1. DR GAYATHRI MARIAPPA

2. OVERVIEW
❖ INTRODUCTION
❖ WHAT IS NEW?
❖ WHAT IS CONTROVERSIAL IN MALAYSIA?
❖ MANAGEMENT ALGORITHM
❖ DO’S
❖ DON’T
❖ TAKE HOME MESSAGE
❖ REFERENCES
2

3. INTRODUCTION
❖ WORLDWIDE PREVALENCE – 16% IN PREGNANCY
❖ SIGNIFICANT MATERNAL & FETAL IMPLICATIONS

5. PATHOPHYSIOLOGY
❖ < 20 weeks of POG
• Anabolic phase
• Increase in Insulin sensitivity
❖ > 20 weeks of POG
• Catabolic phase
• Increase in Insulin resistance

7. MECHANISM OF
INSULIN RESISTANCE
• The pancreas releases 1.5–2.5 times more insulin
in order to respond to the resultant increase in
insulin resistance.Normal patient meets the
demand
In GDM :
• Post receptor defect. Inadequate insulin release

8. MALAYSIA
❖ PREVALENCE OF GDM- 5%
❖ LACK OF STANDARDIZED OF DIAGNOSTIC
CRITERIA
❖ SELECTIVE SCREENING RATHER THEN UNIVERSAL
SCREENING

9. WHAT IS NEW?
❖ DEFINITION
❖ DIAGNOSTIC CRITERIA
❖ EXERCISE IN PREGNANCY
❖ APPROACH TO MANAGEMENT
❖ SAFETY OF OHA?
❖ NEW INSULINS?

10. WHAT IS NEW?
DEFINITION
❖HYPERGLYCAEMIA FOR THE 1ST TIME IN
PREGNANCY – IS NOT ALWAYS GDM
❖DM VS GDM?

11. WHAT IS NEW?
DEFINITION
HYPERGLYCAEMIA IN PREGNANCY :
❖1) TYPE II DM/PREGESTATIONAL
Pregestational DM Cut off values
Fasting >7mmol/L
2 hours post prandial >11.1mmol/L
Random >11.1mmol/L and symptomatic

12. ❖ DIET AND LIFESTYLE MODIFICATIONS –
EXTREMELY BENEFICIAL
❖ START INSULIN – REDUCE MACROSOMIA,
STILLBIRTH AND DYSTOCIA
ACHOIS (NEW ENGLAND JOURNAL MED 2005

13. IMPORTANCE OF
SCREENING
BENEFITS:
❖ALLOWS ACTIVE INTERVENTION
❖REDUCED MACROSOMIA/SHOULDER
DYSTOCIA/BIRTH TRAUMA
RISKS:
❖INCREASED INTERVENTION (EG.IOL)
❖INCREASED MONITORING

14. CONCLUSION SO FAR
❖ GDM IS SIGNIFICANT IN SOUTH EAST ASIA!
❖ THE LOWER THE GLYCAEMIC CONTROL – THE
BETTER
❖ ACTIVE INTERVENTION – IMPROVES OUTCOMES
❖ SCREENING BASED ON RISK FACTORS – 50% OF
PATIENTS WILL BE MISSED

15. WHAT IS CONTROVERSIAL IN
MALAYSIAN CONTEXT?
❖ UNIVERSAL VS SELECTIVE SCREENING
❖ COST EFFECTIVENESS
❖ RESOURCES

16. MALAYSIAN CPG 2009

17. CUT OFF VALUES IN
MALAYSIA?
❖ TILL NEWER GUIDELINES IN THE NEAR
FUTURE,MOGTT VALUES :
❖ FASTING - 5.6 MMOL/L
❖ 2 HOURS POST PRANDIAL - 7.8MMOL/L

18. Almost everyone except
age<25, weight < 27kg/m2
Extremely high risk
Eg Obesity, advanced age,
bad obstetric outcomes
Screen as early as possible (16-
18weeks)
Routine screening
Screen at 24-28weeks
If normal repeat at 28 weeks

19. WHAT’S NEW?
APPROACH TO MANAGEMENT
Active intervention
Advice on lifestyle
modification
Refer dietician as soon possible/ provide
leaflets
Exercise
Blood sugar profile within 2 weeks of diagnosis &
intervention
Start insulin if failure to achieve desired levels within 2
weeks of lifestyle modification

20. VENOUS OR CAPILLARY?
❖ FASTING – CAPILLARY OR VENOUS – SIMILAR
❖ POST PRANDIAL – CAPILLARY > VENOUS

21. 4 POINT OR 7 POINT BSP
??
• No evidence that one is superior then another
• Best outcomes are combination of pre and post
prandial sugars
• Post prandial sugars which are deranged will reflect
on the babes growth

22. Is there any place to monitor glycosylated hemoglobin (HbA1c)
in pregnant women with gestational diabetes? Especially in
relation to predicting fetal morbidity such as macrosomia/
shoulder dystocia?
The NICE guideline on diabetes in pregnancy (National Collaborating Centre) recommends that
HbA1c should not be used routinely for assessing glycaemic control in the second and third
trimesters of pregnancy.
“Do not use routine measurement of HbA1c for management”

23. TREATMENT
1) LIFESTYLE MODIFICATIONS
❖- MILD TO MODERATE EXERCISE
❖- DIETARY MODIFICATIONS
❖2) 7–20% WILL REQUIRE TREATMENT
❖- INSULIN
❖- OHA

24. WHAT’S NEW?
EXERCISE
❖ MILD TO MODERATE NOT WEIGHT BEARING
EXERCISE – PROVEN TO BE SAFE IN PREGNANCY-CYCLING,
SWIMMING, AEROBICS
❖ REDUCE INSULIN REQUIREMENTS
❖ SHORTENS LABOUR
❖ MORE PRONE FOR VAGINAL DELIVERY

25. THERAPEUTIC DIET
❖ AVERAGE WEIGHT - 30–35 KCAL/KG/DAY
❖ OBESE - 24KCAL/KG/DAY
CALORIC COMPOSITION
❖ 40–50% FROM COMPLEX, HIGH-FIBER CARBOHYDRATES
❖ 20% FROM PROTEIN
❖ AND 30–40% FROM PRIMARILY UNSATURATED FATS

26. DIET
❖ DISTRIBUTION :
❖ 10–20% AT BREAKFAST;
❖ 20–30% AT LUNCH;
❖ 30–40% AT DINNER;
❖ AND UP TO 30% FOR SNACKS, ESPECIALLY A
BEDTIME SNACK

27. TARGETS OF GLYCAEMIC
CONTROL
Time Plasma glucose
Fasting < 5.3
1 hr < 8.0
2 hr < (6.7)
If targets
not reached within 2 weeks,
Initiate insulin
International Assoc of Diabetes & Pregnancy Study Groups (IADPSG), D Care 2010;33(3):676-
82

28. OTHER INDICATIONS TO START
INSULIN
❖FETAL GROWTH ABOVE 70TH PERCENTILE OF POPULATION
❖(IMPORTANCE OF GROWTH CHART)
❖POLYHYDRAMNIOS
❖LIMITED ROLE OF HBA1C

29. NEW KID IN THE BLOCK?
❖ RAPID ACTING INSULIN ANALOGS – LISPRO,
ASPART
❖ S/C INSULIN PUMPS
❖ GLARGINE HUMAN INSULIN ANALOG PRODUCED
WITH RECOMBINANT DNA

30. INSULIN ACTION PROFILE

31. OHA? IS IT SAFE?
GLIBENCLAMIDE
- LANGER ET ALL (N ENGL J MED 2000) 402 PATIENTS
- CONVERSION RATE TO INSULIN ONLY 4%
- NOT DETECTED IN CORD BLOOD
- BUT BETTER FASTING GLUCOSE PROFILE
- RECOMMENDED FOR WOMEN WITH PRE EXISTING DM
MULTIPLE STUDIES SINCE THEN – HIGH CONVERSION RATE TO INSULIN (20-30%)

32. OHA?
METFORMIN
❖ ROWAN ET AL. (MIG STUDY)
❖ SIMILAR OUTCOME TO INSULIN
❖ CONVERSION RATE – 46% HAD INADEQUATE CONTROL AND REQUIRED
INSULIN
❖ LOWER MATERNAL WEIGHT GAIN, LOWER GLYCEMIC RANGE AND
COMPLICATIONS

33. IS OHA SAFE?
❖ METFORMIN AND GLIBENCLAMIDE CROSS THE PLACENTA
❖ NO IMMEDIATE SAFETY CONCERNS FOR THE FETUS HAVE BEEN
DEMONSTRATED
❖ POTENTIAL LONG-TERM EFFECTS REMAIN UNDER INVESTIGATION
❖ FDA CLASS B
❖ MAY BE USED IN CERTAIN GROUP OF PATIENTS

34. ANTENATAL MANAGEMENT OF
MONITORING
• 2 weekly BSP till 36 weeks (if within normal
range)
• Weekly BSP if abnormal or escalation of
treatment (till normal)
• Weekly BSP after 36 weeks
TIMING OF DELIVERY
• Offer induction of labour at 38 weeks if on treatment
• Offer induction of labour at 40 weeks if not on treatment
• Earlier if evidence of macrosomia/polyhydramnios or poor control at term
Each visit
Review BP
Screen for PE
GROWTH SCAN
•Scan at 28 and 34 weeks for growth
•Scan at 36 weeks for EBW and serial
growth scans
PLOT GROWTH CHART
GDM

35. ANTENATAL
GOOD CONTROL – CAN BE MANAGED IN HEALTH CLINIC
DIETICIAN REVIEW
WHEN TO REFER TO SPECIALIST CLINIC
-FOR INSULIN COMMENCEMENT
-EVIDENCE OF MACROSOMIA/POLYHYDRAMNIOS

36. FETAL ASSESSMENT
❖ EXCLUDE MACROSOMIA AT TERM (DOCUMENT IN
NOTES)
❖ NO ROLE FOR DOPPLER UNLESS EVIDENCE OF
IUGR
❖ POLYHYDRAMNIOS OR MACROSOMIA IS AN
INDICATION FOR INSULIN/EARLY DELIVERY

37. INTRA-PARTUM CARE
❖ DELIVER AT 40 WEEKS (OFFER IOL)
❖ EARLIER IF POORLY CONTROLLED, DEVELOPED
PIH/PE
❖ IF EVIDENCE OF MACROSOMIA – DELIVER BY LSCS
❖ 2 HOURLY CAPILLARY BLOOD GLUCOSE, MAINTAIN
BETWEEN 4-7MMOL/L (GIK REGIME)

38. POSTPARTUM
❖ IF GDM, NO NEED FOR POST DELIVERY
MONITORING
❖ STOP INSULIN POST DELIVERY (ENSURE SHE HAS GDM & NOT DM)
❖ UNLESS ITS HIGH REQUIREMENT OF INSULIN ANTENATALLY

39. PREVENTION OF NEONATAL
HYPOGLYCAEMIA
❖FEED SOON AFTER BIRTH (WITHIN 30 MINUTES)
❖FREQUENT INTERVALS (EVERY 2–3 HOURS)
❖ROUTINE MONITORING OF BABY
– 2-4 HOURS AFTER BIRTH (PAEDIATRIC REFERRAL
IF <2MMOL/L)

40. POST NATAL CARE
❖ 6 WEEKS – FBS (NICE) (LOW RISK)
HIGH RISK PATIENTS – DO MOGTT
❖ YEARLY FBS
❖ OGTT NEXT PREGNANCY AT 16-18WEEKS

41. DO’S
❖ SCREEN ALMOST EVERYONE
❖ THE LOWER THE GLYCAEMIC CONTROL – THE
BETTER
❖ PATIENT EDUCATION
❖ ACTIVE INTERVENTION – EXERCISE, DIET, INSULIN
❖ MONITORING – CONSIDER LOGISTICS/FEASIBILITY
❖ HAND HELD RECORDS

42. DON’T
❖ LABEL EVERYONE AS GDM
❖ USE FBS/RBS/GLYCOSURIA FOR DIAGNOSIS
❖ 1 HOUR POST PRANDIAL SUGAR
❖ REPEAT 3X OR UNNECESSARILY
❖ DELAY IN DIETARY REFERRAL & LIFESTYLE
MODIFICATIONS
❖ DELAY IN INITIATING INSULIN
❖ EARLIER IOL TO PREVENT MACROSOMIA

43. TAKE HOME MESSAGE
❖ GDM – EXTREMELY IMPORTANT IN MALAYSIA
❖ SCREENING ALLOWS INTERVENTION – SHORT TERM AND LONG TERM
❖ ACTIVE INTERVENTION IMPROVES OUTCOMES
❖ STANDARDISED EVIDENCE BASED APPROACH
❖ INDIVIDUALISED CARE
❖ KEEP ABREAST WITH CHANGES – NEW DEVELOPMENTS ARE COMING OUR
WAY

44. THANK YOU
❖ NICE
❖ WHO 2013 ATLAS
❖ ACOG GDM GUIDELINES