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Gestational diabetes mellitus

Gestational diabetes mellitus. Piyawadee Wuttikonsammakit, M.D. GDM. Prevalence of diagnosed diabetes has increased : 14.5 (1991)  47.9 cases/1000 (2003) Increasing prevalence of type 2 diabetes in younger people

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Gestational diabetes mellitus

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  1. Gestational diabetes mellitus Piyawadee Wuttikonsammakit, M.D.

  2. GDM • Prevalence of diagnosed diabetes has increased : 14.5 (1991) 47.9 cases/1000 (2003) • Increasing prevalence of type 2 diabetes in younger people • Maternal hyperglycemia leads to fetal hyperinsulinemia, obesity & insulin resistance in childhood

  3. GDM • Defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy • Some women with GDM have previously unrecognized overt diabetes • Fasting hyperglycemia early in pregnancy almost invariably represents overt diabetes

  4. Screening • No consensus regarding the optimal approach • Universal or selective screening • Plasma glucose after 50 g glucose test (50 gm glucose challenge test –GCT) is the best to identify women at risk for GDM • One-step approach or two-step approach

  5. Fifth international workshop-conference on gestational diabetes • Low risk : blood glucose testing not routinely required if all the following are present: • Member of an ethnic group with a low prevalence of GDM • No known diabetes in first-degree relatives • Age < 25 years • Weight normal before pregnancy • Weight normal at birth • No history of abnormal glucose metabolism • No history of poor obstetrical outcome

  6. GDM screening • Average risk : perform blood glucose testing at 24-28 weeks using either : • Two-step procedure : 50-g GCT, followed by a diagnostic 100-g OGTT • One-step procedure : diagnostic 100-g OGTT performed on all subjects

  7. GDM screening • High risk : Perform blood glucose testing as soon as feasible, suing the procedures described above if one or more of these are present : • Severe obesity • Strong family history of type 2 diabetes • Previous history of GDM, impaired glucose metabolism, or glucosuria • If GDM is not diagnosed, blood glucose testing should be repeated at 24-28 weeks or at any time there are symptoms or signs suggestive of hyperglycemia

  8. Diagnosis National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979; 28: 1039-57 Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 1982; 144: 768-73 American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2011; 34 (suppl1): S62-S69

  9. WHO criteria diagnosis

  10. GDM

  11. Maternal and fetal effects • Fetal anomalies are not increased • Risk of fetal death is not apparent for those who have diet-treated postprandial hyperglycemia • Elevated fasting glucose levels have increased rates of unexplained stillbirths during the last 4-8 weeks of gestation • Increased frequency of hypertension and cesarean delivery

  12. Macrosomia • ACOG 2000 : birthweight exceeds 4500 g • Anthropometrically different from other LGA infants : excessive fat deposition on the shoulders and trunk • Predisposes to shoulder dystocia or cesarean delivery • Maternal hyperglycemia prompts fetal hyperinsulinemia during second half of gestation, which in turn stimulates excessive somatic growth

  13. Macrosomia and Erb’s palsy

  14. Macrosomia • Neonatal hyperinsulinemia may provoke hypoglycemia (<35 mg/dl) within minutes of birth • Maternal obesity is an independent and more important risk factor for large infants in women with GDM than is glucose intolerance • Maternal obesity is an important confounding factor in the diagnosis of GDM

  15. Management • Diet • Exercise • Glucose monitoring • Insulin

  16. Diet • Average of 30 kcal/kg/d based on prepregnant body weight for nonobese women • 30% caloric restriction for obese women with BMI > 30 kg/m2 • Monitored with weekly tests for ketonuria • Maternal ketonemia linked with impair psychomotor development in offspring

  17. Exercise • Exercise improved cardiorespiratory fitness • Physical activity reduced risk of GDM • Resistance exercise diminished the need for insulin therapy in overweight women with GDM

  18. Body weight control Rasmussen KM, Yaktine Al. Weight gain during pregnancy: reexamining the guildelines. Washington: Committee to Reexamine IOM Pregnancy Weight Guidelines; Institute of Medicine; National Research Council 2009: 254

  19. Glucose monitoring • Aim • Fasting plasma glucose < 95 mg/dl • 1 hr postprandial < 140 mg/dl • 2 hr postprandial < 120 mg/dl

  20. Glucose monitoring • Daily self glucose monitor VS intermittent fasting glucose evaluation semiweekly : fewer macrosomic infants and gain less weight in diet-treated GDM • The women with GDM A2 : 1hour postprandial blood glucose superior to preprandial : fewer neonatal hypoglycemia, less macrosomia, fewer CS for dystocia

  21. Oral hypoglycemic agents • ACOG 2001 has not recommended these agents during pregnancy • Half of maternal concentration in women treated with glyburide • Increasing support use of glyburide as an alternative to insulin in GDM • Meta-analysis 2008 : no increased perinatal risks with glyburide therapy and recommended further randomized trials

  22. Metformin • The Fifth International workshop conference recommended that metformin treatment for GDM be limited to clinical trials with long-term infant follow up • RCT 2008 : metformin VS insulin : not associated with increased perinatal complications, but 46% required supplemental insulin

  23. Insulin therapy • Rapid acting • Short (regular) • Intermediate • Long acting

  24. Insulin acting

  25. Insulin therapy • Initiate insulin if fasting glucose levels > 105 mg/dl • Total dose of 20-30 units daily • Before breakfast is commonly used to initiate therapy • Split-dose insulin (twice daily) : divided into 2/3 intermediate-acting and a third short-acting insulin

  26. Obstetrical management • ACOG 2001 has suggested that CS delivery should be considered in women with a sonographically EFW >= 4500 • Elective induction to prevent shoulder dystocia in women with sonographically diagnosed fetal macrosomia is controversial • Sonographic suspicion of macrosomia was too inaccurate to recommend induction or primary CS delivery without a trial of labor

  27. Obstetrical management • No consensus regarding whether antepartum fetal testing is necessary, and if so, when to begin such testing in women without severe hyperglycemia • Those women who require insulin therapy for fasting hyperglycemia, typically undergo fetal testing and are managed as if they had overt diabetes

  28. Intrapartum management • Labor evaluation • Electronic fetal monitoring • DTX q 1-2 hr • Insulin iv drip • Off insulin after delivery • Newborn evaluation : birthweight, APGAR score, hypoglycemia

  29. Insulin IV drip American College of Obstetricians and Gynecologists. Pregestational diabetes Mellitus. ACOG Practice Bulletin 60. Washington, DC; ACOG; 2005

  30. Postpartum evaluation : Fifth international workshop-conference

  31. Classification of the ADA 2003

  32. Postpartum evaluation • 33-37% underwent postpartum screening tests • Recommendations for postpartum follow-up are based on the 50% likelihood of women with GDM developing overt diabetes within 20 years • If fasting hyperglycemia develops during pregnancy, then diabetes is more likely to persist postpartum • Insulin therapy during pregnancy, and especially before 24 weeks , is a powerful predictor of persistent diabetes

  33. Postpartum evaluation • Women with Hx of GDM are also at risk for cardiovascular complications associated with dyslipidemia, hypertension, abdominal obesity – the metabolic syndrome • Recurrence of GDM in subsequent pregnancies was documented in 40% • Obese women were more likely to have impaired glucose tolerance • Lifestyle behavioral changes : weight control and exercise

  34. Contraception • Low-dose hormonal contraceptives may be used safely by women with recent GDM

  35. Pregestational diabetes mellitus

  36. White classification

  37. Diagnosis of overt diabetes during pregnancy American Diabetes Association 2011

  38. Pregestational diabetes • Pregestational-or overt-diabetes has a significant impact on pregnancy outcome • Related to degree of glycemic control, degree of underlying cardiovascular or renal disease

  39. Pregnancy outcomes

  40. Fetal effects • Improved fetal surveillance, neonatal intensive care, and maternal metabolic control have reduced perinatal losses to 2-4% • Two major causes of fetal death : congenital malformations and unexplained fetal death • Incidence of major malformations in women with type 1 diabetes is approximately 5% • Hyperglycemia-induced oxidative stress that inhibits expression of cardiac neural crest migration

  41. Congenital malformations in infants of women with overt diabetes

  42. Caudal regression syndrome

  43. Pregestational DM • Early abortion is associated with poor glycemic control (HbA1c > 12%, persistent preprandial > 120 mg/dl) • Increased preterm delivery (both spontaneous & indicated) • Macrosomia and hydramnios • IUGR (advanced vascular disease or congenital malformations)

  44. Unexplained fetal demise • Stillbirths without identifiable causes are a phenomenon relatively unique to pregnancies complicated by overt diabetes. • No obvious placental insufficiency, abruption, FGR, or oligohydramnios • Typically large-for-gestational age and die before labor, usually at 35 weeks or later • Hyperglycemia-mediated chronic abberations in transport of oxygen and fetal metabolites

  45. Neonatal mortality and morbidity • Respiratory distress syndrome : fetal lung maturation was delayed in diabetic pregnancies • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Polycythemia • Hypertrophic cardiomyopathy • Long-term cognitive development • Inheritance of diabetes

  46. Maternal effects • Exception of diabetic retinopathy,, the long-term course of diabetes is not affected by pregnancy • Maternal death is uncommon, rates are still increased tenfold • Deaths most often result from ketoacidosis, hypertension, preeclampsia, pyelonephritis, ischemic heart disease

  47. Diabetic nephropathy • 3 stages • 1. microalbuminuria – 30 to 300 mg of albumin/24h : manifest as early as 5 years after onset of diabetes • 2. overt proteinuria – >300 mg/24hr (may develop hypertension) : develop after another 5 to 10 years • 3. end-stage renal disease- rising creatinine, decreased GFR : develop in next 5 to 10 years • PGDM class F significantly increased preeclampsia and indicated preterm delivery

  48. Diabetic retinopathy • The first and most common visible lesions are small microaneurysms followed by blot hemorrhages, hard exudates – benign or nonproliferative retinopathy • Abnormal vessels on background eye disease become occluded, leading to retinal ischemia and infarctions “cotton wool exudate” – preproliferative retinopathy • Neovascularization (in response to ischemia) on retinal surface and out into vitreous cavity and hemorrhage – proliferative retinopathy

  49. Diabetic retinopathy

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