Gestational Diabetes Mellitus.pptx

Gestational Diabetes Mellitus

1. Gestational Diabetes Mellitus Dr Susanta Kumar Behera Asst Professor Dept. of O&G

2. GDM is defined as carbohydrate intolerance of variable severity with onset on first recognition during the present pregnancy irrespective of the fact that the condition persists after pregnancy or not or insulin is used or not for treatment. Includes some women previously unrecognised overt diabetes .

3. Usually presents late in the second or during the third trimester. Majority of women with GDM (>50%) often ultimately develop overt diabetes by next 15 to 20 years.

4. CARBOHYDRATE METABOLISM IN PREGNANCY Placental glucose transport depends on GLUT-1. Principal Glucose transporter GLUT-1 is located in placental syncytiotrophoblast. Pregnancy is a diabetogenic condition due to progressive increase in the Insulin resistance. Diabetogenic Effects of pregnancy as follows 

5. 1. INSULIN RESISTANCE Production of HPL , Cortisol , Estriol , Progesterone all of which have anti-insulin action. Increased Destruction of Insulin by kidney and placenta( Insuli n ase )

6. 2. INCREASED LIPOLYSIS Mother utilises fatty acids for her calorie needs sparing glucose for the foetus. Pregnancy is a state of chronic low grade inflammation(associated with increased circulating Level of CRP & IL-6 ).

7. In early pregnancy there is an increased risk of hyperglycemia due to increased insulin sensitivity. Nausea and vomiting common in the 1 st trimester contribute to reduced intake that can cause hyp o glycemia . When the insulin resistance starts occurring in the 2 nd & 3 rd trimester to provide nutrition to the growing fetus there occurs marked hyperglycemia .

8. GLYCOSURIA IN PREGNANCY During pregnancy renal threshold is diminished due to combined effect of increased GFR & impaired tubular reabsorption of glucose. Present most commonly in mid Pregnancy.

9. Development of Carbohydrate intolerance during pregnancy. Pre-GDM or Overt Diabetes Denotes conception in a women who is already a diabetic. If there is absence of documentation in pre-conception period criteria met in first/early 2 nd trimester is considered to diagnose overt diabetes.

10. Overt Diabetes A Patient with symptoms of polyuria, polydypsia , weight loss and random plasma glucose level of 200 mg/dl or more is considered Overt Diabetes. According to American Diabetes Association(ADA) diagnosis is positive If- Fasting Plasma glucose > 126 mg/dl 2 h r PPBS(75g) value > 200 mg/dl HbA1C > 6.8%

11. White’s Classification of Diabetes in pregnancy Based on Patient’s condition before pregnancy Age of onset Duration of Diabetes Presence of complications

12. Reasons of development of GDM Insulin resistance increases from the 2 nd trimester due to pregnancy hormone and glucose levels r ise in women who don’t have that enough. pancreatic reserve for insulin production specially in women with family history of Diabetes and PCOD .

13. Risk factors for GDM Positive family history of Diabetes (Parents or siblings). Family history should include uncles, aunts, and grand parents. Having a BMI of ≥30 or overweight baby of 4 kg or more. Previous GDM or still birth with pancreatic islet hyperplasia revealed on autopsy. Unexplained perinatal loss.

14. e) Presence of polyhydramnios or recurrent vaginal candidiasis on present pregnancy -Women with PCOS -Hypertension (140/90 mm Hg) f) Persistent glycosuria g) Age over 30 years h) Obesity i ) Ethnic Group ( East Assam, Pacific)

15. SCREENING AND DIAGNOSIS OF DIABETES Universal screening of all pregnant women in GDM is now recommended (ACOG 2018). If selective screening is done 50% cases of GDM maybe missed. All pregnant women should be screened for GDM irrespective of risk factors. Screening is done at 24-28 weeks of gestation. Early screening is recommended (ACOG , ADA) for women with high risk factors.

16. Who Should be Screened Early? Overweight with BMI of 25   and  one or more of the following Physical inactivity Family history of diabetes – 1st degree relative (parent or sibling) Previous pregnancy history of GDM/ Macrosomia (≥ 4000 g) Hypertension (140/90 mm Hg HDL cholesterol ≤ 35 mg/dl (0.90 mmol /L) Fasting triglyceride ≥ 250 mg/ dL (2.82 mmol /L ) PCOS Insulin resistance (e.g., acanthosis nigricans , morbid obesity) Hgb A1C ≥ 5.7%, impaired GTT Cardiovascular disease

17. INTERNATIONAL ASSOCIATION OF DIABETES IN PREGNANCY STUDY GROUP (IADPSG) & AMERICAN DIABETES ASSOCIATION (ADA) CRITERIA Done at 24-28 weeks One step diagnosis : FBS followed by 75 OGTT FBS sample : 92 1 hr sample : 180 2 hr sample : 153 Diagnosis of GDM is made if ≥ 1 value is abnormal

18. ACOG (based on NIH consensus panel findings) supports the ‘ 2 step’ approach (24 to 28 week) Step-1(Screening test) : 1 hour venous glucose measurement following 50gm oral glucose solution) < 140 mg/dl : Normal > 200 mg/dl : GDM confirmed ≥140 mg/dl,< 200 mg/dl : ?GDM : 2 nd step

19. Step-2(Diagnostic test) : 100gm 3 hour oral glucose tolerance test (OGTT) FBS sample : 95 1 hr sample : 180 2 hr sample : 155 3 hr sample : 140 Diagnosis of GDM is based on 2 abnormal values on the 3 hour OGTT

20. DIPSI GUIDELINES ACCORDING TO GOVT OF INDIA First testing should be done during first antenatal contact as early as possible in all pregnancies Universal screening for GDM is performed due to high risk of GDM 1 ST screening : 1 st Antenatal visit

21. 2 nd screening : 24-28 wks of pregnancy Fasting – Not Needed Irrespective of previous meals, 75gm of glucose in water is given

22. Blood Glucose level are checked after 2 hr- >140 but < 200 mg/dl : GDM >200 mg/dl : Pre-Gestational DM Quantity of water : 300ml can mix to be consumed within 5 minutes.

23. If patient vomits after glucose intake  - within 30 mins – repeat testing next day - after 30 mins – continue with the test If patient’s first Antenatal visit is being 28 weeks : Only one test should be done

24. COMPLICATIONS OF GDM MATERNAL COMPLICATIONS Increased chances of pre-eclampsia (25%) Abortion(Recurrent spontaneous abortion may be associated with uncontrolled diabetes) Infections- UTI & Vulvovaginitis

25. 4. Polyhydramnios (25-50%) is a common association(Large baby, large placenta, fetal hyperglycemia leading to polyuria , increased glucose conc. of liquor irritating the amniotic epithelium or increased osmosis)

26. 5. Maternal distress may be due to the combined effect of a oversized fetus and hydramnios. Diabetic Retinopathy Diabetic neuropathy Diabetic nephropathy

27. Remote Complications of mother Reoccurrence occurs in subsequent pregnancies in about 50% cases. 50% of GDM develops overt diabetes in the ensuring 20 years

28. FETAL AND NEONATAL Fetal Macrosomia Increase chance of fetal death Hyperbilirubinemia Hypoglycemia Hyperviscocity Syndrome Hypocalcemia Fetal congenital anomaly Childhood and adult onset obesity

29. What Are Glucose Target Levels? ACOG and ADA recommend the following target levels to reduce risk of macrosomia Fasting or preprandial blood glucose values < 95 mg/ dL Postprandial blood glucose values < 140 mg/ dL at 1 hour and < 120 mg/ dL at 2 hours

30. MANAGEMENT Pre-conceptional counseling Goal : tight control of diabetes before onset of pregnancy. Folic acid supplementation (5mg/day ). Women with pre-existing diabetes should be advised to achieve a HbA1C ≤ 6.5 % prior to conception. Reduces the risk of major fetal malformations and other pregnancy complications.

31. ANTENATAL CARE Pre-Gestational / Gestational diabetes : Anomaly scan at 18-20 weeks (same as all pregnant women) At least 2 growth scans – At 28-30 wks and 34-36 wks ( minimum gap- 3 weeks) PGDM/GDM – Foetus has macrosomy  Growth scan USG is repeated along with ECHO at 20-22 wks of gestation.

32. GDM+controlled blood sugar & no complications GDM+Not controlled blood sugar & no complications like high BP Follow regular antenatal visits 2 nd trimester- 2 weekly visit 3 rd trimester – weekly visit

33. At each visit check BP(Increased risk of pregnancy induced hypertension, Proteinuria, Polyhydramnios) Urine routine microscopy in each trimester (UTI, Vaginal Candidiasis , Asymptomatic bacteriuria) Fetal Growth Due to higher risk of pre-eclampsia low dose Aspirin 150mg daily started since 12 weeks of gestation.

34. Start fetal growth monitoring from 32 weeks (increased risk of IUD & Still birth) Daily fetal movement count by the mother. Advise the mother to lie in left lateral position after meals. Keep a count of fetal movements. Non Stress Test – Weekly Biophysical/modified biophysical profile – Weekly Doppler USG of umbilical artery. Significantly in condition with uteroplacental insufficiency such as PIH & IUGR.

35. W eight Category BMI (Kg/m2) Energy requirement (Kcal/Day) Under weight < 18.5 Energy requirement as per level of activity + 500 kcal/day Normal weight 18.5 – 24.9 Energy requirement as per level of activity Over weight 25 – 29.9 Energy requirement as per level of activity Obese (Grade I, II, III, IV) > 30 Energy requirement as per level of activity – 500 kcal/day

36. Calories as per Pre-pregnant weight Pre-Pregnant weight BMI (Kg/m2) Total Weight gain range (Kg) Normal weight 18.5 – 24.9 11.5 – 16 kg Under weight < 18.5 12.5 – 18 kg Over weight 25 – 29.9 7 – 11.5 kg Obese (Grade I, II, III, IV) > 30 5 - kg

37. Total Calories (3 major meals and 2-3 snacks) should be divided as follows : Carbohydrates - 40% Fats – 40% (Saturated fat < 10% + Cholesterol < 300 mg/day) Protein – 20%

38. MANAGEMENT OF GDM Pregnant women with GDM Medical Nutrition Therapy(MNT) & excercise 2 hr PPBS After 2 weeks <120 mg/dl Continue MNT and excercise ≥120 mg/dl Start oral antidiabetic ( Metformin ) Or Start insulin Monitor 2 hr PPBS every month and manage according to high risk protocol Monitor FBS & 2 hr PPBS every third day(insulin)/ biweekly( Metformin ) and adjust dose to have target blood sugar level Manage according to high risk protocol

39. DOC for diabetes in pregnancy – Insulin National guidelines INDICATIONS FOR STARTING INSULIN : GDM patients if after 2 wks of management, Post prandial (PP value) > 120 mg/dl. Pre-gestational diabetes patients from day-1 of pregnancy. 2 hr PP Value > 200 mg/dl in a pregnant female. INSULIN THERAPY

40. INTERNATIONAL GUIDELINES : INDICATIONS FOR STARTING INSULIN : Metabolic goals met but : Estimated foetal weight is > 90% for gestational age Abdominal circumference is > 75% for gestational age

41. Insulin therapy

42. INSULIN INJECTIONS S/C route. 40 IU/ml vial, human premix insulin (30:70) & insulin syringe (1ml/40IU) are used. Insulin should be stored in refrigerator between 4-8 degree C (Not in freezer). DOSE OF INSULIN Starting dose is calculated as per the 2hr post prandial blood glucose level

43. BLOOD GLUCOSE LEVEL (2 hr PP) DOSE OF INSULIN 120-160 4U 160-200 6U > 200 8U Insulin injection to be given 30 minutes before breakfast. Every 3 rd day fasting blood glucose level (FBS) & 2 hr PPBS are checked If FBS > 95 mg/dl on 3 rd day – Add 2 U dose before breakfast

44. If 2 hr PPBS > 120 mg/dl – Add 2 U dose before breakfast. If both are deranged- Add 4 U dose Again in 3rd day measure fasting blood sugar & 2 hr PPBS Keep titrating till the metabolic goals are met : Continue the same dose of Insulin + MNT

45. ORAL HYPOGLYCEMIC AGENTS IN PREGNANCY Oral Hypoglycemic agents are less potent and cross placenta causing hypoglycemia in the fetus therefore not used . Exceptions- Metformin and G lyburides can be used in Pregnancy

46. OBSTETRIC MANAGEMENT IN GDM Women with GDM that is controlled with only diet and exercise should not be delivered before 39 weeks of gestation, if not indicated. For other reasons and spontaneous onset of labor is waited up to 40 wks and then terminated. GDM cases well controlled by medications. Delivery is recommended at 39 wks to 39 (6/7 days) wks of gestation.

47. In cases of large baby > 4000 gm regarding route of delivery. Patient should be counselled properly. In poorly controlled GDM delivery is considered at 37 wks– 38 (6/7 days) wks. Delivery at < 37 wks is considered only after features of poor glycemic control or abnormal fetal surveillance. Mode of delivery – Planned vaginal delivery. Induction of labor is done as timing of delivery is important.

48. INDICATIONS OF CESARIAN SECTION Obstetrical Reasons : Fetal distress, Contracted pelvis or estimated fetal wt is > 4 kg in a diabetic patients. Presence of vasculopathy (proliferative retinopathy) Obstetric complications like Pre- eclampsia

49. INTRAPARTUM INSULIN REQUIREMENT Labor : Insulin requirement decreased GDM on insulin : Plasma glucose monitoring during labor by a glucometer Day of induction of labor : Morning dose withheld + 2 hrly monitoring plasma glucose IV infusion with NS + Regular insulin : According to blood glucose level

50. BLOOD GLUCOSE LEVEL AMOUNT O INSULIN ADDED IN 500 ML RL/NS BLOOD GLUCOSE 90 – 120 mg/dl 100 ml/hr (16 drops/min) 120 - 140 mg/dl 4U 100 ml/hr (16 drops/min) 140 – 180 mg/dl 6U 100 ml/hr (16 drops/min) >180 mg/dl 8U 100 ml/hr (16 drops/min)

51. Post delivery Follow-up of GDM Patients(National guidelines) Immediate Postpartum care : at increase risk of developing type-2 DM in future. After delivery - Maternal Glucose is Normal ( Usually) 3rd Day of delivery - fasting plasma glucose + 2 hour PPBS >48 hours - Discharged ( unlike normal PNC cases) 6 weeks post partum : 75g GTT - glycaemic status

52. Cutoff For normal blood glucose level Fasting glucose ≥ 126mg/dl 75g OGTT 2 hour plasma glucose Normal < 140 mg/dl Impaired glucose tolereance 140-200 mg/dl Diabetes ≥ 200 mg/dl As per ACOG guidelines, 75g GTT is due between 4 - 12 weeks

53. Contraceptive Advices Barrier method of contractive is ideal for sparing of hormones. Low dose combined oral pills - containing 3rd generation progesterone are effective and have a minimal effect on carbohydrates metabolism IUCD(Both Cu and LNG-IUD ) may be used both are highly effective and safe in women with vasculopathy Sterilization is considered when family is completed.

54. Pregestational Diabetes Female with Diabetes mellitus  conceives  Hyperglycaemia (from day 1 of pregnancy) Fetotoxic  Congenital malformation in foetus Diagnosis of pregestational / overt diabetes FBS ≥ 126 mg/dl 2 hour PPBS (or) RBS ≥ 200 mg/dl HbA1C ≥ 6.5

55. -When a k/c/o diabetes female conceives, risk of structural anomalies can be predicted by risk assessment. -No risk of genetic/ chromosomal anomalous( Down's syndrome or any aneuploidy) HbA1C Levels Risks < 6.5 No risk of congenital malformations 6.5 3% risk 9 15 – 20% risk

56. RISK REDUCTION Tight glucose control : HbA1C < 6.5 FBS = 70 : 100 mg/dl 2 hr PPBS : < 120 mg/dl Drug of choice : Insulin PLANNED PREGNANCY UNPLANNED PREGNANCY STARTED PRE-CONCEPTIONALLY STARTED WHEN PREGNANCY IS DIAGNOSED

57. Folic acid supplementation : 400 mcg/day (same as non diabetic) Best investigation to detect congenital malformation in foetus of diabetic mother- Anomaly scan (at 18-20 wks  detects structural abnormalities) USG at 11-13 wks  for neural tube defects assessment

58. All pregnant females with overt diabetes should undergo foetal ECHO at 22-24 wks (M/C congenital malformations involve CVS) Pregnant diabetic female has high chances of IUD & Still birth  To reduce risk  Foetal monitoring starting from 32 wks of pregnancy

59. MANAGEMENT OF PGDM WITH INSULIN Short or rapid acting insulin (e.g. Lispro & Aspart ) are administered before meals to reduce rise in glucose with food intake. Long acting or basal insulins (NPH, Glargine Detemir) are given to maintain euglycemia between meals and in the fasting state. Usually NPH is used before breakfast with a rapid acting insulin & prior to the evening meal or at bed time.

60. OBSTETRIC MANAGEMENT No complications, well controlled foetal well being good 39-40 wks [expectant management before 40 wks is not recommended] Blood Sugar not well controlled & other complications  Deliver by 37 wks. If foetal compromise/ Antenatal complications  Deliver early  Before 34 wks steroid is given, higher doses of insulin is added to adjust the blood sugar level.

61. MANAGEMENT DURING LABOR In Planed delivery, at morning, usual bed time dose of insulin is given. Morning dose is withheld or reduced if required regular insulin (short acting) should be used instead of long acting insulin, because insulin requirements typically drops after delivery. In labour woman should be hydrated adequately. Normal saline intravenous drip is started. CBG is checked hourly using a bedside glucometer.

62. On the onset of labor after induction or spontaneous labour if glucose level comes down below 70 mg%. It is changed to 5% . Dextrose with 100- 150 ml/hr. The goal is to maintain glucose level between 70- 100 mg% above which regular insulin is given by iv infusion at a rate of 1.25 units/hour.

63. CONGENITAL MALFORMATION IN FETUS Incidence is more in overt diabetic mother- 25% M/C system involved CVS > CNS M/C anomaly overall. VSD > NTD (Neural tube defect) Most specific anomaly overall- Sacral agenesis / Caudal regression syndrome Most specific CVS anomaly – TGA (Transposition of Great vessels) M/C CVS findings – Hypertrophic cardiomyopathy

64. MACROSOMIA Defined as fetal weight more than 90th percentile for that gestational age or estimated Fetal weight equal to or more than 4000gm. Chances of macrosomia increases if mean maternal blood glucose levels > 130 mg/dl RISK FACTORS Diabetic mother Male fetuses Obese mothers Post-term pregnancy

65. Best USG parameter to see macrosomia- Abdominal circumference of foetus ( > 35 cm) In foetus  macrosomia if oxygen requirement is not fulfilled  Episodes of hypoxia Stillbirth/ Sudden IUD occurs. (Maximum in 3 rd trimester) Shoulder dystocia occurs.

66. IN MOTHER Protracted or arrested labor Assisted vaginal birth Caesarean section Genital tract lacerations PPH Uterine rupture

67. SHOULDER DYSTOCIA Diagnosed when delay in the delivery of shoulder ( > 1 min) after the delivery of head. Obstetric emergency. “Turtle Sign” – Head of baby recedes back towards perineum MANEUVER FOR SHOULDER DYSTOCIA McRobert’s Maneuver Rubin-I Maneuver Rubin-II Maneuver Wood’s Corkscrew Maneuver

68. Most common foetal complication of shoulder dystocia – Brachial plexus, injury leading to Erb’s Palsy. Most common maternal complication of shoulder dystocia - PPH

69. NEONATAL COMPLICATIONS Increased neonatal mortality due to prematurity & delay of lung maturity. Hypoglycaemia (Blood sugar < 40 mg/dl ): foetus is hypoglycaemic + increased insulin -As soon as baby is born -Sources of hyperglycaemia -Increased insulin leads to hypoglycaemia

70. 3. Hyperbilirubinemia Due to Hypoxia Increased erythropoiesis Increased foetal RBC with short life span Increased bilirubin

71. Polycythaemia (Due to increased erythropoiesis ) : Hyperbilirubinemia + Polycythaemia  Hyperviscocity syndrome Hypokalaemia , Hypocalcaemia, Hypomagnesemia occurs due to prematurity. Usually Anaemia is not seen in baby of diabetic mother.

72. LONG TERM RISKS OF GDM TO THE MOTHER Increased Dyslipidaemia Increased hypertension Increased abdominal obesity Increased risk of metabolic syndrome Increased recurrence of gestational diabetes Increased risk of development of type-II DM

73. Thank You