Download GESTATIONAL DIABETES Dr Abha Gupta

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Carbohydrate intolerance of any degree with
onset or first recognition during pregnancy.
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ADA (2014 guidelines) defined GDM as
“diabetes diagnosed during pregnancy that is
not clearly overt diabetes”.
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The overall worldwide prevalence :1% - 20%.
International Diabetes federation (2013) :
worldwide 16% live births complicated by
hyperglycemia during pregnancy.
In a study from Haryana the prevalence was
GDM was found to be 7.1% while in another
study from South India it was 16.55%
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GDM to be diagnosed if any of the following
criteria is met:
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FPG ≥ 126 mg/dl (7 mmol/L)
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2hr post 75 gm OGTT ≥ 140 mg/dl ( 7.8
mmol/L)
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Was not evidence based, over 10 years old
hence needed to be updated in light of new
data
Does not differentiate between overt
diabetes and glucose intolerance in
pregnancy.
The diagnostic level of FPG ≥ 126mg/dl( 7
mmol/lt) – universally considered to be too
high.
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Diabetes during pregnancy, symptomatic or
not , is associated with adverse pregnancy
outcomes- what level of hyperglycemia
should be treated is not clear.
Difference in the management approach in
overt diabetes and impaired glucose
tolerance during pregnancy.
DIABETES IN PREGNANCY : Any
of the following
Parameters
Level
fasting plasma
glucose
≥ 7.0 mmol/l (126
mg/ dl)
2-hour plasma
≥ 11.1 mmol/l (200
glucose following a mg/dl)
75g oral glucose
load
random plasma
glucose in the
presence of
diabetes
symptoms
≥ 11.1 mmol/l (200
mg/ dl)
GDM : Any of the following
Parameters
Level
fasting plasma
glucose
≥5.1-6.9 mmol/l (92
-125 mg/dl)
1-hour plasma
≥ 10.0 mmol/l (180
glucose following a mg/dl)
75g oral glucose
load
2-hour plasma
≥ 8.5-11.0 mmol/l
glucose following a (153 -199 mg/dl)
75g oral glucose
load
Diagnostic criteria for GDM is based on adverse pregnancy outcomes as derived from HAPO, 2008
(Hyperglycemia and adverse pregnancy outcomes)study and the recommendations of IADPSG
(International assoc. Of Diabetes & pregnancy study group) consensus panel.
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75-g OGTT, after overnight fast (≥8 h), with
PG measurement fasting and at 1 h and 2 h,
at 24-28 wks in women not previously
diagnosed with overt diabetes
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GDM diagnosis made if PG values meet or
exceed:
 Fasting: 92 mg/dl (5.1 mmol/L)
 1 h: 180 mg/dl (10.0 mmol/L)
 2 h: 153 mg/dl (8.5 mmol/L)
50-g GLT (nonfasting) with PG measurement at 1 h
(Step 1), at 24-28 wks in women not previously
diagnosed with overt diabetes
 If PG at 1 h after load is ≥140 mg/dl
(7.8 mmol/L), proceed to 100-g OGTT
(Step 2), performed while patient is fasting
 GDM diagnosis made when two or more PG levels
meet or exceed:
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Fasting: 95 mg/dl or 105 mg/dl (5.3/5.8)
1 hr: 180 mg/dl or 190 mg/dl (10.0/10.6)
2 hr: 155 mg/dl or 165 mg/dl (8.6/9.2)
3 hr: 140 mg/dl or 145 mg/dl (7.8/8.0)
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Progressive insulin resistance No adequate
insulin GDM
Placental hormones
Maternal adiposity  diabetogenic
adipokines
Defect in β-cell insulin secretion
- Defective first phase insulin response
- Lower insulin response to given glycemic
stimulus
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High risk patients
• Higher pre-pregnant BMI > 27 kg/m2
• Increased gestational weight gain
• Ethnicity  South Asian, Middle East, Black
Caribbean
• Maternal age over 25 years
• Previous GDM
• Previous macrosomic baby weighing 4.5 kg or above,
• Multiparity
• Twin pregnancy
• Family history of diabetes(first-degree relative with
diabetes)
 Women with previous GDM
As soon as possible after booking
- Repeat at 24-28 weeks if first test normal
 All other high risk women
- 24-28 weeks
 Screening  75 gm 2 hr OGTT
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- NICE 2015
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Miscarriage
Pre-eclampsia/ hypertensive disorders of
pregnancy
Increased obstetric interventions
Long term maternal increased risk of T2DM
(50% in next 20 years),CVD,Metabolic syn
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Unexplained stillbirth
Macrosomia/LGA baby
Shoulder dystocia
Neonatal hypoglycemia/hypocalcemia/
hyperbilirubinemia
Delayed lung maturity
Long term-Childhood obesity(2 fold), T2DM
(6 fold)and metabolic syndrome(4 fold)
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GDM has been demonstrated to be an independent risk factor for
various adverse pregnancy outcomes. HAPO study(Hyperglycemia
and adverse pregnancy outcomes-2008)- international
multicentric cohort of 25,505 pregnant women
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GDM treatment consistently demonstrates significant decreases
in adverse outcomes such as macrosomia, LGA , shoulder
dystocia, preeclampsia and and obstetric interventions.
- .ACHOIS Study -2005
-Systematic review by Flavinga et al- effectiveness of GDM
treatment. Diabetic research and clinical practice , 2012
GDM TARGETS
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Preprandial: ≤95* mg/dL (5.3
mmol/L) and either
1-hr postmeal: ≤140 mg/dL
(7.8 mmol/L)
2-hr postmeal: ≤120 mg/dL
(6.7 mmol/)
TARGETS FOR PREEXISTING
TYPE 1 OR 2 DM
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Premeal, bedtime, overnight
glucose:
60-99 mg/dL (3.3-5.4 mmol/L)
Peak postprandial glucose: 100129 mg/dL (5.4-7.1 mmol/L)
A1C: <6.0%
* Diabetes in Pregnancy Study
Group India  90mg%
For GDM pts on pharmacotherapy maintain plasma glucose levels :
>4mmol/lt (72 mg/dl) – NICE 2015
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Medical Nutrition Therapy
Physical exercise  30 min walk (NICE 2015)
Pharmacotherapy
SMBG
Counseling regarding hypoglycemic
symptoms
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Carbohydrate controlled meal plan that
promotes adequate nutrition and appropriate
weight gain, normoglycemia and absence of
ketosis.
Food plan must be flexible and should
incorporate modifiable components
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Calories
IBW – 30 kcal/kg/d
Overweight (1.2 – 1.5 X IBW) – 24kcal/kg/d
Obese > 1.5 X IBW – 12-15 kcal/kg/d
Underweight < 0.8 X IBW – 40 kcal/kg/d
Components
Carbohydrate 40%
Protein 20%
Fat 40 % (saturated < 7%)
Since there is defect in first phase of insulin
secretion the challenge of quantity of food at
one time should be less.
 3 major meals and 3 snacks per day
- Total calories to be divided into 9 portions
- 2 portions = major meal
- 1 portions = snack
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Decreased carbohydrate load in the breakfast
Morning cortisol surge (Dawn
phenomenon) release of blood glucose
from stored sources and hepatic
gluconeogenesis high blood glucose levels.
Split the breakfast portion into two equal
halves  prevents undue peak in blood
glucose levels.
Bedtime snack prevents accelerated
starvation and ketosis overnight.
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ADA, ACOG, NICE, Diabetes in Pregnancy
Study Group in India recommends insulin for
maternal hyperglycemia not meeting the
target levels even with diet and exercise after
about 2 weeks.
Most insulins are category B; glargine and
glulisine are category C.
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Metformin is commonly used because of
strong evidence of its effectiveness in
pregnancy and lactation with minimal risk of
teratogenisity (pregnancy cat B, USFDA
approved-1995, yet not by UK marketing
authorization)
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Oral hypoglycemics like glibenclamide can be
considered (during second and third
trimester) in patients in whom blood glucose
targets are not met with metformin but who
decline insulin therapy or who cannot
tolerate metformin.
Acarbose-found safe in pergnancy.(Bertini et
al,perinatal outcomes &use of OHA.J Perinat
med.2005)
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Noninsulin medications lack sufficient longterm safety data
Because of limited safety data global
recommendations still have kept insulin as
the drug of choice.
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Target glucose of 80 to 110 mg/dL
Maternal glucose > 110 mg/dL insulin drip
If the woman does not require insulin during the
prenatal period, labor and delivery can likely
proceed without special attention to maternal
glycemia.
If insulin is required, and labor and delivery are
to be scheduled, it is preferable to schedule for
the morning hours. In this case, the usual insulin
dose can be administered the evening before
the scheduled delivery, and the morning dose
can be held.
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If the mother took insulin and spontaneous
labor ensues, a dextrose infusion with the
rate adjusted to a target glucose of 80 to 110
mg/dL may be required to prevent maternal
hypoglycemia.
The infant is at greatest risk of hypoglycemia
in the first hours after birth therefore mother
should feed their babies as soon as possible
after birth and then at frequent intervals
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A- assessment of hyperglycemic status
B- breastfeeding
C- contraception(avoid progesterone-only
therapy)
D- diet
E- exercise
F- family oriented motivation & education
G- goals
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All patients with GDM should continue
lifestyle management including diet , regular
physical exercise and maintenance of ideal
body weight
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Women with GDM to be reclassified at 6
weeks with 75gm OGTT (ADA)
If BS profile – WNL  reassess every 3 years
If results  prediabetic rangeassess
annually
If results  diabetic range manage as a
case of diabetes
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Maintaining euglycemic status
Monitoring cardiometabolic parameters BP
Lipid profile
Weight control
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Since the HAPO and other studies have shown
that the association of risk of adverse pregnancy
outcomes is continuous with increasing glucose
level, WHO new (2013) diagnostic criteria for
GDM is based on prognostic accuracy meaning
risk of adverse pregnancy outcomes rather than
on diagnostic accuracy.
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Maternal metabolic characteristics are crucial
determinants of insulin resistance during
pregnancy and in offsprings.
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Treatment of GDM is effective in reducing
many adverse outcomes , the risk reduction
for these outcomes is in general large, the no.
to treat is low and the quality of evidence is
adequate, which justifies treatment of GDM.
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Treatment of choice is diet , physical exercise
with/without insulin.
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Interventions esp. healthy diet, exercise &
weight reduction before ,during and after
pregnancy might be a key to prevent the
vicious cycle that contributes to the epidemic
of obesity, insulin resistance and Type 2 DM .