Diabetes in Diabetes in PregnancyPregnancy

ClassificationClassification

Pregestational diabetesPregestational diabetes

Type 1 DMType 1 DM

Type 2 DMType 2 DM

Secondary DMSecondary DM Gestational diabetes Gestational diabetes

DefinitionDefinition

Gestational diabetes (GDM) is defined as glucose Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first intolerance of variable degree with onset or first recognition during the present pregnancy. recognition during the present pregnancy.

Pregestational diabetes precedes the diagnosis of pregnancy.

Magnitude of problem: GDM Magnitude of problem: GDM

GDM varies worldwide and among different racial and GDM varies worldwide and among different racial and ethnic groups within a countryethnic groups within a country

Variability is partly because of the different criteria and Variability is partly because of the different criteria and screening regimens screening regimens

Whom to screen ?Whom to screen ?

Risk stratification based on certain variablesRisk stratification based on certain variables

Low risk : no screeningLow risk : no screening

Average risk: at 24-28 weeksAverage risk: at 24-28 weeks

High risk : as soon as possibleHigh risk : as soon as possible

To satisfy To satisfy allall these criteria these criteria

Age <25 years Age <25 years

Weight normal before pregnancy Weight normal before pregnancy

Member of an Member of an ethnic group with a low prevalence of GDMethnic group with a low prevalence of GDM

No known diabetes in first-degree relatives No known diabetes in first-degree relatives

No history of abnormal glucose tolerance No history of abnormal glucose tolerance

No history of poor obstetric outcomeNo history of poor obstetric outcome

Low risk for GDMLow risk for GDM

High riskHigh risk

Marked obesityMarked obesity Prior GDMPrior GDM GlycosuriaGlycosuria Strong family historyStrong family history

Intermediate risk

At least one of the criteria in the list

Screening and Diagnosis of Screening and Diagnosis of GDM in the U.S.GDM in the U.S.

Use the 50 g oral glucose Use the 50 g oral glucose challenge with BS taken 1 hour challenge with BS taken 1 hour laterlater Screen all pregnant women @ 24-28 Screen all pregnant women @ 24-28

weeksweeks Test earlier in selected patientsTest earlier in selected patients

Threshold of 130 mg/dL or greaterThreshold of 130 mg/dL or greater

How to screen?How to screen? Oral glucose tolerance Oral glucose tolerance

test ( OGTT) with 100 gm test ( OGTT) with 100 gm glucoseglucose

FastingFasting 95 mg/dl95 mg/dl

1-h1-h 180 mg/dl180 mg/dl

2-h2-h 155 mg/dl155 mg/dl

3-h3-h 140 mg/dl140 mg/dl

• Overnight fast of at least 8 hours

• At least 3 days of unrestricted diet and unlimited physical activity

• > 2 values must be abnormal

Urine glucose monitoring is not useful in gestational Urine glucose monitoring is not useful in gestational diabetes mellitusdiabetes mellitus

Urine ketone monitoring may be useful in detecting Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women insufficient caloric or carbohydrate intake in women treated with calorie restrictiontreated with calorie restriction

Urine monitoring

Problems of GDM: fetalProblems of GDM: fetal

Increases the risk of fetal macrosomiaIncreases the risk of fetal macrosomia Neonatal hypoglycemiaNeonatal hypoglycemia JaundiceJaundice PolycythemiaPolycythemia Hypocalcemia, hypomagnesemiaHypocalcemia, hypomagnesemia Birth traumaBirth trauma PrematurityPrematurity

Problems: fetalProblems: fetal Cardiac( including great vessel anomalies) : Cardiac( including great vessel anomalies) : most commonmost common

Central nervous system: 7.2%Central nervous system: 7.2%

Skeletal: cleft lip/palate, Skeletal: cleft lip/palate, caudal regression syndromecaudal regression syndrome

Genitourinary tract: ureteric duplicationGenitourinary tract: ureteric duplication

Gastrointestinal : anorectal atresiaGastrointestinal : anorectal atresia

Poor glycemic control at time of conception: risk factor

Caudal regression syndrome

Caudal regression syndrome

Problems of GDM: maternalProblems of GDM: maternal

Weight gainWeight gain Maternal hypertensive disordersMaternal hypertensive disorders MiscarriagesMiscarriages Third trimester fetal deathsThird trimester fetal deaths Cesarean delivery (due fetal growth disorders) Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus Long term risk of type 2 diabetes mellitus

Pregnancy in diabetic mother: Pregnancy in diabetic mother: risksrisks

Progression of retinopathy: esp. severe proliferative Progression of retinopathy: esp. severe proliferative retinopathyretinopathy

Progression of nephropathy: especially if renal failure +Progression of nephropathy: especially if renal failure +

Coronary artery disease: Post MI patients: high risk of Coronary artery disease: Post MI patients: high risk of maternal death maternal death

ManagementManagement

Preconception Preconception counsellingcounselling

Diabetic mother : glycemic control with insulin/SMBGDiabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% Target: HbA1c < 7%

Folic acid supplementation: 5 mg/day Folic acid supplementation: 5 mg/day

Ensure no transmissible diseases: HBsAg, HIV, rubellaEnsure no transmissible diseases: HBsAg, HIV, rubella

Try and achieve normal body weight: diet/exerciseTry and achieve normal body weight: diet/exercise

Stop drugs : oral hypoglycemic drugs, ACE inhibitors, Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockersbeta blockers

Clinical parameters: checked Clinical parameters: checked at each visitat each visit

medicationsmedications pre-pregnancy weight pre-pregnancy weight weight gainweight gain edemaedema pallorpallor blood pressure blood pressure Fundal height Fundal height

Patient educationPatient education

Cornerstone in GDM managementCornerstone in GDM management

Maternal complicationMaternal complication Fetal complicationFetal complication Medical Nutrition therapyMedical Nutrition therapy Glycemic monitoring: SMBG and targetsGlycemic monitoring: SMBG and targets Fetal monitoring: ultrasoundFetal monitoring: ultrasound Planning on deliveryPlanning on delivery Long term risksLong term risks

Glycemic targetsGlycemic targets

Fasting venous plasma < 95 mg/dlFasting venous plasma < 95 mg/dl 2 hour postprandial <120 mg/dl2 hour postprandial <120 mg/dl 1 hour postprandial <130 mg/dl (140)1 hour postprandial <130 mg/dl (140)

Pre-meal and bedtime: 60 to 95 mg/dlPre-meal and bedtime: 60 to 95 mg/dl

If diet therapy fails to maintain these targets > 2 times/week, start insulin

These are venous plasma targets, not glucometer targets

Why these tight glycemic Why these tight glycemic

targets?targets? Prospective study in type1 patients with pregnancyProspective study in type1 patients with pregnancy

FBSFBS MacrosomiaMacrosomia

>105 mg/dl>105 mg/dl 28.6 %28.6 %

95-105 95-105 10%10%

<95 mg/dl <95 mg/dl 3%3%

GDM

Failure to maintain glycemic targets

INSULIN THERAPY

Medical nutrition therapy

Medical nutrition therapyMedical nutrition therapy

Promote nutrition necessary for maternal and fetal healthPromote nutrition necessary for maternal and fetal health

Adequate energy levels for appropriate gestational weight Adequate energy levels for appropriate gestational weight

gain,gain,

Achievement and maintenance of normoglycemiaAchievement and maintenance of normoglycemia

Absence of ketones Absence of ketones

Regular aerobic exercisesRegular aerobic exercises

Medical nutrition therapyMedical nutrition therapy

Approximately 30 kcal/kg of ideal body weightApproximately 30 kcal/kg of ideal body weight

> 40-45% should be carbohydrates> 40-45% should be carbohydrates

6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent 6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent ketosis ketosis

Calories guided by fetal well being/maternal weight gain/blood Calories guided by fetal well being/maternal weight gain/blood sugars/ ketonessugars/ ketones

Energy requirements during the first 6 months of lactation Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal require an additional 200 calories above the pregnancy meal plan.plan.

Self monitored blood glucoseSelf monitored blood glucose

4 times/day minimum, fasting and 1 to 2 4 times/day minimum, fasting and 1 to 2 hours after start of mealshours after start of meals

Maintain log bookMaintain log book

Use a memory meterUse a memory meter

Calibrate the glucometer frequentlyCalibrate the glucometer frequently

Fetal monitoringFetal monitoring

Baseline ultrasound : fetal sizeBaseline ultrasound : fetal size At 18-22 weeks: major malformationsAt 18-22 weeks: major malformations

fetal echocardiogramfetal echocardiogram 26 weeks onwards: growth and liquor volume26 weeks onwards: growth and liquor volume III trimester: frequent USG for accelerated growthIII trimester: frequent USG for accelerated growth

( abdominal: head circumference) ( abdominal: head circumference)

Timing of deliveryTiming of delivery

Small risk of late IUD even with good controlSmall risk of late IUD even with good control Delivery at 38 weeksDelivery at 38 weeks Beyond 38 weeks, increased risk of IUD without an Beyond 38 weeks, increased risk of IUD without an

increase in RDSincrease in RDS Vaginal delivery: preferredVaginal delivery: preferred Caesarian section only for routine obstetric indicationCaesarian section only for routine obstetric indication just GDM is not an indication !just GDM is not an indication ! Unfavorable condition of the cervix is a problemUnfavorable condition of the cervix is a problem 4500 grams, cesarean delivery may reduce the likelihood of 4500 grams, cesarean delivery may reduce the likelihood of

brachial plexus injury in the infant (ACOG)brachial plexus injury in the infant (ACOG)

Management of labor and deliveryManagement of labor and delivery

Maternal hyperglycemia in labor: fetal hyperinsulinemia, Maternal hyperglycemia in labor: fetal hyperinsulinemia,

worsen fetal acidosisworsen fetal acidosis Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl ) Feed patient the routine GDM diet Feed patient the routine GDM diet Maintain basal glucose requirementsMaintain basal glucose requirements Monitor sugars 1-4 hrly intervals during labourMonitor sugars 1-4 hrly intervals during labour Give insulin only if sugars more than 120 mg/dlGive insulin only if sugars more than 120 mg/dl

Glycemic management during labourGlycemic management during labour

Later stages of labour: start dextrose to maintain basal Later stages of labour: start dextrose to maintain basal nutritional requirements: 150-200 ml/hr of 5% dextrose nutritional requirements: 150-200 ml/hr of 5% dextrose

Elective LSCS: check FBS, if in target no insulin, start Elective LSCS: check FBS, if in target no insulin, start dextrose dripdextrose drip

Continue hourly SMBGContinue hourly SMBG Post delivery keep patients on dextrose-normal saline till Post delivery keep patients on dextrose-normal saline till

fedfed No insulin unless sugars more than normal ( No insulin unless sugars more than normal ( not GDM not GDM

targets ! )targets ! )

Post partum follow upPost partum follow up Check blood sugars before dischargeCheck blood sugars before discharge

Breast feeding: helps in weight lossBreast feeding: helps in weight loss

Lifestyle modification: exercise, weight reductionLifestyle modification: exercise, weight reduction

OGTT at 6-12 weeks postpartum: classify patients into OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetesnormal/impaired glucose tolerance and diabetes

Preconception counseling for next pregnancyPreconception counseling for next pregnancy

Increased risk of cardiovascular disease,future diabetes and dyslipidemia

Immediate management of neonateImmediate management of neonate

Hypoglycemia : 50 % of macrosomic infants Hypoglycemia : 50 % of macrosomic infants 5–15 % optimally controlled GDM5–15 % optimally controlled GDM

Starts when the cord is clamped Starts when the cord is clamped

Exaggerated insulin release secondary to pancreatic ß-cell Exaggerated insulin release secondary to pancreatic ß-cell hyperplasiahyperplasia

Increased risk : blood glucose during labor and delivery Increased risk : blood glucose during labor and delivery exceeds 90 mg/dlexceeds 90 mg/dl

Anticipate and treat hypoglycemia in the infant

Management of neonateManagement of neonate Hypoglycemia <40 mg/dl Hypoglycemia <40 mg/dl

Encourage early breast feeding Encourage early breast feeding

If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextroseIf symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose

Check after 30 minutes, start feedsCheck after 30 minutes, start feeds

IV dextrose : 6-8 mg/kg/min infusionIV dextrose : 6-8 mg/kg/min infusion

Check for calcium, if seizure/irritability/RDSCheck for calcium, if seizure/irritability/RDS

Examine infant for other congenital abnormalitiesExamine infant for other congenital abnormalities

Long term risk: offspringLong term risk: offspring

Increased risk of obesity and abnormalIncreased risk of obesity and abnormal

glucose toleranceglucose tolerance

Due to changes in fetal islet cell function Due to changes in fetal islet cell function

Encourage breast feeding: less chance of obesity in later Encourage breast feeding: less chance of obesity in later lifelife

Lifestyle modificationLifestyle modification

ConclusionConclusion

Gestational diabetes is a common problem Gestational diabetes is a common problem

Risk stratification and screening is essential in all pregnant Risk stratification and screening is essential in all pregnant womenwomen

Tight glycemic targets are required for optimal maternal Tight glycemic targets are required for optimal maternal and fetal outcomeand fetal outcome

Patient education is essential to meet these targetsPatient education is essential to meet these targets

Long term follow up of the mother and baby is essential Long term follow up of the mother and baby is essential

                                                                                                               

                

17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News ServicesJan. 24, 2005

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