Presentation on theme: "Diabetes in Pregnancy Dr Thomas Paul MD DM (Endo)"— Presentation transcript:
1 Diabetes in Pregnancy Dr Thomas Paul MD DM (Endo) Dr. Mathew John MD DM(Endo)Department of EndocrinologyChristian Medical CollegeVellore
2 Pregnancy may be complicated by diabetes in two distinct forms:Gestational diabetes mellitus (GDM) is defined as glucose intolerance of varying severity with onset or first recognition during pregnancy. This subset constitutes 90% of women with pregnancies complicated by diabetes. The most important perinatal concern in this group is macrosomia with resulting birth trauma. More than 50% women ultimately develop diabetes in the ensuing 20 years and this is linked with obesity.Pre-gestational diabetes is diabetes that antedates pregnancy. Pregnancies which are complicated by pre-gestational diabetes, type-1 or type-2, carry an additional risk to both mother and fetus beyond the effects on fetal growth and development in mid and late pregnancy.
3 ClassificationPregestational diabetes: A lady with known diabetes who conceives while on treatment with diet, oral hypoglycemic agents or insulin.Type 1 DM, Type 2 DM, Secondary DMGestational diabetes mellitus is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy. Some patients with fasting hyperglycemia detected early in pregnancy may be missed cases of diabetes that predated pregnancy. Women found early in pregnancy to have gestational diabetes are a high-risk subgroup.
4 Magnitude of problem: GDM GDM varies worldwide and among different racial and ethnic groups within a country.Variability is partly because of the different criteria and screening regimensPrevalence :India: 0.56% -6% (Ramachandran A et al 1994; Hill et al., 2005)USA: increased from 2.1–4.1% in the period 1994 to 2002 with significant increases in all racial/ethnic groups (Dabelea et al., 2005).Native Americans, Asians, Hispanics, African-American, Aboriginal women are at higher risk (Ferrara, 2007).Ramachandran A, Snehalatha C, Shymala P, Vijay V, Viswanathan M. Prevalence of diabetes in pregnant women--a study from southern India. Diabetes Res Clin Pract. 1994;25:71-74.Hill JC, Krisgnaveni GV, Annamma I, Leary SD, Fall CH. Glucose tolerance in pregnancy in South India: relationships to neonatal anthropometry. Acta Obstet Gynecol Scand. 2005;84:159-65Dabelea, D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, McDuffie RS. Increasing Prevalence of Gestational Diabetes Mellitus (GDM) Over Time and by Birth Cohort. Diabetes Care 2005;28:Ferrara A: Increasing prevalence of gestational diabetes mellitus. Diabetes Care 2007;30:S141-S146
5 Risk Factors for gestational diabetes screening Strong family history of diabetesWomen who have given birth to large infants (>4 kg; 8 lbs 13 oz)History of recurrent fetal lossPersistent glycosuriaAge > 25 yearsPast history of glucose intolerance or diabetes in a previous pregnancy
6 Risk Factors for gestational diabetes screening 7. Obesity; overweight women (>15% of non-pregnant ideal body weight)8. Ethnic group with a high prevalence of diabetes (e.g. Pima Indians, Asians, Hispanic)9. History of stillbirth, unexplained neonatal death, congenital malformations, prematurity.10. History of pre-eclampsia or polyhydraminos11. Chronic hypertension12. Recurrent severe moniliasis or urinary tract infection13. History of traumatic delivery with an associated neurological disorder in the infant
7 Whom to screen? Low risk: no screening Average risk: at 24-28 weeks Risk stratificationLow risk: no screeningAverage risk: at weeksHigh risk: as soon as possibleScreening is ideally initiated between the 24th and 28th weeks of pregnancy or earlier if any of the risk factors are present.
8 Low risk for GDM Age <25 years Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDMNo known diabetes in first-degree relativesNo history of abnormal glucose toleranceNo history of poor obstetric outcome
9 Intermediate risk for GDM Must exhibit one risk factor from the list in slide 5.High risk for GDMMarked obesityPrior GDMGlycosuriaStrong family historyEthnic group with high diabetes prevalence
10 as they belong to a high risk ethnicity All Indian women and women of Indian origin should be screened for gestational diabetes mellitusas they belong to a high risk ethnicity
11 Screening testGlucose Challenge Test (GCT): An excellent screening test for gestational diabetes is the measurement of plasma glucose 1 hour after ingesting 50 g of glucose.A plasma glucose level obtained one hour after a 50 g glucose load administered at any time of the day without regard to the time since the last meal, has become a well validated and widely applied screening procedure for women between 24 and 28 weeks of gestation.Using a cut-off value > 140 mg/dl identifies 80% women with GDMUsing a cut-off value > 130 mg/dl identifies 90% women with GDMWomen with elevated GCT values require a diagnostic oral glucose tolerance test
12 Screening testOral Glucose Tolerance Test (OGTT): Measurement of plasma glucose after ingesting 100 g of glucose.Timing of measurementNational Diabetes Data Group (1979)Carpenter and Coustan (CC) 1982Fasting105 mg/dl95 mg/dl1 hour190 mg/dl180 mg/dl2 hour165 mg/dl155 mg/dl3 hour145 mg/dl140 mg/dl> 2 values must be abnormal; for at least 3 days prior to the test, the patient should have an unrestricted diet and unlimited physical activity. The patient should fast for 8 hours before the test. The CC criteria detects 54% more women with GDM than the NDDG criteriaClassification: and diagnosis of diabetes mellitus and other categories of glucose intolerance: National Diabetes Data Group. Diabetes 1979;28:1039–1057Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol. 1982;144:
13 Urine monitoringUrine glucose monitoring is not useful in gestational diabetes mellitusUrine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction
14 Effects of GDM on the fetus Congenital abnormalitiesNeonatal hypoglycemiaMacrosmia (big baby syndrome > 4 Kg or >8 lb 13 oz)JaundicePolycythemia / hyperviscosity syndromeHypocalcemia, hypomagnesemiaBirth trauma (due to macrosmia and shoulder dystocia)PrematurityHyaline membrane diseaseApnea and bradycardiaThe risk of fetal anomalies is not increased in GDM patients. However, the risks of unexplained still births (during the last 4-8 weeks of gestation) are similar to pre-gestational diabetes.
15 Effects of GDM on neonates Respiratory distressHypoglycemiaHypocalcemiaHyperbilirubinemiaCardiac HypertrophyLong term effects on cognitive development
16 Macrosomic infantMacrosomia (large for gestational age or big baby syndrome)(birth weight >90% percentile for gestational age)Macrosomia is a result of persistent maternal hyperglycemia leading to fetal hyperglycemia and prolonged fetal hyperinsulinism. This stimulates excessive somatic growth mediated by insulin-like growth factors (IGFs). Macrosomia affects all organs except the brain.
17 Congenital abnormalities due to GDM Cardiac (most common): transposition of great vessels, Ventricular septal defect, Atrial septal defectCentral nervous system (7.2%): spina bifida, Anencephaly, hydrocephalusSkeletal: cleft lip/palate, caudal regression syndromeGenitourinary tract: ureteric duplicationGastrointestinal: anorectal atresiaRenal agenesis, Duplex ureters, Cystic KidneySitus inversusPoor glycemic control at time of conception: risk factor
18 Caudal regression syndrome (abnormal development of lower spine)
20 Effects of GDM on the mother Pre-eclampsia: affects 10-25% of all pregnant women with GDMInfections: high incidence of chorioamnionitis and postpartum endometritisPostpartum bleeding: high incidence caused by exaggerated uterine distensionCesarian section more common due to fetal macrosmia and cephalo-pelvic disproportionWeight gainHypertensionMiscarriagesThird trimester fetal deathsLong term risk of type-2 diabetes mellitus
21 Effect of pregnancy on diabetes More insulin is necessary to achieve metabolic controlProgression of retinopathy: esp. severe proliferative retinopathyProgression of nephropathy: especially if renal failure +Increased risk of Coronary artery disease, and a high risk of maternal death in post MI patientsCardiomyopathy
22 Patient education Cornerstone in GDM management Instruct mother about maternal and fetal complicationsMedical Nutrition therapyGlycemic monitoring: teach mother about self monitored blood glucose measurement and glycemic targetsPre-conception counselingFetal monitoring: ultrasoundPlanning on deliveryLong term risks
23 Glycemic control targets Tight glycemic control can reduce fetal risk. But, stringent glycemic control puts the mother at increased risk of hypoglycemic events and the fetus at risk of being small-for-gestational age.American Diabetes Association Recommendations:Fasting whole blood glucose<95 mg/dl1 hr postprandial blood glucose<140 mg/dl2 hr postprandial blood glucose<120 mg/dlThese are venous plasma targets, not glucometer targets
24 Why these tight glycemic targets? Prospective study in type-1 patients with pregnancyFasting blood sugarMacrosomia>105 mg/dl28.6 %95-10510%<95 mg/dl3%
25 Self monitored blood glucose (SBMG) 4 times/day minimum, fasting and 1 to 2 hours after start of mealsMaintain log bookUse a memory meterCalibrate the glucometer frequently
26 Medical Nutrition and Exercise therapy provide necessary nutrients for mother and fetus to ensure adequate gestational weight gaincontrol glucose levelsprevent starvation ketosisaerobic exercise, exercise that does not stress the trunkCurrent weight in relation to ideal body weightDaily caloric intake(kcal/kg)Recommended pregnancy weight gain (kg)<80-90%36-4028-4080-120% (ideal)3025-35%2415-25>150%12-18
27 Medical nutrition therapy Approximately 30 kcal/kg of ideal body weight> 40-45% should be carbohydrates6-7 meals daily (3 meals, 3-4 snacks). Bed time snack to prevent ketosisCalories guided by fetal well being/maternal weight gain/blood sugars/ ketonesEnergy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan
28 Insulin in GDMInsulin used if fasting blood glucose >105 mg/dl or 1 hr postprandial blood glucose >120 mg / dl on a dietUse basal bolus regime or pre-mixed insulinShort acting insulins (e.g. Lispro and Aspart) can be used to achieve postprandial controlLong acting insulins (Glargine and Determir) are NOT licensed in pregnancyInsulin requirements increase by 50% from weeks to weeks, after which insulin needs often stabilize.
29 Oral Hypoglycemic agents Glyburide is a clinically effective alternative to insulin in GDM (Langer et al. 2000)Metformin may be effective in GDM (Ratner et al., 2008; Coustan, 2007)Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med. 2000;343:1134-8Ratner RE, Christophl CA, Metzger BE, Dabalea D, Bennett PH, Pi-Sunyer X, Fowler S, Kahn SE, Diabetes Prevention Program Research Group. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008;93:4774-9Coustan DR Pharmacological management of gestational diabetes: an overview. Diabetes Care. 2007;30 Suppl 2:S206-8.
30 Preconception counseling All women with pre-existing type-1 or type-2 diabetes, when planning on pregnancy, should receive pre-conception counseling so that they understand the importance of achieving near-normal blood glucose before conception to reduce the risk of congenital malformations and spontaneous abortions.Assess maternal and fetal riskMother should learn self-administration of insulin and regular monitoring of blood glucose.Target: HbA1c < 7%Emphasize diet and exerciseFolic acid supplementation: 5 mg/dayEnsure no transmissible diseases: HBsAg, HIV, rubellaTry and achieve normal body weight: diet/exerciseStop drugs: oral hypoglycemic drugs, ACE inhibitors, beta blockers and potentially teratogenic drugs
31 Clinical parameters checked at each visit MedicationsPre-pregnancy weightWeight gainEdemaPallorThyroid enlargementBlood pressureFundal height
32 Laboratory parameters to be monitored at each visit HemoglobinBlood SugarHbA1C (first trimester only)Urine microscopy and albuminThyroid function (if goiter present)
33 Fetal monitoring Baseline ultrasound : fetal size Ultrasound evaluation of neural tube defects and other congenital malformations should begin by weeks ofAt weeks: fetal anatomic survey, major malformationsAt weeks: fetal echocardiogram for cardiac defectsAt 26 weeks onwards: ultrasound to evaluate fetal growth and amniotic fluid volumeThird trimester: Fetal surveillance to reduce risk of still birth: include non-stress test, biophysical profile, maternal monitoring of fetal activity, frequent USG for accelerated growthabdominal: head circumference
34 Timing of deliverySmall risk of late intra-uterine death even with good glycemic controlDelivery usually at 38 weeksBeyond 38 weeks, increased risk of intrauterine death without an increase in RDS
35 Management of labor and delivery Vaginal delivery: preferredCesarian section only for routine obstetric indicationGDM alone is not an indication !> 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of brachial plexus injury in the infantUnfavorable condition of the cervix is a problemMaintain euglycemia during laborMaternal hyperglycemia in labor: fetal hyperinsulinemia and worsen fetal acidosisMaintain sugars: mg/dl (capillary: mg/dl )Feed patient the routine GDM dietMaintain basal glucose requirementsMonitor sugars 1-4 hrly intervals during labourGive insulin only if blood sugar >120 mg/dl
36 Glycemic management during labour Later stages of labour: start dextrose to maintain basal nutritional requirements: ml/hr of 5% dextroseElective Cesarian section: check fasting blood sugar; if within target range no insulin is needed; start dextrose dripContinue hourly self monitored blood glucosePost delivery keep patients on dextrose-normal saline till fedNo insulin unless sugars more than normal ( not GDM targets ! )
37 Post partum follow up Check blood sugars before discharge Breast feeding: helps in weight lossLifestyle modification: exercise, weight reductionOral glucose tolerance test at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetesPreconception counseling for next pregnancyIncreased risk of cardiovascular disease,future diabetes and dyslipidemia
38 Immediate management of neonate Hypoglycemia: 50 % of macrosomic infants5–15 % optimally controlled GDMStarts when the cord is clampedExaggerated insulin release secondary to pancreatic ß-cell hyperplasiaIncreased risk: blood glucose during labor and delivery exceeds 90 mg/dlAnticipate and treat hypoglycemia in the infant
39 Management of neonate Hypoglycemia <40 mg/dl Encourage early breast feedingIf symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextroseCheck after 30 minutes, start feedingIV dextrose : 6-8 mg/kg/min infusionCheck for calcium, if seizure/irritability/RDSExamine infant for other congenital abnormalities
40 Long term risk: offspring Increased risk of obesity and abnormal glucose tolerance due to changes in fetal islet cell functionEncourage breast feeding: less chance of obesity in later lifeLifestyle modification
41 Conclusion Gestational diabetes is a common problem in worldwide Risk stratification and screening is essential in all pregnant women, particularly those from ethnicities with increased riskTight glycemic targets are required for optimal maternal and fetal outcomePatient education is essential to meet targetsLong term follow up of the mother and baby is essential
42 17 pound baby born to Brazilian diabetic mother 17 pound baby born to Brazilian diabetic motherCourtesy: MSNBC News ServicesJan. 24, 2005