1. DIABETES IN PREGNANCY Margarita isabel amoroso-artes, m.d.department of obstetrics & gynecologydavao medical center

2. OBJECTIVES Discuss and define Diabetes in pregnancy Discuss clinical considerations and recommendations

3. References William’s Obstetrics Greasy & Resnik’s Maternal-Fetal Medicine 6th edition ACOG Compendium 2008

4. DIABETES IMPAIRED GLUCOSE TOLERANCE

5. HOW IS DIABETES IN PREGNANCY CLASSIFIED?

6. CLASSIFICATION PREGESTATIONAL OR OVERT GESTATIONAL

7. ETIOLOGICAL CLASSIFICATION

9. OVERT DIABETES IN PREGNANCY HIGH PLASMA GLUCOSE LEVELS GLUCOSURIA KETOACIDOSIS RANDOM PLASMA GLUCOSE >200 MG/DL PLUS POLYDIPSIA, POLYURIA AND UNEXPLAINED WEIGHT LOSS OR A FASTING GLUCOSE EXCEEDING 125 MG/DL

10. HOW SHOULD SCREENING FOR GDM BE ACCOMPLISHED?

11. ALL PREGNANT PATIENTS CLINICAL RISK FACTORS ASSOCIATED WITH INCREASED LIKELIHOOD OF GDM AGE ETHNICITY OBESITY FAMILY HISTORY PAST OBSTETRIC HISTORY

12. LOW RISK MEETS ALL THE CRITERIA: AGE YOUNGER THAN 25 YEARS NOT A MEMBER OF AN ETHNIC GROUP (HISPANIC, AFRICAN, NATIVE AMERICAN, SOUTH OR EAST ASIAN, PACIFIC ISLANDS ANCESTRY) BODY MASS INDEX OF 25 OR LESS NO PREVIOUS HX OF ABNORMAL GLUCOSE TOLERANCE NO PREVIOUS HX OF ADVERSE OBSTETRIC OUTCOME ASSO. W/ GDM NO KNOWN DIABETES IN FIRST DEGREE RELATIVE

13. SCREENING TEST: 50 GM ORAL GLUCOSE CHALLENGE TEST USE HISTORIC RISK FACTORS TO IDENTIFY THE INDIVIDUALS WHO MAY HAVE SUCH A LOW RISK FOR GDM THAT GLUCOSE CHALLENGE TESTING MAY NOT BE WORTHWHILE THERE MAY BE GROUPS AT SUCH HIGH RISK FOR GDM THAT IT MAY BE MORE CONVENIENT AND COST EFFECTIVE TO PROCEED DIRECTLY TO THE DIAGNOSTIC GTT WITHOUT OBTAINING THE SCREENING TEST

14. AT WHAT GESTATIONAL AGE SHOULD LABORATORY SCREENING BE PERFORMED?

15. PREVALENCE OF GDM INCREASES W/ ADVANCING GESTATION 50 GM, 1 HOUR ORAL GLUCOSE CHALLENGE TEST AT 24-28 WEEKS AGE OF GESTATION INSULIN RESISTANCE INCREASES AS PREGNANCY PROGRESSES- TESTING LATER IN PREGNANCY WILL YIELD HIGHER ABNORMAL TESTS

16. PX WITH HX OF GDM PREVIOUS PREGNANCY 30 TO 35% LIKELIHOOD OF RECURRENCE IN SUBSEQUENT PREGNANCY PXS WITH HX OF GDM SHOULD BE TESTED IN BETWEEN PREGNANCIES TO DETECT PREEXISTING DIABETES

17. HOW IS LABORATORY SCREENING ACCOMPLISHED?

18. 50 GM, 1 HOUR GLUCOSE CHALLENGE TEST PURE GLUCOSE LOAD OF 50 GM IN 150 ML OF FLUID GLUCOSE POLYMER SOLUTIONS ( FEWER GI SYMPTOMS) SENSITIVITY: 80-90% THE SCREENING TEST MAY BE ADMINISTERED WITHOUT REGARD TO THE TIME ELAPSED SINCE THE LAST MEAL

19. IS THERE AN APPROPRIATE THRESHOLD VALUE FOR THE LABORATORY SCREENING TEST?

20. AMERICAN DIABETES ASSOCIATION: PAST: 140 MG/CL CURRENT: 130 MG/DL SENSITIVITY: 79% SPECIFICITY: 97% ** EITHER THRESHOLD IS STILL ACCEPTABLE***

21. HOW IS GDM DIAGNOSED?

22. DIAGNOSTIC TEST SPECIFIC: 100 GM, 3 HOUR ORAL GTT POSTIVE DIAGNOSIS REQUIRES 2 OR MORE THRESHOLDS BE MET OR EXCEEDED PXS W/ ONLY ONE ABNORMAL VALUE HAVE INCREASED RISK FOR MACROSOMIC INFANT AND OTHER MORBIDITIES PXS SHOULD REMAIN SEATED DURING THE TEST

23. INSTRUCTED TO FOLLOW AN UNRESTRICTED DIET CONSUMING AT LEAST 150 GM OF CHO PER DAY FOR AT LEAST 3 DAYS PRIOR THE TEST TO AVOID CHO DEPLETION WHICH COULD CAUSE SPURIOUSLY HIGH VALUES ON THE GTT

24. DIAGNOSTIC CRITERIA FOR GDM

25. HOW SHOULD BLOOD GLUCOSE BE MONITORED IN A WOMAN W/ GDM?

26. CAPILLARY GLUCOSE MONITORING Frequency & timing should be individualized Postprandial have the strongest correlation w/ fetal growth Typical glucose monitoring: Rising in the morning 1 or 2 hrs after breakfast Before & after lunch Before dinner Bedtime

27. Target Capillary Glucose Levels Fasting plasma glucose level of 90 to 99 mg/dL (5.0 to 5.5 mmol/L) and 1 hour postprandial plasma glucose level <140 mg/dL (<7.8 mmol/L) or 2 hour postprandial plasma glucose level < 120 to 127 mg/dL (<6.7 to 7,1 mmol/L)

28. Target Plasma Glucose Values: Preprandially: 65 to 95 mg/dL Postprandially: 130 to 140 mg/dL

29. POSTPRANDIAL GLUCOSE VALUES APPEAR TO BE MOST EFFECTIVE AT DETERMINING THE LIKELIHOOD OF MACROSOMIA AND OTHER ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH GDM

30. Recommended Glucose Goal

31. IS THERE A ROLE FOR DIET THERAPY IN THE TREATMENT OF GDM?

32. YES NUTRITIONAL INTERVENTION SHOULD BE STARTED PXS DELIVER FEWER MACROSOMIC INFANTS AMERICAN DIABETES ASSOCIATION: OVESE WOMEN (BMI > 30): MODERATE CALORIC RESTRICTION (30-33%) SUPPLEMENTARY DIETARY FIBER MAY IMPROVE GLYCEMIC CONTROL

33. IS THERE A ROLE FOR ORAL ANTIDIABETIC AGENTS IN THE TREATMENT OF GDM?

34. ORAL ANTIDIABETIC AGENTS CONTRAINDICATED EARLY GENERATION SULFONYLUREAS CROSSES THE PLACENTA STIMULATE FETAL PANCREASE FETAL HYPERINSULINEMIA AND TERATOGENIC

35. Principles of insulin therapy

36. Goal of exogenous insulin therapy during pregnancy: postprandial blood glucose excursions maintained w/in a relatively narrow range (70 to 120 mg/dL) As pregnancy progresses increasing fetal demand for glucose results in lower fasting & between meal blood glucose levels increasing risk of symptomatic hypoglycemia

38. Period of maximal fetal growth velocity & fat accretion occurs at 33.5 wks gestation Delay in therapy by 33-34 wks AOG would miss maximal glycemic intervention effective in modulation fetal growth Allow a 1 to 2 week trial of dietary management

39. Insulin regiment used should be individualized accordin to the patient’s profile Short acting insulin (4 to 8 units to start) before meals If > 10 units of short acting insulin is needed before the noon meal add 6 to 8 doses of NPH before breakfast Doses are scaled up as necessary

40. INTRAPARTUM GLYCEMIC MGT Maternal hyperglycemia perinatal asphyxia & neonatal hypoglycemia Strict maternal euglycemia does not guarantee newborn metabolic stability in infants w/ macrosomia Use of combined insulin & glucose infusion durinnglabor maintains maternal plasma glucose level in narrow range (80 – 110 mg/dL) -- reduces incidence of neonatal hypoglycemia

41. Typical infusion rates 5% Dextrose in Ringer’s lactate at 100 ml/hour AND Lispro or aspart insulin at 0.5 to 1 units per hour CBG monitored q hourly For patients with diet controlled GDM avoiding dextrose in all IV fluids during labor maintains excellent glucose control

42. For CS Procedure should be performed early in the day to avoid prolonged fasting Night before surgery: instructed to take full dose of NPH or glyburide No morning insulin or glyburide should be taken

43. Postpartum Metabolic Mgt In the Recovery Room & after delivery Insulin subcutaneously Insulin dose required after delivery typically 30 to 50% of the preprandial doses required during pregnancy just before delivery

44. IS FETAL ASSESSMENT INDICATED IN PREGNANCIES COMPLICATED BY GDM?

45. Antepartumfetal testing recommended 3rd trimester Goal mgt: prevent stillbirth adn asphyxia while optimizing the opportunity for safe vaginal delivery Monitoring fetal growth to determine proper timing & route of delivery and testing for fetal well being at frequent intervals

47. Fetal movement counting

48. When and how should deliveries be accomplished in patients with GDM?

49. Timing of delivery should minimize neonatal morbidity & mortality while maximizing the likelihood of vaginal delivery Optimal time for delivery: 38.5 to 40 weeks Labor or Cesarean? ACOG recommended primary cesarean for diabetic gravidas with EFW greater than 4500 gm to reduce risk of shoulder dystocia

50. Indications for delivery in diabetic pregnancy

51. Confirmation of fetal maturity before termination of pregnancy

52. Should women with a history of GDM be screened postpartum?

53. Women w/ a history of GDM are at increased risk developing diabetes (generally type 2) later in life

54. What are the fetal effects of GDM?

55. Fetal Effects Abortion Preterm Delivery Malformations Unexplained Fetal Demise Hydramnios

56. Fetal Death In pregnancies not receiving optimal care After 36 wks gestation in pxs w/ Vascular disease Poor glycemic control Hydramnios Fetalmacrosomia Preeclampsia Chronic hypoxia as likely cause of fetal death

58. Neonatal Effects Respiratory distress Hypoglycemia Hypocalcemia Hyperbilirubienmia Cardiac Hypertrophy Long Term Cognitive Development Inheritance of Diabetes Altered Fetal Growth

59. What are the Maternal Effects

60. Diabetic Nephropathy Diabetic Retinopathy Diabetic Neuropathy Preeclampsia Ketoacidosis Infections