GDM (1) (1).pptx small presentation for students
- 1. 1 Diabetes Mellitus in Pregnancy Dr. KISHOR KHADKA 2nd Year Resident MDGPEM
- 2. 2 INTRODUCTION • Diabetes mellitus is a metabolic disorder due to decrease in insulin secretion or increase in insulin resistance or both causing abnormalities of carbohydrate, protein and lipid metabolism • Most common medical complication during pregnancy • Major cause of maternal, perinatal morbidity & mortality • Excellent glycemic control-improves perinatal outcome
- 3. 3 INCIDENCE • 1% - 14% (Diabetic Care 2006) • varies acc. to ethnicity, selection criteria and diagnostic test • Asians: 5-8% • DM in pregnancy • GDM- 87.5% • Type I DM-7.5% • Type II DM-5% (NICE 2008) • >50% of GDM patients- develop type 2DM (Obstet Gynecol 2003;101:380-92)
- 4. 4 Classification of diabetes mellitus in pregnancy 1. Gestational diabetes mellitus 2. Pregestational or overt diabetes mellitus
- 5. 5 Pregestational diabetes mellitus • it is pregnancy in a known or overt diabetic • Either type 1(insulin dependent diabetes mellitus) or type 2(non insulin dependent diabetes mellitus) • Type 1 ocurs in a younger age group and end organ complications are more leading to ketosis and have increased maternal and obstetric risks • Type 2 is rare during pregnancy and maybe seen in obese or women above 35 years of age
- 6. 6 Diagnosis of overt DM • According to ADA and WHO • Women with random plasma glucose >200mg/dL plus classic signs and symptoms like polyuria, polydipsia and unexplained weight loss • Or those with fasting blood glucose >125 mg/dL • ADA and WHO also consider plasma glucose >200mg/dL 2 hr after 75gm glucose to be diagnostic.
- 7. 7 • IADPSG 2010 recommends • Fasting plasma glucose ≥126 mg/dL • HbA1C ≥ 6.5% • Random plasma glucose ≥200mg/dL
- 8. 8 Gestational diabetes mellitus • Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. WHO 1999;Expert 2000;ACOG 2013 • Generally occurs in the latter half of pregnancy and has no effect on organogenesis/congenital defects • Disappears after delivery and if not could be overt diabetes which had begun with the pregnancy
- 9. 9 Risk factors for GDM • Obesity (>200 lbs or >15% of non pregnant ideal body weight) • Positive family history of diabetes (sibling or parent) • Persistent glycosuria • H/o of diabetes in previous pregnancy • H/o stillbirth or unexplained neonatal death • H/o delivery of large infant (>4 kg) • H/o traumatic delivery with neurological disorder in infants • Polyhydramnios
- 11. 11 Pregnant women can be classified as low, moderate and high risk based on various factor Adapted from the fourth international workshop conference on GDM, 1998 Low risk : blood glucose screening not routinely required in these : • Age < 25 • Member of an ethnic group with low prevalence of GDM • No history of diabetes in first degree relative • No history of abnormal glucose metabolism • Weight normal before pregnancy • Weight normal at birth
- 12. 12 Moderate risk : One or more of the following • Age> 25yr • Member of an ethnic group with high prevalence of GDM • Diabetes in first degree relative • Weight high at birth In these women blood glucose testing be done at 24-28 weeks
- 13. 13 High risk : • Marked obesity • Strong family history of type 2 DM • Previous history of GDM or impaired glucose tolerance or glycosuria or macrosomic baby In these women, glucose testing should be done as soon as possible.
- 14. 14 For Screening there is controversies either it should be universal or selective Universal screening recommended by • IADPSG • WHO • ADA • DIPSI • ACOG Selective screening recommended by • NICE Screen if any of the following is present: BMI> 30 kg/m² Previous macrosomic baby ≥4.5 kg Previous GDM Family history of diabetes (first- degree relative with diabetes) Family origin with a high prevalence of diabetes
- 15. 15 When to screen • IADPSG, ADA, WHO, DIPSI, FIGO recommends screening at 1st visit • ACOG recommends screening at 24-28 WOG
- 16. 16 Screening test • Glucose challenge test(GCT) is used commonly • 50gms of oral glucose is given between 24-28wks irrespective of the time or the meal and blood glucose is determined one hour later • A plasma value of >7.8mmol(140mg/dl) is the cutoff level for diagnostic test • This test can be done during the booking visit in a high risk patient • GCT has a high sensitivity(79%) and specificity(83%) • Screen negative patients should ideally have a subsequent testing at 34wks as repeat screening may become positive as insulin resistance becomes more marked with advancing pregnancy
- 17. 17 Diagnostic test • Oral glucose tolerance test(OGTT) is performed for the diagnosis of gestational diabetes • Maybe done by WHO(world health organization) or NDDG(national diabetes data group) guidelines recommended by american college of obstetricians and gynaecologists • We use 2-hour 75-gram OGTT • After an overnight fast with unrestricted diet for the preceding 3 days, the fasting blood sugar is tested • Then 75gms of oral glucose is given followed by glucose levels at the end of 1 and 2 hour
- 18. 18 Frequency of screening IADPSG WHO DIPSI ACOG NICE 2 times in all 2 times in all 3 times in all Once in low risk Once only in high risk(24- 28weeks) 1st :1st visit 1st :1st visit 1st :1st visit Twice in high risk Twice in those who had history of GDM 2nd :24-28weeks 2nd :24-28weeks 2nd :24-28weeks 3rd :32-34weeks
- 19. 19 Traditional criteria for diagnosis of GDM Criteria Fasting 1 hour 2 hour 3 hour Carpenter and coustan 95 mg/dL 180 mg/dL 155 mg/dL 140 mg/dL NDDG 105 mg/dL 190 mg/dL 165 mg/dL 145 mg/dL
- 20. 20 Diagnosis of GDM according to different criteria approach Glucose load (Gram) Diagnostic criteria Glucose threshold (mg/dl) Abnormal values Fasting 1hr 2hr 3hr 2 step 100 NDDG ACOG 105 190 165 145 2 2 step 100 CC ACOG 95 180 155 140 2 1 step 75 DIPSI 140 1 1 step 75 IADPSG(2010) ADA(2011) WHO(2013) 92 180 153 1 1 step 75 NICE 2015 101 140 1
- 21. 21 Impact of diabetes on pregnancy Fetal effect • Spontaneous abortion • Preterm delivery • Fetal malformation • Altered fetal growth • Unexplained fetal demise • Polyhydramnios Neonatal effect • Respiratory distress syndrome • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Cardiomyopathy • Inheritance of diabetes
- 22. 22 Maternal effect • Preeclampsia • Diabetic nephropathy • Diabetic retinopathy • Diabetic neuropathy • Diabetic ketoacidosis • Infections
- 23. 23 Fetal effect Spontaneous abortion : • 25% elevated risk • Fasting persistently more than 120mg/dL • HbA1c > 12% Preterm delivery : • 26% elevated risk • Overt DM is an undisputed risk
- 24. 24 Malformations: • Overt DM • 11% elevated risk • Accounts almost half of perinatal death in diabetic pregnancies • Cardiac malformation accounts for more than half of anomalies
- 25. 25 Congenital malformation Occurs in case of pregestational diabetes mellitus • HbA1c level in first trimester may help predict risk of occurrence of congenital anomalies • < 7% : no greater risk than nondiabetic • 7-8.5% : 5% risk • > 10% : 22 %risk
- 26. 26 Altered fetal growth : • LGA : Commonly defined as fetal or neonatal weight at or above the 90th centile for gestatonal age • IUGR : Those complicated with preeclampsia or with vasculopathy causing uteroplacental insufficiency.
- 27. 27 Unexplained fetal demise : • 3-4 times elevated risk • These stillbirth are unexplained because common risk factors like obvious placental insufficiency, placental abruption, oligohydramnios, FGR are not identified. • One hypothesis is that hyperglycemia mediated chronic aberration in oxygen and fetal metabolite transport cause lactic acidosis.
- 28. 28 Polyhydramnios : Maternal hyperglycemia fetal hyperglycemia Fetal diuresis Polyhydramnios
- 29. 29 Neonatal effect Respiratory distress syndrome : • Gestational age rather than diabetes causes RDS Hypoglycemia : • Rapid drop in plasma blood glucose attributed to hyperplasia of fetal beta islet cells induced by chronic maternal hyperglycemia. Hyperbilirubinemia and polycythemia : • Hyperglycemia mediated elevation in maternal affinity for oxygen causes fetal hypoxia causing elevated fetal erythropoitein level and red cell production
- 30. 30 Cardiomyopathy : • Right Ventricular hypertrophy, due to insulin excess in fetus • Ventricular septal hypertrophy • Leads to obstructive cardiac failure • Most affected newborn are asymptomatic following birth and hypertrophy usually resolves in the month after delivery.
- 31. 31 Maternal effects Preeclampsia : • 3.7 times elevated risk • More risk with overt DM • With coexistent chronic HTN 12 times increase risk of developing preeclampsia Diabetic neuropathy : • Is uncommon in pregnancy but form of it, diabetic gastropathy can be troublesome during pregnancy. • It causes nausea and vomiting, nutritional problem and difficulty with glucose control • Treatment of hyperemesis gravidarum can be challenging with this condition.
- 32. 32 Diabetic nephropathy : • Approximately 5% of pregnant women with diabetes already have renal involvement. • In general, pregnancy does not worsen diabetic nephropathy those with mild renal impairment but those with moderate to severe renal impairment may have accelerated progression of the disease.
- 33. 33 Diabetic ketoacidosis : • This serious complication develops in approximately 1% of diabetic pregnancy • Of gravidas with DKA less than 1% dies but perinatal mortality rate from a single episode of DKA may reach 35% • DKA may develop due to hyperemesis gravidarum, infections, insulin noncompliance, beta mimetic drug given for tocolysis and corticosteroid given to induce fetal lung maturation.
- 34. 34 Infections : • The rate of many infections are higher in diabetic pregnancies • Commonly include vulvovaginitis, urinary and respiratory tract infection.
- 35. 35 Management
- 36. 36 PRECONCEPTION COUNSELLING • It is a high risk pregnancy, regular follow-ups and compliance • Evaluation of end organ damage like nephropathy-24hr urinary protein, creatinine clearance, BUN, urine c/s • Diabetic nephropathy with fundus examination • Blood pressure and ECG and ECHO • Oral drugs to insulin • Lifestyle changes like wt management, daily exercise, stop smoking and alcohol • Folic acid for 3mths to prevent neural tube defects • Contraindications to pregnancy include coronary artery disease, untreated proliferative retinopathy, serious renal insufficiency or proteinuria
- 37. 37 ANTEPARTUM • Should be registered early and follow up regularly depending on the glycemic control and obstetric complications • In the first visit, evaluate for end organ damage like retinopathy and nephropathy • Pre-existing retinopathy requiring laser therapy needs termination of pregnancy • Screening for nephropathy with an overnight or 24hr urine for albuminuria • If RFT is significantly impaired(creatinine>3.6mg/dl), she has a risk of dialysis in pregnancy, so MTP should be offered
- 38. 38 ANTEPARTUM • Antenatal visits have to be frequent • Admissions maybe required for stabilization of blood sugar, adjustment of the insulin dose and manage complications • Antenatal visits should be every 2 wks until 32-34wks and wkly thereafter • Routine monitoring of blood pressure, wt. gain, fetal movements, proteinuria and fetal growth are made • Pregestational diabetics are managed in the inpatient from 34wks and if there is difficulty in blood sugar control
- 39. 39 Medical nutrition therapy Definition : Carbohydrate controlled meal plan that promotes adequate nutrition, adequate weight gain and normoglycemia with absence of ketosis. Nutrition intervention is the first line therapy 50% of the women will meet target values of glucose control within first 2 weeks of dietary therapy
- 40. 40 No definitive research that identifies a specific optimal calorie in GDM The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intake (DRI). DRI for all pregnant women recommends a minimum of: o175 g carbohydrate/day, o71 g of protein, o28 g of fiber. ADA 2008
- 41. 41 Diabetic diet • Carbohydrate : 55 % • Protein : 20 % • Fat ( <10% saturated fat) : 25% • Given in 6 divided meals ( 3 major and 3 minor meals )
- 42. 42 Exercise • It is an adjunct to diet therapy • 30 minutes of mild to moderate exercise daily helps in improving glycemic control by improving insulin sensitivity. • Light exercise in form of walking especially after a meal helps in reducing post prandial glucose level.
- 43. 43 PHARMACOTHERAPY INSULIN : Recommendations BY FIGO Oral therapy failure One of the risk factors • Diabetes < 20 weeks of gestation • Oral therapy for more than 30 weeks • FBS > 110 mg/dl • 1-hour PPBS > 140 mg/dl • Weight gain > 12 kg
- 44. 44 By ADA 2020 and ACOG 2018 : First line therapy if glycemic control is not achieved after dietary intervention By DIPSI : Fasting blood glucose > 95 mg/dL after 2 weeks of Medical Nutrition Therapy BY NICE 2015 : FBS ≥ 126 mg/dL at diagnosis FBS 110-125 mg/dL and there is macrosomia or polyhydramnios
- 45. 45 Types of insulin Types of insulin Onset of action Peak Duration Short acting Lispro Glulisine Aspart Regular <15 min <15 min < 15 min 30-60 min 30-90 min 30-90 min 30-90 min 2-3 hr 3-4 hr 3-4 hr 3-4 hr 4-6 hr Intermediate acting NPH 1-4 hr 6-10 hr 10-16 hr Long acting Detemir Glargine 1-4 hr 1-4 hr Minimal Minimal Upto 24 hr Upto 24 hr
- 46. 46 INSULIN REGIMEN - Popular regimes use a mixture of short acting(soluble) and medium acting insulin(NPH or lente) -It is given 20-30miutes before the main morning and evening meals -Two-thirds of the total dose may be given in the morning and the remaining one-third of the total dose can be given in the evening -Human insulin if preferred
- 47. 47 Patient on insulin should be taught self administration and should be educated about the symptoms of hypoglycemia like • Palpitation • Sweating • Dizziness • Visual changes • Headache • Hunger
- 48. 48 Oral hypoglycemic agents : Metformin and glyburide Compared to insulin OHA have Lower cost No need for self injection Lower hypoglycemia risk : 1-5 % ( women on insulin have a 70% risk at some point of their pregnancy)
- 49. 49 Metformin : Biguanides ( decrease hepatic gluconeogenesis and glycogenolysis, delays intestinal absorption of glucose and increase insulin sensitivity) • Pregnancy category : B • Treatment with metformin in first trimester was associated with 57% protection effect with an anomaly rate of 1.7% in metformin group and 7.2% in control group. (Gilbert et al. systemic review and meta analysis)
- 50. 50 • Glyburide : Sulphonylureas (Stimulate secretion of insulin and its sensitivity, reduction of hepatic glucose production) • Pregnancy category : B
- 51. 51 Blood glucose monitoring in pregnancy NICE 2020 • If the patient is on diet, OHA and single dose of insulin : 4 times daily blood glucose monitoring is recommended i.e, fasting and 1 hour post meal • If the patient is on multiple daily insulin injections : 7 times daily blood glucose monitoring is recommended i.e, Fasting and after breakfast, before and after lunch, before and after dinner and at 3 am
- 52. 52 Target glucose level during pregnancy TIME BLOOD GLUCOSE LEVEL Fasting 60-95mg/dl Before lunch, dinner, bedtime snack <100mg/dl After meal <120mg/dl 2 to 6 AM >60mg/dl
- 53. 53 Management during different trimesters First trimester • Education to the mother regarding Home monitoring of blood glucose Tight glycemic control Insulin requirement and diet • Evaluation of retinopathy and neuropathy • USG : 12 week nuchal translucency
- 54. 54 Second trimester • Monitoring and management of obstetrics and medical complications • Fetal monitoring Anomaly scan at 18-24 WOG Fetal echo at 20-24 WOG Scan for growth and liquor volume at 26 WOG
- 55. 55 Third trimester • Serial USG estimation for fetal weight • Glycemic control : Insulin requirement plateaus or decrease after 34- 36 weeks • Weekly visit after 32 WOG • Fetal surveillance : To prevent IUFD To safely delay the delivery
- 56. 56 Antepartum fetal surveillance • Daily fetal movement count • NST : twice weekly in controlled IDDM started at 32-34 WOG • Biophysical profile weekly • Doppler scan : For early detection of IUGR in patient with vasculopathy and preeclampsia.
- 57. 57 Timing of delivery ACOG 2007 • GDM on diet : Wait for spontaneous onset of labor till 40 WOG followed by induction. • GDM on Insulin/ OHA : Induction at 38 WOG If EFW > 4.5 KG : Elective LSCS
- 58. 58 Intrapartum management • Usual dose of intermediate-acting insulin at bedtime. • Withhold morning dose of insulin • FBS, S. electrolytes, Urine sugar & ketones • IV infusion of NS to maintain hydration • Blood glucose monitoring 2 hourly in latent phase and hourly in active phase • Blood glucose level should be maintained between 70 – 100 mg/dL
- 59. 59 • Once active labour begins or BS<70 mg/dl, infusion changed from NS to 5% Dextrose at 100-125 ml/hour to achieve a glucose level of approximately 100mg/dl. • Regular insulin is administered by intravenous infusion in U/hour if glucose levels exceed 100mg/dl ACOG 2005
- 60. 60 Low dose insulin infusion for the diabetic women during intrapartum period ACOG 2005 Blood glucose in mg/dL Insulin dosage in U/hr Intravenous fluid 125ml/hr < 100 O 5% dextrose 100-140 1 5% dextrose 141-180 1.5 Normal saline 181-220 2 Normal saline >220 2.5 Normal saline
- 61. 61 Insulin therapy during caesarean section • Usually planned in early morning • Administer night dose of intermediate-acting insulin • Skip morning dose of insulin • Blood sugar monitoring • Start NS • 5% dextrose if blood sugar < 70mg/dl • Insulin infusion if blood sugar >100mg/dl
- 62. 62 Albert regimen for GIK : The rule of 10 • 10% dextrose 500ml+10 unit regular insulin+10 mEq KCL at 100ml/hour • This regimen is for blood glucose level upto 180 mg/dl • CBG must be monitored every 1-2 hour on GIK regimen
- 63. 63 • Blood glucose 120-180mg/dL - use the same regimen • Below 120mg/dl- reduce insulin by 5 units • Below 80 mg/dl- stop infusion and administer IV bolus of 50% dextrose • Above 180mg/dl- add insulin 5 units
- 64. 64 Postpartum management • The insulin dose decreases after delivery and a pregestational diabetic can be commenced on her prepregnancy regime • Breast feeding should be encouraged • GDM women on insulin can stop insulin after delivery • They should be monitored with blood glucose levels for 48 hrs • A 2hr 75gmOGTT is done for GDM women at 6wks post- partum, 1 yr, 3yr • Even if it is normal gestational diabetes tends to recur and have a 30-50% chance for type2 DM by 15-20yrs • They should continue the diet and exercise regimen
- 65. 65 At 6-12 week postpartum 75gm OGTT WHO 2013 Normal Diabetes mellitus Impaired glucose tolerance FBS <110 mg/dL 126mg/dL 110- 125mg/dL 2hr <140 mg/dL 200mg/dL 140-199mg/dL
- 66. 66 Follow up • Normal GTT : Screening every 3 year • Impaired glucose tolerance : screening every year
- 67. 67 References • Williams obstetrics 26th edition • UPTODATE • WHO guidelines • ACOG guidelines • NICE guidelines • ADA, FIGO, IADPSG, DIPSI
- 68. 68 THANK YOU