Diabetes in Pregnancy

Classification Pregestational diabetes Pregestational diabetes Type 1 DM Type 1 DM Type 2 DM Type 2 DM Secondary DM Secondary DM Gestational diabetes Gestational diabetes

Definition Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Pregestational diabetes precedes the diagnosis of pregnancy.

Magnitude of problem: GDM GDM varies worldwide and among different racial and ethnic groups within a country GDM varies worldwide and among different racial and ethnic groups within a country Variability is partly because of the different criteria and screening regimens Variability is partly because of the different criteria and screening regimens

Whom to screen ? Risk stratification based on certain variables Risk stratification based on certain variables Low risk : no screening Low risk : no screening Average risk: at weeks Average risk: at weeks High risk : as soon as possible High risk : as soon as possible

To satisfy all these criteria Age <25 years Age <25 years Weight normal before pregnancy Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDM Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of abnormal glucose tolerance No history of poor obstetric outcome No history of poor obstetric outcome Low risk for GDM

High risk Marked obesity Marked obesity Prior GDM Prior GDM Glycosuria Glycosuria Strong family history Strong family history Intermediate risk At least one of the criteria in the list

Screening and Diagnosis of GDM in the U.S. Use the 50 g oral glucose challenge with BS taken 1 hour later Use the 50 g oral glucose challenge with BS taken 1 hour later Screen all pregnant weeks Screen all pregnant weeks Test earlier in selected patients Test earlier in selected patients Threshold of 130 mg/dL or greater Threshold of 130 mg/dL or greater

How to screen? Oral glucose tolerance Oral glucose tolerance test ( OGTT) with 100 gm glucose test ( OGTT) with 100 gm glucose Fasting 95 mg/dl 1-h 180 mg/dl 2-h 155 mg/dl 3-h 140 mg/dl Overnight fast of at least 8 hours At least 3 days of unrestricted diet and unlimited physical activity > 2 values must be abnormal

Urine glucose monitoring is not useful in gestational diabetes mellitus Urine glucose monitoring is not useful in gestational diabetes mellitus Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction Urine monitoring

Problems of GDM: fetal Increases the risk of fetal macrosomia Increases the risk of fetal macrosomia Neonatal hypoglycemia Neonatal hypoglycemia Jaundice Jaundice Polycythemia Polycythemia Hypocalcemia, hypomagnesemia Hypocalcemia, hypomagnesemia Birth trauma Birth trauma Prematurity Prematurity

Problems: fetal Cardiac( including great vessel anomalies) : most common Cardiac( including great vessel anomalies) : most common Central nervous system: 7.2% Central nervous system: 7.2% Skeletal: cleft lip/palate, caudal regression syndrome Skeletal: cleft lip/palate, caudal regression syndrome Genitourinary tract: ureteric duplication Genitourinary tract: ureteric duplication Gastrointestinal : anorectal atresia Gastrointestinal : anorectal atresia Poor glycemic control at time of conception: risk factor

Caudal regression syndrome

Problems of GDM: maternal Weight gain Weight gain Maternal hypertensive disorders Maternal hypertensive disorders Miscarriages Miscarriages Third trimester fetal deaths Third trimester fetal deaths Cesarean delivery (due fetal growth disorders) Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus Long term risk of type 2 diabetes mellitus

Pregnancy in diabetic mother: risks Progression of retinopathy: esp. severe proliferative retinopathy Progression of retinopathy: esp. severe proliferative retinopathy Progression of nephropathy: especially if renal failure + Progression of nephropathy: especially if renal failure + Coronary artery disease: Post MI patients: high risk of maternal death Coronary artery disease: Post MI patients: high risk of maternal death

Management

Preconception counselling Diabetic mother : glycemic control with insulin/SMBG Diabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% Target: HbA1c < 7% Folic acid supplementation: 5 mg/day Folic acid supplementation: 5 mg/day Ensure no transmissible diseases: HBsAg, HIV, rubella Ensure no transmissible diseases: HBsAg, HIV, rubella Try and achieve normal body weight: diet/exercise Try and achieve normal body weight: diet/exercise Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockers Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockers

Clinical parameters: checked at each visit medications medications pre-pregnancy weight pre-pregnancy weight weight gain weight gain edema edema pallor pallor blood pressure blood pressure Fundal height Fundal height

Patient education Cornerstone in GDM management Maternal complication Maternal complication Fetal complication Fetal complication Medical Nutrition therapy Medical Nutrition therapy Glycemic monitoring: SMBG and targets Glycemic monitoring: SMBG and targets Fetal monitoring: ultrasound Fetal monitoring: ultrasound Planning on delivery Planning on delivery Long term risks Long term risks

Glycemic targets Fasting venous plasma < 95 mg/dl Fasting venous plasma < 95 mg/dl 2 hour postprandial <120 mg/dl 2 hour postprandial <120 mg/dl 1 hour postprandial <130 mg/dl (140) 1 hour postprandial <130 mg/dl (140) Pre-meal and bedtime: 60 to 95 mg/dl Pre-meal and bedtime: 60 to 95 mg/dl If diet therapy fails to maintain these targets > 2 times/week, start insulin These are venous plasma targets, not glucometer targets

Why these tight glycemic targets? Prospective study in type1 patients with pregnancy Prospective study in type1 patients with pregnancy FBSMacrosomia >105 mg/dl 28.6 % % <95 mg/dl 3%

GDM Failure to maintain glycemic targets INSULIN THERAPY Medical nutrition therapy

Promote nutrition necessary for maternal and fetal health Promote nutrition necessary for maternal and fetal health Adequate energy levels for appropriate gestational weight gain, Adequate energy levels for appropriate gestational weight gain, Achievement and maintenance of normoglycemia Achievement and maintenance of normoglycemia Absence of ketones Absence of ketones Regular aerobic exercises Regular aerobic exercises

Medical nutrition therapy Approximately 30 kcal/kg of ideal body weight Approximately 30 kcal/kg of ideal body weight > 40-45% should be carbohydrates > 40-45% should be carbohydrates 6-7 meals daily( 3 meals, 3-4 snacks). Bed time snack to prevent ketosis 6-7 meals daily( 3 meals, 3-4 snacks). Bed time snack to prevent ketosis Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan. Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan.

Self monitored blood glucose 4 times/day minimum, fasting and 1 to 2 hours after start of meals 4 times/day minimum, fasting and 1 to 2 hours after start of meals Maintain log book Maintain log book Use a memory meter Use a memory meter Calibrate the glucometer frequently Calibrate the glucometer frequently

Fetal monitoring Baseline ultrasound : fetal size Baseline ultrasound : fetal size At weeks: major malformations At weeks: major malformations fetal echocardiogram fetal echocardiogram 26 weeks onwards: growth and liquor volume 26 weeks onwards: growth and liquor volume III trimester: frequent USG for accelerated growth III trimester: frequent USG for accelerated growth ( abdominal: head circumference) ( abdominal: head circumference)

Timing of delivery Small risk of late IUD even with good control Small risk of late IUD even with good control Delivery at 38 weeks Delivery at 38 weeks Beyond 38 weeks, increased risk of IUD without an increase in RDS Beyond 38 weeks, increased risk of IUD without an increase in RDS Vaginal delivery: preferred Vaginal delivery: preferred Caesarian section only for routine obstetric indication Caesarian section only for routine obstetric indication just GDM is not an indication ! just GDM is not an indication ! Unfavorable condition of the cervix is a problem Unfavorable condition of the cervix is a problem 4500 grams, cesarean delivery may reduce the likelihood of brachial plexus injury in the infant (ACOG) 4500 grams, cesarean delivery may reduce the likelihood of brachial plexus injury in the infant (ACOG)

Management of labor and delivery Maternal hyperglycemia in labor: fetal hyperinsulinemia, Maternal hyperglycemia in labor: fetal hyperinsulinemia, worsen fetal acidosis worsen fetal acidosis Maintain sugars: mg/dl (capillary: mg/dl ) Maintain sugars: mg/dl (capillary: mg/dl ) Feed patient the routine GDM diet Feed patient the routine GDM diet Maintain basal glucose requirements Maintain basal glucose requirements Monitor sugars 1-4 hrly intervals during labour Monitor sugars 1-4 hrly intervals during labour Give insulin only if sugars more than 120 mg/dl Give insulin only if sugars more than 120 mg/dl

Glycemic management during labour Later stages of labour: start dextrose to maintain basal nutritional requirements: ml/hr of 5% dextrose Later stages of labour: start dextrose to maintain basal nutritional requirements: ml/hr of 5% dextrose Elective LSCS: check FBS, if in target no insulin, start dextrose drip Elective LSCS: check FBS, if in target no insulin, start dextrose drip Continue hourly SMBG Continue hourly SMBG Post delivery keep patients on dextrose-normal saline till fed Post delivery keep patients on dextrose-normal saline till fed No insulin unless sugars more than normal ( not GDM targets ! ) No insulin unless sugars more than normal ( not GDM targets ! )

Post partum follow up Check blood sugars before discharge Check blood sugars before discharge Breast feeding: helps in weight loss Breast feeding: helps in weight loss Lifestyle modification: exercise, weight reduction Lifestyle modification: exercise, weight reduction OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes Preconception counseling for next pregnancy Preconception counseling for next pregnancy Increased risk of cardiovascular disease, future diabetes and dyslipidemia

Immediate management of neonate Hypoglycemia : 50 % of macrosomic infants Hypoglycemia : 50 % of macrosomic infants 5–15 % optimally controlled GDM 5–15 % optimally controlled GDM Starts when the cord is clamped Starts when the cord is clamped Exaggerated insulin release secondary to pancreatic ß-cell hyperplasia Exaggerated insulin release secondary to pancreatic ß-cell hyperplasia Increased risk : blood glucose during labor and delivery exceeds 90 mg/dl Increased risk : blood glucose during labor and delivery exceeds 90 mg/dl Anticipate and treat hypoglycemia in the infant

Management of neonate Hypoglycemia <40 mg/dl Hypoglycemia <40 mg/dl Encourage early breast feeding Encourage early breast feeding If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose Check after 30 minutes, start feeds Check after 30 minutes, start feeds IV dextrose : 6-8 mg/kg/min infusion IV dextrose : 6-8 mg/kg/min infusion Check for calcium, if seizure/irritability/RDS Check for calcium, if seizure/irritability/RDS Examine infant for other congenital abnormalities Examine infant for other congenital abnormalities

Long term risk: offspring Increased risk of obesity and abnormal Increased risk of obesity and abnormal glucose tolerance glucose tolerance Due to changes in fetal islet cell function Due to changes in fetal islet cell function Encourage breast feeding: less chance of obesity in later life Encourage breast feeding: less chance of obesity in later life Lifestyle modification Lifestyle modification

Conclusion Gestational diabetes is a common problem Gestational diabetes is a common problem Risk stratification and screening is essential in all pregnant women Risk stratification and screening is essential in all pregnant women Tight glycemic targets are required for optimal maternal and fetal outcome Tight glycemic targets are required for optimal maternal and fetal outcome Patient education is essential to meet these targets Patient education is essential to meet these targets Long term follow up of the mother and baby is essential Long term follow up of the mother and baby is essential

17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News Services Jan. 24, 2005

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