Updated 2015-2016

1. Gestational Diabetes
Gestational Hypertension
Dr. TAHER KARIRI
FAMILY PHYSICIAN

2. Outline
Gestational diabetes
▫ Epidemiology/Types
▫ Screening and Diagnosis
▫ Management
Gestational Hypertension
oEpidemiology/Types
▫ Diagnosis
▫ Management

3. • Diabetes in Pregnancy: 2 Categories
Pregestational diabetes Gestational diabetes
Pregnancy in
pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Diabetes diagnosed in
pregnancy

4. Pre-existing diabetes in pregnancy
Elevated glucose levels can have adverse
effects on the fetus
▫ 1st trimester  ↑ fetal malformations, spontaneous
abortions
▫ 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications

5. Preconception Counseling for Pregestational
Diabetes
 1. Attain a preconception A1C of ≤7.0% (if safe)
 2. Assess for and manage any complications
 3. Switch to insulin if on oral agents
 4. Folic Acid 5 mg/d: 3 months pre-conception to 12 weeks post-
conception
 5. Discontinue potential embryopathic meds:
 Ace-inhibitors/ARB
 Statin therapy

6. Screen for Complications:
Pre-pregnancy
Screening for:
 Retinopathy: Need ophthalmological evaluation
 Nephropathy: Assess creatinine + urine
microalbumin / creatinine ratio (ACR)
▫ Women with microalbuminuria or overt nephropathy are
at ↑ risk for hypertension and preeclampsia

7. Postpartum care for pre-existing
diabetes
1. Adjust insulin  at risk of hypoglycemia
2. Encourage women to breastfeed
3. Metformin and glyburide may be used during breast-feeding
 no long term data but appears safe
4. Screen for postpartum thyroiditis in T1DM  check TSH
at 6-8 weeks postpartum

8. The terminology for describing diabetes first diagnosed
during pregnancy varies among national organizations
"gestational diabetes" has been defined as onset or
first recognition of abnormal glucose tolerance during
pregnancy ACOG
describe diabetes diagnosed during the second half of
pregnancy, (IADPSG), (ADA), (WHO)

9. Pathphysiology
Insulin resistance, mediated primarily by placental
secretion of diabetogenic hormones including :
growth hormone,
corticotropin-releasing hormone,
 placental lactogen,
Progesterone
pancreatic function is insufficient to overcome the
insulin resistance associated with the pregnant state

10. Prevalence
• Prevalence of gestational diabetes is about 6 to 7% in the
United States (range 1 to 25 percent )
• prevalence rates are higher in African American, Hispanic
American, Native American, Pacific Islander, and South or
East Asian women than in white women
• Prevalence has been increasing over time, possibly due to
increases in mean maternal age and weight .

12. GDM: Detection & Diagnosis
• Risk assessment at the first prenatal visit
High risk patients
Or
Low risk patients

13. Risk factors
Personal history of IGT or
gestational diabetes in a
previous pregnancy
Member of one of the
following ethnic groups
Family history of diabetes,
especially in first degree
relatives
Prepregnancy ,BMI >30
kg/m2,.
Glycosuria at the first prenatal
visit
Maternal age >25 years of age
Previous delivery of a baby >9 pounds
(4.1 kg)
Previous unexplained perinatal loss or
birth of a malformed infant
Maternal birthweight 4.1 kg or < 2.7 kg
Medical condition associated with
development of diabetes, metabolic syndrome,
(PCOS), current use of glucocorticoids, HTN

14. SCREENING AND DIAGNOSTIC
TESTING
• The purpose of screening : is to identify
asymptomatic pregnant women with a high
probability of developing diabetes followed by
appropriate therapy
• Can decrease fetal and maternal morbidity,
particularly macrosomia, shoulder dystocia, and
preeclampsia
• cost-effective for prevention of type 2 diabetes in
populations with a high prevalence of gestational
diabetes and type 2 diabetes.

15. GDM: Detection & Diagnosis
• Screening for gestational diabetes is usually
done between 24 and 28 weeks of pregnancy.
• However, screening may be done earlier in the
pregnancy if you have risk factors for gestational
diabetes, such as:
• A history of gestational diabetes in a previous pregnancy
• Obesity
• Glucose (sugar) in your urine
• A strong family history of diabetes

16. GDM: Detection & Diagnosis
• Women at high risk of GDM should have glucose
testing at the first antenatal visit
If not found to have GDM at that initial screening, retested at
between 24 and 28 weeks gestation

17. • ARE there any criteria for
selecting high risk pregnant
women for early
screening/testing ?????
no validated criteria

18. USPSTF
Asystematic review by the (USPSTF) on the accuracy of
screening tests for gestational diabetes,:
the benefits and harms of screening before and after 24 weeks of
gestation, and the benefits and harms of treatment, found good
evidence to support universal screening after 24 weeks.
A 2014 (USPSTF) guideline concluded available evidence
was insufficient to assess the balance of benefits and harms
of screening for diabetes in asymptomatic pregnant women
before 24 weeks of gestation

19. • (IADPSG) suggested that the decision to test for diabetes at
the first prenatal visit should be based upon the background
frequency of abnormal glucose metabolism in the population
and on local circumstances .
• In agreement with (ADA) ,(ACOG) suggests early pregnancy
screening for undiagnosed type 2 diabetes in women with risk
factors (eg, previous gestational diabetes or known impaired
glucose metabolism, obesity)

20. GDM: Detection & Diagnosis
• Diagnosis of GDM with
a 100-g oral glucose
load
• Fasting ≥95 mg/dl
• 1-h 180
• 2-h 155
• 3-h 140
• Diagnosis of GDM with
a 75-g oral glucose load
• Fasting ≥92 mg/dl
• 1-h 180
• 2-h 153

21. Two-step approach

22. patients unable to tolerate oral
hyperosmolar glucose:
e.g dumping syndrome after a roux-en-Y gastric bypass
procedure
*Serial glucose monitoring:
*Fasting plasma glucose :
USPSTF, FBG less than 85 mg/dL by 24 weeks of gestation performed
well for identifying women who did not have gestational diabetes.
*Intravenous GTT

24. American College of Obstetricians and Gynecologists (ACOG, two step
approach
●International Association of Diabetes and Pregnancy Study Groups
(IADPSG, one step approach
●American Diabetes Association (ADA, one step or two step approach)
●World Health Organization (WHO, one step approach
●Canadian Diabetes Association (CDA, two step [preferred] or one step
approach)
●The Endocrine Society (one step approach)
●Australasian Diabetes in Pregnancy Society (WHO approach)
●National Institute for Health and Care Excellence (NICE, United
Kingdom)

25. In a prospective study in which the two step
approach was replaced by the one step approach,
othe prevalence of gestational diabetes increased 3.5-
fold
o, pregnancy outcomes improved significantly, and
o the change was cost-effective

26. • The authors perform universal testing for overt diabetes at the
initial prenatal visit by checking A1C; a diagnosis of overt
diabetes is made when A1C is ≥6.5 percent (≥48 mmol/mol)
• perform a glucose tolerance test (GTT) when A1C is 5.7 to 6.4
percent (39 to 46 mmol/mol) at the first prenatal visit
• Early in pregnancy, we recommend a 75-gram, two-hour oral
GTT and American Diabetes Association criteria for diagnosis of
overt diabete
Screening at first antenatal visit

27. Several adverse outcomes have been
associated with diabetes during pregnancy
• Preeclampsia
• Hydramnios
• Macrosomia and large for gestational age infant
• Fetal organomegaly (hepatomegaly, cardiomegaly)
• Maternal and infant birth trauma
• Operative delivery
• Perinatal mortality
• Neonatal respiratory problems and metabolic
complications (hypoglycemia, hyperbilirubinemia,
hypocalcemia, erythremia)

28. RATIONALE FOR TREATMENT
• Identifying women with GDM is important to
minimize maternal and neonatal morbidity.
• A 2013 systematic review and meta-analysis of randomized
trials for the US Preventive Services Task Force found that
appropriate management of GDM (nutritional therapy, self
blood glucose monitoring, administration of insulin if
target blood glucose concentrations are not met with diet
alone) resulted in reductions in :
• Preeclampsia
• Birth weight >4000 grams
• Shoulder dystocia

29. • ADA and ACOG glucose targets
Glycemic Management During
Pregnancy
Target glucose values
Fasting PG ≤95 mg/dL
1h postprandial PG ≤140 mg/dL
2h postprandial PG ≤120 mg/dL

30. NUTRITIONAL THERAPY
• The goals of medical nutritional therapy are to:
• Achieve normoglycemia
• Prevent ketosis
• Provide adequate weight gain based on maternal body mass
index (BMI)
• Contribute to fetal well-being

31. IOM Guidelines for Gestational Weight
Gain
Pre-Pregnancy BMI Recommended range
of total weight gain
(Kg)
Recommended range
of total weight gain
(lb)
BMI <18.5 12.5 – 18.0 28 – 40
BMI 18.5 - 24.9 11.5 – 16.0 25 – 35
BMI 25.0 - 29.9 7.0 – 11.5 15 – 23
BMI > or = 30 5.0 – 9.0 11 – 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI

32. In clinical practice, women often
require 1800 to 2500 kcal per day
the caloric requirementbody weight
30 kcal/kg/dayideal body weight
22 to 25 kcal/kg/dayoverweight
12 to 14 kcal/kg/daymorbidly obese women
up to 40 kcal/kg/dayunderweight

33. Weight loss in pregnancy is not generally recommended,
although controversy exists regarding this recommendation
for markedly obese women
 obese women (BMI >30 kg/m2), a modest energy restriction
to reduce weight gain can be achieved by restricting caloric
intake by about 30 % below the Dietary Reference Intakes
(DRI) for pregnant women

34. A typical meal:
(3 small-to-moderate sized meals and 2 to 4 snacks).
• Carbohydrate intake: 35 to 40%
• Protein: 20%
• Fat: 40%, saturated fat <7 percent of total calories.

35. EXERCISE
• increased tissue sensitivity to insulin.
• fasting and postprandial blood glucose concentrations can be
reduced.

36. GLUCOSE MONITORING
• After initially diagnosed with GDM,,measure blood glucose
concentration at least four times daily
(fasting and one or two hours after the first bite of each meal)
• Decrease the frequency of glucose monitoring when good
glycemic control is accomplished with medical nutritional
therapy

37. MONITORING FOR KETONURIA
• We do not routinely monitor urinary ketones in
women with GDM.
• Diabetic ketoacidosis is extremely rare in women
with gestational diabetes
Test their urine for ketones if:
 the blood glucose concentration is above 180 mg/dL
 during periods of illness or stress,
 if there are symptoms compatible with ketoacidosis such as nausea,
vomiting, and abdominal pain.

38. If normoglycemia cannot be maintained by medical nutritional
therapy, then anti-hyperglycemic agents should be initiated
Target glucose values
Fasting PG ≤95 mg/dL
1h postprandial PG ≤140 mg/dL
2h postprandial PG ≤120 mg/dL
Targets not met within 2 weeks start PHARMACOLOGIC
THERAPY
Caution

39. PHARMACOLOGIC THERAPY
• Insulin (and some insulin analogs)
• Oral anti-hyperglycemic agents.
• Hospitalization is not necessary to initiate
insulin UNLESS,,,,

40. Insulin
• Four to six glucose measurements each day are needed to optimize
therapy (fasting and one or two hours postprandial with the possible
addition of pre-lunch and pre-dinner)
TYPE:
 -human insulin is the least immunogenic
 rapid acting insulin analogs only lispro and aspart have been investigated in
pregnancy and shown to have acceptable safety profiles
 Long-acting insulin analogs (insulin glargine, insulin detemir) have not been
studied extensively in pregnancy.
• Based on available data, we prefer use of human NPH insulin as part of a multiple
injection regimen in pregnant women with GDM

41. Insulin
Dose:
• The dose of insulin varies in different individuals
• total insulin dose ranging from 0.7 to 2 units per kg
• The dose and type of insulin used is calculated based
upon the specific abnormality of blood glucose noted
during monitoring

42. a patient whose glucose elevations are mostly postprandial
regardless of body weight, is prescribed------
 a starting dose of 30 units (20 units of intermediate acting
insulin and 10 units of rapid acting insulin)
in the morning prior to breakfast
If the post-dinner glucose level remains elevated, then an
additional injection of rapid acting insulin is given just prior to
dinner.

43. • If fasting glucose is elevated,: intermediate acting insulin can
be given along with the dinner dose of rapid acting insulin, or
can be administered separately at bedtime
• Sometimes an additional dose of rapid acting insulin is
necessary to maintain euglycemia after lunch, so that a
total of four injections per day are needed.
• If low glucose values are encountered more than once at
the same time of day, insulin doses are adjusted
downward accordingly.

44. Oral anti-hyperglycemic agents
• ADA ,ACOG have endorsed the use of oral anti-
hyperglycemic agents during pregnancy.
• in the United States, such therapy has not been specifically
approved for treatment of GDM by the FDA.
• reasonable alternative for women who fail nutritional therapy
and refuse to take, or are unable to comply with, insulin
therapy.

45. Glyburide
has become the most common drug treatment
for GDM
A major advantage of glyburide over metformin is that it is usually
effective as single agent therapy
Higher risk of macrosomia , higher mean birth weight, higher rate of
any neonatal hypoglycemia
No studies of long-term effects in offspring (eg, developmental
outcomes, metabolic effects) have been published
Starting doses of 2.5 to 5 mg once daily, the dose is increased as
needed to a maximum of 20 mg/day

46. Metformin
• Second and third trimester metformin treatment of GDM appears to
be safe in the short term.
• a theoretical risk that fetal exposure to an insulin sensitizing agent
such as metformin has long-term effects on offspring.

47. • Use of thiazolidinediones, glitinides (repaglinide
and nateglinide), and GLP-1 during pregnancy is
considered experimental.
There are no controlled data available in
pregnancy.

48. MATERNAL PROGNOSIS
• Most women with GDM are normoglycemic after delivery.
• high risk for recurrent GDM, prediabetes ,and overt diabetes over
the subsequent five years
• Recurrence : One-third to two-thirds of women with GDM will have
GDM in a subsequent pregnancy,( older, more parous)
• GDM is predictive of an increased risk of developing type 2
diabetes, type 1 diabetes, metabolic syndrome, and cardiovascular
disease.

49. Follow-up and prevention of type 2
diabetes — ACOG , the ADA
• An oral glucose tolerance test 6 to 12 weeks after delivery, using
the two-hour 75 gram oral glucose tolerance test .
• A FBG test and (A1C) are an reasonable alternative
• Prediabetes should be counseled about their subsequent risk for
developing overt diabetes and referred for discussion of
management options.

50. Gestational hypertension

51. Definition
sustained BP readings of ≥140/90 mmHg during
pregnancy after 20 weeks’ gestation in a
previously normotensive patient, without the
presence of proteinuria (<300 mg in 24 hours).
All manifestations of gestational hypertension are presumptive
until retrospectively confirmed bycomplete resolution of
hypertension and any other new abnormalities by 12 weeks
postpartum; otherwise, other diagnoses should be considered.

52. Epidemiology
• In the UK, gestational hypertension and pre-eclampsia 5% to 6
• in the US range from 2% to 12%.
• Healthy nulliparous women higher rates (6% to 17%)
compared with multiparous women (2% to 4%).
• African-American women may be at greater risk than
white women.
• more often in twin pregnancies than in singleton
pregnancies

54. Aetiology
• The exact aetiology of gestational hypertension
remains unknown.
• It is thought that insulin resistance???

55. Classification
• Report of (ACOG) Task Force on
Hypertension in Pregnancy
1/Chronic hypertension:
• BP ≥140/90 mmHg (preferably on 2 occasions less than 1
week apart):
• Before pregnancy or up to 20 weeks' gestation
• New hypertension after 20 weeks' gestation that persists for 12
weeks postpartum.

56. 2/Gestational hypertension (transient
hypertension of pregnancy):
• New hypertension in pregnancy without proteinuria.
Normotensive by 12 weeks postpartum.
3/Pre-eclampsia/eclampsia:
• Pregnancy-specific syndrome that usually occurs after
20 weeks' gestation
• BP >140/90 mmHg and proteinuria >300 mg/24 hours
• Eclampsia is defined as seizures in a woman with pre-
eclampsia not attributable to other causes.

57. 4/Chronic hypertension with superimposed
pre-eclampsia:
patients with chronic hypertension and one or more:
• New onset of proteinuria
• Hypertension with proteinuria after 20 weeks' gestation
• Sudden increase in proteinuria that was present before
pregnancy
• Sudden increase in BP that had otherwise been well
controlled
• Thrombocytopenia (<100 x 10^3/microlitre)
• Elevated liver enzymes (ALT or AST).

58. Risk factors
• Nulligravidity (6% to 17%)
• black or Hispanic ethnicity,
• multiple pregnancies,
• obesity,
• the mother herself being born small for gestational age.
• type 1 diabetes
• migraine

59. diagnosis
A diagnosis of gestational hypertension should be
made only after 2 readings ≥140/90 mmHg,
spaced at least 6 hours apart but no more than 7
days apart.

61. Diagnostic tests
• Urinalysis.
• FBC
• LFTs
• electrolytes, urea, creatinine
• uric acid
• fetal ultrasound
• proteinuria (24-hour urine collection): Protein
levels above 0.3 g/dL in 24 hours are diagnostic for pre-
eclampsia.

62. • Severity classification of gestational
hypertension:
• Mild: BP measurements between 140/90 mmHg and
160/110 mmHg.
• Severe: sustained BP elevations for a minimum of 6 hours
with systolic BP of at least 160 mmHg and/or diastolic BP of
at least 110 mmHg.

65. women ≤37 weeks' gestation
mild or moderate hypertension <160 mmHg and
<110 mmHg)
1st: lifestyle modification , diet.
weight loss is not recommended for obese patients
severe hypertension:
1st : antihypertensive treatment

66. women >37 weeks' gestation
mild or moderate hypertension
1st: induction of labour/delivery
If the patient does not respond to medical induction, then
delivery by caesarean is necessary.
severe hypertension
1st: antihypertensive treatment + induction of
labour/delivery

69. References