Whats new in gdm
- 2. OVERVIEW ❖ INTRODUCTION ❖ WHAT IS NEW? ❖ WHAT IS CONTROVERSIAL IN MALAYSIA? ❖ MANAGEMENT ALGORITHM ❖ DO’S ❖ DON’T ❖ TAKE HOME MESSAGE ❖ REFERENCES 2
- 3. INTRODUCTION ❖ WORLDWIDE PREVALENCE – 16% IN PREGNANCY ❖ SIGNIFICANT MATERNAL & FETAL IMPLICATIONS
- 5. PATHOPHYSIOLOGY ❖ < 20 weeks of POG • Anabolic phase • Increase in Insulin sensitivity ❖ > 20 weeks of POG • Catabolic phase • Increase in Insulin resistance
- 7. MECHANISM OF INSULIN RESISTANCE • The pancreas releases 1.5–2.5 times more insulin in order to respond to the resultant increase in insulin resistance.Normal patient meets the demand In GDM : • Post receptor defect. Inadequate insulin release
- 8. MALAYSIA ❖ PREVALENCE OF GDM- 5% ❖ LACK OF STANDARDIZED OF DIAGNOSTIC CRITERIA ❖ SELECTIVE SCREENING RATHER THEN UNIVERSAL SCREENING
- 9. WHAT IS NEW? ❖ DEFINITION ❖ DIAGNOSTIC CRITERIA ❖ EXERCISE IN PREGNANCY ❖ APPROACH TO MANAGEMENT ❖ SAFETY OF OHA? ❖ NEW INSULINS?
- 10. WHAT IS NEW? DEFINITION ❖HYPERGLYCAEMIA FOR THE 1ST TIME IN PREGNANCY – IS NOT ALWAYS GDM ❖DM VS GDM?
- 11. WHAT IS NEW? DEFINITION HYPERGLYCAEMIA IN PREGNANCY : ❖1) TYPE II DM/PREGESTATIONAL Pregestational DM Cut off values Fasting >7mmol/L 2 hours post prandial >11.1mmol/L Random >11.1mmol/L and symptomatic
- 12. ❖ DIET AND LIFESTYLE MODIFICATIONS – EXTREMELY BENEFICIAL ❖ START INSULIN – REDUCE MACROSOMIA, STILLBIRTH AND DYSTOCIA ACHOIS (NEW ENGLAND JOURNAL MED 2005
- 13. IMPORTANCE OF SCREENING BENEFITS: ❖ALLOWS ACTIVE INTERVENTION ❖REDUCED MACROSOMIA/SHOULDER DYSTOCIA/BIRTH TRAUMA RISKS: ❖INCREASED INTERVENTION (EG.IOL) ❖INCREASED MONITORING
- 14. CONCLUSION SO FAR ❖ GDM IS SIGNIFICANT IN SOUTH EAST ASIA! ❖ THE LOWER THE GLYCAEMIC CONTROL – THE BETTER ❖ ACTIVE INTERVENTION – IMPROVES OUTCOMES ❖ SCREENING BASED ON RISK FACTORS – 50% OF PATIENTS WILL BE MISSED
- 15. WHAT IS CONTROVERSIAL IN MALAYSIAN CONTEXT? ❖ UNIVERSAL VS SELECTIVE SCREENING ❖ COST EFFECTIVENESS ❖ RESOURCES
- 17. CUT OFF VALUES IN MALAYSIA? ❖ TILL NEWER GUIDELINES IN THE NEAR FUTURE,MOGTT VALUES : ❖ FASTING - 5.6 MMOL/L ❖ 2 HOURS POST PRANDIAL - 7.8MMOL/L
- 18. Almost everyone except age<25, weight < 27kg/m2 Extremely high risk Eg Obesity, advanced age, bad obstetric outcomes Screen as early as possible (16- 18weeks) Routine screening Screen at 24-28weeks If normal repeat at 28 weeks
- 19. WHAT’S NEW? APPROACH TO MANAGEMENT Active intervention Advice on lifestyle modification Refer dietician as soon possible/ provide leaflets Exercise Blood sugar profile within 2 weeks of diagnosis & intervention Start insulin if failure to achieve desired levels within 2 weeks of lifestyle modification
- 20. VENOUS OR CAPILLARY? ❖ FASTING – CAPILLARY OR VENOUS – SIMILAR ❖ POST PRANDIAL – CAPILLARY > VENOUS
- 21. 4 POINT OR 7 POINT BSP ?? • No evidence that one is superior then another • Best outcomes are combination of pre and post prandial sugars • Post prandial sugars which are deranged will reflect on the babes growth
- 22. Is there any place to monitor glycosylated hemoglobin (HbA1c) in pregnant women with gestational diabetes? Especially in relation to predicting fetal morbidity such as macrosomia/ shoulder dystocia? The NICE guideline on diabetes in pregnancy (National Collaborating Centre) recommends that HbA1c should not be used routinely for assessing glycaemic control in the second and third trimesters of pregnancy. “Do not use routine measurement of HbA1c for management”
- 23. TREATMENT 1) LIFESTYLE MODIFICATIONS ❖- MILD TO MODERATE EXERCISE ❖- DIETARY MODIFICATIONS ❖2) 7–20% WILL REQUIRE TREATMENT ❖- INSULIN ❖- OHA
- 24. WHAT’S NEW? EXERCISE ❖ MILD TO MODERATE NOT WEIGHT BEARING EXERCISE – PROVEN TO BE SAFE IN PREGNANCY-CYCLING, SWIMMING, AEROBICS ❖ REDUCE INSULIN REQUIREMENTS ❖ SHORTENS LABOUR ❖ MORE PRONE FOR VAGINAL DELIVERY
- 25. THERAPEUTIC DIET ❖ AVERAGE WEIGHT - 30–35 KCAL/KG/DAY ❖ OBESE - 24KCAL/KG/DAY CALORIC COMPOSITION ❖ 40–50% FROM COMPLEX, HIGH-FIBER CARBOHYDRATES ❖ 20% FROM PROTEIN ❖ AND 30–40% FROM PRIMARILY UNSATURATED FATS
- 26. DIET ❖ DISTRIBUTION : ❖ 10–20% AT BREAKFAST; ❖ 20–30% AT LUNCH; ❖ 30–40% AT DINNER; ❖ AND UP TO 30% FOR SNACKS, ESPECIALLY A BEDTIME SNACK
- 27. TARGETS OF GLYCAEMIC CONTROL Time Plasma glucose Fasting < 5.3 1 hr < 8.0 2 hr < (6.7) If targets not reached within 2 weeks, Initiate insulin International Assoc of Diabetes & Pregnancy Study Groups (IADPSG), D Care 2010;33(3):676- 82
- 28. OTHER INDICATIONS TO START INSULIN ❖FETAL GROWTH ABOVE 70TH PERCENTILE OF POPULATION ❖(IMPORTANCE OF GROWTH CHART) ❖POLYHYDRAMNIOS ❖LIMITED ROLE OF HBA1C
- 29. NEW KID IN THE BLOCK? ❖ RAPID ACTING INSULIN ANALOGS – LISPRO, ASPART ❖ S/C INSULIN PUMPS ❖ GLARGINE HUMAN INSULIN ANALOG PRODUCED WITH RECOMBINANT DNA
- 31. OHA? IS IT SAFE? GLIBENCLAMIDE - LANGER ET ALL (N ENGL J MED 2000) 402 PATIENTS - CONVERSION RATE TO INSULIN ONLY 4% - NOT DETECTED IN CORD BLOOD - BUT BETTER FASTING GLUCOSE PROFILE - RECOMMENDED FOR WOMEN WITH PRE EXISTING DM MULTIPLE STUDIES SINCE THEN – HIGH CONVERSION RATE TO INSULIN (20-30%)
- 32. OHA? METFORMIN ❖ ROWAN ET AL. (MIG STUDY) ❖ SIMILAR OUTCOME TO INSULIN ❖ CONVERSION RATE – 46% HAD INADEQUATE CONTROL AND REQUIRED INSULIN ❖ LOWER MATERNAL WEIGHT GAIN, LOWER GLYCEMIC RANGE AND COMPLICATIONS
- 33. IS OHA SAFE? ❖ METFORMIN AND GLIBENCLAMIDE CROSS THE PLACENTA ❖ NO IMMEDIATE SAFETY CONCERNS FOR THE FETUS HAVE BEEN DEMONSTRATED ❖ POTENTIAL LONG-TERM EFFECTS REMAIN UNDER INVESTIGATION ❖ FDA CLASS B ❖ MAY BE USED IN CERTAIN GROUP OF PATIENTS
- 34. ANTENATAL MANAGEMENT OF MONITORING • 2 weekly BSP till 36 weeks (if within normal range) • Weekly BSP if abnormal or escalation of treatment (till normal) • Weekly BSP after 36 weeks TIMING OF DELIVERY • Offer induction of labour at 38 weeks if on treatment • Offer induction of labour at 40 weeks if not on treatment • Earlier if evidence of macrosomia/polyhydramnios or poor control at term Each visit Review BP Screen for PE GROWTH SCAN •Scan at 28 and 34 weeks for growth •Scan at 36 weeks for EBW and serial growth scans PLOT GROWTH CHART GDM
- 35. ANTENATAL GOOD CONTROL – CAN BE MANAGED IN HEALTH CLINIC DIETICIAN REVIEW WHEN TO REFER TO SPECIALIST CLINIC -FOR INSULIN COMMENCEMENT -EVIDENCE OF MACROSOMIA/POLYHYDRAMNIOS
- 36. FETAL ASSESSMENT ❖ EXCLUDE MACROSOMIA AT TERM (DOCUMENT IN NOTES) ❖ NO ROLE FOR DOPPLER UNLESS EVIDENCE OF IUGR ❖ POLYHYDRAMNIOS OR MACROSOMIA IS AN INDICATION FOR INSULIN/EARLY DELIVERY
- 37. INTRA-PARTUM CARE ❖ DELIVER AT 40 WEEKS (OFFER IOL) ❖ EARLIER IF POORLY CONTROLLED, DEVELOPED PIH/PE ❖ IF EVIDENCE OF MACROSOMIA – DELIVER BY LSCS ❖ 2 HOURLY CAPILLARY BLOOD GLUCOSE, MAINTAIN BETWEEN 4-7MMOL/L (GIK REGIME)
- 38. POSTPARTUM ❖ IF GDM, NO NEED FOR POST DELIVERY MONITORING ❖ STOP INSULIN POST DELIVERY (ENSURE SHE HAS GDM & NOT DM) ❖ UNLESS ITS HIGH REQUIREMENT OF INSULIN ANTENATALLY
- 39. PREVENTION OF NEONATAL HYPOGLYCAEMIA ❖FEED SOON AFTER BIRTH (WITHIN 30 MINUTES) ❖FREQUENT INTERVALS (EVERY 2–3 HOURS) ❖ROUTINE MONITORING OF BABY – 2-4 HOURS AFTER BIRTH (PAEDIATRIC REFERRAL IF <2MMOL/L)
- 40. POST NATAL CARE ❖ 6 WEEKS – FBS (NICE) (LOW RISK) HIGH RISK PATIENTS – DO MOGTT ❖ YEARLY FBS ❖ OGTT NEXT PREGNANCY AT 16-18WEEKS
- 41. DO’S ❖ SCREEN ALMOST EVERYONE ❖ THE LOWER THE GLYCAEMIC CONTROL – THE BETTER ❖ PATIENT EDUCATION ❖ ACTIVE INTERVENTION – EXERCISE, DIET, INSULIN ❖ MONITORING – CONSIDER LOGISTICS/FEASIBILITY ❖ HAND HELD RECORDS
- 42. DON’T ❖ LABEL EVERYONE AS GDM ❖ USE FBS/RBS/GLYCOSURIA FOR DIAGNOSIS ❖ 1 HOUR POST PRANDIAL SUGAR ❖ REPEAT 3X OR UNNECESSARILY ❖ DELAY IN DIETARY REFERRAL & LIFESTYLE MODIFICATIONS ❖ DELAY IN INITIATING INSULIN ❖ EARLIER IOL TO PREVENT MACROSOMIA
- 43. TAKE HOME MESSAGE ❖ GDM – EXTREMELY IMPORTANT IN MALAYSIA ❖ SCREENING ALLOWS INTERVENTION – SHORT TERM AND LONG TERM ❖ ACTIVE INTERVENTION IMPROVES OUTCOMES ❖ STANDARDISED EVIDENCE BASED APPROACH ❖ INDIVIDUALISED CARE ❖ KEEP ABREAST WITH CHANGES – NEW DEVELOPMENTS ARE COMING OUR WAY
- 44. THANK YOU ❖ NICE ❖ WHO 2013 ATLAS ❖ ACOG GDM GUIDELINES