3. AGENDA
Gestational diabetes mellitus(GDM).
Hyperglycemia and Adverse Pregnancy Outcomes
(HAPO) study.
Shared Care of Diabetes with pregnancy.
Pre-Conception Counseling to Women with
Diabetes.
Diabetes in pregnancy: Future risks for mothers
and offspring.
The practice of fasting among pregnant women
with diabetes during Ramadan.
Oral Ant Diabetic Drugs (ADD) in Pregnancy and
Lactation. Fetal and neonatal Safety .
4. Challenges in gestational diabetes
mellitus
Gestational diabetes (GDM) is common and
affects approximately 1 in 25 pregnancies
globally.
Undiagnosed or inadequately treated GDM can
lead to larger than normal babies and higher
rates of problems with the pregnancy and
increased infant deaths and fetal abnormalities.
Women with GDM are at increased risk of
developing diabetes and the offspring of GDM
pregnancies are at increased risk of obesity and
type 2 diabetes in later life.
Colagiuri Abst.108
5. Cytokine Profile and Markers
Oxidative Stress in Women with GDM
Women with GDM have more risk to have
increased CVD markers, expressed at higher levels
ofTNF-α, LPO and lower levels of catalase and
SOD.
This unfavorable cytokine profile and increased
oxidative stress, which remains in the postpartum
period, high serum levels of CRP, interleukin 6,
HOMA-IR and LDL-C i.e a permanent state of
metabolic dysfunction would make them more
likely to develop DM and CVD in the future.
(B. Edalat etal., -Diosdado etal.,Abstract: P-1365)
7. Predictor markers for GDM
Early pregnancy low βhCG is associated with the
GDM and, secretory defect and insulin resistance.(R.
Helal etal., Abstract: D-0655)
Serum Apo C-III(one of apolipoprotein synthesized
in the liver and is markedly secreted in insulin-
resistant state) levels in GCT positive subjects and
patients with GDM found to be higher than in
GCT negative subjects and non-pregnant women.
(T. Hiyoshi etal. Abstract: D-0656)
8. Screening for GDM
A woman may NOT need screening for GDM if she meets ALL of the
following criteria:
less than 25 years old
not a member of a racial or ethnic group
with a high prevalence of diabetes (eg,
Hispanic, African, Native American, South
or East Asian, or Pacific Islands ancestry)
a body mass index (BMI) 25
no history of abnormal glucose tolerance
no previous history of adverse pregnancy
outcomes usually associated with GDM
no known diabetes in first-degree relative
9. Hyperglycemia & Adverse Pregnancy
Outcome (HAPO) Study
The objective of this study was to clarify
associations of levels of maternal glucose lower
than those diagnostic of diabetes with
perinatal outcome.
This was accomplished by performing a 75-g
oral glucose tolerance test (OGTT) on a
heterogeneous, multinational, multicultural,
ethnically diverse cohort of >25,000 women in
the third trimester of gestation.
(B. Metzger,Abstract 173)
10. HAPO study, revealed three
principal findings
1-Strong associations exist between maternal glucose levels
(fasting, 1-hour and 2-hour) during pregnancy and pre-
eclampsia.
2-There are strong and continuous associations between
maternal plasma glucose levels, increased birth weight
and cord-blood serum C-peptide levels with no apparent
thresholds.
3-Glucose levels during pregnancy are associated with
primary caesarean section, premature delivery, birth
injury (such as shoulder dystocia), intensive neonatal care,
and jaundice.
11. In response to this and other studies, the
InternationalAssociation of Diabetes and
Pregnancy Study Groups (IADPSG) has
formulated new guidelines for screening and
diagnosis of diabetes in pregnancy.
Key components of the IADPSG guidelines include the
recommendation to screen high-risk women at the
first encounter for pre-gestational diabetes, to screen
universally at 24–28 weeks’ gestation, and to screen
with use of the 75-g oral glucose tolerance test
interpreting abnormal fasting, 1-h, and 2-h plasma
glucose concentrations as individually sufficient for the
diagnosis of gestational diabetes.
12. Opponents to the IADPSG
recommendations will likely be those
who favor risk-based screening in
addition to those who endorse the 50-g
glucose challenge test followed by the
100-g oral glucose tolerance test as a
more cost-effective, familiar, and
possibly, well-validated screening tool.
13. American College of Obestetric and
Gynaecology Committee on Obstetric Practice
Recommendations
Number 504, September 2011
All pregnant women should be screened for GDM,
whether by patient history, clinical risk factors, or a
50-g, 1-hour loading test to determine blood
glucose levels.
The diagnosis of GDM can be made based on the
result of the 100-g, 3-hour oral glucose tolerance
test, for which there is evidence that treatment
improves outcome. A positive diagnosis requires
that two or more thresholds be met or exceeded.
14. Diagnosis of GDM based on the one-step
screening and diagnosis test outlined in
the International Association of Diabetes
in Pregnancy Study Group guidelines is
not recommended at this time because
there is no evidence that diagnosis using
these criteria leads to clinically significant
improvements in maternal or newborn
outcomes and it would lead to a
significant increase in health care costs.
15. Shared care in management of
diabetes with pregnancy
The effective management of pregnancies
complicated by diabetes is a shared
responsibility—an equal partnership between
health care professionals and a responsible
woman, so as pregnancy outcomes for
women with diabetes would be similar to the
outcomes for women without diabetes.
Unfortunately this has not been realized with
the risk of congenital malformations,
stillbirths, and neonatal death remaining as
high as 3–10 times that of the background
population .
16. Proper approach to pregnancy
management in diabetes can be
successfully implemented even in
low-to-middle income countries.
(X.Yang, Abstract: P-1724)
17. Pre-Conception Counseling to
Women with Diabetes
Preconception counseling was associated with
better glycemic control 3 months preconception.
Rates of preconception counseling in women
with diabetes remain low despite the recognized
importance of adequate preparation for
pregnancy.(27%-37%).
A high proportion of pregnancies in women with
diabetes, however, are known to be unplanned
and this is a challenge to achieving high rates of
attendance for preconception counseling.
Diabetes Care March 2010 vol. 33 no. 3 586-588
18.
19. PRECONCEPTION CARE PROGRAM
To prevent excess spontaneous abortions and
congenital malformations in infants of diabetic
mothers, diabetes care and education must begin
before conception.This is best accomplished by a
multidisciplinary team that includes a diabetologist,
internist, or family practice physician skilled in
diabetes management; an obstetrician familiar with
the management of high-risk pregnancies; diabetes
educators, including a nurse, dietitian, and social
worker; and other specialists, as deemed necessary.
(C. Rasmussen, Abstract: P-1738)
20. The model of diabetes preconception and early
pregnancy health care is interactive. It includes
four main elements:
1) patient education about the interaction of
diabetes, pregnancy, and family planning;
2) education in diabetes self-management skills;
3) physician-directed medical care and laboratory
testing;
4) counseling by a mental health professional when
indicated to reduce stress and improve
adherence to the diabetes treatment plan.
All four elements are important for patients to
achieve the level of sustained glycemic control
necessary to prevent excess congenital
malformations and spontaneous abortions.
21. Diabetes in pregnancy: Future
risks for mothers and offspring
1 - Evaluated evidence that maternal
diabetes plays a role in offspring
diabetes
2 - Consider potential mechanisms
to explain the trans-generational
risk.
3 - Consider directions to reduce the
risk to mother and foetus.
22. Maternal contributions to subsequent metabolic
disease in her offspring (P. Gluckman, Abstract: 389)
These relationships operate through
epigenetic processes.They may also
operate over more than one generation
through direct and indirect forms of non-
genomic (epigenetic) inheritance.
A variety of maternal circumstances can
affect the offspring's metabolic
phenotype including variation in
maternal; nutrition across the range of
intakes both in early and late pregnancy.
23. Evolved constraints on the transduction of
environmental information from mother to
fetus in humans resulting first born children
to be at greater risk of obesity because of
greater constraint on their intrauterine
development.
Maternal obesity, gestational diabetes and
premature weaning also have long term
effects of disease risk through altering
developmental trajectories.
24. The practice of fasting among pregnant women
with diabetes during Ramadan
An improvement in overall blood sugar control
was noted in the fasting group with the HbA1c
dropping more in fasting than in the non-fasting
group.
Weight gain more in non-fasting than in the
fasting pregnant ones
.
Patients with type 2 diabetes or gestational
diabetes may safely fast in pregnancy if
provided with adequate medical support.
Mahmood etal. , Abstract: P-1546).
25. What does the evidence say about the fetal
and neonatal safety about the use
of Oral Ant Diabetic Drugs (ADD) in
Pregnancy and Lactation (Y. Masood etal.,
Abstract: D-0760)
Corniche hospital experience with Metformin
in pregnancy
(Salih etal., Abstract: P-1542)
26. Results & Conclusions:
• Glyburide and metformin are not teratogenic in
humans when used in clinically recommended doses.
• Glyburide may be used for treatment of gestational
diabetes in some women.
• Metformin may be used safely for ovulation in
women with PCOS.
• Metformin reduces the development of GDM, was
not teratogenic and did not affect birth length,
weight, growth motor or social development in
children in first 18 months of life
•
27. Tolbutamide, Chloropropamide cross
into the breast milk
• None of the glyburides pass in the
breast milk samples.
• METFORMIN: Excreted in the breast
milk at very low levels
• No differences in weight, height or
motor-social development of the
newborn or in the infants up to 3-6
months of age are reported.
28. Conclusions:
•There is evidence that certain oral hypoglycemic
drugs might be safe in pregnancy, or at least, are
significantly less dangerous to the developing
fetus than poorly controlled diabetes.
• Metformin, Glyburide and Glypizide are compatible
with breast feeding
• If the patient needs intervention but refuses insulin
therapy, Patient must be made aware of potential
or probable risks in Pregnancy of oral
Hypoglycemic drugs
