(GDM) Defined as any degree of glucose intolerance with onset or first recognition during pregnancy Women with GDM: May have only a minimal insulin deficiency Control blood glucose adequately with a meal plan
May have a more severe insulin deficiency
Require insulin along with nutritional therapy
American Diabetes Association. Diabetes care 2004;27 Suppl1:S88-S90
Joslin diabetes center Available at:
Gestational Diabetes Mellitus
(contd) GDM may revert to impaired glucose tolerance (IGT) or even normal glucose tolerance after delivery GDM usually lasts only through the pregnancy Women with diabetes may be at greater risk of developing T2DM later stages of life (30 60%) 4
Joslin diabetes center Available at: http://www.joslin.org/info/diabetes-
Gestational Diabetes Mellitus
(contd) Long-term considerations in GDM: Obesity and other factors promote insulin resistance Enhance the risk of T2DM after GDM
Markers of islet celldirected autoimmunity are
associated with an increase in T1DM risk Offspring of women with GDM are at increased risk: Obesity Glucose intolerance Diabetes in late adolescence and young adulthood
American Diabetes Association. Diabetes care 2004;27
Agenda
Gestational Diabetes Mellitus
Epidemiology Risk Factors Clinical features Diagnosis Treatment Potential Complications Conclusion
Epidemiology of GDM Affects nearly 7% of all pregnancies More than 200,000 cases annually
Nearly 50% of women with a history of GDM
develop T2DM within 5 10 years after delivery GDM in India: More common in women living in urban areas than in the rural areas
American Diabetes Association. Diabetes care 2004;27
Suppl1:S88-S90 IDF Available at : http://www.idf.org/types-diabetes Accessed
Increasing age Family history of diabetes Short stature Low birth weight Parity
McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-
Risk Factors for GDM (contd)
Maternal clinical factors:
10
Overweight/obesity Diet high in red and processed meat Pregnancy weight gain Physical inactivity Polycystic ovarian syndrome - thalassemia trait High blood pressure Multiple pregnancy
McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-
Risk Factors for GDM (contd)
Past obstetric history Macrosomia Stillbirth Past GDM
11
McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-
Risk Category and Clinical
Characteristics High risk
Marked obesity Diabetes in first-degree relative Current glycosuria Previous history of GDM or Glucose intolerance Previous infant with macrosomia
Average risk Neither high or low risk
12
Perkins JM, et al. Clinical diabetes.
Risk Category and Clinical
Characteristics (contd) Low risk
13
Age < 25 years
No previous poor obstetrical outcomes Belongs to a low-risk ethnic group* No diabetes in first-degree relatives Normal prepregnancy weight and Weight gain during pregnancy No history of abnormal glucose tolerance
Diagnosis of GDM Risk assessment for GDM should be undertaken at the first prenatal visit High risk of GDM:
Marked obesity Personal history of GDM Glycosuria Strong family history of diabetes
Essential for Indian pregnant women:
Eleven-fold increased risk of developing glucose
intolerance during pregnancy as compared to Caucasian women
Essential to undergo glucose testing as soon
as feasible 17
American Diabetes Association. Diabetes care 2004;27
Suppl1:S88-S90
Diagnosis of GDM (contd)
Women with low-risk do not require testing: Age<25 years Normal weight before pregnancy Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetric outcome
18
American Diabetes Association. Diabetes care 2004;27
Diagnosis of GDM (contd)
Use standard diagnostic criteria to screen for T2DM at the first prenatal visit in those with risk factors:
19
HbA1c 6.5% OR Fasting plasma glucose is 126 mg/dL OR 2-h plasma glucose during OGTT 200 mg/dL OR Random plasma glucose 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis
American Diabetes Association. Diabetes Care 2012; 35
Diagnosis of GDM (contd)
In pregnant women not previously known to have diabetes, screen for GDM at 2428 weeks gestation, using a 75-g 2-h OGTT GDM is diagnosed if any of the following plasma glucose values are exceeded: Fasting 92 mg/dL 1 h 180 mg/dL 2 h 153 mg/dL
20
American Diabetes Association. Diabetes Care 2012; 35
Glycaemic Goals in GDM
SMBG: Preprandial 95mg/dL and either: 1-h postmeal 140mg/dL or 2-h postmeal 120mg/dL
HbA1c < 6%
21
American Diabetes Association. Diabetes Care 2012; 35
Treatment of GDM Medical nutrition therapy (MNT) For all women with GDM Individualized Provision of adequate calories and nutrients to meet the needs of pregnancy Consistent with the maternal blood glucose goals
24
American Diabetes Association. Diabetes care 2004;27
Treatment of GDM (contd)
Insulin is the drug of choice when medical nutrition therapy alone does not provide adequate control Oral hypoglycaemic agents are generally not recommended during pregnancy SMBG guides the insulin doses and regimen timings Insulin analogues not been adequately tested in GDM 25
American Diabetes Association. Diabetes care 2004;27
Treatment of GDM (contd)
Calculation of Insulin Dose Weight in kilograms k = total insulin requirement, k = 0.7, 0.8, and 0.9 for first, second, and third trimesters, respectively
50% of total insulin requirement = Daily
basal insulin dosage Administered before breakfast (8:00 A.M.), before supper (4:00 P.M.), and at midnight
26
Angelina L. Diabetes Spectrum.2007;
Treatment of GDM (contd)
NPH insulin have been used extensively to treat GDM If the FPG > 90 mg/dl, then NPH at a dose of 0.2 units/kg/day should be initiated at bedtime Next, if both FPG and PPG levels are elevated, a rapid- acting analog should be added with meals 27
Perkins JM, et al. Clinical diabetes.
Treatment of GDM (contd)
Administer insulin based on FPG, premeal, and 1-hour postprandial glucose readings Treat high FPG with bedtime NPH Treat pre-dinner hyperglycemia with prebreakfast NPH Treat bedtime hyperglycemia with predinner NPH Treat abnormal postprandial glucose with rapid-acting insulin (lispro or aspart) immediately before the offending meal 28
Jovanovic L,. Medical Management of Pregnancy
Complicated by Diabetes. 3rd ed. Alexandria, Va: American
Treatment of GDM (contd)
May need up to 6 injections/day (3 NPH, 3 lispro or aspart), same as protocol for preexisting diabetes Evaluate regimen for 1 week Adjust as needed to maintain blood glucose levels <90 mg/dL before meals <120 mg/dL 1 hour post-meal
29
Jovanovic L,. Medical Management of Pregnancy Complicated
by Diabetes. 3rd ed. Alexandria, Va: American Diabetes
Treatment of GDM (contd)
Role of Insulin Analogues Human insulin: Least immunogenic commercial preparation
Rapid-acting insulin analogues: lispro and
aspart:
30
Develop antibodies at rates and titers are
comparable to human regular insulin1 Short duration of action Better control postprandial glycaemia Less postprandial hypoglycaemia than regular insulin More effective than regular human insulin in achieving goal glucose levels and reducing the risk of fetal macrosomia 1. Metzger BE, et al. Diabetes 2 Care. 2007 ;30 Not been found to cross the placenta Suppl 2:S251-60.
Treatment of GDM (contd)
Role of Insulin Analogues Lispro and aspart have been investigated in pregnancy and demonstrated:
Clinical effectiveness Minimal transfer across the placenta No evidence on teratogenesis Improves postprandial glucose excursions compared with human regular insulin Lower risk of delayed postprandial hypoglycaemia
31
Metzger BE, et al. Diabetes Care. 2007 ;30
Treatment of GDM (contd)
Role of Insulin Analogues Glulisine use in pregnancy: No reports are available Insulin preparations of low antigenicity: Minimizes the trans placental transport of insulin antibodies
32
Metzger BE, et al. Diabetes Care. 2007 ;30 Suppl
Treatment of GDM (contd)
Role of Insulin Glargine Studies
Type of n diabete s
Treatment with glargine
Outcome
Woolderink et al.
Type 1
5 Treated throughout pregnancy; 2 began glargine in second trimester
HbA1C 6.4% No congenital malformations
Dolci et al.
Type 1 1 and Addisons disease
Second trimester
Compared to NPH in first trimester, better control with glargine
Di Cianni et al.
Type 1
First trimester
No congenital malformations
Devlin et al.
Type 1
Second and third
trimester
Better glycemic control with glargine than NPH
Holstein et al. 33
Type 1
First, second, and third Better glycemic
Trujillo. Diabetes Spectrum. trimester control with glargine
Treatment of GDM (contd)
Role of Insulin Analogues Insulin glargine does not cross the human placenta to a measurable extent Rapid-acting analogues have the advantage of dosing 510 minutes before meals, vs. 30 45 minutes before meals with regular insulin
Follow-up Monitoring blood glucose at home is important: Tailoring specific treatment Making adjustments as needed Several studies have shown that monitoring four times daily leads to more favorable glycaemic control Check premeal and 2-hour postmeal glucose levels Keep a track on carbohydrate consumption Monitoring for fasting ketonuria in the morning Helps in guiding the level of carbohydrate restriction 36
Perkins JM, et al. Clinical diabetes.
Postpartum follow-up Maternal insulin requirements drop markedly in the postpartum period Because patients with GDM have a high risk of developing T2DM
Important to continue screening these
patients Poor insulin secretion during pregnancy is predictive of diabetes after delivery
37
Perkins JM, et al. Clinical diabetes.
Postpartum follow-up (contd)
Patients need to minimize insulin resistance: Exercise Maintenance of normal weight Avoidance of drugs that induce insulin resistance
38
Perkins JM, et al. Clinical diabetes.
Postpartum follow-up (contd)
ADA recommendations: An annual fasting blood glucose test A 6-week postpartum 75-g 2-hour OGTT Contraception to ensure that patients will not conceive in the face of marked hyperglycaemia Lead to increased congenital malformations and dysorganogenesis
39
Perkins JM, et al. Clinical diabetes.
Conservative Recommendations to Women Let health care practitioners know of any history of GDM Get tested 612 weeks postpartum, then every 12 years Reach prepregnancy weight 612 months postpartum If still overweight, lose at least 57% of weight slowly, over time, and keep it off 40
delay or prevent T2DM Offspring can lower risk by: Eating healthy foods Being active Avoiding overweight
47
Ratner RE. Diabetes Care. 2007;30 Suppl
Conclusion Women with GDM are at greater risk of developing T2DM in later stages of life (3060%) Tight glycaemic control is essential to prevent maternal and neonatal complications Insulin is the drug of choice if MNT alone cannot achieve adequate glycaemic control Increasing evidence in favour of insulin glargine use in pregnancy Women with GDM need regular follow up postpartum 48
