Transcript How to screen?

Diabetes in Pregnancy
Classification
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Pregestational diabetes
Type 1 DM
Type 2 DM
Secondary DM
Gestational diabetes
Definition
Gestational diabetes (GDM) is defined as glucose
intolerance of variable degree with onset or first
recognition during the present pregnancy.
Pregestational diabetes precedes the diagnosis
of pregnancy.
Magnitude of problem: GDM
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GDM varies worldwide and among different racial and
ethnic groups within a country
Variability is partly because of the different criteria and
screening regimens
Whom to screen ?
Risk stratification based on certain variables
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Low risk : no screening
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Average risk: at 24-28 weeks
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High risk : as soon as possible
Low risk for GDM
To satisfy all these criteria
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Age <25 years
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Weight normal before pregnancy
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Member of an ethnic group with a low prevalence of GDM
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No known diabetes in first-degree relatives
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No history of abnormal glucose tolerance
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No history of poor obstetric outcome
Intermediate risk
At least one of the criteria in the list
High risk
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Marked obesity
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Prior GDM
Glycosuria
Strong family history
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Screening and Diagnosis of GDM in
the U.S.
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Use the 50 g oral glucose challenge with BS
taken 1 hour later
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Screen all pregnant women @ 24-28 weeks
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Test earlier in selected patients
Threshold of 130 mg/dL or greater
How to screen?
Oral glucose tolerance
test ( OGTT) with 100 gm
glucose
Fasting
95 mg/dl
1-h
180 mg/dl
2-h
155 mg/dl
3-h
140 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 monitoring
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Urine glucose monitoring is not useful in gestational
diabetes mellitus
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Urine ketone monitoring may be useful in detecting
insufficient caloric or carbohydrate intake in women
treated with calorie restriction
Problems of GDM: fetal
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Increases the risk of fetal macrosomia
Neonatal hypoglycemia
Jaundice
Polycythemia
Hypocalcemia, hypomagnesemia
Birth trauma
Prematurity
Problems: fetal
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Cardiac( including great vessel anomalies) : most common
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Central nervous system: 7.2%
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Skeletal: cleft lip/palate, caudal regression syndrome
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Genitourinary tract: ureteric duplication
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Gastrointestinal : anorectal atresia
Poor glycemic control at time of conception: risk factor
Caudal regression syndrome
Caudal regression syndrome
Problems of GDM: maternal
 Weight gain
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Maternal hypertensive disorders
Miscarriages
Third trimester fetal deaths
Cesarean delivery (due fetal growth disorders)
Long term risk of type 2 diabetes mellitus
Pregnancy in diabetic mother: risks
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Progression of retinopathy: esp. severe proliferative
retinopathy
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Progression of nephropathy: especially if renal failure +
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Coronary artery disease: Post MI patients: high risk of
maternal death
Management
Preconception counselling
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Diabetic mother : glycemic control with insulin/SMBG
Target: HbA1c < 7%
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Folic acid supplementation: 5 mg/day
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Ensure no transmissible diseases: HBsAg, HIV, rubella
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Try and achieve normal body weight: diet/exercise
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Stop drugs : oral hypoglycemic drugs, ACE inhibitors,
beta blockers
Clinical parameters: checked at each visit
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medications
pre-pregnancy weight
weight gain
edema
pallor
blood pressure
Fundal height
Patient education
Cornerstone in GDM management
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Maternal complication
Fetal complication
Medical Nutrition therapy
Glycemic monitoring: SMBG and targets
Fetal monitoring: ultrasound
Planning on delivery
Long term risks
Glycemic targets
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Fasting venous plasma < 95 mg/dl
2 hour postprandial <120 mg/dl
1 hour postprandial <130 mg/dl (140)
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Pre-meal and bedtime: 60 to 95 mg/dl
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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 targets?
Prospective study in type1 patients with pregnancy
FBS
Macrosomia
>105 mg/dl
95-105
<95 mg/dl
28.6 %
10%
3%
GDM
Medical nutrition therapy
Failure to maintain glycemic
targets
INSULIN THERAPY
Medical nutrition therapy
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Promote nutrition necessary for maternal and fetal health
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Adequate energy levels for appropriate gestational weight
gain,
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Achievement and maintenance of normoglycemia
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Absence of ketones
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Regular aerobic exercises
Medical nutrition therapy
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Approximately 30 kcal/kg of ideal body weight
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> 40-45% should be carbohydrates
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6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent
ketosis
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Calories guided by fetal well being/maternal weight gain/blood
sugars/ ketones
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Energy requirements during the first 6 months of lactation
require an additional 200 calories above the pregnancy meal
plan.
Self monitored blood glucose
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4 times/day minimum, fasting and 1 to 2
hours after start of meals
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Maintain log book
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Use a memory meter
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Calibrate the glucometer frequently
Fetal monitoring
Baseline ultrasound : fetal size
 At 18-22 weeks: major malformations
fetal echocardiogram
 26 weeks onwards: growth and liquor volume
 III trimester: frequent USG for accelerated growth
( abdominal: head circumference)
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Timing of delivery
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Small risk of late IUD even with good control
Delivery at 38 weeks
Beyond 38 weeks, increased risk of IUD without an
increase in RDS
Vaginal delivery: preferred
Caesarian section only for routine obstetric indication
just GDM is not an indication !
Unfavorable condition of the cervix is a problem
4500 grams, cesarean delivery may reduce the likelihood of
brachial plexus injury in the infant (ACOG)
Management of labor and delivery
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Maternal hyperglycemia in labor: fetal hyperinsulinemia,
worsen fetal acidosis
Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )
Feed patient the routine GDM diet
Maintain basal glucose requirements
Monitor sugars 1-4 hrly intervals during labour
Give insulin only if sugars more than 120 mg/dl
Glycemic management during labour
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Later stages of labour: start dextrose to maintain basal
nutritional requirements: 150-200 ml/hr of 5% dextrose
Elective LSCS: check FBS, if in target no insulin, start
dextrose drip
Continue hourly SMBG
Post delivery keep patients on dextrose-normal saline till
fed
No insulin unless sugars more than normal ( not GDM
targets ! )
Post partum follow up
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Check blood sugars before discharge
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Breast feeding: helps in weight loss
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Lifestyle modification: exercise, weight reduction
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OGTT at 6-12 weeks postpartum: classify patients into
normal/impaired glucose tolerance and diabetes
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Preconception counseling for next pregnancy
Increased risk of cardiovascular disease,
future diabetes and dyslipidemia
Immediate management of neonate
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Hypoglycemia : 50 % of macrosomic infants
5–15 % optimally controlled GDM
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Starts when the cord is clamped
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Exaggerated insulin release secondary to pancreatic ß-cell
hyperplasia
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Increased risk : blood glucose during labor and delivery
exceeds 90 mg/dl
Anticipate and treat hypoglycemia in the infant
Management of neonate
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Hypoglycemia <40 mg/dl
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Encourage early breast feeding
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If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose
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Check after 30 minutes, start feeds
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IV dextrose : 6-8 mg/kg/min infusion
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Check for calcium, if seizure/irritability/RDS
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Examine infant for other congenital abnormalities
Long term risk: offspring
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Increased risk of obesity and abnormal
glucose tolerance
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Due to changes in fetal islet cell function
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Encourage breast feeding: less chance of obesity in later
life
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Lifestyle modification
Conclusion
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Gestational diabetes is a common problem
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Risk stratification and screening is essential in all pregnant
women
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Tight glycemic targets are required for optimal maternal
and fetal outcome
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Patient education is essential to meet these targets
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Long term follow up of the mother and baby is essential
17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News Services
Jan. 24, 2005
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