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Gestational Diabetes: Diagnosis, Treatment Long Term Management, and Followup

Gestational Diabetes: Diagnosis, Treatment Long Term Management, and Followup. Eric Lind Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine And Health Sciences Assistant Medical Director Altru Diabetes Center

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Gestational Diabetes: Diagnosis, Treatment Long Term Management, and Followup

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  1. Gestational Diabetes:Diagnosis, TreatmentLong Term Management, and Followup Eric Lind Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine And Health Sciences Assistant Medical Director Altru Diabetes Center Grand Forks, ND

  2. Objectives • Discuss Gestational Diabetes Mellitus (GDM) and Treatment • Recognize common problems of GDM in Pregnancy • Discuss long term followup of Gestational Diabetes Mellitus (GDM)

  3. Gestational Diabetes Mellitus

  4. Gestational Diabetes • Reduced sensitivity to insulin in 2nd and 3rd trimesters • “Diabetogenic State” when insulin production doesn’t meet with increased insulin resistance Hod and Yogev Diabetes Care 30:S180-S187, 2007 Crowther, et al NEJM 352:2477–2486, 2005 Langer, et al Am J Obstet Gynecol 192:989–997, 2005

  5. Gestational Diabetes • Human placental lactogen, leptin, prolactin, and cortisol result in insulin resistance • Lack of diagnosis and treatment-increased risk of perinatal morbidities Hod and Yogev Diabetes Care 30:S180-S187, 2007 Crowther, et al NEJM 352:2477–2486, 2005 Langer, et al Am J Obstet Gynecol 192:989–997, 2005

  6. Gestational Diabetes Occurs in 2-9% of pregnancies ~135,000 cases in U.S. annually Management can include insulin (usually preferred, better efficacy) or sulfonylureas (in very select cases) Am J Obstet Gynecol 192:1768–1776, 2005 Diabetes Care 31(S1) 2008 Diabetes Care 25:1862-1868, 2002

  7. Gestational Diabetes and Type 2 Diabetes Risk • Gestational Diabetes should be considered a pre-diabetes condition • Women with gestational diabetes have a 7-fold future risk of type 2 diabetes vs.women with normoglycemic pregnancy Lancet, 2009, 373(9677): 1773-9

  8. Gestational Diabetes-Screening • Screen all very high risk and high risk • Very high risk: Previous GDM, strong FH, previous infant >9lbs • High risk: Those not in very high risk or low risk category

  9. Gestational Diabetes-Screening • Low Risk (all of following) • Age <25 years • Weight normal before pregnancy • Member of an ethnic group with a low prevalence of diabetes Diabetes Care 31(S1) 2008

  10. Gestational Diabetes-Screening • Low Risk (all of following)(cont’d) • No known diabetes in first-degree relatives • No history of abnormal glucose tolerance • No history of poor obstetrical outcome Diabetes Care 31(S1) 2008

  11. Gestational Diabetes Screening • 2 step approach oral glucose tolerance test (OGTT) • 1) 50gm 1 hour OGTT • 2) 100gm 2 hour OGTT

  12. Gestational Diabetes-Screening • GDM screening at 24–28 weeks: • Two-step approach: • 1) Initial screening: plasma or serum glucose 1 h after a 50-g oral glucose load • Glucose threshold • 140 mg/dl identifies 80% of GDM • 130 mg/dl identifies 90% of GDM Diabetes Care 31(S1) 2008

  13. Gestational Diabetes-Screening • GDM screening at 24–28 weeks: • Two-step approach (cont’d) • 2) 3 hour OGTT* (100g glucose load) Fasting: >95 mg/dl (5.3 mmol/l)1 h: >180 mg/dl (10.0 mmol/l)2 h: >155 mg/dl (8.6 mmol/l)3 h: >140 mg/dl (7.8 mmol/l) *2 of 4 Diabetes Care 31(S1) 2008

  14. Gestational Diabetes Management • Dietician • Diabetes Educator • Consider referral to Diabetologist or Endocrinologist • Moderate Physical Activity ~30 minutes daily when appropriate Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care 30:S251-S260, 2007

  15. Glucose Control in GDM • Preprandial: <95 mg/dl, and either: 1-h postmeal:<140 mg/dl or 2-h postmeal: <120 mg/dl andUrine ketones negative Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care 21(2):B161–B167, 1998

  16. Gestational Diabetes-Medications • Patients who do not meet metabolic goals within one week or show signs of excessive fetal growth • Insulin has been the usual first choice • Sulfonylureas (glyburide) may be used in select patients • Other diabetes medications not recommended in GDM Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care 30:S251-S260, 2007 Langer et al N Engl J Med 343:1134–1138, 2000

  17. Diabetes MedicationsInsulins-Safety • Aspart, Lispro, NPH, R, Lispro protamine all Category B and used in pregnancy • All other insulins Category C • Human Insulins-Least Immunogenic • Breastfeed-All insulins considered safe Data from Package Inserts

  18. Gestational Diabetes-Management • Fasting, pre-meal, 2-hour post-prandial blood glucose probably all important • Mean blood glucose >105-115, greater perinatal mortality • A1C in GDM probably not important Am J Obstet Gynecol 192:1768–1776, 2005 ADA Position Statement Pettit, et al Diabetes Care 3:458–464, 1980 Karlsson, Kjellmer Am J Obstet Gynecol 112:213–220, 1972 Langer, et al Am J Obstet Gynecol 159:1478–1483, 1988

  19. Insulin Dosing-GDM • Insulin dosing: • Can use usual weight based dosing (i.e., 0.5 u/kg) • Practical dosing can be to start 10 units NPH with evening meal • Most will titrate to BID, with eventual addition of Regular or Rapid Acting BID

  20. Alternate Insulin Dosing in GDM • Regular or rapid acting (lispro or aspart) with meals, NPH at bedtime • NPH + Regular or rapid acting in AM, regular or rapid acting at supper, NPH at bedtime • Titrate insulin based on SBGM values, tested fasting, pre-meal, 2 hour post-meal, bedtime, occasional 3 AM.

  21. Gestational Diabetes Complications

  22. GDM Complications Macrosomia Fractures Shoulder dystocia Nerve palsies (Erb’s C5-6) Neonatal hypoglycemia Pregnancy outcomes can be very poor with HTN/nephropathy Gabbe, Obstetrics: Normal and Problem Pregnancies 2002

  23. Gestational Diabetes:Outcomes • Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study 28,000 women • Four primary outcomes: 1) weight above the 90th percentilefor gestational age 2) primary cesarean delivery 3) clinical neonatalhypoglycemia 4) cord-blood serum C-peptide level above the90th percentile (fetal hyperinsulinemia) NEJM (358) 2008

  24. Gestational Diabetes:Outcomes • Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) • Five secondary outcomes 1)premature delivery (before 37 weeks) 2)shoulderdystocia or birth injury 3)need for intensive neonatal care 4)hyperbilirubinemia 5)preeclampsia NEJM (358) 2008

  25. HAPO Primary and Secondary Outcomes NEJM (358) 2008

  26. Gestational Diabetes: Post-natal • GDM is a prediabetes syndrome • Some women will have frank type 2 diabetes presenting in pregnancy • Blood glucose testing first few days after delivery Kitzmiller, et al Diabetes Care 30:S225-S235, 2007

  27. GDM Post-natal and Long Term Followup

  28. Gestational Diabetes: Post-natal • Fasting glucose rechecked 6-12 weeks following delivery • Every 6 months thereafter to be screened for type 2 diabetes • Higher risk of developing Type 2 Diabetes Kitzmiller, et al Diabetes Care 30:S225-S235, 2007

  29. Case Study • 28 y/o caucasian female • 2nd pregnancy • 1st pregnancy at age 22, term male infant, 10 lbs 2oz, normal delivery • “Thinks had high blood sugar” • Very high risk (>9 lb infant, possible GDM)

  30. Case Study • No other significant medical history No tobacco • Physical Exam: VS normal 5’ 2” 210 lbs BMI 38.4 Remainder consistent with 12 weeks gestation

  31. Case Study • 26 weeks, no problems, maybe slightly large for dates • 12 lb weight gain • Went directly to 3 hour GTT (100g)

  32. Case Study • FBG: 94 ( > 95) • 1 hour: 192 (>180) • 2 hour: 160 (>155) • 3 hour: 149 (>140) • 3 of 4 values abnormal= GDM

  33. Case Study • Referred to Diabetes Educator and Dietician • SMBG: FBG, pre-meal, 2 hour post-prandial, HS, 3 am prn • Meal Plan • No contraindications to exercise, encouraged to walk 15 min/daily

  34. Glucose Control in GDM • Preprandial: <95 mg/dl, and either: 1-h postmeal:<140 mg/dl or 2-h postmeal: <120 mg/dl andUrine ketones negative Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care 21(2):B161–B167, 1998

  35. Case Study • Returns one week later • Has been following meal plan “90% of time” • Has walked 15 minutes 2 times • Has 4 FBG > 100 • 6 other values above target

  36. Case Study • Referred to Diabetes Educator for insulin start • NPH 10 units, 3 units Insulin aspart BID • Phone followup q 3 days • Continues appropriate clinic appointments

  37. Case Study • 1-2 SMBG values out of target 1st week • 3 weeks later, FBG, 2 hour post lunch and 2 hour post supper elevated about ~50% of time • NPH increased in PM (or could move to HS), insulin aspart added at lunch (2 or 3 units) and increased at supper

  38. Case Study • Normal vaginal delivery at 38 weeks • 8lb 10oz healthy female infant • Patients FBS day after delivery 90 • Enrolled in Diabetes Prevention Program • Converted to type 2 diabetes 2 years later • Had lap-band 4 years later

  39. Gestational Diabetes MellitusRisk of Type 2 Diabetes • Meta analysis: 20 studies 675,455 women • 7-fold increase in risk of type 2 diabetes following gestational diabetes vs. normoglycemic pregnancy • Post pregnancy surveillance important Bellamy, L. et al. Lancet, 2009, 373(9677): 1773-9

  40. 5 Reasons to perform glucose tolerance testing after pregnancies complicated by GDM: • 1) The substantial prevalence of glucose abnormalities detected by 3 months postpartum. • 2) Abnormal test results identify women at high risk of developing diabetes over the next 5–10 years (15-50% risk) • 3)Ample clinical trial evidence in women with glucose intolerance that type 2 diabetes can be delayed or prevented by lifestyle interventions or modest and perhaps intermittent drug therapy. Kitzmiller, et al Diabetes Care 30:S225-S235, 2007 Kim et al Diabetes Care 25:1862-1868, 2002 Lauenborg, et al Diabetes Care 27:1194-1199, 2004

  41. 5 Reasons to perform glucose tolerance testing after pregnancies complicated by GDM: cont’d • 4) Women with prior GDM and IGT or IFG have CVD risk factors. Interventions may also reduce subsequent CVD, which is the leading cause of death in both types of diabetes. GDM 71% higher risk of future CVD-other risk factors (HTN, lipids, smoking) assessed and managed • 5) Identification, treatment, and planning pregnancy in women developing diabetes after GDM should reduce subsequent early fetal loss and major congenital malformations. Kitzmiller, et al Diabetes Care 30:S225-S235, 2007 Shah, et al Diabetes Care 31:1668-1669, 2008

  42. Type 2 Diabetes Prevention • Lifestyle- over 50% reduction of future type 2 diabetes • Bariatric (Lap-Band-future preg?)- strong consideration in BMI >40 or >35 with co-morbid conditions • Future treatments/prevention- no current medication role, possible in future

  43. Diagnosis Guidelines Category FPG (mg/dL) Normal <100 Impaired Fasting Glucose (IFG) 100 – 125 Diabetes >126** • OR A1C >6.5 • ** On 2 separate occasions American Diabetes Association

  44. Initial Type 2 Diabetes Treatment • Current guidelines (ADA/EASD, AACE) recommend metformin at diagnosis in additional to lifestyle management • Diabetes Educator/Dietician • Eye Exam • Evaluation of cholesterol and blood pressure

  45. Key References • Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care July 2007 30:S251-S260 • American Diabetes Association Consensus Statement Pre-existing DM in Pregnancy Diabetes Care May 2008 vol. 31 no. 5 1060-1079 • American Diabetes Association: Clinical Practice Recommendations: http://care.diabetesjournals.org/content/33/Supplement_1 2010 • International Diabetes Federation: http://www.idf.org/global-guideline-pregnancy-and-diabetes2009

  46. Summary • GDM: Meet targets, avoid hypoglycemia, reduce risk of complications • GDM is a pre-diabetes syndrome • Many women with GDM will go on to have repeat GDM or type 2 DM and have CVD risk

  47. Acknowledgements • William Zaks, M.D., Ph.D., Assistant Medical Director Altru Diabetes Center Grand Forks, ND Slide and Content Review

  48. Contact Info/Slide Decks/Media e-mail eric.l.johnson@med.und.edu ejohnson@altru.org Phone 701-795-2861 or 701-777-3811 Slide Decks (Diabetes, Tobacco, other)http://www.med.und.edu/familymedicine/slidedecks.html iTunes Podcasts (Diabetes)http://www.med.und.edu/podcasts/ or iTunes>>search UND Medcast (1/21/10 release) WebMD Page:http://www.webmd.com/eric-l-johnson Diabetes e-columns (archived): http://www.ndhealth.gov/diabetescoalition/DrJohnson/DrJohnson.htm

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