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GESTATIONAL DM

Gestational DM

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GESTATIONAL DM

  1. 1. GESTATIONAL DIABETES (GD) Prof. Aboubakr Elnashar Benha ubiversity Hospital, Egypt elnashar53@hotmail.com ABOUBAKR ELNASHAR CONTENTS 1. DEFINITION 2. INCIDENCE 3. CLINICAL FEATURES 4. IMPORTANCE 5. SCREENING AND DIAGNOSIS 6. MANAGEMENT 1. MEDICAL 2. OBSTETRIC 1. ANTENATAL 2. INTRAPARTUM 3. POSTPARTUM ABOUBAKR ELNASHAR
  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

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