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Gestational Diabetes

Gestational Diabetes. Definition. Any degree of glucose intolerance with onset or 1 st recognition during pregnancy. Diabetes Care, 2003 Jan:26(1):s103 prevalence 1.4 – 14% UTD 11.2. Etiology. Early pregnancy

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Gestational Diabetes

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  1. Gestational Diabetes

  2. Definition • Any degree of glucose intolerance with onset or 1st recognition during pregnancy. Diabetes Care, 2003 Jan:26(1):s103 • prevalence 1.4 – 14% UTD 11.2

  3. Etiology • Early pregnancy estrogen-progesteron counterbalance • 2nd trimester  hPL,  Cortisol,  Prolactin • Underlying  cell defect Evidence-Based Diabetes Care 2001

  4. Risk Factors • Age • +ve F Hx. of DM • Increasing obesity, Wt. gain in early adulthood • Ethnicity Asians5, Hispanics2.5, African Americans2 • Cigarette smoking Evidence-Based Diabetes Care 2001

  5. Short Term Risk for The Fetus • Macrosomia & possible birth trauma • Neonatal hypoglycemia • Jaundice • Hypocalcemia • Polycythemia • RDS • Myocardial hypertrophy

  6. Long Term Risks for The Offsprings • Susceptibility for glucose intolerance •  Insulin resistance during puberty • Obesity

  7. Mother’s Risks • Long term risk for DM 50% diabetes, 75% any IGT • Rarely DKA, Retinopathy • Preeclampsia • Polyhydramnios • Fetal macrosomia • Birth trauma • Operative delivery • Perinatal mortality

  8. Risk Factors for Progression to Diabetes •  Prepregnancy BMI • Severity of glucose intolerance during pregnancy • Earlier gestational age of onset • FPG • Need for insulin • Presence of higher glucose values on postpartum OGTT

  9. Screening • Selective ( ADA & ACOG ) • Universal * If screening had been selective, 10% of women with GDM have been missed

  10. Screening (continued)

  11. Screening (continued) • Low risk • Age<25 yr • Nl weight before pregnancy • Member of an ethnic group with low prevalence of GDM • No known diabetes in 1st degree relatives • No Hx. of abn. Glucose tolerance • No Hx. of adverse pregnancy outcomes often associated with GDM Diabetes Care, 2003 Jan:26(1):S34

  12. Screening(continued) • High Risk • Marked obesity (prepregnancy Wt. of 110% of IBW) • Personal Hx. of GDM • Strong F Hx. of diabetes • Glycosuria Diabetes Care, 2003 Jan:26(1):S34 • Age>25 yr • Hx. of abn. glucose tolerance • Previous large baby • PCO • Maternal low birth Wt. • The mother was large at birth • Member of an ethnic group with a higher than Nl rate of type2 DM • Previous unexplained prenatal loss or birth malformed child UTD 11.2

  13. Screening(continued) • Timing • High risk : 1st prenatal visit If -ve • Mod. risk : between 24-28 wks • Low risk : need no glucose testing Diabetes Care, 2003 Jan:26(1):S34

  14. UTD 11.2

  15. UTD 11.2

  16. Management • Diet : in women who do not meet criteria for gestational diabetes (abnormal GTT) if they have FPG >90 mg/dL or an abnormal GCT. • Exercise • Insulin : ٭when FPG >90 mg/dl & 1hr PP blood sugar >120 mg/dl ٭15% of women with GDM require insulin Rx.

  17. Management (continued) • Caloric Allotment •30 kcal per present weight in kg per day in pregnant women who are 80 to 120 % of IBW at the start of pregnancy. •24 kcal per present weight in kg per day in overweight pregnant women (120 to 150 % of IBW). •12 to 15 kcal per present weight in kg per day for morbidly obese pregnant women (>150 % of IBW). •40 kcal per present weight in kg per day in pregnant women who are < 80 % of IBW.

  18. Management (continued) • Insulin Regimen if ↑FPG : NPH 0.15 IU/kg before bedtime  if ↑PP blood glucose : Insulin regular or lispro 1.5 IU/10gr CHO before breakfast & 1 IU/10gr CHO before lunch and dinner meals.

  19. Management (continued)  if both ↑FPG & ↑PP blood glucose : four-injection per day regimen should be initiated : NPH 45% Regular 55% 30% breakfast 22% breakfast 15% bedtime 16.5% lunch 16.5% dinner

  20. Management (continued) • Goal of glucose concentration FPG <90 mg/dl BS 1hr PP <140 mg/dl Plasma BS 2hr PP <120 mg/dl

  21. Management (continued) • Postpartum F/U ٭1/3 to 2/3 of women will have gestational diabetes in a subsequent pregnancy. ٭As many as 20 % of women with GDM have IGT during the early postpartum period. ٭The risk of type 2 diabetes is also importantly affected by body weight, being 50 to 75 % in obese women versus < 25 % in women who achieve IBW after delivery. ٭GDM is also a risk factor for the development of type 1 diabetes. Specific HLA alleles (DR3 or DR4) may predispose to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies.

  22. Postpartum F/U •Immediately after delivery, FPG should be < 115 mg/dL & one-hour PP should be <140 mg/dL. •~ 6-8 wks after delivery, or shortly after cessation of breast feeding, a two-hour 75 gr OGTT is recommended by the ADA and the 4th International Workshop-Conference on GDM.

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