Docstoc

Gestational Diabetes Mellitus -

Document Sample
Gestational Diabetes Mellitus - Powered By Docstoc
					Gestational Diabetes Mellitus

  Dr. R V S N Sarma., M.D., M.Sc., (Canada)
  Consultant Physician & Chest Specialist
  Visit us at: www.drsarma.in


                                GDM
Gestational Diabetes Mellitus

  Is it physiological?
  Is it a disease?
  Should we screen for gdm?
  Does it require treatment?
  Recent RCTs settled the issues   GDM
  Crowther et al. NEJM 2005;352
                      GDM
Glucose Intolerance in Pregnancy




                        Prevalence
                     of GDM 3 to 18 %

www.drsarma.in                          3
GDM - Definition
                             GDM
  • Distinguish GDM from Pre-gestational DM
  • Abnormal Glucose Tolerance
  • Onset (begins) with pregnancy or
  • Detected first time during pregnancy
  • No h/o of pre pregnancy DM or IGT
  • Hb A 1 c is usually < 7.5 in GDM
  • In DM + Pregnancy it is > 7.5
  • GDM is a forerunner of T2DM
www.drsarma.in                            4
Pathogenesis of GDM
                                  GDM
  • Pregnancy is Diabetogenic condition
  • A Wonderful Metabolic Stress Test
  • Placental Diabetogenic Hormones
     – Progesterone, Cortisol, GH
     – Human Placental Lactogen (HPL), Prolactin
  • Insulin Resistance (IR), ↑  cell stimulation
  • Reduced Insulin Sensitivity up to 80%
  • Impaired 1st phase insulin, Hyperinsulinemia
  • Islet cell auto antibodies (2 to 25% cases)
  • Glucokinase mutation in 5% of cases
www.drsarma.in                                      5
Fundamental Defect in GDM
                               GDM
  • The hormones of pregnancy cause IR
  • They also cause direct hyperglycemia
  • But, the basic defect is
  • The maternal pancreatic  cells are unable
    to compensate for this increased demand




www.drsarma.in                                   6
Normal Glucose Tolerance
                  GDM



www.drsarma.in             7
Abnormal GT in GDM
                 GDM



www.drsarma.in       8
Risk Stratification for GDM
                                        GDM
  • High Risk Group (Indians mostly)
        – BMI  30; PCOD; Age > 35 years
        – F h/o DM; Ethnic predisposition; Acanthosis
        – Previous h/o GDM, IGT, Macrosomic baby
  • Low Risk Group
        – Age < 25, BMI < 23, No F h/o DM or IGT
        – No bad obstetric history; No ↑ risk ethnicity
  • Intermediate Risk Group
        – Not falling in the above two classes
www.drsarma.in                         Adopted from ADA guidelines   9
Whom to Screen for GDM ?
                                          GDM
  • Low Risk Group
        – No screening required for GDM
  • Intermediate Risk Group
        – Screen around 24–28 weeks of gestation
  • High Risk Group
        –   As soon as possible after conception
        –   Must - before 24–28 weeks of gestation
        –   Better do a full 3 hr OGTT for GDM
        –   If negative – screening in 2nd & 3rd trimester
www.drsarma.in                           Adopted from ADA guidelines   10
Indian Scenario
                              GDM
  • Since the pregnant mothers without any of
    the risk factors are so very few in India
  • Since we boast of being in the DM capitol
  • We need to screen all pregnant women
  • And identify early the GDM problem
  • We have enough tough maternal problems
  • Let us at least treat a treatable problem


www.drsarma.in                             11
GDM – Two Step Screening
                                        GDM
  • Two Step Screening
        –   Do a Random Glucose Challenge Test (GCT)
        –   50 grams of oral glucose any time of day
        –   1 hour post test for plasma glucose (1 hr PG)
        –   Result > 180 mg% - Dx of GDM confirmed
        –   Result > 140 mg% - Dx of GDM suspected
        –   140 to 180 – We need OGTT (100 g) to confirm
  • One Step Screening
        – OGTT – 3 hours after 100 g of oral glucose
www.drsarma.in                                          12
Glucose Challenge Test (GCT)
                  GDM



www.drsarma.in             13
Please be specific
                              GDM
  • Do not use the ‘loose’ word ‘Blood Sugar’
  • Be specific to measure ‘Plasma Glucose’
  • Always venous sample for OGTT
  • No capillary blood testing for OGTT
  • NaF to be added as anticoagulant to blood
  • Centrifuge to separate plasma immediately
  • Plasma glucose to be estimated a.s.a.p
  • Glucometer can be used for monitoring
www.drsarma.in                             14
OGTT –100g –3 hour Test
                                               GDM
                 Test sample timing   Plasma Glucose value


                   Fasting (mg%)              95


                   1 hour (mg%)               180


                   2 hour (mg%)               155


                   3 hour (mg%)               140


www.drsarma.in                                               15
Some Questions
                             GDM
  When to order for USG ?
  • Scan for anomalies at 20-weeks
  • Growth scans from 26-28 weeks
  Breast feed or not after delivery ?
  • Must give breast feeding
  • This reduces maternal glucose
    intolerance
www.drsarma.in                          16
GDM – Fetal Morbidity
                                    GDM
  •   Macrosomia of the baby
  •   CPD – Shoulder Dystocia
  •   Intrapartum Trauma – Feto-maternal
  •   Congenital Anomalies, HCM
  •   Neonatal Hypoglycemia
  •   Neonatal Hypocalcemia
  •   Neonatal Hyperbilirubinemia
  •   Respiratory Distress Syndrome (RDS)
  •   Polycythemia (secondary) in the new born
www.drsarma.in                                   17
Macrosomia
                                        GDM
  • Birth weight > 4000 g - 90th percentile GA
  • ↑ Intrapartum feto-maternal trauma
  • Increased need for C- Section
  • 20 – 30% of infants of GDM – Macrosomic
  • Maternal factors for Macrosomia
        –   Uncontrolled Hyperglycemia
        –   Particularly postprandial hyperglycemia
        –   High BMI of mother
        –   Older maternal age, Multiparity
www.drsarma.in                                        18
Macrosomic Newborn (4.2kg)
                 GDM



www.drsarma.in           19
Shoulder Dystocia
                    GDM



www.drsarma.in        20
Macrosomia
                                    GDM
                  GDM      Non DM   P value


   Birth Weight   3512 g   3333 g   < 0.05


   LGA            40.4%     13.7%   < 0.001


   Macrosomia     32.0%     11.0%   < 0.01
Neonatal Hypoglycemia
                               GDM
  • Due to fetal hyperinsulinemia
  • Neonatal plasma glucose < 30 mg%
  • Poor glycemic control before delivery
  • Increases perinatal morbidity
  • Congenital anomalies – 3 to 8 times more
  • More if periconception hyperglycemia
  • Assoc. maternal fasting hyperglycemia

www.drsarma.in                                 22
Minor Adverse Health Effects
                  Normal      GDM
                                         GDM
                                           DM        P

 Birth Wt (g)    3303±64     3649±51     3849±72   <0.01
 Macrosomia(%)      8          36          47      <0.01
 C-S                5          10          14      <0.01
 Hypoglycemia       2          28          52      <0.01
 Hypocalcemia       0           4           7      <0.01
 Hyperbilirubinemia 15         23          21      <0.01
 Polycythemia       0           7          11      <0.01
 Cord C-Pep       1.18±0.1   2.07±0.12   2.98±0.22 <0.01
 Cord Glu         100±3.6    103±2.9     114±5.5   <0.01
Major Adverse Health Effects
                            Normal
                                     GDM
                                      DM
 CNS                        6.4%     18.4%
 Congenital heart disease   7.5%     21.0%
 Respiratory disease        2.9%     7.9%
 Intestinal atresia         0.6%     2.6%
 Anal atresia               1.0%     2.6%
 Renal & Urinary defect     3.1%     11.8%
 Upper limb deficiencies    2.3%     3.9%
 Lower limb deficiencies    1.2%     6.6%
 Upper + Lower spine        0.1%     6.6%
 Caudal digenesis           0.1%     5.3%
Neonatal Complications
                                 GDM
                     DM    GDM   Normal p-value

T. hypoglycemia(%)    52   28      3      <0.01
P. hypoglycemia(%)    6     2      0      <0.01
Hypocalcemia(%)       5     5      0      <0.01
Hyperbilirubinemia(%) 21   23     15      <0.01
Trans tachypnea(%)    5     2      0      <0.01
Polycythemia(%)      11     7      0      <0.01
RDS(%)                5     2      0      <0.01
IUGR(%)               2     1      0      <0.05
                               GDM
Congenital Anomalies - DM Control

 Maternal HbA1c levels
      < 7.2          Nil
       7.2-9.1       14%
       9.2-11.1      23%
      > 11.2         25%
 Critical periods - 3-6 weeks post conception
 Need pre-conceptional metabolic care
Late effects on the offspring
                            GDM
  • Increased risk of IGT
  • Future risk of T2DM
  • Risk of Obesity




www.drsarma.in                  27
Maternal Morbidity
                               GDM
  • Hypertension; Insulin Resistance
  • Preeclampsia and Eclampsia
  • Cesarean delivery; Pre term labour
  • Polyhydramnios – fluid > 2000 ml
  • Post-partum uterine atony
  • Abruptio placenta



www.drsarma.in                           28
Risk of T2DM after GDM
                                      GDM
  •   IGT and T2DM after delivery in 40% of GDM
  •   R.R of T2DM for all with GDM is 6 (C.I. 4.1 – 8.8)
  •   Must be counseled for healthy life style
  •   Re-evaluate with 75 g OGTT after 6 wk, 6 months
  •   More risk - if GDM before 24 wks of gestation
  •   High levels of hyperglycemia during pregnancy
  •   If the mother is obese and has +ve family h/o
  •   GDM in previous pregnancies and age > 35 yrs.
  •   High risk ethnic group (like Indians)
www.drsarma.in                                        29
A Delicate Balance !
                                    GDM
  • Plasma Glucose values in pregnancy
    hang on a delicate balance
  • If the Mean Plasma Glucose (MPG) is
        – Less than 87 mg% - IUGR of fetus
        – More than 104 mg% - LGA of fetus
  • It is imp. to screen for hypothyroidism



www.drsarma.in                                30
Women with T2DM
                                GDM
  • T2DM patients must plan their pregnancy
  • Preconception Hb A1c  7.00; MAU estimate
  • OADs should be discontinued; Folic acid +
  • Start on Insulin and titrate for euglycemia
  • Nutrition and weight gain counseling
  • ACEi and ARB must be substituted
  • Screening for retinopathy; nephro (eGFR <90)
  • Must avoid hypoglycemia and ketosis
  • SMBG must be trained and started
www.drsarma.in                                31
GDM – Glycemic Targets
                                                   GDM
            Recommended values for         Glycemic Targets

                 Pre-pregnancy Hb A1c    7.00 (if possible  6.00)

                   Pregnancy values              Range

                        FPG                      70 - 95

                        1 hr PPG                100 – 140

                        2 hr PPG                90 – 120

                        Hb A1c                     6.00

www.drsarma.in                                                        32
GDM and MNT
                                       GDM
  •   Two weeks trial of Medical Nutrition Therapy
  •   Pre-pregnancy BMI is a predictor of the efficacy
  •   If target glycemia is not achieved initiate insulin
  •   MNT – extra 300 calories in 2 and 3rd trimesters
  •   Calories – 30 kcal/kg/day = 1800 kcal for 60 kg
  •   If BMI > 30; then only 25 kcal/kg/day
  •   3 meals and 3 snacks – avoid hypoglycemia
  •   50% of total calories as CHO, 25% protein & fat
  •   Low glycemic, complex CHO, fiber rich foods
www.drsarma.in                                          33
Diet therapy in GDM
                           GDM
• Small, frequent meals
• Avoid eating for two
• Avoid fasts and feasts
• Avoid health drinks
• Eat a bedtime snack
Tips for diet management
                    GDM
             • Small breakfast
             • Mid morning snack
             • High protein lunch
             • Mid afternoon snack
             • Usual dinner
             • Bed time snack
GDM and Exercise
                               GDM
  • Recumbent bicycle
  • Upper body egometric exercises
  • Moderate exercises
  • Mother to palpate for uterine contractions
  • Walking is the simplest and easiest
  • Continue pre pregnancy activity
  • Do not start new vigorous exercise

www.drsarma.in                               36
GDM and Insulins
                                     GDM
  •   In 10 to 15% of GDM, MNT fails –Start on insulin
  •   Good glycemic control – No increased risk
  •   Human Insulins only – Not Analogs
  •   Daily SMBG up to 7 times!
  •   Insulin Glargine (Lantus) – Not to be used at all
  •   Insulin Lispro tested and does not cross placenta
  •   Insulin Aspart not evaluated for safty
  •   CSII may be needed in some cases
  •   Oral drugs not recommended (SU?, Metformin?)
www.drsarma.in                                       37
Insulin Regimen
                                  GDM
  • If MNT fails after 2 - 4 weeks of trial
  • Initiate Insulin + Continue MNT
  • Dose: 0.7, 0.8 and 0.9 u/kg – 1, 2 & 3 trim.
  • Eg. 1st trim – 64 kg = 0.7 x 64 = 45 units
  • Give 2/3 before BF = 30 units of 30:70 mix
  • Give 1/3 before supper = 15 u of 50:50 mix
  • Increase total dose by 2-4 units based on BG
  • After BG levels stabilize – monitor till term

www.drsarma.in                                      38
GDM and Delivery
                                GDM
  • Delivery until 40 weeks is not recommended
  • Delivery before 39th week – assess the
    pulmonary maturity by phosphatase test on
    amniocentesis fluid
  • C - Section may be needed (25 -30%)
  • Be prepared for the neonatal complications
  • Assess the mother after delivery for glycemia
  • May need to continue insulin for a few days
  • Pre-gestational DM–Insulin (30% less) or OAD
www.drsarma.in                                39
punarapi jananam punarapi maranam
Once again is the birth, sure follows the death
punarapi jananee jaTarae sayanam |
Yet again, is the slumber in the uterine filth
iha samsaarae bahu dustaarae
he! what to say of this miserable troth
kripayaa paarae paahi muraarae ||
O! lord, save us from this cyclical myth
          Jagad Guru Adi Sankaracharya’s Bhaja Govindam
                 Punarapi Garbham
                   Yet another conception


                 Punarapi Prasavam

                                    GDM
                   Yet another child-birth

www.drsarma.in                               41
                 Punarapi Jananee
                 Once again for the mom


                 Sisuvau KaTinam

                                   GDM
                 and the babe, the miseries

www.drsarma.in                                42
                 Iha Madhu maehae
                  This Diabetes you see


                  Bahu Dustarae

                                   GDM
                   Terrible to the core

www.drsarma.in                            43
                 Kripaya Nivaaare
                 Please put an end to this


                 Nipunarae vidyae

                                   GDM
                  O! Doctor, the expert !

www.drsarma.in                               44
Punarapi Jananam
                   GDM



www.drsarma.in       45

				
DOCUMENT INFO