Gestational diabetes Q & A

GESTATIONAL DIABETES MANAGEMENT

Iris Thiele Isip Tan MD, MSc, FPCP, FPSEMClinical Associate Professor, UP College of Medicine

2 Mar 2012

Wednesday, November 21, 12

Q1

Which of the following women will you screen for gestational diabetes?

a) 25 y.o. G1P0 whose mother has diabetes

b) 38 y.o. G3P0 with recurrent first-trimester abortions

c) 27 y.o. G2P1

d) All of the above


All pregnant women

should be screened for GDM.

Unite for Diabetes CPG 2010


Risky

Filipino women are at increased risk for diabetes in pregnancy.

ASGODIP Data n/N

Low risk 35/853

High risk 136/350

Overall 171/120314.2%

Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy: Preliminary Data on Prevalence. PJIM 1996:34:67-68.


Risky

http://www.flickr.com/photos/mikewade/3267336862/

Macrosomia

Birth injuries

http://www.flickr.com/photos/clairity/1385780317/

Shoulder Dystocia

Increased risk of

perinatal morbidity

http://www.flickr.com/photos/jessicafm/280232106/

Hypoglycemia

http://www.flickr.com/photos/tessawatson/379265818/










Risky

Cesearean Section

Pregnancy-induced hypertension

Preeclampsia

Increased risk of

maternal morbidity

Type 2 diabetes mellitus

http://www.flickr.com/photos/j2dread/4501366303/http://www.flickr.com/photos/ulybug/512369383/

http://www.flickr.com/photos/78428166@N00/4921825364/


http://www.flickr.com/photos/j2dread/4501366303/

http://www.flickr.com/photos/j2dread/4501366303/

http://www.flickr.com/photos/ulybug/512369383/

http://www.flickr.com/photos/ulybug/512369383/



“... women with GDM without risk factors appear to be no different from women with GDM and risk factors.”

International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes


Q1

Which of the following women will you screen for gestational diabetes?

a) 25 y.o. G1P0 whose mother has diabetes

b) 38 y.o. G3P0 with recurrent first-trimester abortions

c) 27 y.o. G2P1

d) All of the above


Q2

a) prior history of GDM

b) glucosuria

c) family history of diabetes

d) prior macrosomic baby

Which of the following factors best predict risk of GDM?


UNITE CPG

Risk Factors for GDM

Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3

Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4)

Family history of diabetes (OR 7.1 [95%CI 5.6, 8.9]1; OR 2.74 [95%CI 1.47, 5.11]3)

Prior macrosomic baby (OR 5.59 [95%CI 2.68, 11.7])3

Age >25 years old (OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37 [95%CI 1.45, 7.85]3)


UNITE CPG

Risk Factors for GDM

Diagnosis of polycystic ovary syndrome (OR 2.89 [95%CI 1.68, 4.98])5

Overweight or obese before pregnancy

(BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/m2 OR 2.65 [95%CI 1.36, 5.14]3

Macrosomia in current pregnancy (PPV 40% 4)

Polyhydramnios in current pregancy (PPV 40% 4)

Intake of drugs affecting carbohydrate metabolism


Q2

a) prior history of GDM

b) glucosuria

c) family history of diabetes

d) prior macrosomic baby

Which of the following factors best predict risk of GDM?


Q3

a) Test high-risk women at the soonest possible time

b) Women without risk factors should be tested between 24-28 wks AOG

c) Testing for gestational diabetes should still be carried out in women at risk even beyond 24-28 wks AOG

d) All of the above

For pregnant women, when should testing be done?


Testing

Bihasa MTG et al. Screening for gestational diabetes: Report from ASGODIP participating hospital: Veterans Memorial Medical Center. PJIM 1996:34:57-61.

%

AOG testedAOG testedAOG tested

% <20 weeksn=19

21-30 weeksn = 74

31-40 weeksn = 60

Negative for GDM 95 92 85

Positive for GDM 5 8 15

ASGODIP (Veterans Memorial Medical Center)


Q3

a) Test high-risk women at the soonest possible time

b) Women without risk factors should be tested between 24-28 wks AOG

c) Testing for gestational diabetes should still be carried out in women at risk even beyond 24-28 wks AOG

d) All of the above

For pregnant women, when should testing be done?


Q4

a) 75-g OGTT

b) 100-g OGTT

c) 50-g GCT

d) FBS

Which test should be used to screen for GDM?


Use OGTT

NOT to be used for diagnosis of GDM

★ Capillary blood glucose★ RBS★ Fructosamine★ FBS★ Hba1c★ Urine glucose


One-step

“A one-stage definitive procedure is preferred.”

International Diabetes Federation (2009)Global Guideline on Pregnancy & Diabetes

50-g glucose challenge test (GCT)

Oral glucose tolerance test (OGTT)

75-g or 100 g


OGTT

100-g more cumbersome;

4 blood samples

100-g OGTT duration 3 hours

100-g OGTT high glucose

load often unpalatable

75-g OGTT international standard in

non-pregnant


CPG

Philippine Diabetes CPG has endorsed the use of the 75-g OGTT.


Q4

a) 75-g OGTT

b) 100-g OGTT

c) 50-g GCT

d) FBS

Which test should be used to screen for GDM?


Q5

a) Low CHO intake for past 3 days

b) Fast for 10 to 16 h

c) Slow walking is not permitted

d) Supine position during test

Which of the following is true of the OGTT procedure?


OGTT

CHO intake of at least 150 g/day 3 days prior

Fast for 10 to 16 hours

75 grams of anhydrous dextrose powder as chilled 25% solution (400 cc) flavored with calamansi

Drink within 5 minutes (first swallow is time zero)

Terminate test should nausea and vomiting occur

Collect samples at 0, 1 and 2 hours


OGTT

Abstain from tobacco, coffee, tea, food and alcohol during test

Sit upright and quietly during the test

Slow walking is permitted but avoid vigorous exercise


Q5

a) Low CHO intake for past 3 days

b) Fast for 10 to 16 h

c) Slow walking is not permitted

d) Supine position during test

Which of the following is true of the OGTT procedure?


Q6

a) 75-g OGTT: FBS 90 1h 190 2h 150

b) 75-g OGTT: FBS 98 1h 190 2h 150

c) 100-g OGTT: FBS 98 1h 190 2h 150 3h 140

d) All of the above

Which of the following results is/are consistent with GDM?


CPG

Thresholds for

diagnosis

ADAADA IADPSG 75-g*

Thresholds for

diagnosis 100-g 75-gIADPSG

75-g*

FBS 95 95 92

1 h 180 180 180

2 h 155 155 153

3 h 140 - -

* Requires only 1 threshold value exceeded


Q6

a) 75-g OGTT: FBS 90 1h 190 2h 150

b) 75-g OGTT: FBS 98 1h 190 2h 150

c) 100-g OGTT: FBS 98 1h 190 2h 150 3h 140

d) All of the above

Which of the following results is/are consistent with GDM?

IADPSG

ADA

ADA


CPG

Thresholds for

diagnosis

ADAADA IADPSG 75-g*

Thresholds for

diagnosis 100-g 75-gIADPSG

75-g*

FBS 95 95 92

1 h 180 180 180

2 h 155 155 153

3 h 140 - -

* Requires only 1 threshold value exceeded


OGTT

ACOG recommends against IADPSG consensus

Diagnosis of GDM based on the 1-step screening and diagnosis test outlined in the IADPSG guidelines is not recommended at this time because there is no evidence that diagnosis using these criteria leads to clinically significant improvement in maternal or newborn outcomes, and it would lead to a significant increase in healthcare costs.

ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3


Q7

a) Do NOT prescribe less than 1500 cal/day for multiple pregnancy

b) For overweight women, reduce energy intake by no more than 30% of habitual intake

c) Monitor urine ketones at bedtime to detect starvation ketonuria

d) Non-caloric sweeteners are NOT allowed.

Which of the following is TRUE of dietary management for GDM?


Diet

Pregravid BMI Category kcal/kg/dayLow (BMI <18.5 kg/m2) 36-40Normal (BMI 18.5-24.9 kg/m2) 30High (BMI 25-29.9 kg/m2) 24Obese (BMI >29.9 kg/m2) 12

Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

Recommended DailyCaloric Intake


Diet

International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes

For considerably overweight women with GDM, reduce energy intake by no more than 30% of habitual intake

Total cal/day = 1,800-2,000 Not less than 2,000 cal/day if multiple pregnancy


“Non-caloric sweeteners may be used in moderation.”

ADA GDM Position Statement 2004


Q7

a) Do NOT prescribe less than 1500 cal/day for multiple pregnancy

b) For overweight women, reduce energy intake by no more than 30% of habitual intake

c) Monitor urine ketones at bedtime to detect starvation ketonuria

d) Non-caloric sweeteners are NOT allowed.

Which of the following is TRUE of dietary management for GDM?


Q8

a) <28-40 lbs

b) 25-35 lbs

c) 15-25 lbs

d) 11-20 lbs

For a woman with normal BMI, what is the allowed weight gain in pregnancy?


Text

Weight gain during pregnancy

Product of conception

Fetus, placenta, amniotic fluid

Maternal tissue expansion

Uterus, breasts, blood volume

Maternal fat reserve

12.5 kg British cohort of >3800 primigravidae eating without restriction


IOM

* Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester

Prepregnancy BMI

Total weight gain (lbs)

Rates of weight gain* 2nd and 3rd

trimester (lbs/week)UnderweightBMI <18.5 <28-40 1

(1-1.3)Normal weightBMI 18.5-24.9 25-35 1

(0.8-1)OverweightBMI 25.0-29.9 15-25 0.6

(0.5-0.7)ObeseBMI >30.0 11-20 0.5

(0.4-0.6)


Q8

a) <28-40 lbs

b) 25-35 lbs

c) 15-25 lbs

d) 11-20 lbs

For a woman with normal BMI, what is the allowed weight gain in pregnancy?


Q9

a) For women on dietary intervention alone, monitor BG 6x a day.

b) For women treated with insulin, postprandial monitoring is superior to pre-prandial.

c) If on insulin, test BG before breakfast to detect hypoglycemia.

d) Daily SMBG does not appear to be superior to intermittent office monitoring.

Which of the following is TRUE of self-monitoring of blood glucose?


“For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.” ADA GDM Position Statement 2004


Diet onlyMonitor BG 4x a day (prebreakfast and 1 h after the first bite of food at each meal)

AACE 2007


Q9

a) For women on dietary intervention alone, monitor BG 6x a day. 3x a day

b) For women treated with insulin, postprandial monitoring is superior to pre-prandial.

c) If on insulin, test BG before breakfast to detect hypoglycemia. Test at night

d) Daily SMBG does not appear to be superior to intermittent office monitoring.

Which of the following is TRUE of self-monitoring of blood glucose?


Q10

a) Between 60 to 90 mg/dL for fasting and less than 120 mg/dL 1 hour after the first bite of food at each meal (postprandial)

b) Not more than 95 mg/dL for fasting and less than 120 mg/dL 2 hours postprandial

c) 90 mg/dL for fasting and less than 140 mg/dL 2 hours postprandial

d) None of the above

What are the targets for SMBG?


Between 60 to 90 mg/dL (fasting) and less than 120 mg/dL (1 hour after the first bite of food at each meal)

AACE 2007


Q10

a) Between 60 to 90 mg/dL for fasting and less than 120 mg/dL 1 hour after the first bite of food at each meal (postprandial)

b) Not more than 95 mg/dL for fasting and less than 120 mg/dL 2 hours postprandial

c) 90 mg/dL for fasting and less than 140 mg/dL 2 hours postprandial

d) None of the above

What are the targets for SMBG?


Q11

a) Yes

b) No

Can we give Metformin for GDM?


OHA

METFORMIN: Off-label use

★ Use of Metformin or glibenclamide during pregnancy NOT an approved indication

★ Discuss with patients

★ Obtain and document informed consent.

Canadian Diabetes Association 2008


Insulin

Insulin remains the agent of choice“In poorly resourced areas of the world, the theoretical disadvantages of using oral glucose-lowering agents ... far less than the risks of non-treatment.” IDF 2009


Q11

a) Yes

b) No

Can we give Metformin for GDM?


Q12

a) Consider insulin when diet and exercise fail to maintain glucose targets in 1-2 weeks

b) Ultrasound shows incipient fetal macrosomia (AC >70th percentile)

c) Start daily insulin at 0.1-0.3 u/kg BW

d) All of the above

When and how should insulin be started in GDM?


Insulin

ADA ProtocolFasting whole BG >95 mg/dL1-h postprandial whole BG >140 mg/dL2-h postprandial whole BG >120 mg/dL


Dr. JovanovicFasting plasma glucose >90 mg/dL (5 mmol/L)1-h PP whole BG >120 mg/dL (6.7 mmol/L)

Insulin Initiation


Q12

a) Consider insulin when diet and exercise fail to maintain glucose targets in 1-2 weeks

b) Ultrasound shows incipient fetal macrosomia (AC >70th percentile)

c) Start daily insulin at 0.1-0.3 u/kg BW

d) All of the above

When and how should insulin be started in GDM?


Q13

a) Give dextrose-containing IV fluids

b) Give short-acting insulin for CBG>140 mg/dL

c) Check CBG q hourly.

d) All of the above

Which of the following is true of management during labor?


ASGODIP

Infusion of 500 ml 5% dextrose/saline x 4 hCBG q 4hGive short-acting insulin for CBG >140 mg/dL

- Dose equal to mmol of CBG i.e. 12 u for 12 mmol/L

- Dose equal to 1/20th of mg/dL of CBG i.e. 12 u for 240 mg/dL

Omit insulin for CBG <140 mg/dL

Protocol for Spontaneous Delivery


ASGODIP

Resume diet GDMs with high insulin requirements during pregnancy should have glucose profilesGive insulin if BG persistently high (>200 mg/dL)

After delivery


Q13

a) Give dextrose-containing IV fluids

b) Give short-acting insulin for CBG>140 mg/dL

c) Check CBG q hourly.

d) All of the above

Which of the following is true of management during labor?


Q14

a) Schedule 75-g OGTT 6 weeks after follow-up

b) Measure FBS every 3 years

c) Advise patient not to get pregnant again

d) Breastfeeding should be limited

Which of the following is true of postpartum follow-up?


Annual follow-upMeasure FBS Assess weight reduction Review pregnancy plans



Ff-up

All patients with prior GDM should be educated re:

lifestyle modifications

Maintain normal body weight: MNT and physical activity

ADA GDM Position Statement 2004

Women with IFG or IGT postpartum: intensive MNT and individualized exercise program


Ff-up

Planning subsequent pregnancies

Plan future pregnancies in consultation with health care provider

Assess glucose tolerance prior to conception to assure normoglycemia at time of conception

Canadian Diabetes Association 2008


Q14

a) Schedule 75-g OGTT 6 weeks after follow-up

b) Measure FBS every 3 years

c) Advise patient not to get pregnant again

d) Breastfeeding should be limited

Which of the following is true of postpartum follow-up?


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Health & Medicine

Gestational diabetes Q & A