Gestational DM

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. 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. 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. 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. ▪
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. 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. 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. ▪
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. 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. ▪
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. 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. ▪
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. 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