Gestational diabetes mellitus

powerpoint on GDM for undergraduates & Postgraduates

1. Gestational Diabetes M ellitus DR ANITA RAMESH

2. OVERVIEW DEFINITION PREVALENCE RISK FACTORS MATERNAL COMPLICATIONS FETAL COMPLICATIONS SCREENING DIAGNOSIS ANTENATAL MANAGEMENT INTRANATAL MANAGEMENT POSTNATAL MANAGEMENT PREVENTION

3. DEFINITION of GDM Any amount of carbohydrate intolerance diagnosed for the first time during pregnancy It can be a PRE EXISTING DM or GESTATIONAL DM How to differentiate? D o HbA1C….If > or equal to 6.5% it is pre existing DM,FBS>126mg%, R BS>200mg%............OVERT DIABETES 90% GDM & 10%PREXISTING DM

4. GESTATIONAL DIABETES MELLITUS Hyperglycemia during pregnancy that is not chronic diabetes Hyperglycemia diagnosed for the first time during pregnancy May occur anytime during pregnancy but most likely after 24 weeks

5. PREVALENCE 22 million women between 20 to 39 yrs have diabetes-2010 data Expected to rise by 20 percent in next 10 years Women with IGT or pre diabetes have the potential to develop GDM if they become pregnant In India prevalence is 1% to 14%percent GDM is more prevalent in urban areas compared to rural areas Almost 50%will develop OVERT DM in next 10-15 years GDM leads to diabetes & obesity in the offspring

6. EFFECT OF PREGNANCY ON GLUCOSE METABOLISM PREGNANCY IS A DIABETOGENIC STATE HPL,E,P,CORTISOL & ENZYME INSULINASE HPL,E,P & C ortisol cause insulin resistance Increased insulinase activity destroys insulin Pregnancy unmasks DM in latent diabetic subjects. 90% of women show increased insulin secretion to counter this insulin resistance. Those 10% show insulin resistance. Basically GDM unmasks chronic beta cell function of pancreas.

7. CLASSIFICATION

8. RISK FACTORS FOR GDM Age >30yrs BMI >25kg/m2.Obese patients Family history of DM in first degree relatives Ethnicity:Prevalent in S outh A sians Previous OH:H/O GDM in prev pregnancies,Stillbirth,Repeated miscarriages,Macrosomic baby,Unexplained perinatal loss Recurrent vaginal candiasis or polyhydramnios in present pregnancy

9. MATERNAL COMPLICATIONS Early pregnancy: S pontaneous miscarriages Late pregnancy: PE 25%,UTI,Macrosomia,hydramnios 25%-50% Delivery: P reterm labour 26%, Instrumental delivery, Traumatic delivery, CS, PPH, Maternal morbidity/mortality Puerperium: Infections,Lactation failure Long term complications: GDM in subsequent pregnancy,DM,CVD

10. FETAL COMPLICATIONS DIABETIC EMBRYOPATHY:Congenital malformations(increasing sugar levels r not favourable for organogenesis).Risk is5% if HbA1C <8% & 25% if HbA1C>10% FETAL MACROSOMIA:Shoulder dystocia,Traumatic delivery,CS NEONATAL COMPLICATIONS:Hypoglycemia,Hypocalcemia,Hypomagnesemia,Hyperbilirubinemia,RDS,Cardiomyopathy Unexplained IUD:Risk is more in the last 4 to 6 weeks of pregnancy

11. CAUSE OF IUD Uncontrolled diabetes…mat hyperglycemia….fetal hyperinsulinemia ….fetal hypoglycemia….hypoxia Fetal hyperinsulinemia ….increased oxygen demand of fetus HbA1C binds oxygen more but releases less oxygen…fetal hypoxia Overt diabetes… vasculopathy …placental insufficiency…FGR

12. HOW TO DIAGNOSE GDM.Screening versus Diagnostic Test Purpose is to identify asymptomatic individuals with a high probability of having or developing a specific disease UNIVERSAL SCREENING IS ADVISED FOR DIAGNOSING GDM

13. WHOM TO SCREEN? UNIVERSAL SCREENING IS THE OPTIMUM APPROACH AS INDIAN WOMEN HAVE 11 FOLD RISK OF DEVELOPING GLUCOSE INTOLERANCE DURING PREGNANCY COMPARED TO CAUCASIAN WOMEN

14. HOW TO SCREEN?DIPSI CRITERIA Diabetes in Pregnancy Study Group of India ONE STEP APPROACH On 14 th mar 2017,GOI asked for universal screening All women have to be screened at 24 to 28weeks of gestation with 2 hrs 75 gms oral glucose

15. HOW DIPSI TEST IS PERFORMED? SINGLE STEP TEST No need to keep the patient fasting 75g glucose is orally administered by diluting in 300ml water. Blood glucose levels are monitored after 2hrs If vomiting occurs within 30 minutes,the test has to be repeated The threshold level of equal to or > than 140 is the cut off for diagnosis of GDM

16. ADVANTAGES OF DIPSI SIMPLE,ECONOMICAL,ACCEPTABLE PATIENT DOES NOT NOT HAVE TO FAST DIPSI has got more sensitivity & negative predictive value

17. DIPSI CRITERIA

18. WHEN TO DO DIPSI? First booking visit 24-28 weeks[GOI/DIPSI} 32-34weeks{ dipsi }

19. Why to do DIPSI? Identify & treat the patients Prevent diabetes in the 2 generations

20. MANAGEMENT OF GDM Educate the patient Tight glycemic control.Target FBS 90mg%,1 hr PPBS 140mg% & 2 nd hour PPBS 140mg% Monitoring the patient and the fetus Labour management Multidisciplanary approach:obstretician,diabetologist,dietician,neonatologist

21. EDUCATING A GDM PATIENT DIETARY CHANGES:replace with low glycemic foods Discuss appropriate weight gain during pregnancy EXERCISE :Daily 30mins to I hour of moderate exercise Start with MNT IF UNCONTROLLED:INSULIN THERAPHY Or METFORMIN THERAPHY(OHAs) Self monitoring of glucose Self administration of insulin

22. MNT(MEDICAL NUTRITION THERAPHY) Adequate nutrition.Well balanced diet Adequate weight gain Prevention of ketosis(overt diabetes) Prevention of postprandial hyperglycemia If within 2 weeks glucose levels r not under control ..switch to drugs GDM DIET-30kcal/kg/d in normal weight women,24kcal/kg/d for overweight women & 12kcal/kg/d for morbidly obese patients Diet should have 40%carb,30%protein & 30% fat Usually 3 meal & 3 snacks with breakfast 10%,lunch30% & dinner 30%,30% snacks

23. TARGET WEIGHT GAIN IN GDM BMI<18.5kg/m29(underweight)----12.5kg-18kgs BMI18.5-24.9kg/m2(ideal)---11.5-16kgs BMI25-29.9kg/m2(overweight)--------7-11.5kgs BMI>30kg/m2(obese)--------5-9kgs

24. Insulin Initiation During Pregnancy About 50% women treated with diet alone will require additional theraphy with insulin GDM patients require low doses of insulin compared to pre existing DM patients Insulin is given subcutaneously Recombinant human insulin is most preferred Start with 4 units of premixed(30/70)insulin BB.Give 30mins BB.If not controlled increase every 4 th day by 2 U till 10 units.Usually they don’t need >20units Insulin dose has to be individualised ………0.7units/kg daily Two thirds of insulin is administered in the morning & 1/3 rd in the evening with 1:2 ratio of short to intermediate or long acting insulin

25. Insulin options safe in pregnancy name type onset peak duration dosage Aspart Rapid acting 15min 60min 2hrs Start of each meal Lispro Rapid acting 15min 60min 2hrs Start of each meal Reg insulin Intermediate acting 60mins 2-4hrs 6hrs 60-90mins before meal NPH Intermed acting 2hrs 4-6hrs 8hrs Every 8 hrs Detemir Long acting 2hrs 12hrs Every 12hrs

26. OHA /INSULIN IN GDM Metformin or insulin can be started if MNT fails.Insulin is the first choice & metformin can be given after 20 WOG Insulin can be started anytime during pregnancy Metformin max dose is 2g/day

27. MONITORING BLOOD GLUCOSE(SMBG) Atleast 4 times self monitoring Fasting & three 2hrs postprandial If target levels r achieved,lab monitoring to be done once a month till 28 weeks 28-32 weeks,lab monitoring of plasma glucose done every 2 weeks >32 weeks…once a week Do FUNDOSCOPY,MONITORING MICROALBUMINURIA GLUCOSE

28. GLYCAEMIC TARGETS Mean plasma glucose of 105mg/dl Fasting plasma glucose at 90mg/dl & PP at 120mg/dl Mean plasma glucose not to go below 86

29. MONITORING DURING PREGNANCY FIRST TRIMESTER Clinical exam,Dating scan,NT scan,Double marker test,Color doppler for prediction of PIH SECOND TRIMESTER Clinical exam,Anomaly scan,fetal 2D echo at 24 weeks THIRD TRIMESTER Clinical exam,DFKC,Growth scans at 28,32,36 weeks,Color doppler if indicated,AFI,NST (32 weeks onward)

30. WHEN TO DELIVER? Deliver in a tertiary care hospital Timing & mode of delivery GDM controlled on diet alone & no complications:deliver at 40 weeks GDM on insulin theraphy:induction at 38 weeks Vaginal delivery is allowed if macrosomia is ruled out Morning dose of insulin is omitted Glucose levels r checked hourly with glucometer IV infusion of NS started If glucose levels <70mg%,D5 is started If glucose levels>140mg% regular insulin is administered in IV infusion

31. INSULIN DOSAGE IN LABOUR ACC TO BG LEVELS Blood glucose mg/dl Insulin dosage Iv fluids at 125ml/ hr <100 D5 100-140 1 D5 141-180 1.5 NS 181-220 2 NS >220 2.5 NS

32. If baby weight >4kgs deliver by CS If uncontrolled sugar levels or any other complicating factor,deliver the fetus If preterm…steroids r to be given with strict monitoring of BG levels

33. INTRAPARTUM CARE FIRST STAGE If hyperglycemia controlled on diet & spont labour …admission CTG,PARTOGRAM,GLUCOMETER MONITORING 2 HRLY[Sugars 80 to 120} If hyperglycemia controlled by insulin/ metformin,spont labour …….same as above & IV fluid as per blood sugar levels INSTITUTIONAL DELIVERY EXPERT OBST CONTINUOUS CTG

34. SECOND STAGE Controlled ARM Anticipate shoulder dystocia Neonatologist THIRD STAGE AMTSL Prevent traumatic or atonic PPH

35. POSTPATUM CARE Careful glucose monitoring for 2 hrs postdelivery & for 48 hrs Regular postnatal care OGTT at 6 weeks postpartum Note:maternal insulin requirements fall significantly immediately after delivery and continue to decline(insulin drip can be reduced or stopped after delivery)

36. IMMEDIATE POSTPARTUM CARE STOP insulin AS GLUCOSE CONTROL WILL BE ACHIEVED IN MOST WOMEN IMMEDIATELY AFTER DELIVERY CONTINUE PREPRANDIAL BGL FOR 24 HRS IF preprandial BG 72-126…discontinue monitoring If BG <72 OR >126…MED OPINION 1-8% may be glucose intolerant & need OHAs Metformin,glibenclamide,glyburide r safe during lactation

37. RISK FACTORS FOR PERSISTENT DIABETES Pregnant FBS >126 Diagnosis of GDM during first trimester A prior history of GDM

38. MONITOR FOR PERSISTENT DIABETES( longterm consequences) OGTT to be done at 6 weeks postpartum to screen for persistent diabetes 50%o f GDM will develop type 2 DM within 15 yrs of delivery If GDM on insulin,50% will develop type 2 DM in 5 years Recommended lifelong screening for diabetes every 3 yrs Early glucose monitoring in future pregnancy(risk of recurrence is 30% -50%)

39. CONTRACEPTIVE ADVICE Barrier methods POP/DMPA COC/Implants are contraindicated with macrovascular disease

40. FETAL LONGTERM CONSEQUENCES Increased risk of developing OBESITY,DIABETES FETAL ONSET OF ADULT DISEASE GESTATIONAL PROGRAMMING:process whereby stresses or stimuli that occur at sensitive periods of fetal dev permanently change structure,physiology and metabolism that predisposes individuals to diseases in adult life.intrauterine exposure to diabetogenic environment is risk factor fpr dev of DM in adult life.

41. CONCLUSION(KEY POINTS) Universal testing of all pregnant women Testing to be done twice in pregnancy..once at 1 st visit & second at 24-28 weeks Single step test recommended Start on MNT for patients with positive OGTT test>140mg/dl If not controlled start on OHA or insulin In uncontrolled diabetes or those with obstetric indication early delivery recommended after steroid theraphy Vaginal delivery preferred but LSCS for macrosomia /obstetric indication Neonatal monitoring for hypoglycemia & other complications Postpartum evaluation of glycemic status at 6 weeks to be done postdelivery

42. THANK YOU ALL FOR PATIENT HEARING