This document discusses updates to the management of gestational diabetes mellitus (GDM). It outlines the current practice of selective screening between 24-28 weeks gestation, and diagnosis using oral glucose tolerance tests. New recommendations include universal screening for all pregnant women and revised diagnostic thresholds from the WHO. The document also reviews new evidence for treating GDM with oral hypoglycemic agents like metformin and glyburide, in addition to or instead of insulin. It concludes by questioning if practices in Sarawak could be updated.

1. O&G Update 2014
Hospital Sarikei, Sarawak
yongsoonleong@yahoo.com
What’s New in GDM?

2. Scopes
What’s new in GDM?
Our Current
Practice
What’s New? Anything we
can change?

3. Our Current Practice
What’s new in GDM?

4. Terminology
Gestational DM
Pregestational
DM
Likely
Pregestational
DM

5. Selective screening of GDM

6. When to screen?
24 – 28 weeks gestation
2 hours
75-g
oral glucose tolerance test (OGTT)
16 – 18 weeks gestation if previous
history of GDM.
If normal, repeat another one at
24 – 28 weeks gestation

7. Diagnosis of GDM
WHO 1999 used Fasting Blood Sugar ≥ 7.0 mmol/L
or 2-H Plasma Glucose ≥ 7.8 mmol/L
(following 75g oral glucose load) as abnormal MOGTT result.
MOH uses Fasting Blood Sugar ≥ 5.6 mmol/L
or 2-H Plasma Glucose ≥ 7.8 mmol/L
(following 75g oral glucose load) as abnormal MOGTT result.
What’s new in GDM?

8. How
to
treat
?
- Diet Control
- Insulin
What’s new in GDM?

9. What’s new?
What’s new in GDM?

10. Terminology
• FPG ≥ 7.0 mmol/L
• 2HPG ≥ 11.1 mmol/L (75g oral glucose
load)
• RPG ≥ 11.0 mmol/L in the presence of
diabetes symptoms
DM in
Pregnancy
• FPG = 5.1 – 6.9 mmol/L
• 1HPG ≥ 10.0 mmol/L (75g oral glucose
load)
• 2HPG = 8.5 – 11.0 mmol/L (75g oral
glucose load)
Gestational
DM
Diagnostic Criteria & Classification of Hyperglycaemia First Detected in Pregnancy.
WHO (2013)

11. UNIVERSAL SCREENING
Reduces incidence of macrosomia & hypertensive disorders
Diagnostic Criteria & Classification of Hyperglycaemia First Detected in Pregnancy.
WHO (2013)

12. How
to
treat
?
- Diet Control
- Insulin
- Oral hypoglcaemic agent
What’s new in GDM?

13. Oral Hypoglycaemic Agent (OHA)
• Metformin
• Well studied in MiG Trial
• 46% will need addition of insulin eventually
• FDA Class B, safe in pregnancy
• MiG-TOFU: children exposed to metformin had larger measures of
subcutaneous fat
Rowan JA et. al. MiG Trial Investigators. Metformin versus insulin for the treatment
of gestational diabetes. N Eng J Med 2008; 358:2003-2015

14. Oral Hypoglycaemic Agent (OHA)
• Glyburide (glibenclamide)
• Relatively safe alternative to insulin therapy
• 20% will need addition of insulin eventually
• Possible risk of neonatal hypoglycaemia /
hyperbilirubinaemia
Thomas R.M. Glyburide for the Treatment of Gestational Diabetes. A critical
appraisal. Diabetes Care 2007; 30(Sup 2):S209-S213

15. Anything we can change?
What’s new in GDM?

16. Can we change
the practice in
Sarawak?
What’s new in GDM?
Universal
Screening
MOGTT values
OHA
(metformin,
glibenclamide)

17. TTHHAANNKKSS……