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DDiiaabbeetteess aanndd pprreeggnnaannccyy 
Nguyen Thy Khue, MD, PhD
DDiiaabbeetteess iinn pprreeggnnaannccyy 
 2-20% of all pregnancies 
 Pregestational diabetes (approximately 
20%) 
 Ge...
WWhhaatt iiss ggeessttaattiioonnaall ddiiaabbeetteess 
 ”Any degree of glucose intolerance 
with onset or first recogniti...
PPaatthhoopphhyyssiioollooggyy ooff GGDDMM 
Increased Insulin resistance 
Increased insulin secretion 
Adequate in the fir...
CCoommppaarriissoonn wwiitthh ttyyppee 22 ddiiaabbeetteess 
Increased Insulin resistance 
Inadequate Insulin secretion 
St...
RRiisskk ffaaccttoorr ooff GGDDMM 
 Obesity or excessive gestational weight gain 
 Ethnicity associated with higher type...
RRiisskk ffaaccttoorr ooff GGDDMM 
 Previous poor obstetric outcome 
 Previous GDM 
 Polycystic Ovarian Syndrome 
 Age...
Pedersen Hypothesis 
PPlalacceenntata 
MMaateternrnaal lh hyyppeergrglylycceemmiaia 
FFeetatal lh hyyppeergrglylycceemmiai...
Perinatal ccoonnsseeqquueenncceess ooff GGDDMM 
Outcome Odds ratio 
Macrosomia 2.66 
Large for gestational age 3.28 
Caesa...
MMaatteerrnnaall ccoonnsseeqquueenncceess ooff GGDDMM 
 Type 2 diabetes 
 Relative risk 7.7 (up to 60% at 16 years) 
 M...
Impact of GDM on Pregnancy Outcomes 
The Hyperglycemia and Adverse Pregnancy 
Outcomes (HAPO) Study 
Rationale: 
•Overt di...
HAPO Protocol 
75 g OGTT 24-32 weeks 
Fasting, 1 & 2 hr venous plasma 
N = 25,505 
Unblinded at field centre if 
OGTT fast...
HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy 
OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy 
• N=23,316 ...
HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy 
OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy 
HAPO Study ...
HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy 
OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy 
Outcome 
Od...
IADPSG Consensus CCoonnffeerreennccee 22001100 
GDM* Overt 
diabetes 
Fasting plasma glucose – 
mg/dl (mmol/l) 
≥92 
(5.1)...
GGDDMM pprreevvaalleennccee IIAADDPPSSGG ccrriitteerriiaa 
Data from Sacks et al Frequency of Gestational Diabetes Mellitu...
Outcomes of GDM Pregnancies in Urban 
Vietnam 
• Most available data on the pregnancy outcomes of GDM 
are from high-incom...
Neonatal Outcomes of GDM Pregnancies in 
Urban Vietnam 
No GDM 
Borderline GDM 
(IADPSG +ve; 
2010 ADA -ve) 
GDM 
(2010 AD...
Maternal Outcomes of GDM Pregnancies in 
Urban Vietnam 
No GDM 
Borderline GDM 
(IADPSG +ve; 
2010 ADA -ve) 
GDM 
(2010 AD...
International 
Recommendations on 
Screening for GDM
GDM: Clinical Risk Assessment 
Risk category Clinical characteristics 
High risk Obesity 
Family history 
Personal history...
When to screen for GDM? 
For women at high risk: 
• Screen for undiagnosed T2DM at first 
prenatal visit. 
• Diabetes dete...
When to screen for GDM? 
For women at average risk: 
• Screen for GDM at 24-28 weeks gestation. 
• Due to increasing globa...
Screening and Diagnosis of GDM 
Criteria Diagnosis 
ADA (2014) GDM defined when any of the following values are exceeded: ...
Screening for GDM (ADA 2014) 
• Perform a 75 g OGTT, with plasma 
glucose measurement fasting, and at 1 
and 2 hrs, at 24-...
GDM Diagnosis 
• Plasma glucose values: 
– Fasting ≥92 mg/dL 
– 1 hr ≥180 mg/dL 
– 2 hr ≥153 mg/dL 
• Women found to meet ...
Selection of a Screening Strategy in 
Low-/Middle-Income Countries 
• In resource-poor settings, screening must be 
optimi...
Treatment ooff mmiilldd GGDDMM LLaannddoonn eett aall 
Outcome Routine care 
(n=510) 
Intervention 
(n=490) 
p value 
Hypo...
Treatment ooff mmiilldd GGDDMM LLaannddoonn eett aall 
Outcome Routine care 
(n=510) 
Intervention 
(n=490) 
p value 
Caes...
Glycemic Targets During Pregnancy: 
AACE & ADA Guidelines1,2 
Glucose 
Increment Patients with GDM 
Patients with 
Preexis...
Glycemic Targets During Pregnancy: 
Expert Recommendations 
Some experts recommend more stringent goals 
(in particular, f...
Glucose Monitoring in GDM: 
Self-Monitoring of Blood Glucose 
• Self-monitoring of blood glucose (SMBG) is the 
cornerston...
Glucose Monitoring in GDM: HbA1C 
• Provides valuable supplementary information for glycemic 
control 
• To safely achieve...
Diet/Exercise 
 Traditionally carbohydrate restriction to 
approximately 40% of total intake 
 Limited evidence 
 Appro...
Carbohydrate Source Exchange 
1 Exchange : 175 calorie, 4 g protein, 40 g CHO
MMaannaaggeemmeenntt ooff GGDDMM 
• Medical nutrition therapy (MNT) and lifestyle 
changes can effectively manage 80% to 9...
Insulin 
 Most experience with human insulin 
 Regular insulin, NPH 
 Insulin aspart and lispro appear safe and 
effect...
Gestational Diabetes Mellitus (GDM): 
Initiation of Insulin 
Glucose Levels for Insulin Initiation in GDM1 
Fasting plasma...
Choice of Insulin 
Insulin Options Shown to Be Safe During Pregnancy1 
Name Type Onset Peak 
Effect Duration Recommended 
...
Insulin Use During Pregnancy 
1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):...
Women with GDM History 
80-90% of women with mild GDM can be 
managed by lifestyle changes alone 
ADA. Standards of Medica...
Summary 
• It is important to screen pregnant patients at 
risk of GDM to achieve an early diagnosis. 
• Diagnostic criter...
Summary (cont.) 
• Women at high risk should be screened for TD2M at 
their first prenatal visit. 
• Women at average risk...
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Nguyen thy khue

  1. 1. DDiiaabbeetteess aanndd pprreeggnnaannccyy Nguyen Thy Khue, MD, PhD
  2. 2. DDiiaabbeetteess iinn pprreeggnnaannccyy  2-20% of all pregnancies  Pregestational diabetes (approximately 20%)  Gestational diabetes (GDM - approximately 80%)
  3. 3. WWhhaatt iiss ggeessttaattiioonnaall ddiiaabbeetteess  ”Any degree of glucose intolerance with onset or first recognition during pregnancy” (1980-2010)  GDM vs ”overt diabetes” detected in pregnancy (2010) Metzger et al. Summary and recommendations of the Fourth International Workshop-Conference Diabetes Care 1998 International Association for Diabetes in Pregnancy Study Groups. Recommendations on the diagnosis and classification of hyperglycaemia during pregnancy Diabetes Care 2010
  4. 4. PPaatthhoopphhyyssiioollooggyy ooff GGDDMM Increased Insulin resistance Increased insulin secretion Adequate in the first trimester Inadequate as gestation progress Inadequate insulin secretion HYPERGLYCEMIA Buchanan et al. GDM: risks and management during and after pregnancy Nat Rev Endocrinol 2012 Nov;8(11):639-49
  5. 5. CCoommppaarriissoonn wwiitthh ttyyppee 22 ddiiaabbeetteess Increased Insulin resistance Inadequate Insulin secretion Stumvoll et al. Type 2 diabetes:principles of pathogenesis and therapy Lancet 2005 365(9467):1333-46
  6. 6. RRiisskk ffaaccttoorr ooff GGDDMM  Obesity or excessive gestational weight gain  Ethnicity associated with higher type 2 diabetes risk  Current glucocorticoid use  Hypertension  Family history of diabetes  Glycosuria
  7. 7. RRiisskk ffaaccttoorr ooff GGDDMM  Previous poor obstetric outcome  Previous GDM  Polycystic Ovarian Syndrome  Age 25 or over  Previous macrosomic baby  Maternal macrosomia or low birth weight
  8. 8. Pedersen Hypothesis PPlalacceenntata MMaateternrnaal lh hyyppeergrglylycceemmiaia FFeetatal lh hyyppeergrglylycceemmiaia Fetal hyperglycemia Fetal hyperglycemia and hyperinsulinemia FFeetatal lh hyyppeerirninssuulilnineemmiaia and hyperinsulinemia 1. Congenital anomalies 1. Congenital anomalies (peri-conceptional) (peri-conceptional) 2. Decreased early growth (0-20 weeks 2. Decreased early growth (0-20 weeks gestation) gestation) 3. Hyperinsulinemia (>20 weeks gestation) 3. Hyperinsulinemia (>20 weeks gestation) 1. Neonatal 1. Neonatal hypoglycemia (0-7 days hypoglycemia (0-7 days postnatal) postnatal) 2. Surfactant deficiency 2. Surfactant deficiency (neonatal) (neonatal) 3. Immature liver 3. Immature liver metabolism (neonatal) metabolism (neonatal) aa. .J Jaauunnddicicee 1. Fetal macrosomia (>20 weeks gestation) 1. Fetal macrosomia (>20 weeks gestation) a. Birth asphyxia b. Cardiomyopathy c. TTN a. Birth asphyxia b. Cardiomyopathy c. TTN 2. Fetal hypoxia 2. Fetal hypoxia (>30 weeks gestation) (>30 weeks gestation) aa. .P Poolylyccyyththeemmiaia cc. .I rIoronn a abbnnoormrmaaliltiiteiess b. Stroke, b. Stroke, Poor RVT Poor RVT neurodevelopmental neurodevelopmental outcome outcome
  9. 9. Perinatal ccoonnsseeqquueenncceess ooff GGDDMM Outcome Odds ratio Macrosomia 2.66 Large for gestational age 3.28 Caesarean section 1.88 Shoulder dystocia 4.07 Hypoglycemia 10.38 Hyperbilirubinemia 3.87 Erythrocytosis 10.88 Respiratory complications 4.40 Stillbirth 1.91 Langer et al. Gestational diabetes: the consequences of not treating Am J Obst Gynecol 2005 23(3):196-8
  10. 10. MMaatteerrnnaall ccoonnsseeqquueenncceess ooff GGDDMM  Type 2 diabetes  Relative risk 7.7 (up to 60% at 16 years)  Metabolic syndrome  3-fold increase (38.4 vs. 13.4%)at 9.8 years  Cardiovascular disease  Hazard ratio 1.66 at 12.3 years
  11. 11. Impact of GDM on Pregnancy Outcomes The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study Rationale: •Overt diabetes increases the risk of adverse pregnancy outcomes. •What level of glucose intolerance during pregnancy, short of diabetes, is associated with the risk of adverse outcomes? Metzger BE, et al. HAPO Study Cooperative Research Group. N Eng J Med 2008;358:1991-2002.
  12. 12. HAPO Protocol 75 g OGTT 24-32 weeks Fasting, 1 & 2 hr venous plasma N = 25,505 Unblinded at field centre if OGTT fasting >105 &/or 2 hr >200 or random glucose ≥160 ~36 wks Or <45 mg/dL 1,443 (5.7%) incomplete 23,316 Standard care for field centre Cord glucose & C-peptide Neonatal glucose: 1-2 hr of age Anthropometrics by 72 hr: 746 (2.9%) unblinded Length, head circ, weight, skin folds x3 for treatment Metzger BE, et al. HAPO Study Cooperative Research Group. N Eng J Med 2008;358:1991-2002.
  13. 13. HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy • N=23,316 women • 75g OGTT 24-32 weeks gestation – Fasting glucose ≤ 5.8 mmol/L – 2-hour glucose ≤ 11.1 mmol/L • Composite of 4 perinatal outcomes HAPO Study Group. Hyperglycemia and Adverse Pregnancy Outcomes NEJM 2008 358:1991–2002
  14. 14. HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy HAPO Study Group. Hyperglycemia and Adverse Pregnancy Outcomes NEJM 2008 358:1991–2002
  15. 15. HHyyppeerrggllyycceemmiiaa aanndd AAddvveerrssee PPrreeggnnaannccyy OOuuttccoommeess ((HHAAPPOO)) ssttuuddyy Outcome Odds Ratio Fasting glucose Odds Ratio 1-hour glucose Odds Ratio 2- hour glucose Birth weight > 90th centile 1.38* 1.46* 1.38* Cord C-peptide >90th centile 1.55* 1.46* 1.37* Primary Caesarean Section 1.11* 1.10* 1.08* Clinical neonatal hypoglycaemia 1.08 1.13* 1.10 *statistically significant HAPO Study Group. Hyperglycemia and Adverse Pregnancy Outcomes NEJM 2008 358:1991–2002
  16. 16. IADPSG Consensus CCoonnffeerreennccee 22001100 GDM* Overt diabetes Fasting plasma glucose – mg/dl (mmol/l) ≥92 (5.1) ≥126 (7.0) 1-hour glucose- mg/dl (mmol/L) ≥180 (10.0) 2-hour glucose- mg/dl (mmol/L) ≥153 (8.5) ≥200 (11.1) *only one abnormal value required International Association for Diabetes in Pregnancy Study Groups. Recommendations on the diagnosis and classification of hyperglycaemia during pregnancy Diabetes Care 2010 33(3):676-82
  17. 17. GGDDMM pprreevvaalleennccee IIAADDPPSSGG ccrriitteerriiaa Data from Sacks et al Frequency of Gestational Diabetes Mellitus at Collaborating Centers Based on IADPSG Consensus Panel– Recommended Criteria Diabetes Care 2012 35:526–528
  18. 18. Outcomes of GDM Pregnancies in Urban Vietnam • Most available data on the pregnancy outcomes of GDM are from high-income countries. • 2,772 Vietnamese women in Ho Chi Minh City were monitored through routine prenatal care. – 75 g OGTT between 24-32 weeks. – GDM diagnosis using either 2010 ADA criteria (2 positive results from OGTT), or IADPSG criteria (1 positive result from OGTT) No GDM Borderline GDM (IADPSG +ve; 2010 ADA -ve) GDM (2010 ADA +ve) Prevalence 79.6% 14.5% 5.9% BMI 20.45 kg/m2 21.10 kg/m2 21.81 kg/m2 Hirst JE, et al. PLoS Med 2012;9(7):e1001272.
  19. 19. Neonatal Outcomes of GDM Pregnancies in Urban Vietnam No GDM Borderline GDM (IADPSG +ve; 2010 ADA -ve) GDM (2010 ADA +ve) Gestation at birth (weeks) 1.48% 1.67% 1.70% Preterm delivery (<37 weeks) 6.55% 9.59%* 14.02%* >90th percentile for gestational age 11.76% 16.06% 18.90% <10th percentile for gestational age 8.04% 6.99% 6.10% Clinical neonatal hypoglycemia 0.70% 2.33%* 14.02%* Jaundice requiring phototherapy 3.02% 4.15% 4.27% Intensive neonatal care 4.0% 4.40% 5.49% Perinatal death 0.4% 0.8% 0% Hirst JE, et al. PLoS Med 2012;9(7):e1001272.
  20. 20. Maternal Outcomes of GDM Pregnancies in Urban Vietnam No GDM Borderline GDM (IADPSG +ve; 2010 ADA -ve) GDM (2010 ADA +ve) Preeclampsia 1.63% 2.59% 0.61% Primary caesarean section 33.46% 31.35% 40.85% Induction of labour 2.84% 3.88% 7.64%* Severe perineal trauma 2.81% 3.06% 2.78% Postpartum hemorrhage (>500 mL) 4.32% 4.15% 3.66% Hirst JE, et al. PLoS Med 2012;9(7):e1001272.
  21. 21. International Recommendations on Screening for GDM
  22. 22. GDM: Clinical Risk Assessment Risk category Clinical characteristics High risk Obesity Family history Personal history IGT Prior macrosomic infant Current glycosuria Average risk Neither low or high risk Low risk <25 yrs Low-risk ethnicity No family history Normal pre-pregnancy weight and pregnancy weight gain No personal history of abnormal glucose levels No prior poor obstetrical outcomes ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
  23. 23. When to screen for GDM? For women at high risk: • Screen for undiagnosed T2DM at first prenatal visit. • Diabetes detected during this visit constitutes a diagnosis of overt, not gestational, diabetes. ADA. Standards of Medical Care in Diabetes. Diabetes Care 2014;37(suppl 1):S14-S80.
  24. 24. When to screen for GDM? For women at average risk: • Screen for GDM at 24-28 weeks gestation. • Due to increasing global rates of diabetes, ADA recommends: – 2-hr 75 g OGTT. – Consider a single abnormal value as diagnostic. ADA. Standards of Medical Care in Diabetes. Diabetes Care 2014;37(suppl 1):S14-S80.
  25. 25. Screening and Diagnosis of GDM Criteria Diagnosis ADA (2014) GDM defined when any of the following values are exceeded: Fasting ≥92 mg/dL (5.1 mmol/L) 1-h ≥180 mg/dL (10.0 mmol/L) 2-h ≥153 mg/dL (8.5 mmol/L) IADPSG GDM defined as at least one value meeting the threshold: Fasting plasma glucose ≥5.1 mmol/L 1-h plasma glucose ≥10.0 mmol/L 2-h plasma glucose ≥8.5 mmol/L WHO GDM defined as diabetes or impaired glucose tolerance. Diabetes defined as at least one value meeting the threshold: •Fasting plasma glucose ≥7.0 mmol/L •2-h plasma glucose ≥11.1 mmol/L Impaired glucose tolerance defined as: •Fasting plasma glucose <7.0 mmol/L •2-h plasma glucose ≥7.9 mmol/L ADIPS GDM defined as at least one value meeting the threshold: Fasting plasma glucose ≥5.5 mmol/L 2-h plasma glucose ≥8.0 mmol/L
  26. 26. Screening for GDM (ADA 2014) • Perform a 75 g OGTT, with plasma glucose measurement fasting, and at 1 and 2 hrs, at 24-28 weeks gestation in women not previously diagnosed with overt diabetes. • Perform OGTT in the morning after an overnight fast of at least 8 hrs. ADA. Standards of Medical Care in Diabetes. Diabetes Care 2014;37(suppl 1):S14-S80.
  27. 27. GDM Diagnosis • Plasma glucose values: – Fasting ≥92 mg/dL – 1 hr ≥180 mg/dL – 2 hr ≥153 mg/dL • Women found to meet criteria at first prenatal visit should receive a diagnosis of overt diabetes. ADA. Standards of Medical Care in Diabetes. Diabetes Care 2014;37(suppl 1):S14-S80.
  28. 28. Selection of a Screening Strategy in Low-/Middle-Income Countries • In resource-poor settings, screening must be optimized to reduce cost.1 • A 2013 study of Vietnamese patients found that: • Using a risk-threshold of 3%, the ADA 2010 criteria had a sensitivity of 93% for GDM patients. • Selective screening of patients results in 27% fewer glucose tolerance tests than systematic screening.2 • The study authors concluded that the ADA 2010 strategy may be a reasonable approach in conditions of limited resources.2 1.Gupta Y, Gupta A. Diabetes Care 2013;36(10):e185. 2.Tran TS, et al. Diabetes Care 2013;36(3):618-24.
  29. 29. Treatment ooff mmiilldd GGDDMM LLaannddoonn eett aall Outcome Routine care (n=510) Intervention (n=490) p value Hypoglycaemia 15.4% 16.3% 0.75 Perinatal death 0.0% 0.0% N/A Elevated cord C-peptide 22.8% 17.7% 0.07 Birth trauma 1.3% 0.6% 0.33 Neonatal jaundice 12.9% 9.6% 0.12 Birth weight>4kg 14.3% 5.9% <0.001* Large for gestational age 14.5% 7.1% <0.001* *p<0.05 03-12-14 29 Landon et al. A multicentre, randomized trial of treatment for GDM NEJM 2009 361(14):1339-48
  30. 30. Treatment ooff mmiilldd GGDDMM LLaannddoonn eett aall Outcome Routine care (n=510) Intervention (n=490) p value Caesarean section 33.8% 26.9% 0.02* Shoulder dystocia 4.0% 1.5% 0.02* Preeclampsia 5.5% 2.5% 0.02* **pp<<00..0055 LLaannddoonn eett aall.. AA mmuullttiicceennttrree,, rraannddoommiizzeedd ttrriiaall ooff ttrreeaattmmeenntt ffoorr GGDDMM NNEEJJMM 22000099 336611((1144))::11333399--4488
  31. 31. Glycemic Targets During Pregnancy: AACE & ADA Guidelines1,2 Glucose Increment Patients with GDM Patients with Preexisting T1DM or T2DM Preprandial, premeal ≤95 mg/dL (5.3 mmol/L) Premeal, bedtime, and overnight glucose: 60-99 mg/dL (3.4-5.5 mmol/L) Postprandial, post-meal 1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or 2-hour post-meal: ≤120 mg/dL (6.7 mmol/L) Peak postprandial glucose 100-129 mg/dL (5.5-7.1 mmol/L) A1C A1C ≤6.0% 1. AACE. Endocr Pract. 2011;17(2):1-53. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-66.
  32. 32. Glycemic Targets During Pregnancy: Expert Recommendations Some experts recommend more stringent goals (in particular, for patients on insulin therapy) to prevent maternal and fetal complications1,2 Glucose Increment Patients With Gestational Diabetes Mellitus (GDM)1 Patients With Preexisting T1DM or T2DM1,2 Preprandial, premeal ≤90 mg/dL (5.0 mmol/L)1,2 Postprandial, post-meal 1-hour post-meal: ≤120 mg/dL (6.7 mmol/L)1,2 A1C A1C <5.0%3 A1C <6.0%4 1. LeRoith D, et. al. Endocrinol Metab Clin N Am. 2011;40(1): xii-919. 2. Castorino K et al. Curr Diab Rep, 2012;12:53-59. 3. L. Jovanovic; personal communication. 4. AACE. Endocr Pract. 2011;17(2):1-53.
  33. 33. Glucose Monitoring in GDM: Self-Monitoring of Blood Glucose • Self-monitoring of blood glucose (SMBG) is the cornerstone of diabetes management in gestational diabetes mellitus (GDM)1 • ADA guidelines for pregnant patients requiring insulin: – SMBG ≥3 times daily – More frequent SMBG may be required, including:2 • Morning fasting • Premeal (breakfast, lunch, and dinner) • 1-hour postprandial (breakfast, lunch, and dinner) • Before bed3 1. Jovanovic L, et al. Diabetes Care. 2011;34(1):53-54. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11- S66. 3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. .
  34. 34. Glucose Monitoring in GDM: HbA1C • Provides valuable supplementary information for glycemic control • To safely achieve target glucose levels, combine A1C with frequent self-monitoring of blood glucose (SMBG)1,2 • Recent research suggests weekly HbA1C during pregnancy:1 – SMBG alone can miss certain high glucose values – SMBG + HbA1C = more complete data for glucose control – Clinicians can further optimize treatment decisions with weekly HbA1C 1. Jovanovic L, et al. Diabetes Care. 2011;34(1):53-54. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.
  35. 35. Diet/Exercise  Traditionally carbohydrate restriction to approximately 40% of total intake  Limited evidence  Appropriate weight gain  Maximum 9kg if obese  Exercise plus diet lower glucose /HbA1c  High level of exercise in studies  Evidence for perinatal outcome measurements lacking
  36. 36. Carbohydrate Source Exchange 1 Exchange : 175 calorie, 4 g protein, 40 g CHO
  37. 37. MMaannaaggeemmeenntt ooff GGDDMM • Medical nutrition therapy (MNT) and lifestyle changes can effectively manage 80% to 90% of mild GDM cases1,2 • As pregnancy progresses, glucose intolerance typically worsens; patients may ultimately require insulin therapy1,3 1. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-66. 3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4.
  38. 38. Insulin  Most experience with human insulin  Regular insulin, NPH  Insulin aspart and lispro appear safe and effective  Insulin detemir appears safe and effective  Insulin glargine is likely to be safe, but less evidence to date
  39. 39. Gestational Diabetes Mellitus (GDM): Initiation of Insulin Glucose Levels for Insulin Initiation in GDM1 Fasting plasma glucose ≤105 mg/dL (5.8 mmol/L) 1-hour postprandial plasma glucose ≤155 mg/dL (8.6 mmol/L) 2-hour postprandial plasma glucose ≤130 mg/dL (7.2 mmol/L) 1. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
  40. 40. Choice of Insulin Insulin Options Shown to Be Safe During Pregnancy1 Name Type Onset Peak Effect Duration Recommended Dosing Interval Aspart Rapid-acting (bolus) 15 min 60 min 2 hrs Start of each meal Lispro Rapid-acting (bolus) 15 min 60 min 2 hrs Start of each meal Regular insulin Intermediate-acting 60 min 2-4 hrs 6 hrs 60-90 minutes before meal NPH Intermediate-acting (basal) 2 hrs 4-6 hrs 8 hrs Every 8 hours Detemir Long-acting (basal) 2 hrs n/a 12 hrs Every 12 hours 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.
  41. 41. Insulin Use During Pregnancy 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53. 3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
  42. 42. Women with GDM History 80-90% of women with mild GDM can be managed by lifestyle changes alone ADA. Standards of Medical Care in Diabetes. Diabetes Care 2014;37(suppl 1):S14-S80.
  43. 43. Summary • It is important to screen pregnant patients at risk of GDM to achieve an early diagnosis. • Diagnostic criteria (based on HAPO findings) aim to decrease the risk of hyperglycemia in both mothers and infants.
  44. 44. Summary (cont.) • Women at high risk should be screened for TD2M at their first prenatal visit. • Women at average risk should be screened for GDM at 24-28 weeks gestation. • 2 hr 75 g OGTT should be used with a single abnormal value qualifying as diagnostic. • 80-90% of mild GDM cases could be managed by lifestyle changes and medical nutrition therapy

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