2. Gestational Diabetes
Could Be Prevented ?
Prof.Lobna Farag Eltoony
Head Of internal medicine department
Head of Diabetes and Endocrine Unit
Assiut University

3. Gestational Diabetes
One of the most challenging aspects of
diabetes practice
Seemingly easy: Practically difficult
Needs a lot of commitment on part of
doctor, patient and family
Success can be achieved if we try
together

4. Introduction
Diabetes mellitus, whether gestational or
pregestational, represents one of the most
challenging medical complications
encountered in pregnancy.
A comprehensive and multidisciplinary
approach is required to improve maternal and
neonatal outcomes.

5. Diabetes in pregnancy
Pre-existing diabetes Gestational diabetes
Pre-existing diabetes
IDDM
(Type1)
NIDDM
(Type2) True GDM

7. Growth Abnormalities(1)
Two Extremes Of Growth Abn:

10. Diabetes in Pregnancy:
Avoiding Complications
• Advances in diagnosis and treatment have dramatically
reduced morbidity and mortality in both mothers and
infants1,2
Preconception care
• Renal impairment, cardiac disease, neuropathy3
Careful evaluations
at each visit
• 1st trimester through 1st year postpartum
• Examine active lesions more frequently1
Regular
ophthalmologic exams
• Target: systolic BP 110-129 mmHg; diastolic BP 65-79
mmHg
• Lifestyle changes, behavior therapy, and pregnancy-safe
medications (ACE inhibitors and ARBs contraindicated in
pregnancy)3
Hypertension
management
1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Jovanovic L, et al. Diabetes Care.
2011;34(1):53-54.
3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. ADA. Diabetes Care.
2013;36(suppl 1):S11-S66.

12. Insulin Use During Pregnancy
Patient Education
•Insulin administration, dietary modifications in response to self-monitoring of blood glucose (SMBG), hypoglycemia
awareness and management1
Basal Insulin
•Intermediate- or long-acting insulin administered by injection, or
•Rapid-acting insulin administered by insulin pump2,3
Postprandial Hyperglycemia
•Recommended approach: rapid-acting insulin analogues2
•Alternative approach: regular insulin to control postprandial glucose spikes; must be administered 60-90 minutes prior
to meals (considered less effective than rapid-acting insulin and may increase hypoglycemia risk)3
Insulin Options
•Insulin NPH: safe intermediate alternative (category B)2
•Insulin detemir: safe long-acting alternative (category B)2,3
•Lispro and aspart: safe rapid-acting insulin analogues (category B)2,3
•Insulin glargine: frequently prescribed in pregnancy; however, safety in pregnancy has not been definitively established
(category C)2,3
1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53.
3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

13. Insulin Delivery Throughout Pregnancy
Calculating Daily Insulin Dose for Pregnancy
With Preexisting Diabetes
Gestational
week
4–12
12–24
24–38
38–42
0.7 U
0.8 U
0.9 U
1.0 U
Insulin dose
Multiplied by
current
pregnant
weight in kg
Jovanovic L. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY:
Marcel Dekker Inc; 2002:139-151

15. Diabetes and embryogenesis
Early fetal loss due to
apoptosis ofblastocyst,
modulated by regulatory
gene Bax, which is
stimulated by high BG
Malformation rate 3X
higher [4-10%]
High BG reduces total
cell mass and number of
blastocysts, esp in inner
cell layer
Cardiac 4x
Anencephaly 5x
Spina bifida 3x
Caudal regression syn 212x
Arthrogryposis 28x
Cleft lip/palate 1.5x
Ureteric duplication 23x
Renal agenesis 5x
Pseudohermaphroditism 11x
Anorectal atresia 4x

16. Gestational diabetes
Definition
• Glucose intolerance with onset or first
recognition during pregnancy
• Characterized by β-cell function that is
unable to meet the body’s insulin
needs
ADA 2015

18. Maternal hyperglycemia
Fetal hyperglycemia
Fetal hyperinsulinemia
Pederson
Hypothesis
(1952)
Macrosomia,organomegaly, polycythaemia,
hypoglycemia, RDS
Pathogenesis of Gestational diabetes

19. Problems with the Current
Diagnostic Criteria for GDM

21. NO CONSENSUS ON GDM
SCREENING
Who ? Why? When? How?

22. SELECTIVE VS UNIVERSAL
SCREENING
American Diabetes Association (ADA) 2015
recommends screening for selective (high risk)
population. But compared to selective screening,
universal screening for GDM detects more cases
and improves maternal and neonatal prognosis
[Cosson EASD 2004] , hence universal screening for
GDM is essential.

23. Risk factors for GDM
High risk
• Obesity
• Diabetes in 1st degree
relative
• Previous history of GDM
or glucose intolerance
• Previous infant with
macrosomia > 3.5 kg
• High risk ethnic group;
South Asian, East Asian,
Indigenous American or
Australian, Hispanic
• PCOS
Low risk
• Age less than 25 years
• No previous poor
pregnancy outcomes
• No diabetes in 1st degree
relatives
• Normal prepregnancy
weight and weight gain
during pregnancy
• No history of abnormal
glucose tolerance
Perkins, Dunn, Jagastia, 2007

24. Why diagnose and treat GDM?
• Short term risks for the mother
– Development of gestational hypertension, and preeclampsia
– Operative delivery - related to macrosomia
– Polyhydramnios
– Premature labour
• Long term risks for the mother
– Development of type 2 diabetes (30-60% depending on
population)
– Development of cardiovascular disease
CDA, 2013
Metzger, Buchanan, et al. 2007

25. Why diagnose and treat GDM?
no increase in congenital anomalies
Short term risks for the baby
– Macrosomia
– Neonatal hypoglycemia
– Jaundice
– Preterm birth
– Birth injury
– Hypocalcemia/ hypomagnesimia
– Respiratory distress syndrome
Long term risks for the baby
– Obesity
– Type 2 diabetes

26. Shoulder dystocia and Erb’s palsy

27. The evolution of a diagnostic
controversy
How?
1 hr 50 g OGTT.
2 hr 75 g oral OGTT
3 hr 100 g OGTT

29. Gestational Diabetes Care
In Upper Egypt

30. Objectives
Establish 5 GDM care and control centers in
University hospitals .
The existing government healthcare centers
will be involved and strengthened to perform
GDM screening and care.
Reduction of the incidence of future diabetes
of women that diagnosed with GDM and her
baby .
Training of health care providers.
NGO's women self help groups will be involved
for their effective participation.
Raising the public awareness.

31. Screening and care
Assiut
GDM care and
control center
Al-Fayoum
GDM care center
Beni-Suif
GDM care center
El-Menia
GDM care
center
Sohag-Nagh
Hammady
GDM care center

32. PROJECT ACTIVITIES
The project
combines hospital
based care with
community based
primary care in
order to detect
gestational
diabetes early and
ensure proper
management of the
disease.
Capacity
building
Screenin
g & care
Increase
awarenes
s

34. When to screen
Screening for GDM
• Screening should be done at 24-28 weeks
• Diagnosis based on a 75 gm glucose load
• 2 hr >140 mg/dl
• If woman tests negative, screening at 32 weeks also may be
necessary in presence of high risks
The IDF WINGS expert committee advises using WHO
criteria for the project in view of the logistic simplicity
and lower cost
World Health Organization, 2013

35. Diet
Exercise
Glucose monitoring
Insulin other medications
Management

36. Primary prevention of gestational diabetes for
women who are overweight and obese: a
randomised controlled trial.
CONCLUSIONS: The results indicate that
there may be some benefits of dietary
counseling,, or an exercise program.
However, better-designed studies are
required to generate higher quality
evidence.
Oostdam,N., Van Poppel,M.N.M., Wouters,M.G.A.J., & van,Mechelen W. (2011). Interventions for preventing
gestational diabetes mellitus: A systematic review and meta-analysis. Journal of Women's Health, 20(10),
1551-1563. BMC Pregnancy Childbirth. 2013 Mar 13;13:65. doi: 10.1186/1471-2393-13-65.

37. Dietary Modifications
Decrease carbohydrate content 40%
Frequent small feedings
Small breakfast meals
Bedtime snacks
No > 10 hours overnight fast
NO JUICE
Adequate calorie intake

38. Exercise improved cardiorespiratory fitness
Physical activity reduced risk of GDM
Resistance exercise diminished the need for
insulin therapy in overweight women with
GDM
Exercise

40. Target Blood Glucose Values
for GDM
Glucose level
Fasting - 90-99 mg/dL (5.0–5.5 mmol/L)
1- hr PP - < 140 mg/dL (7.8 mmol/L)
2- hr PP - < 120-127 mg/dL (6.7–7.1 mmol/L)
Fifth International Workshop Conference on Gestational Diabetes

42. Pharmacologic Therapy
( When MNT alone fails ,
insulin has traditionally been instituted )
1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.
3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.
5. Micronase PI. Pifizer. Division of Pifizer, NY, NY, 2010. 6. Diabeta PI. Sanofi-Aventis U.S. Bridgewater, NJ, 2009.
7. Lamis Latif, ,The British Journal of Diabetes & Vascular Disease 13(4) 178–182 © The Author(s) 2013.
Medication Crosses
Placenta
Classification 2 most commonly prescribed oral antihyperglycemic
agents during pregnancy1,2
Metformin Yes Category B1 Metformin and glyburide should not be used in the first
trimester, because its effects, if any, on the embryo are
unknown , may be insufficient to maintain normoglycemia
at all times, particularly during postprandial periods2
Metformin improved insulin sensitivity , Wt. , risk of pre-
eclampsia , operative deliver & treatment satisfaction or
QoL7
Glyburide Minimal
transfer
Some formulations
category B, others
category C1,5,6
 AACE guidelines recommend insulin as the optimal approach1
 Due to efficacy and safety concerns, the ADA does not recommend
oral antihyperglycemic agents for (GDM) or preexisting T2DM3,4

44. Screening and care
GDM is not of itself an indication for cesarean
delivery.
Breast-feeding, as always, should be
encouraged in women with GDM.
Screen women with GDM for persistent
diabetes at 6–12 weeks postpartum, using the
OGTT and non pregnancy diagnostic criteria.
- impaired fasting………….(repeat annually )
- Normal……………………(repeat every 3 years

45. Normal glucose tolerance 5
Impaired glucose tolerance 3
Diabetes mellitus 1
1/9
5/93/9
Normal glucose tolerance Impaired glucose tolerance Diabetes mellitus
Post partum follow up at 6 weeks

48. TARGET GROUP
all pregnant women.
General population.
Health professional providing the service
in different centers from both public and
private sectors in Upper Egypt cities

50. Gestational Diabetes Education and Diabetes Prevention Strategies
•February 2015, 28 (1)
ADA
..
. It is important for health care providers to take a
proactive approach to create awareness in women with
GDM that their own and their child's lifelong risk for
developing type 2 diabetes is increased.
1- Future risk of developing type 2 diabetes after diagnosis of
GDM for themselves and their children
2-Recommended follow-up care with their health care
provider after birth of the child
3-Prevention of type 2 diabetes
Diabetes Prevention Program (DPP) results
Role of breastfeeding
4-Nutrition recommendations for lactation
5-Effect of contraceptive medications on blood glucose

51. Conclusion
Women with a history of GDM as well as
their offspring exposed to maternal
diabetes in utero should be a major area
of focus for preventive medicine .
Preventive measures against Type 2 DM
should start during intrauterine period
and continue throughout life from early
childhood .

52. Conclusion
So, a short term intensive care gives a
long term pay off in the primary
prevention of obesity, IGT and diabetes
in the offspring.
The maternal health and fetal outcome
depends upon the care by the
committed team of diabetologists,
obstetricians and neonatologists.
So , Don’t hesitate and join us in our
GDM project in upper Egpt Extending it
to all Egypt .

53. LOBNA