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Managing Gestational Diabetes my way: An Obstetrician’s View

Managing Gestational Diabetes my way: An Obstetrician’s View. Robert Fraser MD FRCOG University of Sheffield. Gestational Diabetes and Congenital Malformations Gestational Diabetes and Fetal Metabolism Management of Gestational Diabetes Timing of Delivery in Gestational Diabetes.

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Managing Gestational Diabetes my way: An Obstetrician’s View

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  1. Managing Gestational Diabetes my way:An Obstetrician’s View Robert Fraser MD FRCOG University of Sheffield

  2. Gestational Diabetes and Congenital Malformations • Gestational Diabetes and Fetal Metabolism • Management of Gestational Diabetes • Timing of Delivery in Gestational Diabetes

  3. Database: Pregnancies by Diagnostic Classification

  4. Gestational Diabetes and Congenital Malformations

  5. Congenital Malformation Rates

  6. Patterns of Malformations and Relationships to Initial Maternal Fasting Serum Glucose Levels in Gestational Diabetes

  7. Congenital Malformations and Initial Fasting Blood Glucose and Maternal BMI in Gestational Diabetes (n= 1971)

  8. Congenital Malformations in Gestational Diabetes

  9. Preimplantation Embryo Development stroma Oviduct Uterine horn                                 epithelia expanded blastocyst 1cell trophectoderm morula 8cell                             inner cell mass hatched blastocyst 2cell Day post-coitum 5 1 2 3 4 Embryonic genome activation Cavitation

  10. 75 50 % Embryos 25 0 0.2 5.56 15.56 25.56 1. Embryopathic Concentrations % 2cells forming hatched expanded blastocysts 2: P<0.001 (n>201) Morphological development % Blastocysts % Blastocysts Hatching 4cell  Blastocyst Glucose (mM) 2cell  Arrested development

  11. Gestational Diabetes and Fetal Metabolism

  12. The Relationship between Birth Weight Ratio and mean HbA1c in Pregnancy

  13. Amniotic Fluid Insulin Levels in Pregnancies Complicated by Maternal Diabetes

  14. Correlation Between Cord Plasma Insulin and Liquor Insulin Levels

  15. Management of Gestational Diabetes

  16. 50 40 30 Insulin mu/l 20 10 0 25 30 35 40 45 Weeks of Pregnancy Weiss 1986

  17. ACHOIS Trial • Women with IGT • Randomised • “Not Gestational Diabetes Group” • Routine Obstetric Care (Double-Blind) • “Glucose Intolerance Group” • Diet, Blood Sugar Monitoring + Insulin if blood sugar rises

  18. ACHOIS Result Summary “Significant excess of Adverse Perinatal Outcomes in Untreated Women”

  19. Can insulin treatment be rationalized?

  20. Size at Birth

  21. Neonatal Morbidity

  22. Ultrasound Measurements of Fetal Abdominal Circumference

  23. RCT of Glycaemic Parameters ± Fetal Ultrasound to Determine Insulin Therapy in GDM • 98 women with FGP 5.8 – 6.7 mmol/L • Experimental group – insulin only if AC ≥ 70th centile or Plasma Glucose > 6.7 mmol/L • Control group – all received insulin (targets: preprandial ≤ 5.0, 2h postprandial ≤ 6.7) (Kjos et al 2001)

  24. RCT of Glycaemic Parameters ± Fetal Ultrasound to Determine Insulin Therapy in GDM

  25. Timing of Delivery in Gestational Diabetes

  26. Insulin requiring diabetes in pregnancy:A randomised trial of active induction of labour and expectant management 200 subjects (187 GDM 13 Type 2) Randomised at 38 weeks gestation Active group: Induction within 5 days Expectant group: Twice weekly CTG and weekly Amniotic Fluid Volume measurement until labour (Kjos et al 1993)

  27. RCT of active induction of labour and expectant management

  28. Cord Blood Insulin Levels in Pregnancies Complicated by Maternal Diabetes and Controls

  29. Cord Plasma Insulin levels in Relation to Maternal Early Pregnancy BMI Soltani 1997

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