Gestational Diabetes MellitusMellitus

Dr Zarean

Dr valian

Case 1

• 26yG2Ab1

• PMH: neg

• Pregestational weight:57kg and BMI:23.7 kg.m2

• OGTT with 75g of glucose in 25 weeks was performed:

• FBS:95mg/dl• FBS:95mg/dl

• 1h:117mg/dl

• 2h:95mg/dl

• In application of IADPSGc, her diagnosis was GDM.

• Instruction:

Self monitoring of blood glucose (SMBG) in our GDM unit

Nutritional and lifestyle recommendationsNutritional and lifestyle recommendations

A week later

• Fasting and pre-dinner capillary blood glucose levels were found to exceed 95 mg/dl (5.3 mmol/L) in 4 out of 5 times

• Basal insulin (insulin NPH) was initiated in her 26th week of gestation

• Was titrated weekly to 6 IU at 29 gestational weeks

At 32 weeks

• capillary blood glucose levels were >140 mg/dl (7.8 mmol/L) 1 hour following breakfast and lunch, reaching levels up to 165 mg/dl (9.2 mmol/L),

• Insulin novorapid was initiated before both meals

At week 34

• Was receiving 6 IU of NPH insulin, 2 IU of novorapid insulin before breakfast and 4 IU before lunch

• Doses were maintained until week 39

• At 38 weeks her BW was 75 Kg and her BMI 32 Kg.m-2

• At week 40+3 days, following vaginal delivery, a male nenonate was born:

• Apgar score of 9 and 10 at 1/5 minutes• Apgar score of 9 and 10 at 1/5 minutes

• Umbilical artery pH 7.32

• Birth weight of 3,200 g

• No other medical complications were recorded.

• Three months after delivery: The patient’s body weight lowered to 58 kg and presented a normal 75 g OGTT on diet alone.

Case2

• 26yG1

• PMH: hypothyroidism five years before pregnancy

• DH: levothyroxine

• FBS: 94mg/dl

• OGTT with 75g glucose was not performed• OGTT with 75g glucose was not performed

• HbA1C:6%

• Patient went to another hospital, where CCc were applied, and GDM ruled out

• Received no instructions regarding lifestyle and nutrition for GDM

• Patient continued her obstetrical follow-up at our hospital

• The 32 week fetal ultrasound showed:

A single cephalic male fetus

BPD : 86 mm

HC: 308 mm

AC: 300 mm

FL: 64 mm

Weight estimation was 2300 g (percentile 98)

Was considered (LGA)

At week 34

• Ultrasound examination revealed:

A single cephalic fetus

BPD: 90mm

AC: 356 mm

FL: 71 mmFL: 71 mm

Weight estimation was 3498 g. (percentile 100)

• Pregestational BW was 74 kg and BMI 29.6 Kg.m-2, increasing to 89 Kg at week 34.

• She was instructed with nutritional and lifestyle recommendations.

• Three days later, her capillary blood glucose levels:• Three days later, her capillary blood glucose levels:

• Fasting, was found to exceed 105 mg/dl (5.83 mmol/l), with normal 1 hour postprandial values.

• The patient was started on insulin NPH, 6 IU, and her capillary glucose levels met target levels 2 days later.

• Her capillary glucose levels remained on target

Week 39+6 days

• Had a vaginal delivery with episiotomy.

• A male son was born

• Weighing 4,040 g

• With apgar scores of 9/10 at 1/5 minutes

• Umbilical artery pH 7.33. • Umbilical artery pH 7.33.

• There were no post-partum complications

SCREENING AND DIAGNOSTIC TESTING

• Two-step approach –most widely used approach:

• The first step is a 50-gram one-hour glucose challenge test (GCT).

• Screen-positive patients go on to the second step: 100-gram, three-hour oral glucose tolerance test (GTT)> diagnostic test for GDM

• One-step approach –only a 75-gram, two-hour oral GTT.• One-step approach –only a 75-gram, two-hour oral GTT.

50-gram one-hour glucose screenGCT or GLT

• A 50-gram oral glucose load is given without regard to the time elapsed since the last meal and plasma glucose is measured one hour later

• Positive screen: ≥130 mg/dL, ≥135 mg/dL, or ≥140mg/dL (7.2 mmol/L, 7.5 mmol/L, or 7.8 mmol/L).

• Women with 50-gram one-hour glucose results ≥200 mg/dL (11.1 mmol/L),= diagnosis of gestational diabetes mellitus

75-gram two-hour glucose screen

• If a 75-gram two-hour GTT is planned and the fasting glucose level is ≥92 mg/dL (5.1 mmol/L), then the diagnosis of gestational diabetes mellitus is made and the GTT is cancelled

• The 75-gram two-hour oral GTT is more convenient, better tolerated, • The 75-gram two-hour oral GTT is more convenient, better tolerated, and more sensitive

RECOMMENDATIONS OF NATIONAL AND INTERNATIONALORGANIZATIONS FOR SCREENING AND DIAGNOSIS OF DIABETES IN PREGNANCY

• ACOG > two-step approach

• International Association of Diabetes and Pregnancy Study Groups (IADPSG) > one-step approach

• American Diabetes Association (ADA)> one-step or two-step approachapproach

• WHO > one-step approach

• Canadian Diabetes Association (CDA) > two-step [preferred] or one-step approach

• The Endocrine Society (one-step approach)

• Australasian Diabetes in Pregnancy Society (WHO approach)

• International Federation of Gynecology and Obstetrics (FIGO) > (one-step approach)

Approach

• Performs testing for overt diabetes at the initial prenatal visit in patients with risk factors by checking A1C

• Diagnosis of overt diabetes is made when A1C is ≥6.5 percent

• Early in pregnancy> ADA criteria for diagnosis of overt diabetes

• ACOG criteria & (IADPSG)/ADA criteria for diagnosis of gestational • ACOG criteria & (IADPSG)/ADA criteria for diagnosis of gestational diabetes mellitus at 24 to 28

Managment

Hyperglycemia and Adverse Pregnancy Outcome

• Continuous relationship between maternal glucose and adverse outcomes:

• FBS: 100 to 105 mg/dL (5.6 to 5.8 mmol/L) associated with a risk of macrosomia

• Overly tight metabolic control in gestational diabetes (ie,average• Overly tight metabolic control in gestational diabetes (ie,averageblood glucose levels ≤86 mg/dL) can result in an increase in SGA

EXERCISE

• Both fasting and postprandial blood glucose concentrations can be reduced

• Need for insulin may be obviated

• ADA encourages a program of moderate exercise as part of the treatment plantreatment plan

Gestational Diabetes Mellitus and Frequency of BloodGlucose Monitoring: A Randomized Controlled Trial• Mendez-Figueroa H, Schuster M, Maggio L, et al.

• Obstet Gynecol 2017; 130:163.

• Testing blood glucose every other day versus four times daily resulted in similar birth weights and frequency of macrosomia

One hour postprandial monitoring was associated with the following benefits ascompared with preprandial monitoring:

• Better glycemic control

• A lower incidence of LGA• A lower incidence of LGA

• A lower rate of cesarean delivery for CPD

Glucose target

• ADA and ACOG glucose targets are:

• FBS :

• Uptodate: oral antihyperglycemic agents are a reasonable alternative

• ACOG and ADA: prefer use of insulin but have endorsed the use of oral antihyperglycemic agents (metformin or glyburide) in certain circumstances

• ACOG: recommends metformin over glyburide as the preferred oral

PHARMACOLOGIC THERAPY

• ACOG: recommends metformin over glyburide as the preferred oral antihyperglycemic agent

• FDA: such therapy has not been specifically approved

Oral anti-diabetic pharmacological therapies for the treatment ofwomen with gestational diabetes

• Brown J. et al

• Glyburide was compared with metformin in a 2017 Cochrane Database Syst Revsystematic review

• Clinically important pregnancy outcomes are generally similarClinically important pregnancy outcomes are generally similar

• Metformin use resulted in:

Lower mean birth weight

Less gestational weight gain

Less composite neonatal death or serious morbidity.

Type of insulin

• Only lispro and aspart have been investigated in pregnancy and are comparable in immunogenicity to human regular insulin

• Detemir or glargine appear to be safe for use in pregnancy

• We prefer use of human NPH insulin

• 0.7 to 2 units per kg (present pregnant weight) to achieve glucose • 0.7 to 2 units per kg (present pregnant weight) to achieve glucose control

Follow-up and prevention of type 2 diabetes

• Oral GTT 4 to 12 weeks after delivery, using the two-hour 75 g

• FBS

• Diabetes is diagnosed if:

FBS≥126 mg/dL (7.0 mmol/L)

Two-hour glucose is ≥200 mg/dL (11.1 mmol/L)Two-hour glucose is ≥200 mg/dL (11.1 mmol/L)

Prevention of diabetes in women with a history ofgestational diabetes: effects of metforminand lifestyle interventions

• Ratner RE, Christophi CA, Metzger BE, et al.

• J Clin Endocrinol Metab 2008

• Intensive lifestyle and metformin therapy reduced the incidence of future diabetes by approximately 50 percent compared with placebo

• Metformin was much more effective than lifestyle intervention• Metformin was much more effective than lifestyle intervention

Follow-up laboratory testing

• At a minimum of every three years

• More frequent screening (every one or two years) may also be indicated in:

women with other risk factors for diabetes

women who may become pregnant againwomen who may become pregnant again

• Two-hour 75 g oral GTT is the more sensitive test for diagnosis of diabetes and impaired glucose tolerance in most populations

Assesment of fetal growth

Estimators of birth weight in pregnant women requiring insulin: acomparison of seven sonographic models

• McLaren RA, Puckett JL, Chauhan SPAm

• Obstet Gynecol 1995; 85:565

• One review of pregnant women with diabetes treated with insulin found that the sonographically estimated fetal weight had to be ≥4800 grams for there to be at least a 50 percent chance the infant's ≥4800 grams for there to be at least a 50 percent chance the infant's birthweight would be ≥4500 grams

Timing of deliveryTiming of delivery

A2 GDM

• GDM whose glucose levels are medically managed with insulin or oral agents

• Induction of labor at 39 weeks of gestation

• Induction of labor prior to 39 weeks of gestation:

If a concomitant medical condition (eg, hypertension) is present If a concomitant medical condition (eg, hypertension) is present

glycemic control is suboptimal

ACOG suggests:

• Women with GDM well controlled with medication:

• Delivery at 39+0 to 39+6 weeks

• Women with poor glycemic control:

• Delivery at 37+0 to 38+6 weeks of gestation may be reasonable

• Delivery prior to 37+0 weeks should only be done when more aggressive eforts to control blood sugars, such as hospitalization, have failed.

Labor and delivery

• Women with GDM who were euglycemic without use of insulin or oral antihyperglycemic drugs during pregnancy:

Do not normally require insulin during labor and delivery

Do not need their blood glucose levels checked hourly

• Women with GDM who used insulin or oral antihyperglycemic drugs • Women with GDM who used insulin or oral antihyperglycemic drugs to maintain euglycemia:

Occasionally need insulin during labor and delivery to maintain euglycemia

Checking blood glucose measurements

• The Endocrine Society:

Suggests target glucose levels of 72 to 126 mg/dL (4.0 to 7.0 mmol/L)

Check blood glucose measurements every two hours during labor

Begin intravenous insulin at glucose levels above 120 mg/dL (6.7 Begin intravenous insulin at glucose levels above 120 mg/dL (6.7 mmol/L)

POSTPARTUM MANAGEMENT AND FOLLOW-UP

• Check glucose concentrations for 24 to 72 hours after delivery

• If FBS suggest overt diabetes (FBS ≥126 mg/dL [7 mmol/L] or random glu ≥200 mg/dL [11.1 mmol/L]), treatment is warranted

• Women who have FBS< 126 mg/dL (7mmol/L) after delivery should have a two-hour 75-gram OGTT 6 to 12 weeks postpartumhave a two-hour 75-gram OGTT 6 to 12 weeks postpartum

Lactation and Progression to Type 2 Diabetes Mellitus AfterGestational Diabetes Mellitus: A Prospective Cohort Study

• Gunderson EP, Hurston SR, Ning X, et al.

• Ann Intern Med 2015; 163:889

• Breastfeeding decreased the incidence of diabetes two years after a diagnosis of gestational diabetes mellitus compared with not breastfeedingbreastfeeding

• Thank you for your attention