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Gestational diabetes new

Diagnosis and treatment of gestational diabetes

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Gestational diabetes new

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  1. GESTATIONAL DIABETES Professor doctor l Mohammed Ahmed Bamashmos( MD) Professor of Internal Medicine (Sanaa University)

  2. • يرﺗﻔﻣﻟالﯾﻘﺛﻟافﯾﺿﻟاﻲﻧءﺎﺟدﻗ يرﻛﺳاروزهوﻣﺳايذﻟااذھ ﮫﻧالﺑﮫﻣﻌطوﻠﺣسﯾﻟذا يرﻣرﻣﻟاﻲﻠظﻧﺣﻟاﻲﻣﻘﻠﻌﻟا ﺎﮭﻠﻛذﺋاذﻠﻟانﻣتﻌﻧﻣدﻘﻠﻓ رظﻧﻣﻟاﻲﮭﺷنﻣﻰﺗﺣتﻣرﺣو

  3. Definition •Carbohydrate intolerance that begin and or first recognized during pregnancy •Diagnostic category ; • - GDM A1 ( controlled by MNT only ) • - GDM A2 ( need pharmacological therapy ) •15% of GDM remain diabetic ( type 2 ) •50-60% well become diabetic ( within 5-10 years ) •Prevalence ; 5%

  4. Risk factors • Very high risk ; • - severe obesity • - prior history of GDM or delivery of large for gestational age infant • - presence of glycosuria • - PCOS • - family history • Low risk ; • - age under 25 • - normal weight prior to pregnancy • - no known diabetes in first degree relative • - no history of abnormal GTT • - low risk of ethnic group • - •

  5. Pathogenesis •Diabetogenic effect of pregnancy ; • 1- insulin resistance due to; • - production of human placental lactogen • - production of cortisol , estradiol, and progesterone • - rules of cytokines • 2- destruction of insulin by kidney and placenta • 3- increased lipolysis • 4- changes in gluconeogenesis • 5- beta cell dysfunction

  6. Diagnosis • 1 - if patients is symptomatic • order for FBS and or RBS or OGTT avoid HbA1C • WHO diagnosis ; if one or more of following criteria are met ; • FBG ; 5.1-6.9 mmol /l , 1 hour PG ≥ 10 mmol/l , or 2hour plasma glucose 8.5-10 • 2-- -if asymptomatic ; • screening test ; • The NICE guidelines recommend screening with WHO OGTT criteria at 24 to 28 weeks' gestation, except in women with previous GDM, who are screened at 16 to 18 weeks and again at 28 weeks if the first OGTT was normal. [4] • Timing • - in the first visit ; in those with high risk factors • - at 16- 18 weeks of gestation in those with previous GDM • - at 24 to 28 weeks of gestation for those with medium or low risk •

  7. •steps of screening ; • . Either one-step or two-step screening methods may be used. [2] The IADPSG recommends a one-step test, [7] while the National Institute of Health and the American Congress of Obstetricians and Gynecologists (ACOG) recommend a two-step test. [9] The ADA recognise that there are data to support both approaches. [2] •

  8. Treatment target • - NICE guideline ‘ • - pre-prandial blood glucose ( 63- 106 mg/ dl ) • - 1 hour post prandial ( less than 140 mg / dl ) • ADA guideline ; • - pre prandial ≤ 95 md / dl • - plus either 1-hour post-prandial ≤140 mg/dL (7.8 mmol/L) or 2-hour post-prandial ≤120 mg/dL (6.7 mmol/L). [2] - Target blood glucose values in women with pre-existing type 1 or type 2 diabetes, per ADA guidelines, are as follows, if goals can be reached without significant hypoglycemia: pre-meal, bedtime, and overnight glucose 60 to 99 mg/dL (3.3-5.4 mmol/L); peak post-prandial glucose 100 to 129 mg/dL (5.4-7.1 mmol/L); HbA1c <42 mmol/mol (<6.0%).

  9. Treatment types • 1- physical activity ; • moderate intensively regular exercise ( walking 30 minutes or more at least 5 days per week if no medical contraindication ) • 2- MNT; diet ; • - caloric restriction ; 30-35% Kcal /kg • - types ; • - carbohydrates ; 40-50% of total caloric • - complex carbohydrates • - high fiber • - low glycemic index • - protein ; 20% • - fat ; 30-40% less than 10% saturated

  10. • 2- pharmacological treatment ; • Indication ; • 1- more severe hyperglycemia ( FBG ≥ 125 mg /dl . RBG ≥ 200 mg • 2 - CDA and NICE recommended starting pharmacological treatment if glycemic control not achieved after 1-2 weeks of life style intervention • 3- if fetal macrosomia is suspected by U/S • Types • While insulin has been the drug of choice for managing gestational diabetes for years, there is not much specific guidance available as to which product is the first-line choice and what the appropriate dosing parameters are. Both ACOG and ADA acknowledge that glyburide and metformin have been used for gestational diabetes with safety and efficacy similar to insulin's. The most recent practice bulletin from ACOG states that both insulin and oral medications are equivalent in efficacy and that either may be considered first-line in the management of GDM.5

  11. 1- Metformin • - indication ; as second line treatment when patients refuse insulin or cannot be used safely • - mechanism of action benefit ; • - it overcome IR • - no risk of hypoglycemia • - benefit in PCOS • - decrease maternal weight • - decrease risk of PIH - adverse effect - - preterm deliveries • - contraindication

  12. 3- Insulin therapy • • indication ; its first line therapy • Types ; • 1- human insulin • - short acting ; • - intermediate acting ( NPH ) • 2- insulin analogues • - rapid acting ( lispro . Aspart ) • - long acting ( detemir • - insulin regimen • 1- basal insulin ; if only FBG is elevated higher than 90- 95 mg • 2- basal bolus , if both FBS and postprandial BS is elevated

  13. • - insulin dose • The total daily insulin requirement during the first trimester, is 0.7 units/kg/day, while in the second trimester it is 0.8 units/kg/day, and in the third trimester, it is 0.9–1.0 units/kg/day. This does not necessarily fit all pregnancies. Usually, in pregestational diabetes, the total insulin dose is up to twice higher than in GDM •

  14. Complication of insulin therapy • Maternal complications associated with insulin therapy • - Maternal hypoglycemia • Prevalence 20% • Who to avoid • - avoid tight glycemic target ; • FBS above 3.7 mmol/l (66 mg/dl) according to CDA, or above 3.9 mmol/l (70 mg/dl) according to ADA . • - use insulin analogues • Maternal hypoglycemia aff ffects the fetus just in severe cases when is associated with loss of consciousness or secondary to trauma. Also, it was observed that repeated episodes could lead to growth over the 90th percentile . These episodes are more likely to be present in the first trimester in women who had pregestational diabetes than in GDM

  15. • Fetal complications associated with insulin therapy • 1 - Neonatal hypoglycemia • 2- congenital anomaly ; with use of lispro , glargine

  16. • Indication of antepartum fetal testing ; •- for women with a hypertensive disorder, prior stillbirth, or suspected macrosomia, fetal testing is undertaken • - women on pharmacotherapy with either insulin and/or oral agents (class A2) undergo at least weekly fetal testing beginning at 32 weeks’ gestation • Time of delivery. • - in well controlled women ; • - 39 ± 6 weeks of gestation in women with GDM on pharmacological therapy • - 39 ± 0 to 40± 6 weeks in women with well controlled GDM on diet • In not well controlled ; • - 37 ±0 to 38 ± 6

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