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Gestational DM

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  2. 2. PHYSIOLOGICAL CHANGES 1. Insulin resistance & relative glucose intolerance. ▪ Increasing after the first trimester ▪ Due to diabetogenic(anti-insulin)hormones secreted by placenta ▪ human placental lactogen ▪ Cortisol ▪ Glucagon ▪ oestrogen ▪ progesterone ▪ Insulin requirements increase throughout, maximal at term. ABOUBAKR ELNASHAR 2. The renal tubular threshold for glucose falls: ▪ Glycosuria ▪ Glycosuria is not a reliable diagnostic tool for impaired glucose tolerance or diabetes in pregnancy. 3. Starvation results in early breakdown of triglyceride: liberation of fatty acids&ketone bodies: increased risk of ketoacidosis. ▪ This is most marked in the third trimester. ABOUBAKR ELNASHAR
  3. 3. ABOUBAKR ELNASHAR 1. DEFINITION ▪ CHO intolerance of variable severity with onset or first recognition during the present pregnancy (National Diabetes Data Group,1985) ▪ Thus, it includes women with pre-existing but previously unrecognized diabetes (20–30%). ABOUBAKR ELNASHAR
  4. 4. 2. INCIDENCE ▪ Hugely variable ▪ Depending on ▪ Definition ▪ Ethnicity ▪ Population under study. ▪ Using the definition for IGT: 3%–6%. ▪ Using the new diagnostic criteria by International Association of the Diabetes&Pregnancy Study Groups (IADPSG): 18%, but varied from 9% to 26% in different centers. ABOUBAKR ELNASHAR 3. CLINICAL FEATURES ▪ Usually asymptomatic ▪ Develops in the second or third trimester ▪ Induced by ▪ Maternal changes in CHO metabolism and ▪ Decreased insulin sensitivity. ▪ Diagnosed by Routine biochemical screening ▪ Suspected ▪ In: Macrosomic fetus, polyhydramnios, persistent heavy glycosuria or recurrent infections ▪ Retrospectively: (with random plasma glucose or HbA1C) following an IUFD or birth of a severely macrosomic infant. ABOUBAKR ELNASHAR
  5. 5. ▪ Risk factors for gestational diabetes 1. Previous GDM 2. Family history of diabetes 3. Previous large-for-gestational-age infants 4. Obesity 5. Older age at pregnancy 6. Family origin with a high prevalence of diabetes ▪ South Asian, black Caribbean, and Middle Eastern. ABOUBAKR ELNASHAR ▪ Associated with increased 1. Perinatal morbidity &mortality ▪ in the same way, but to a much lesser degree, than pre-existing diabetes 2. Macrosomia 3. PET. ▪ No increase in the congenital abnormality rate, except in those women with unrecognized diabetes pre- dating the pregnancy & hyperglycaemia in the first trimester. ABOUBAKR ELNASHAR
  6. 6. 4. IMPORTANCE OF GDM 1. Women identified as having GDM have a greatly increased risk (40%–60%) of developing type 2 diabetes within 10–15 ys. ▪ Modification of diet & lifestyle with the correction or avoidance of obesity may prevent or delay the development of diabetes later in life. ▪ Even if prevention is not possible, earlier diagnosis resulting from careful follow up ABOUBAKR ELNASHAR 2. A small proportion of women identified as having GDM will in fact have had diabetes pre-dating the pregnancy. They are, therefore, at risk from all the features associated with pre-existing diabetes in pregnancy, including in the case of type 1 diabetes, ketoacidosis. 3. Women with GDM have a higher incidence of macrosomia and adverse pregnancy outcome than control populations without GDM. ABOUBAKR ELNASHAR
  7. 7. 5. SCREENING AND DIAGNOSIS ▪ The Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) ▪ International Association of Diabetes and Pregnancy Study Groups (IADPSG) ▪ The IADPSG criteria use one or more of the following values from a 75-g OGTT for the diagnosis of GDM: ▪ Fasting ≥5.1 mmol/L (92 mg/dL) ▪ 1 hour ≥10.0 mmol/L (180 mg/dL) ▪ 2 hours ≥8.5 mmol/L (153 mg/dL) ▪ Using these thresholds, there are strong (1.5-fold significant increased risk) associations with PET and shoulder dystocia and birth injury. ▪ WHO recommended using the IADPSG criteria ABOUBAKR ELNASHAR ▪ NICE advocates screening only the following groups of women with an OGTT at 24–28 w. ▪ Family history of diabetes in first-degree relative ▪ Previous macrosomic baby (>4.5 kg) ▪ Obesity (body mass index [BMI] >30 kg/m 2 ) ▪ Family origin with high prevalence of diabetes (South Asian, Caribbean and Middle Eastern) ▪ The NICE diagnostic criteria for GDM are ▪ Fasting serum glucose ≥5.6 mmol/L(100mg/dl) or ▪ 2-hour serum glucose ≥7.8 mmol/L(140mg/dl). ABOUBAKR ELNASHAR
  8. 8. ▪ Women with previous GDM should be offered ▪ Self-monitoring of blood glucose or be ▪ Screened with an OGTT at ▪ 16–18 w and again at ▪ 28 w if this is negative. ▪ NICE ▪ does not recommend ▪ screening with random blood glucose, fasting blood glucose, urinalysis or glucose challenge tests. ▪ It does however recommend measuring HbA1c levels in all women with GDM at the time of diagnosis to identify those who may have pre-existing type 2 diabetes. ABOUBAKR ELNASHAR 6. MANAGEMENT Medical Management 1. Lifestyle advice 1. Dietary modification 1. Reduced fat, increased fibre. 2. CHO with a low glycaemic index (resulting in slower more even release of glucose) (e.g., bran). 3. BMI >27: calorie restriction to 25 kcal/kg/d which is not thought to increase the risk of ketonuria. 4. Avoid large quantities of high-calorie carbonated drinks, fresh fruit juice or high-calorie snack foods 2. Regular exercise: 30 minutes of moderate exercise daily. ABOUBAKR ELNASHAR
  9. 9. 2. HBGM ▪ an integral part of management since it allows the woman immediate feedback. 3. Hypoglycaemic therapy. 1. Persistent postprandial hyperglycaemia (>7.8 mmol/L (140mg/dl) 1 hour post-meal) or 2. Fasting hyperglycaemia (>5.3 mmol/L) (95mg/dl) despite compliance with diet & lifestyle changes for 2 ws ▪ This should be in addition to, not instead of, dietary treatment. ABOUBAKR ELNASHAR ▪ NICE support metformin&glibenclamide (glyburide) to treat GDM. ▪ Metformin ▪ No difference in perinatal outcomes in women treated initially with insulin or metformin. ▪ 46% of women in the metformin group required the addition of insulin to achieve glycaemic targets. ▪ Glibenclamide ▪ does not cross the placenta, safe & effective ▪ Lower failure rate in terms of percentage of women needing insulin than metformin ▪ Metformin is preferred in overweight women. ▪ It is offered to women ▪ cannot tolerate metformin or ▪ metformin is insufficient & decline insulin. ABOUBAKR ELNASHAR
  10. 10. ▪ Insulin ▪ Rapid -acting insulin analogues as with pre-existing diabetes, although it may only be needed before some meals. ▪ In severe cases, where there is F hyperglycaemia, intermediate-acting insulin in addition may be required at night. ▪ A four-times-daily basal bolus insulin regime, with adjustment according to postprandial rather than pre-meal glucose readings: improved ▪ Glycaemic control ▪ Outcomes compared to two-times-daily mixed insulin & adjustment based on pre-meal glucose values. ABOUBAKR ELNASHAR Obstetric Management 1. Antenatal 1. Regular checks: blood pressure & urinalysis especially towards term {GDM is associated with increased risk of PET} 2. Regular US: for f growth aid in timing& mode of delivery 3. Elective birth ▪ At 40 + 6 w or sooner if there are maternal or f complications ▪ By induction of labour or elective CS (NICE,2015) ▪ Diabetes is not a contraindication to vaginal birth after CS ABOUBAKR ELNASHAR
  11. 11. 2. Intrapartum ▪ Those on small doses (<20 U/day) of insulin: manage without insulin during delivery {women do not eat much during labour}. ▪ Those on larger doses of insulin: managed as women with pre- existing diabetes with I.V. dextrose& insulin sliding scale. ▪ Intrapartum target blood glucose: 4–7 mmol/L (72-126mf/dl) are the same as preexisting diabetes. ▪ Following delivery of placenta ▪ Insulin infusion should be discontinued. ▪ All oral hypoglycaemic drugs should also be stopped. ▪ Blood glucose should be checked prior to transfer to community care to ensure normoglycaemia. ABOUBAKR ELNASHAR 3. Postpartum management ▪ FBG at 6–13 w post-natal & then annually to screen for diabetes (NICE, 2015) ▪ If FBG < 6 mmol/l (108mg/dl): continue annual monitoring ▪ If FBG 6–6.9 mmol/l *(108-125mg/dl): high risk of type 2 diabetes ▪ If FBG ≥ 7.0 mmol/l (125mg/dl): likely type 2 DM ▪ Other countries use other screening postpartum such as an OGTT at 6 w postnatal. ABOUBAKR ELNASHAR
  12. 12. ▪ Counseling ▪ Risks of future diabetes ▪ Awareness of the symptoms of hyperglycaemia. ▪ Lifestyle advice concerning exercise & diet, particularly reduced fat intake. ▪ Obese: to lose weight postpartum ▪ All should be advised to avoid obesity. ABOUBAKR ELNASHAR 7. RECURRENCE ▪ GDM usually recurs in subsequent pregnancies. ▪ If a woman has lost a lot of wt between pregnancies & modified her diet substantially, she may not develop GDM. ▪ Women should be advised of the risk of recurrent GDM & future type 2 diabetes. ▪ Adequate contraception & pre-pregnancy counseling. ▪ Women with previous GDM should have F blood glucose or HbA1C checked prior to conception to detect diabetes that may have developed since the last pregnancy. ABOUBAKR ELNASHAR
  13. 13. CONCLUSION ▪ Prevalence depends on ethnicity& criteria used for diagnosis. ▪ The importance of diagnosing GDM relates to the high risk of future diabetes, the detection of pre-existing diabetes and a risk of macrosomia and adverse pregnancy outcome. ▪ The association between maternal hyperglycaemia and adverse outcomes is linear with no threshold. ▪ Treatment of GDM reduces b wt & adverse perinatal outcomes. ▪ Management: diet and exercise in the first instance followed by oral hypoglycaemic agents and then insulin in resistant cases. ▪ Pregnancy and the puerperium provide a unique opportunity for education regarding lifestyle and dietary changes. ABOUBAKR ELNASHAR