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Gdm Satellite Congress

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Gdm Satellite Congress

  1. 1. Gestational Diabetes Mellitus Screening Diagnosis Challenges in management Dr Hema Divakar
  2. 2. GDM  GDM refers to women who are shown to be diabetic for the first time during pregnancy  regardless of whether diabetes persists after pregnancy
  3. 3. Screening for GDM
  4. 4. Story of failure to screen  Society of obstetricians – Canada  Recommend universal screening  Doctor failed to implement this policy  Missed the diagnosis  Did not request ultrasound  Baby – macrosomic / erbs / 4.4 kg/shoulder dystocia  Court found that his care was negligent  He failed to follow guideline recommendations
  5. 5. Universal screening for GDM is essential  The prevalence of GDM in India varied from 15 to 21% in different parts of the country compared to 3.8 % in the west It is generally accepted that women of Asian origin and especially ethnic Indians, are at a higher risk of developing GDM (and subsequent type 2 diabetes)
  6. 6. Screening for GDM  Indians fall into the high-risk category for developing GDM  therefore universal screening is recommended in pregnancy
  7. 7. When ??  offer universal screening – to ALL antenatal  women at 24 – 28 wks of gestation  and an early screening at booking if there  are additional risk factors identified by history o Previous unexplained loss at term o Previous baby weight > 4 kg o Previous Pregnancy with GDM o Strong F/H
  8. 8.  Patients who had GDM in a previous pregnancy have a 33–50% likelihood of recurrence in a subsequent pregnancy.  Therefore women who have had GDM in a previous pregnancy must be screened at first booking and then at regular intervals.
  9. 9. Screening - HOW ???  50 gm GCT for screening  Ref : Sacks DA. et al. How reliable is the fifty-gram, one-hour glucose screening test? AM J OBSTET GYNECOL 1989; 161(3):642-645  Glucose screening and testing-American Pregnancy Association (Aug 2007)  ADA/NDDG and Medical Journal of Australia 2005, 183(6):288-289  No short cuts  Venous sample more reliable in correctly diagnosing GDM  Glucometer vs Venous Sample  Reference : Journal of Obs & Gynae of India. Glucometer screening of Gestational Diabetes, Vinita Das. et al. KGMC, Lucknow (INDIA) November/December 2006, 499-501
  10. 10. Screen Positive  GCT >140 mg/dl subjected to OGTT with 100 gms Glucose.
  11. 11.  100 gm OGTT according to Carpenter & Coustan criteria  Fasting <95 mg/dl  1 hours <180 mg/dl  2 hours <155 mg/dl  3 hours <140mg/dl  Gestational Diabetes Mellitus (GDM) is diagnosed Diagnosis
  12. 12. One step test – screening and diagnosis  75g oral glucose load*,  without regard to the time of the last meal.  2 hours later  A venous blood sample  GDM is diagnosed if 2 hr plasma glucose is ≥ 140 mg/dl.  Avoids – multiple visits/multiple samples  Validated by dr Seshiah and team – Chennai  Published in ACTA – 2009
  13. 13.  Once diagnosed as Gestational diabetes the patients are under the care of a team for monitoring of maternal sugar and fetal well being. The team - Endocrinologist Dietician Obstetrician Pediatrician Sonologist Management Approach Multi-Disciplinary
  14. 14. Maternal Risks  Hypoglycaemia  Diabetic Ketoacidosis  Retinopathy  Nephropathy  Hypertension  Atherosclerosis  Neuropathy  Infection  Operative Delivery
  15. 15. Fetal Risks  Congenital Anomalies  Early pregnancy losses  Preterm labor  Fetal Growth - macrosomia  Shoulder Dystocia & birth trauma
  16. 16. Neonatal Complications  Hypoglycaemia  Hyperbilirubinemia  Hypocalcaemia  Polycythemia  Cardiomyopathy  RDS
  17. 17. Diet  Dietician charts a diet plan according to patients  Body Weight  Obese women : 25-30 kcal / kg  Non-obese : 35 –40 kcal /kg  Dietary compliance is evaluated and reinforced during weekly hospital visits  Targeted values are  Fasting < 95 mg/dl  1 hour post meal < 140 mg/dl
  18. 18. Glucose Monitoring  For further quality control, blood glucose is measured in the laboratory at weekly visit  Patients on insulin therapy are instructed to use Glucometer and self monitor blood glucose at home
  19. 19. Patient Education The compliance with the treatment plan depends on the patient’s understanding of:  The implications of GDM for her baby and herself   The dietary and exercise recommendations   Self monitoring of blood glucose  Self administration of insulin and adjustment of insulin doses
  20. 20. The role of oral antidiabetic agents in the treatment of GDM  Oral antidiabetic agents have, till now, been contraindicated in pregnancy.  Glyburide, a secondgeneration sulfonylurea, was compared with insulin in a randomized trial among patients with GDM who failed to achieve adequate glycemic control with diet alone Glucose control was similar, and the glyburide group had pregnancy outcomes similar to those of the insulin group,including rates of cesarean delivery, preeclampsia, macrosomia (>4 kg), and neonatal hypoglycemia.  Further study is recommended before the use of newer oral  hypoglycemic agents can be supported for use in pregnancy
  21. 21.  At 28 weeks – Inj Betnesol 12 mg 2 doses  All patients on diet therapy before 32 weeks are followed by fortnight visit and weekly visits thereafter  Patients on insulin therapy are always monitored by weekly visit Antepartum Management
  22. 22. Antepartum Management(contd) …  As per ACOG recommendations for GDM patients weekly fetal surveillance was started from 32nd week of gestation for Clinical Examination Growth profile Biophysical profile Non stress test
  23. 23.  The decision for intervention depends on the maternal outcome variables such as  Poor glycemic control  on diet / insulin or Macrosomia  Surveillance test showing non-assuring / omnious NST – flat NST Decision for Intervention Liq
  24. 24. Timing of delivery   Good glucose control with diet and exercise  and no complications: expectant management till 40 weeks of gestation   GDM on insulin: induction of labour at 38 weeks because the incidence of shoulder dystocia   GDM with HTN or previous stillbirth: induction of labour at 37-38 weeks depending on the condition of the fetus
  25. 25. Post Partum Management  Maternal sugars are monitored  Every 6-8 hours for the first post operative day  Every 12 hours in the 2nd POD  4th POD Fasting / 1 hour post meal  Patients were reviewed after 6 weeks with  Fasting / 2 hour post OGTT with 75 gms glucose  Advise on contraception and weight reduction and long term risk of Diabetes and risk of GDM in subsequent pregnancy is given
  26. 26.  With good obstetric care, theWith good obstetric care, the perinatal mortality rate for a GDMperinatal mortality rate for a GDM pregnancy is similar to that in thepregnancy is similar to that in the non-diabetic populationnon-diabetic population
  27. 27. The future …..The future …..  women who exhibit glucose intolerance during pregnancy have an increased risk of developing type 2 diabetes within 15 years . Children born out of these – childhood obesity / adult onset diabetes
  28. 28.  Timely action taken now in screening all pregnant women for glucose intolerance achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability the vicious cycle of transmitting glucose intolerance from one generation to another
  29. 29.  More to understandMore to understand  More to doMore to do
  30. 30. Thank YouThank You Dr Hema DivakarDr Hema Divakar

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