Upload
shereenakmal
View
237
Download
0
Embed Size (px)
Citation preview
8/9/2019 Underwood - GDM
1/33
Gestational DiabetesGestational DiabetesReview & Advances in TreatmentReview & Advances in Treatment
Virginia Underwood, Capt, USAF, MCVirginia Underwood, Capt, USAF, MC
Family Practice ResidentFamily Practice ResidentDavid Grant Medical CenterDavid Grant Medical Center
8/9/2019 Underwood - GDM
2/33
OverviewOverview
DefinitionDefinition
ScreeningScreening
Conventional TreatmentsConventional Treatments New TreatmentsNew Treatments
GoalsGoals
Postpartum ScreeningPostpartum Screening
8/9/2019 Underwood - GDM
3/33
QuestionsQuestions
Does screening for and treating GDM affectDoes screening for and treating GDM affect
infant or maternal morbidity or mortality?infant or maternal morbidity or mortality?
Does antepartum fetal testing prevent stillbirthDoes antepartum fetal testing prevent stillbirthor infant morbidity?or infant morbidity?
Does postpartum glucose tolerance testing haveDoes postpartum glucose tolerance testing have
an appreciable long term impact on women withan appreciable long term impact on women with
a history of GDM?a history of GDM?
8/9/2019 Underwood - GDM
4/33
EpidemiologyEpidemiology
33--7% of pregnant women in the U.S.7% of pregnant women in the U.S.
Increasing prevalenceIncreasing prevalence
Risk factors:Risk factors: >25 yrs>25 yrs
Hispanic, Native American, South or East Asian, PacificHispanic, Native American, South or East Asian, PacificIslands, African AmericanIslands, African American
BMI >25BMI >25
Previous history glucose intolerancePrevious history glucose intolerance History obstetric outcomes associated with GDMHistory obstetric outcomes associated with GDM
History diabetes in a first degree relativeHistory diabetes in a first degree relative
8/9/2019 Underwood - GDM
5/33
Question #1
Question #1
Does screening for and treating GDMDoes screening for and treating GDM
affect infant or maternal morbidity oraffect infant or maternal morbidity ormortality?mortality?
8/9/2019 Underwood - GDM
6/33
GDM CriteriaGDM Criteria
NationalNational
Diabetes DataDiabetes Data
Group*Group*
AmericanAmerican
DiabetesDiabetes
Association*Association*
World healthWorld health
OrganizationOrganization
Carpenter andCarpenter and
Coustan*Coustan*
FastingFasting 105105 9595 126 126 9595
1 hour1 hour 190190 180180 -- 180180
2 hours2 hours 165165 155155 140 140 155155
3 hours3 hours 145145 140140 -- 140140
*2 or more criteria met = positive diagnosis (cutoff points inmg/dl)
=
8/9/2019 Underwood - GDM
7/33
Screening & DiagnosisScreening & Diagnosis
Screen: 50g glucose 1 hour glucose challengeScreen: 50g glucose 1 hour glucose challenge nonnon--fasting state (higher or similar values with fast)fasting state (higher or similar values with fast)
Diagnosis: 100g,3
hour glucose tolerance testDiagnosis: 100g,3
hour glucose tolerance test Positive test = 2 or more thresholds met/exceededPositive test = 2 or more thresholds met/exceeded
No smoking priorNo smoking prior
Unrestricted diet: at least 150g carbohydrates/d forUnrestricted diet: at least 150g carbohydrates/d for
at least 3 days prior (to avoid spurious high values)at least 3 days prior (to avoid spurious high values) One abnormal value with increased risk forOne abnormal value with increased risk for
macrosomic infants & associated morbiditiesmacrosomic infants & associated morbidities
8/9/2019 Underwood - GDM
8/33
When to Screen?When to Screen?
2424--28 weeks gestation28 weeks gestation
Early screening:Early screening:
marked obesitymarked obesity personal history of GDM (33personal history of GDM (33--50% likelihood50% likelihood
recurrence)recurrence)
glycosuriaglycosuria
strong family history of diabetesstrong family history of diabetes
8/9/2019 Underwood - GDM
9/33
Maternal glucoseintolerance
Adverse pregnancyoutcomes
8/9/2019 Underwood - GDM
10/33
RecommendationsRecommendations
USPSTF: evidence is insufficient to recommend for orUSPSTF: evidence is insufficient to recommend for oragainst routine screeening. (did find fairagainst routine screeening. (did find fair -- goodgoodevidence that screening for GDM and treatment ofevidence that screening for GDM and treatment of
hyperglycemia could reduce the frequency of fetalhyperglycemia could reduce the frequency of fetalmacrosomia)macrosomia)
ADA: officially recommends screening for GDM, butADA: officially recommends screening for GDM, butmay omit low risk womenmay omit low risk women
ACOG: universal screening is the most sensitiveACOG: universal screening is the most sensitiveapproach; screening may be omitted in low risk women,approach; screening may be omitted in low risk women,but universal screening as more practical approachbut universal screening as more practical approach
8/9/2019 Underwood - GDM
11/33
Treatment QuestionsTreatment Questions
Does GDM pose serious risks to offspring?Does GDM pose serious risks to offspring?
Does treatment reduce those risks?Does treatment reduce those risks?
Does treatment reduce other risks associatedDoes treatment reduce other risks associatedwith GDM (obesity/diabetes in offspring)?with GDM (obesity/diabetes in offspring)?
Does reducing glycemia reduce risks?Does reducing glycemia reduce risks?
(macrosomia & cesarean delivery)(macrosomia & cesarean delivery)
8/9/2019 Underwood - GDM
12/33
Potential risksPotential risks
MacrosomiaMacrosomia
Brachial plexus injuryBrachial plexus injury
Fracture with deliveryFracture with delivery
Fetal hypoglycemiaFetal hypoglycemia
Fetal hyperbilirubinemiaFetal hyperbilirubinemia
Fetal hypocalcemiaFetal hypocalcemia
Childhood obesityChildhood obesity
NeuropsychologicalNeuropsychologicaloutcomesoutcomes
Development of diabetesDevelopment of diabetes
Perinatal mortalityPerinatal mortality
33rdrd/4/4thth degree lacerationsdegree lacerations
Instrument deliveriesInstrument deliveries
Cesarean deliveryCesarean delivery
PreeclampsiaPreeclampsia
Future diabetes mellitusFuture diabetes mellitus
8/9/2019 Underwood - GDM
13/33
Confounding FactorsConfounding Factors
Fetal size: maternal glucose levels, maternalFetal size: maternal glucose levels, maternal
BMI, pregnancy weight gain, parityBMI, pregnancy weight gain, parity
Spectrum of sugars of normal to diabeticSpectrum of sugars of normal to diabeticpatients (single abnormal value of3hGTTpatients (single abnormal value of3hGTT large for gestational infants)large for gestational infants)
Normal pregnancies with very narrow glucoseNormal pregnancies with very narrow glucose
range (euglycemia difficult to achieve)range (euglycemia difficult to achieve)
Alerting physicians to increased riskAlerting physicians to increased risk
8/9/2019 Underwood - GDM
14/33
Confounding FactorsConfounding Factors
Large number of subjects neededLarge number of subjects needed
450 infants undergoing cesarean delivery to450 infants undergoing cesarean delivery to
prevent one permanent brachial plexus injuryprevent one permanent brachial plexus injury Lowered cesarean delivery threshold: resultingLowered cesarean delivery threshold: resulting
morbidity and costs outweigh benefits?morbidity and costs outweigh benefits?
8/9/2019 Underwood - GDM
15/33
ResearchResearch--Crowther et al.Crowther et al.
Multicenter, 1000 womenMulticenter, 1000 women
75g oral glucose tolerance test between 2475g oral glucose tolerance test between 24--32 weeks32 weeksgestationgestation
Subjects: below 140 fasting, and between 140Subjects: below 140 fasting, and between 140--198 at 2198 at 2hours after glucose challengehours after glucose challenge
Intervention: glucose monitoring, dietaryIntervention: glucose monitoring, dietarycounseling/insulin to maintain sugarscounseling/insulin to maintain sugars
Goals: premeal/fasting
8/9/2019 Underwood - GDM
16/33
Crowther et al. ResultsCrowther et al. Results
Intervention group with reduced:Intervention group with reduced:
Perinatal death (5 v. 0)Perinatal death (5 v. 0)
Shoulder dystociaShoulder dystocia Bone fractureBone fracture
Nerve palsyNerve palsy
Macrosomia (4kg: 21% v. 10%)Macrosomia (4kg: 21% v. 10%)
Postpartum depression (health status)Postpartum depression (health status)
8/9/2019 Underwood - GDM
17/33
Crowther et al. ResultsCrowther et al. Results
Cesarean delivery rates similar between groupsCesarean delivery rates similar between groups
Control group with reduced:Control group with reduced:
Inductions of laborInductions of laborAdmissions to neonatal intensive care unitAdmissions to neonatal intensive care unit
8/9/2019 Underwood - GDM
18/33
ResearchResearch-- Langer et al.Langer et al.
555 gestational diabetics diagnosed after 37555 gestational diabetics diagnosed after 37
weeks v. 1110 subjects treated for gestationalweeks v. 1110 subjects treated for gestationaldiabetes mellitus and 1110 nondiabetic subjectsdiabetes mellitus and 1110 nondiabetic subjects
Adverse outcomes: 59% for untreated, 18% forAdverse outcomes: 59% for untreated, 18% fortreated, and 11% for nondiabetictreated, and 11% for nondiabetic
22-- to 4to 4--fold increase in metabolic complicationsfold increase in metabolic complications
and macrosomia/LGA in the untreated group &and macrosomia/LGA in the untreated group &no difference between nondiabetic and treatedno difference between nondiabetic and treated
Increasing evidence that identifying women
with GDM is important because appropriatetherapy can decrease fetal and maternalmorbidity, particularly macrosomia
8/9/2019 Underwood - GDM
19/33
Upcoming studiesUpcoming studies
MaternalMaternal--Fetal Medicine Network multicenterFetal Medicine Network multicenter
trial of treatment of mild GDMtrial of treatment of mild GDM
HAPOHAPO-- Hyperglycemia and Adverse PregnancyHyperglycemia and Adverse PregnancyOutcome studyOutcome study
8/9/2019 Underwood - GDM
20/33
Treatment RecommendationsTreatment Recommendations
American Diabetes Association:American Diabetes Association:
Nutrition counselingNutrition counseling
Carbohydrates: 35Carbohydrates: 35--40% of daily calories40% of daily calories (caution for ketosis(caution for ketosis IQ/psychomotorIQ/psychomotor
development)development)
BMI >30kg/mBMI >30kg/m22: lowering daily calories by30% (goal: lowering daily calories by30% (goal
25kcal/kg actual weight per day)25kcal/kg actual weight per day)
8/9/2019 Underwood - GDM
21/33
Treatment RecommendationsTreatment Recommendations
Trial 2 weeks (if initial fasting 95 unlikely to be controlled
Exercise:Exercise:Weight reduction and improve glucose metabolismWeight reduction and improve glucose metabolism
Effects on fasting glucose/tolerance & macrosomiaEffects on fasting glucose/tolerance & macrosomia
8/9/2019 Underwood - GDM
22/33
Glucose goalsGlucose goals
Fasting
8/9/2019 Underwood - GDM
23/33
MonitoringMonitoring
Frequency not establishedFrequency not established
Reduces?:Reduces?:
Perinatal mortality/hypoglycemia/shoulder dystociaPerinatal mortality/hypoglycemia/shoulder dystocia MacrosomiaMacrosomia
Timing:Timing:
Fasting v. postprandial (nadirs v. glucose excesses)Fasting v. postprandial (nadirs v. glucose excesses)
1h v. 2h postprandial1h v. 2h postprandial
Severe/preexistent v. mildSevere/preexistent v. mild frequencyfrequency
8/9/2019 Underwood - GDM
24/33
InsulinInsulin
When:When:
> 95 or 105 fasting> 95 or 105 fasting
>120 2 h postprandial>120 2 h postprandial Initial dose: 0.7U/kg/dayInitial dose: 0.7U/kg/day
AM 2/3AM 2/3 2/3 NPH, 1/3 Reg2/3 NPH, 1/3 Reg
PM 1/3PM 1/3
1/2 NPH, 1/2 Reg1/2 NPH, 1/2 Reg *once daily ultralente with very short acting*once daily ultralente with very short acting
lispro insulinlispro insulin
8/9/2019 Underwood - GDM
25/33
Oral hypoglycemicsOral hypoglycemics
Previous concerns: (Diabinese & Orinase)Previous concerns: (Diabinese & Orinase) 11stst generation sulfonylureasgeneration sulfonylureas
Potential teratogenicityPotential teratogenicity
Transport across placenta (hypoglycemia)Transport across placenta (hypoglycemia)
Glyburide:Glyburide: 22ndnd generation sulfonylureageneration sulfonylurea
Does not enter fetal circulation (in vitro/vivo)Does not enter fetal circulation (in vitro/vivo)
Comparable maternal/neonatal outcomesComparable maternal/neonatal outcomes
Less maternal hypoglycemiaLess maternal hypoglycemia Metformin (PCOS, gestational diabetes, first trimesterMetformin (PCOS, gestational diabetes, first trimester
miscarriage rates)miscarriage rates)
8/9/2019 Underwood - GDM
26/33
GlyburideGlyburide
Start: 2.5 mg once or twice dailyStart: 2.5 mg once or twice daily
Increase: by 2.5 mg to 5 mg at weekly intervals asIncrease: by 2.5 mg to 5 mg at weekly intervals asneeded until maximum dose of 20 mg dailyneeded until maximum dose of 20 mg daily
Peak plasma level of glyburide: 2Peak plasma level of glyburide: 24 hours after4 hours afteradministrationadministration
Timing administration with hyperglycemiaTiming administration with hyperglycemia(daytime/fasting)(daytime/fasting)
Fasting hyperglycemia on diet: higher dose/bidFasting hyperglycemia on diet: higher dose/bid 55--20% conversion to insulin20% conversion to insulin
*fasting plasma glucose
8/9/2019 Underwood - GDM
27/33
Question #2
Question #2
Does antepartum fetal testing preventDoes antepartum fetal testing prevent
stillbirth or infant morbidity?stillbirth or infant morbidity?
8/9/2019 Underwood - GDM
28/33
Antepartum Fetal TestingAntepartum Fetal Testing
Purpose: identify patients at risk for stillbirthPurpose: identify patients at risk for stillbirth
Stillbirth rare occurrenceStillbirth rare occurrence
Practice patterns: starting at 32Practice patterns: starting at 32--40 weeks gestation40 weeks gestation
ACOG:ACOG:
Glucose not well controlledGlucose not well controlled
Requiring insulinRequiring insulin
Concomitant hypertensionConcomitant hypertension NST/AFI, full biophysical profileNST/AFI, full biophysical profile
No evidence regarding fetal ultrasoundNo evidence regarding fetal ultrasound macrosomiamacrosomia
Insufficient evidence regardingimpact of antenatal fetal testing on
stillbirth rate, and neonatal
morbidity
8/9/2019 Underwood - GDM
29/33
Question #3Question #3
Does postpartum glucose tolerance testingDoes postpartum glucose tolerance testinghave an appreciable long term impact onhave an appreciable long term impact on
women with a history of GDM?women with a history of GDM?
8/9/2019 Underwood - GDM
30/33
Postpartum screeningPostpartum screening
50% women with GDM developing diabetes50% women with GDM developing diabetes
mellitus in a 28yr study (v. 7% of controls)mellitus in a 28yr study (v. 7% of controls)
Possible preexistent diabetesPossible preexistent diabetes 66--8wks postpartum8wks postpartum
2h OGTT (75g)2h OGTT (75g)
Impaired: 140Impaired: 140--199 (100199 (100--125)125)
DM: 200 ( 126)DM: 200 ( 126)
Diet, exercise, weight reduction counselingDiet, exercise, weight reduction counseling
No long-term follow-up studies thatverify the benefit of postpartum
diagnostic testing
8/9/2019 Underwood - GDM
31/33
SummarySummary
DefinitionDefinition
ScreeningScreening
Conventional TreatmentsConventional Treatments New TreatmentsNew Treatments
GoalsGoals
Postpartum ScreeningPostpartum Screening
8/9/2019 Underwood - GDM
32/33
BibliographyBibliography
1. Langer O, Conway DL, Berkus MD, Xenakis EM1. Langer O, Conway DL, Berkus MD, Xenakis EM--J, Gonzales O. A comparison of glyburideJ, Gonzales O. A comparison of glyburideand insulin in women with gestational diabetes mellitus. NEJM 2000;343:1134and insulin in women with gestational diabetes mellitus. NEJM 2000;343:11348.8.
2. Saade, George. Gestational Diabetes Mellitus: A Pill or a Shot?. Obstetrics & Gynecology2. Saade, George. Gestational Diabetes Mellitus: A Pill or a Shot?. Obstetrics & Gynecology2005; 105:4562005; 105:456--7.7.
3. Turok d, Ratcliffe S, Baxley E. Management of gestational diabetes mellitus. American Family3. Turok d, Ratcliffe S, Baxley E. Management of gestational diabetes mellitus. American FamilyPhysician 2003; 68: 1767Physician 2003; 68: 1767--1772.1772.
4. Greene M, Solomom C. Gestational diabetes mellitus4. Greene M, Solomom C. Gestational diabetes mellitus time to treat. NEJM 2005; 352: 2544time to treat. NEJM 2005; 352: 2544--2546.2546. 5. Crowther C, Hiller J, MossJ, McPhee A, Jeffries W, RobinsonJ. Effect of treatment of5. Crowther C, Hiller J, MossJ, McPhee A, Jeffries W, RobinsonJ. Effect of treatment of
gestational diabetes mellitus on pregnancy outcomes. NEJM 2005; 352: 2477gestational diabetes mellitus on pregnancy outcomes. NEJM 2005; 352: 2477--2486.2486. 6. Kjos S, Buchanan T. Gestational Diabetes Mellitus6. Kjos S, Buchanan T. Gestational Diabetes Mellitus current concepts. NEJM 1999; 341:current concepts. NEJM 1999; 341:
17491749--1756.1756. 7. Naylor C, Phil D, Sermer M, Chen E, Farine D. Selective screening for gestational diabetes7. Naylor C, Phil D, Sermer M, Chen E, Farine D. Selective screening for gestational diabetes
mellitus. NEJM 1997; 337: 1591mellitus. NEJM 1997; 337: 1591--1597.1597.
8. Caughey A. Management of Diabetes in Pregnancy. Johns Hopkins Advanced Studies in8. Caughey A. Management of Diabetes in Pregnancy. Johns Hopkins Advanced Studies inMedicine 2006: 309Medicine 2006: 309--318.318. 9. Gestational Diabetes. ACOG Practice Bulletin. 2006: 5189. Gestational Diabetes. ACOG Practice Bulletin. 2006: 518--531.531.
8/9/2019 Underwood - GDM
33/33
Questions?Questions?
Sugar-free chocolate
mousse cake