2-h OGTT 24-28 wks <140 100-g OGTT Thresholds FPG >7 mmol/L .0 FPG 95 mg/dL 75-g OGTT 2h Overt diabetes 1-h 180 mg/dL 140 mg/dL 75-g OGTT any value 2-h 155 mg/dL FPG 5.1 mmol/L (92 mg/dL) 3-h 140 mg/dL 1-h 10 mmol/L (180 mg/dL) at least 2 2-h 8.5 mmol/L (153 mg/dL)
  • 12. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Referred for rapid weight gain of 5 kg in the last 4 weeks Her mother has type 2 diabetes FBS or 75-g OGTT?
  • 13. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG 75- g OGT T: Fa stin g 102 ⤳ GDM 1 h PG 192 by FBS 2 h PG 155 criterion
  • 14. Diet prescription in GDM? “Initiate MNT immediately once diagnosed.” AACE 2007
  • 15. “All women with GDM should receive nutritional counseling by a registered dietitian when possible.” ADA GDM Position Statement 2004 Choose where possible CHO from low GI sources Lean proteins including oily fish Balance of poly- and monounsaturated fats NICE 2008
  • 16. If pre-pregnancy BMI >27, restrict caloric intake to <25 kcal/kg/day ... ... and take moderate exercise (>30 min daily). NICE 2008 Obese women (BMI >30): 30-33% calorie restriction (to ~25 kcal/kg actual weight/day) Restrict CHO to 35-40% of calories. ion Statement 2004 ADA GDM Posit
  • 17. Monitor urine ketones before breakfast to detect starvation ketonuria 3 meals and 3 snacks 50-60% complex high fiber carbohydrates 18-20% protein or at least 75 g <30% fats ASGODIP 1996
  • 18. “Non-caloric sweeteners may be used in moderation.” ADA GDM Position Statement 2004
  • 19. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Ht 165 cm Wt 90 kg TC R = 90 x 25 kc al/kg = 2250 kc al/day 3 me als an d 3 sna cks CH O (50%) 281 g CH ON (20%) 112 g fats (30%) rest Ur ine keton es at ff- up
  • 20. Blood glucose monitoring? “SMBG is essential during pregnancy.” Canadian Diabetes Association 2008
  • 21. “Daily SMBG appears to be superior to intermittent office monitoring of plasma glucose.” ADA GDM Position Statement 2004 “For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.” ADA GDM Position Statement 2004
  • 22. Both preprandial and postprandial testing are recommended. If on insulin, test at night because of increased risk of nocturnal hypoglycemia. Canadian Diabetes Association 2008
  • 23. Patients should intensively monitor BG AACE 2007 Insulin therapy Diet only Monitor BG 6x a day Monitor BG 4x a day (before each meal* and (prebreakfast and 1 h 1 h after the first bite of after the first bite of food food at each meal) at each meal) * to determine insulin dosage correction
  • 24. “Urine glucose monitoring is not useful in GDM.” ADA GDM Position Statement 2004 “Urine ketone monitoring may be useful in detecting insufficient or caloric or CHO intake in women treated with caloric restriction.” ADA GDM Position Statement 2004
  • 25. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM MNT started Monitor CBG 3x a day, alternate between - prebreakfast and 1 h after breakfast & lunch - 1 h after meals
  • 26. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM After 2 weeks Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130- 150 mg/dL
  • 27. How long can we wait before declaring diet therapy a failure?
  • 28. Consider insulin when ... Diet and exercise fail to maintain glucose targets during a period of 1-2 weeks Ultrasound suggests incipient fetal macrosomia (AC >70th percentile) NICE 2008
  • 29. Glucose targets 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
  • 30. “HbA1c should not be used routinely for assessing glycemic control in the second and third trimesters of pregnancy.” NICE 2008
  • 31. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130-150 mg/dL Start insulin to bring down postprandial CBGs
  • 32. Can we give Metformin in GDM? Ho w ab ou t Gli ben cla mide?
  • 33. Off-label use Use of metformin or glibenclamide during pregnancy not an approved indication Discuss with patients Canadian Diabetes Association 2008
  • 34. Option of giving metformin or glibenclamide Obtain and document informed consent. “... tailored to glycemic profile of, and acceptability to, the individual woman.” Me tfo rm in in Ges tat ion al Dia betes (M iG) Stu dy NICE 2008
  • 35. Combination therapy MiG study Women taking metformin (who had insulin added) required lower insulin dose ? metformin + glibenclamide IDF 2009
  • 36. 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
  • 37. Recommended insulin regimens? Prandial, basal bolus, split-mixed? Analogues?
  • 38. Initiate a basal-bolus regimen if a patient cannot maintain glucose targets with diet alone. NPH insulin (basal) and rapid-acting insulin at meals Subcutaneous insulin infusion with an insulin pump AACE 2007
  • 39. Insulin regimens in GDM Intermediate-acting insulin 30 min prebreakfast and presupper + rapid-acting insulin 3 injections of rapid-acting insulin given 30 min before each meal + intermediate- acting OR long-acting insulin at bedtime ASGODIP 1996
  • 40. Insulin therapy in GDM Initiating dose depends on the blood glucose May start daily insulin dose 0.1-0.3 u/kg BW ASGODIP 1996
  • 41. Which type of insulin and which regimen? Discuss with patient. “ ... rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy ...” NICE 2008
  • 42. 31/F obese pregnant (pre-pregnancy BMI 30) 20 weeks AOG Diagnosed GDM Ht 165 cm Wt 90 kg Preprandial CBGs 70-80 mg/dL 1h Postprandial CBGs 130-150 mg/dL Start prandial (regular) insulin i.e. 4-6 units premeals tid
  • 44. Subsequent Visits Every 2 weeks for Glycemic control: check 2-h PPBG Obstetric complications: macrosomia, IUGR, preeclampsia, and hydramnios ASGODIP 1996
  • 45. Ultrasound At first visit to determine age of pregnancy At 20-22 wks to detect malformations At 32-34 wks to monitor growth ASGODIP 1996
  • 47. Protocol for Spontaneous Delivery Infusion of 500 ml 5% dextrose/saline x 4 h CBG q 4h Give short-acting insulin for CBG >140 mg/dL - Dose equal to mmol of CBG i.e. 12 u for 12 mmol/L - Dose equal to 1/20th of mg/dL of CBG i.e. 12 u for 240 mg/dL Omit insulin for CBG <140 mg/dL ASGODIP 1996
  • 48. Maternal hyperglycemia is the main cause of neonatal hypoglycemia Insulin is still required before active labor; SC or IV to maintain BG 70-90 mg/dL Infuse glucose 2.5 mg/kg/ min Measure CBG q hourly Double the glucose infusion for the next hour if BG <60 mg/dL Give regular insulin SC or IV for BG >120 mg/dL AACE 2007
  • 49. 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 1996
  • 51. Reclassify at least 6 weeks after delivery Reassess q 3 years if normal BG postpartum Test for diabetes annually if with IFG or IGT postpartum ADA GDM Position Statement 2004
  • 52. 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
  • 53. 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
  • 54. “As always, solutions of an immediate problem raise questions for the future.” Robert G. Moses, MD
  • 55. ht tp:/ w w. slide sh are.net/i sip ta n /w Thank You h ttp://www.endocrine-witch.info