Gestational DiabetesThe Therapeutical Education “ in Team“
Master for Sanitary OperatorsFebruary 21, 2009
Pisa, Italy, Accademia Palace Hotel
Obstetric Management in Women affected by Gestational Diabetes
Dr. Lorella Battini, MD, Prof. of OGASH General Coordinator of OGASH Institutions
Europe Chairman of OGASHWinner of Prof Joseph Jordania International Prize 2008
Nominated “OGASH Professor ” for the E.T. Rippmann Medal de Onoare
Diabetes Care 30:S175-S179, 2007DOI: 10.2337/dc07-s212
© 2007 by the American Diabetes Association
Obstetric Management in Gestational Diabetes
Deborah L. Conway, MD From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center–San Antonio, San Antonio, Texas
ACOG Practice Bulletin 2001
AOGOI, Rivista di Ostetricia Ginecologia Pratica e Medicina Perinatale, vol XXII, n° 3/4, 2007
DIABETES CARE, Ed. Italiana, All. a, ADA, maggio 2003
NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period
Bibliographical Sources
Optimizing outcomes for women with gestational diabetes mellitus (GDM)
and their fetuses
“ Multidisciplinary Team Play Strategies”
• careful metabolic management (Diabetologists)
• appropriately applied fetal surveillance techniques (Obstetrics )
• thoughtful selection of the most advantageous timing and route of delivery
Warning !Whenever possible, these clinical decisions should be based on the highest level of evidence available and should weigh the likelihood and seriousness of both
maternal and fetal/neonatal morbidity
1997- Workshop-Conference on GDM
“ The summary statement ”
“ the lack of data from controlled clinical studies on which management
recommendations can be based was a prominent theme of discussion regarding antepartum management of GDM" (1).
Major Risk Factors for GD
• Age >35 years• Istgrade family History : Diabetes• Previous GDM• Glycosuria• Obesity: BMI>28• Macrosomia (>4 Kg)• Significant weight increase in Pregnancy• Acceleratad or dismorfic fetal growth • History of unexplained stillbirth
OMS
EARLY GCT (50 gr)
Negative GCT:
Basal Value < 95
1 h post-load < 140
Preconceptional Planning
FLOW CHART
Screening GDM precoce
UO Ost-Gin 2 AOUP
Direttore: Dr. MG Salerno
Flow Chart
Joint Diab/Obstet.Ambulatory AOUP
Early
GDM Screening
Fetal surveillance
• All women with GDM should monitor fetal movements during the last 8–10 weeks of pregnancy and report immediately any reduction in the perception of fetal movements.
• Non-stress testing and / and/or CST and/or biophysical profile testing should be "considered" since 32 weeks’ gestation in women with poor glycaemic control, or on insulin, or who have concomitant perinatal risk factors
• Non-stress testing should be "considered" and "at or near" term in women requiring only dietary management and without concomitant perinatal risk factors
ACOG Practice Bulletin 2001
Fetal surveillance
• Biophysical profile testing and/or Doppler velocimetry to assess umbilical blood flow "may be considered" in cases of “ excessive or poor fetal growth “, or when there are comorbid conditions, such as GESTOSIS SYNDROME ( “RIPPMANN ’s SYNDROME “ ) or obstetric history positive for further pathology
Fetal surveillance• For uncomplicated, well controlled GDM, treated with only diet, and without further
perinatal risk factors
No sufficient evidence to propose an optimal monitoring strategy,
thus the following chances are allowed:
• The same tests of complicated GDM since 32nd week of gestation
• Routine monitoring protocol of normal pregnancies
ACOG Practice Bulletin 2001
• The presence of GDM is not by itself an indication for cesarean delivery.
• There are no data to support a policy of caesarean delivery purely on the basis of GDM
However:
• MACROSOMIA • SHOULDER DYSTOCIA
• CLAVICULAR FRACTURE• BRACHIAL PALSY
• UNEXPLAINED INTRAUTERINE FETAL DEATH• PERINATAL MORBIDITY
are more common in women with GDM, thereforeElective Cesarean Delivery
is reasonable when macrosomia has been detected (EFW>4500g), on the basis of obstetric history,
pelvimetry and careful assessment of risk- benefits balance
Mode of Delivery in GD
Timing of Delivery in GD
• GD is not an indication for caesarean or spontaneous delivery before 38 weeks’ gestation, in the absence of evidence of fetal compromise or other maternal risk factors.
HoweverGestational prolonging beyond 38th weeks may lead to
• Increased risk of fetal macrosomia
Without • Reducing caesarean section risk
Thus • Delivery in the course of 38° week of gestation is
recommended, unless obstetrical factors don’t indicate different management
ADA, Official Position, 2003
ACOG Pract. Bulletin, 2001: Not recommended delivery before 40 ws. in uncomplicated GD, without further maternal and/or fetal
indications
Preexisting Diabetes MellitusSummary of Management in Pregnancy
• Preconceptional Planning after optimizing HbA1C < 6.5g/dl (OMS)
• Multidisciplinary team approach and follow-up• Strict and intensive SMBG • Maintenance of blood glucose fasting value < 95-90• Maintenance of blood glucose 1h postprandial value < 130• Avoidance of hypoglycaemia • 5 mg folic acid until 12 weeks gestation• Physical activity planning• Increased frequency of screening for retinopathy• Intensive follow up for prevention and/or early detections of
complications • Delivery in III Level Obstetric Department with NICU• Breast feeding recommended
Preexisting Diabetes: Monitoring fetal growth and
well-being
• Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks
• Women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being.
Preexisting Diabetes: Timing and mode of birth
• pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks
• diabetes should not in itself be considered a contraindication to attempting vaginal birth
• pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section
(1) NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period (2) NICE (July 2008 re-issued guidance). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period
Conclusion
The diagnostical-therapeutical route,shared and managed by a
multidisciplinar and multiprofessional team is the
fundamental instrument to make safe pregnancy in diabetic women.
Conclusion
• A. The activation of a structured screening for GDM diagnosis is an essential instrument to avoid unappropriate and late OGTT check
• To early detect Patients affected by GDM and manage them to safe delivery
• B. Women affected by pregestational Diabetes Mellitus can live safe pregnancy and delivery, giving birth in a 3rd level Obstetric Unit linked to a Neonatal Intensive Care Unit
Saint Vincent Declaration, 1989 (OMS)
Diabetic Woman in Pregnancy is a Patient “at
risk”
By Saint Vincent Declaration, in 1989, WHO addressed the following Mission to the
International Scientifical Diabetology community:
1. To dramatically reduce risk in diabetic women as that in non diabetics
2. To early detect GDM For preventing adverse outcome in Mother and
Babies by an adequate screening in “ women at risk “
THE JOINT INTERDEPARTMENT DIABETOLOGIC-OBSTETRIC SERVICE for DIABETES and PREGNANCY- AOUP-PISA
G. Di Cianni, L. Volpe, A. Bertolotto, C.Lencioni, A. Ghio, V. Resi L. Battini
Dietologist: M. Corfini Nurses: M. Carnevale, A. Civitelli, A. Favati, S. Nuvola, L. Tesi
Saint Vincent Declaration, 1989 (OMS)