Dr Malleswar Rao Kasina, MD,DGO

1. GESTATIONALDIABETES MELLITUS & Preexisting (Overt) Diabetes(Screening, Diagnosis, Management and Follow-up) Dr Malleswar Rao Kasina, MD,DGO

5. White classification • Based on maternal and obstetric risk factors, graded from A (best) to F (worst) designed to predict pregnancy outcomes

7. 1971 and further updated in 1980 to incorporate ischemic heart disease and renal transplantation

8. Introduction Gestational diabetes mellitus (GDM): Diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes. (American Diabetes Association, 2017)

9. DEFINITION & MAGNITUDE • A carbohydrate intolerance of varying degrees & severity with onset or first recognition during pregnancy with a probable resolution after the end of pregnancy • Not the same as Type 1 or Type 2 Diabetes • Varies worldwide & among different racial and ethnic groups within a country • Prevalence in India: • Chennai : 0.56% (Ramachandran A, 2002) • Mysore Parthenon Study: 6% ( Fall C,2000)

10. DEFINITION OF GDM • GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. • and disappear after 6 weeks post partum • After 6 weeks post partum , if MGTT • NORMAL = GDM • ABNORMAL = TYPE 2 DM Source: American Diabetes Association 2009

11. ETIOLOGY • Pregnancy pro-diabetic state • Pregnancy  marked insulin resistance  increased insulin requirement  GDM • Complicates 4% of all pregnancies • 60% to 80 % of women with GDM are obese & experience insulin resistance & GDM

12. MECHANISM OF INSULIN RESISTANCE • The pancreas releases 1.5–2.5 times more insulin in order to respond to the resultant increase in insulin resistance.Normal patient meets the demand • In GDM : • Post receptor defect. Inadequate insulin release

13. Pregnancy Pathophysiology • Glucose is a teratogen at high levels • Crosses placenta readily while insulin cannot • Insulin resistance occurs because hormonal changes associated with pregnancy partially block the effects of insulin • Insulin resistance causes glucose to be shunted from mother to the fetus to facilitate fetal growth and development

14. Subsequent increase in insulin resistance causes maternal glucose levels to increase 80% of non-pregnant women Increased insulin resistance Decreased insulin secretion Increased maternal glucose GDM • GDM disappears after pregnancy • Useful physiologic process out of balance

15. PATHOPHYSIOLOGY • < 20 weeks of POG • Anabolic phase • Increase in Insulin sensitivity • > 20 weeks of POG • Catabolic phase • Increase in Insulin resistance

16. Pathophysiology • Early in pregnancy, maternal estrogen and progesterone increase and promote pancreatic ß-cell hyperplasia and increased insulin release • As pregnancy progresses, increased levels of human placental lactogen, cortisol, prolactin, progesterone, and estrogen lead to insulin resistancein peripheral tissues. • Table 1 describes the diabetogenic potency and time of peak effect of these hormones. The timing of these hormonal events is important in regard to scheduling testing for GDM

17. GDM results when there is delayed or insufficient insulin secretion in the presence of increasing peripheral resistance

18. Discussion • What are the risk factors for gestational diabetes? • What risk factors do you see most often in your setting?

19. Risk factors for GDM Low risk • High risk • Obesity • Diabetes in 1st degree relative • Previous • history of GDM or glucose intolerance • complicated pregnancy • infant with macrosomia > 3.5 kg • Older age • High risk ethnic group; South Asian, East Asian, Indigenous American or Australian, Hispanic • PCOS • Age less than 25 years • No previous poor pregnancy outcomes • No diabetes in 1st degree relatives • Normal prepregnancy weight and weight gain during pregnancy • No history of abnormal glucose tolerance Perkins, Dunn, Jagastia, 2007

20. Is Hypertension a risk factor? • Hypertension prior to pregnancy or during 1st trimester – doubled the risk of GDM – independent of maternal weight • Hence all women with hypertension should be screened for GDM Hedderson, Ferrara, 2008

21. Why diagnose and treat GDM? • Short term risks for the mother • Development of gestational hypertension, worsening essential hypertension or development of preeclampsia • Operative delivery - related to macrosomia • Polyhydramnios • Premature labour • Long term risks for the mother • Development of type 2 diabetes in next ~10 years (30-60% depending on population) • Development of cardiovascular disease CDA, 2013 Metzger, Buchanan, et al. 2007

22. Why diagnose and treat GDM? • Short term risks for the baby • Macrosomia • Neonatal hypoglycemia • Jaundice • Preterm birth • Birth injury • Hypocalcemia/ hypomagnesimia • Respiratory distress syndrome • Long term risks for the baby • Obesity • Type 2 diabetes

23. Screening • Whom to screen • When to screen • How to screen

24. Venous or capillary • The venous plasma is the gold standard • Where laboratory facilities or technicians are not available, capillary glucose estimations may be done using a hand held glucose meter. • The glucose meter must be standardized with a lab and calibrated against the lab on a regular basis.

25. Screening for GDM • Indians fall into the high-risk category for developing GDM • therefore universal screeningis recommended in pregnancy

26. When ?? • offer universal screening – to ALL antenatal • women at 24 – 28 wks of gestation • and an early screening at booking if there • are additional risk factors identified by history o Previous unexplained loss at term o Previous baby weight > 4 kg o Previous Pregnancy with GDM o Strong F/H

27. Diagnosis of Diabetes in non-pregnant women & menOGTT is not recommended for routine clinical use.The FPG is the preferred test to diagnose diabetes in children & non-pregnant adults.Use of the A1C for the diagnosis of diabetes is not recommended at this time. ADA recommendations. American Diabetes Association Criteria for Glycemic abnormalities

28. When to screen to rule out unidentified pre-existing diabetes?First trimester • Screening in 1st trimester • Fasting plasma glucose >126 mg/dl (7 mmol/L) • or • HbA1c >6.5% • or • Random >200mg/dl (11.1 mmol/L) • or • 2hr value in OGTT >200mg/dl (11.1 mmol/L) • If overt diabetes is detected, it must be treated appropriately. ADA, 2015

29. Fasting and & postprandial venous plasma sugar during pregnancy

30. When to screen for GDM?24-28 Weeks (One Step Strategy) • Screening should be done at 24-28 weeks • Diagnosis based on a 75 gm glucose load given in fasting state • GDM diagnosed when one or more of the following is present • Fasting 92 - 125 mg/dl (5.0 – 6.9 mmol/L) • 1 hour post 75 gm load >180 mg/dl (10 mmol/L) • 2 hour post 75 gm load >153mg/dl (8.5 mmol/L) • If woman tests negative, screening at 32 weeks also may be necessary in presence of high risks World Health Organization, 2013

31. DIAGNOSIS • TWO-STEP STRAREGY • 50-75g oral glucose challenge • Single serum glucose measurement @ 1 hr • <7.8 mmol/L(<140mg/dL)  normal • >7.8 mmol/L(>140mg/dL) • 100-g oral glucose challenge • Serum glucose measurements in fasting state, I, II & III hrs • Normal values • Fasting < 5.8 mmol/L (<105mg/dL) • I hr  < 10.5 mmol/L (<190mg/dL ) • II hr  < 9.1 mmol/L (<165mg/dL) • III hr  < 8.0 mmol/L (<145mg/dL)

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