Diabetes in pregrancy.asdasdasd (1).pptx

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1. D i a b e t e s i n P r e g n a n c y

2. Diabetes in pregnancy Pr e -ex i st i n g diabetes Ges t ation a l diabetes IDDM ( T y p e 1 ) NIDDM (Type2) Pr e -ex i st i n g diabetes T r u e GD M

3. Gestational diabetes mellitus Pre Existing Diabetes Diagnosed before the start of pregnancy OR Hyperglycemia diagnosed for the first time in pregnancy. Meets WHO criterion for diabetes mellitus in the nonpregnant state May occur any time during pregnancy including the first trimester Hyperglycemia during pregnancy that is not diabetes Hyperglycemia diagnosed for the first time during pregnancy May occur any time during pregnancy but most likely >24 weeks

4. Prevalence 22 million women between 20-39 yrs have diabetes -2010 data Expected to rise by 20% in next 10 years 54 million women with IGT or pre diabetes have the potential to develop GDM if they become pregnant. The prevalence of GDM in India varies from 3.8 to 21% in different parts of the country, depending on the geographical locations and diagnostic methods used. GDM has been found to be more prevalent in urban areas than in rural areas

5. Overview Definition Screening Diagnosis Ante natal Management Intra natal Management Post natal Management Prevention

6. Pathophysiology of GDM Ge s ta ti o nal diabetes mellitus Insulin resistance due to placental secretion of anti- insulin hormones Maternal hepatic glucose production increases by 15%- 30% to meet fetal demand late in pregnancy Pancreatic  -cell dysfunction due to Genetics Autoimmune disorders Chronic insulin resistance Inturrisi M, et al. Endocrinol Metab Clin N Am . 2011;40:703-726. Metzger BE, et al. Diabetes Care . 2007;30(2):S251-S260.

7. S C R EE N I N G V E R SU S D I AG N O S T I C T E S T I N G The purpose of screening is to identify asymptomatic individuals with a high probability of having or developing a specific disease.

8. W ho m t o s c r ee n ? Universal screening appears to be the optimum approach as the Indian women have 11 fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women .

9. W h i c h s c r e e n i n g me t h o d ? D i a b e t e s i n P r eg n a n c y St u d y G r o u p o f I nd i a ( D I P S I ) C r i t e r i a One step approach - The one step approach has been proposed by the DIPSI and endorsed by the GOI . On 14th March 2007, Government of India issued the instructions that universal screening of glucose intolerance during pregnancy should be mandatory. The order recommends that all women should be screened between 24 and 28 weeks of gestation with 2 h 75 g oral glucose.

10. How to do it ? 75 gms glucose with 300 ml water Irrespective of last meal Ingestion to be completed within 5-10 min Measure blood sugar after 2 hour If vomiting within 30 min of intake-repeat test next day

11. Interpretation of DIPSI Test

12. Advantages of DIPSI Criteria simple, feasible, convenient, economical and acceptable in Indian scenario In India, women have to travel long distances for check-up, hence this non-fasting single test becomes more acceptable to the pregnant women Indian population is diverse and variable, hence international criteria on Indian population may not be practical and feasible.

13. Screening U n i v e r sal screening First booking visit - GOI / DIPSI 24- 28 weeks - GOI / DIPSI 32-34 weeks - DIPSI

14. W h y D iagno s e an d T r ea t GD M ? Identifying women with GDM is important because appropriate therapy can decrease maternal and fetal morbidity . Can prevent two generations from developing diabetes in the future.

15. Maternal problems Early pregnancy - spontaneous miscarriage Pregnancy - PE, Gestational HT, UTI, Macrosomia, hydramnios De li v e r y - P T B , in s t r ume n t al deli v e r y , t r aum a tic d eli v e r y , C S, P o s tpa r tum infections, PPH, maternal mortality/ morbidity Puerperium - infections, lactation failure Long term postpartum - weight retention , GDM in subsequent pregnancy , DM, CVD

16. Fetal problems Still birth / Neonatal deaths congenital malformations Erb’s palsy Shoulder dystocia / RDS cardiomyopathy Hypoglycaemia Hyperbilirubinaemia / Polycythemia Hypocalcimia

17. GDM diagnosed - what next ?

18. Outline for GDM management Primary management strategy for GDM: dietary changes and exercise If uncontrolled hyperglycemia with lifestyle change: Insulin should be first line therapy Use Metformin, if insulin cannot be used

19. Management Issues- Patient education Medical Nutrition therapy Pharmacological therapy Glycemic monitoring: SMBG & Targets Fetal monitoring: ultrasound Planning on delivery Postpartum care

20. GDM: Management During Pregnancy Receive nutrition counseling by registered dietician to achieve their nutrition, weight and blood glucose goals Eat healthy diet and Replace high-Glycemic Index foods with low-Glycemic Index foods to reduce need for insulin initiation Discuss appropriate weight gain and healthy lifestyle interventions throughout pregnancy

21. Medical Nutrition Therapy (MNT) Therapeutic goals: adequate nutrition Adequate weight gain prevention of ketosis Prevention of postprandial hyperglycemia.

22. Individualized diet plan based on level of activity and BMI

23. GDM Diet Diet- 30 kcal/kg – normal weight women, 24 Kcal/kg for overweight women, and 12 Kcal/kg for morbidly obese women. Diet should contain carbohydrate 50%, protein 20% and fat 25-30%. Usually three meal regimen, with breakfast 25% of the total intake, lunch 30%, dinner 30%.

24. Physical Activity Unless contraindicated, physical activity should be included in a pregnant woman’s daily regimen Regular moderate-intensity physical activity (eg, walking) can help to reduce glucose levels in patients with GDM Other appropriate forms of exercise during pregnancy Cardiovascular training with weight-bearing, limited to the upper body to avoid mechanical stress on the abdominal region

25. Target weight gain in GDM Prepregnancy BMI Category Total weight gain <18.5 Underweight 12.5-18 Kg 18.5-24.9 Normal weight 11.5-16 Kg 25-29.9 Overweight 7-11.5 Kg >30 Obese 5-9 Kg

26. I ns u li n i n i t i a t i o n d u r i n g p r e g n a n c y About 50% of women initially treated with diet alone will require additional therapy, and insulin therapy usually is recommended. Insulin management must be individualized , but most pregnant women require about 0.7 units/kg daily. two thirds of the insulin is administered in the morning and one third is administered in the evening, with a 1:2 ratio of short- to intermediate- (or long-) acting insulin. Kahn, CR, King GL., Moses AC., . Joslin's Diabetes Mellitus (14th Edition).Weir GC., Jacobson AM., Smith RJ JOSLIN DIABETES CENTER. Boston, Lippincott Williams & Wilkins, 2005, chapter 61

27. Status of OHA in pregnancy Metformin and the sulfonylurea glyburide are the 2 most commonly prescribed oral antihyperglycemic agents during pregnancy Due to efficacy and safety concerns, the ADA and DIPSI does not recommend oral antihyperglycemic agents for gestational diabetes mellitus (GDM) or preexisting T2DM Medication Crosses Placenta Classification Notes Metformin Yes Category B Metformin and glyburide may be insufficient to maintain normoglycemia at all times, particularly during postprandial period Glyburide M i n i mal transfer Some formulations category B, others category C

28. OHA in pregnancy Metformin Insulin sensitizer Give with meal Start at 500 mg once or twice daily with food Increase slowly weekly to 2000 mg per day (2500 mg/day) No teratogenic risks demonstrated pregnancy risk factor: B (No evidence of risk in studies) Not FDA approved for use in pregnancy

29. Monitoring Blood Glucose At least 4 times-self monitoring Fasting and 3 one and half hour postprandial After achieving target level, lab monitoring till 28wks- once in a month 28-32 weeks once in 2 weeks >32 once a week Other parameters to be monitored: fundus,micro albuminuria

30. Glycemic targets Mean plasma glucose -105 mg/dl maintaine FPG at 90 & PP at 120 Mean plasma glucose should never go below 86

31. GOI, MOHFW

32. Monitoring during pregnancy

33. Fetal monitoring Baseline ultrasound : fetal size At 18-22 weeks -major malformations & fetal echocardiogram 26 weeks onwards -growth and liquor volume III trimester –frequent USG for accelerated growth (abdominal: head circumference), weight gain, AFI

34. When to deliver ? (FIGO recommendations)

35. Care in labour & delivery Institutional delivery Presence of expert obstetrician Close electronic monitoring

36. Care in labour & delivery Close monitoring in second stage W/F foetal distress Vaginal delivery should be preferred and LSCS should be done for obstetric indications only.

37. Insulin Management during Labour & Delivery Usual dose of intermediate-acting insulin is given at bedtime Morning dose of insulin is withheld I.V infusion of normal saline is begun Once active labor begins or glucose levels fall below 70 mg/dl, infusion is changed from saline to 5% dextrose & delivered at a rate of 2.5 mg/kg/min Glucose levels are checked hourly using a portable meter allowing for adjustment in infusion rate Regular (short-acting) insulin is administered by iv infusion if glucose levels exceed 140 mg/dl

38. Immediat e postpartu m care - GDM on MNT Cease blood glucose monitoring immediately after delivery Regular postnatal care OGTT 6 weeks postpartum American Diabetes Association. Standards for medical care in diabetes 2018. Diabetes Care 2018

39. I mm e d i a t e p o s t p a r t u m c a r e GDM on OHAs In most women, glucose tolerance will normalize immediately after delivery Cease pharmacological therapy immediately after delivery Continue pre prandial BGL monitoring QID for 24 hrs If preprandial BGL 72 – 126mg/dl – discontinue monitoring If BGL <72mg/dl or >126mg/dl – seek medical review and continue monitoring 1 – 8% may continue to be glucose intolerant and need OHAs Metformin, glibenclamide / glyburide safe during lactation Queensland clinical guideline 2015

40. Preprandial BGL monitoring QID for 24 hrs If BGL >126mg/dl –medical review & start OHAs Insulin therapy is generally not indicated unless marked fasting hyperglycemia (200–250 mg/dL) Queensland clinical guideline 2015 I mme d i a t e p o s t p a r t u m c a r e GDM on Insulin

41. R i s k f a c t o r s f o r p e r s i s t e n t d i ab e t e s Pregnancy fasting glucose levels greater than or equal to 126 mg/dL Diagnosis of GDM during the first trimester A prior history of GDM without documented normal glucose tolerance outside of pregnancy Metzger BE. Summary and recommendations of the 4th International Workshop- Conference on Gestational Diabetes Mellitus. Diabetes Care 1998;21(Suppl 2):B1617.

42. Monitor for persistent diabetes Recommend OGTT at 6 weeks postpartum to screen for persistant diabetes Recommend lifelong screening for diabetes every 3 yrs Early glucose monitoring in future pregnancy

43. Breast feeding should be encouraged to breastfeed immediately after delivery in order to avoid neonatal hypoglycemia [Grade D, Consensus] and to continue for at least 3-4 months postpartum in order to prevent childhood obesity [Grade C, Level 3] and diabetes in the offspring [Grade D, Level 4] and to reduce risk of type 2 diabetes and hypertension in the mother [Grade C, Level 3]

44. Contraceptive choices Barrier LARC POP / DMPA COC / implants/ rings - contraindicated with macrovascular disease

45. Can we Prevent GDM ? In women at high risk for GDM based on pre- existing risk factors, nutrition counseling should be provided on healthy eating and prevention of excessive gestational weight gain in early pregnancy, ideally before 15 weeks of gestation, to reduce the risk of GDM [Grade B, Level 2]

46. Key points  Universal testing of all pregnant women for GDM  Testing recommended twice in pregnancy; at 1 st antenatal visit and then at 24-28 weeks of gestation. DIPSI recommends additional screening at ~34 weeks.  Single step 75 gm 2 hr OGTT test performed.  Pregnant women testing positive(2hr OGTT≥140mg/dL) should be started on MNT for 2 weeks.  If 2 hr PPBS ≥120 mg/dL after MNT and physical exercise, medical management (metformin or insulin therapy) of pregnant women to be started as per guidelines.  Early delivery with administration of prophylactic corticosteroid therapy for fetal lung maturity to be planned only if uncontrolled blood sugar or any other obstetric indication  Vaginal delivery preferred, LSCS for only obstetric indications or fetal macrosomia.  Neonatal monitoring for hypoglycemia and other complications  Postpartum evaluation of glycemic status by a 75 g OGTT at 6 weeks after delivery.