1. DR Akinyemi Olaleye MBBS, FWACS, DGE

2. Review basic physiology of gestational diabetes Review fetal and maternal implications Review current recommendations for screening for GDM Review recommendations from the 5 th International Workshop-Conference on Gestational Diabetes Mellitus Review use of insulin analogs in pregnancy Review use of oral antihyperglycemic agents in pregnancy

3.  Definition: metabolic disorder ◦ Abnormality in carbohydrate metabolism ◦ Relative or absolute insulin lack.  20 th century witness remarkable outcome.  Before this life expectancy was short  Survivors had infertility.  Those who got pregnant had disastrous outcome. MM=30-60%, PM=60%.

4.  In 1921 banting and best discovered insulin.  Fertility was restored  MM improved remarkably.  PM remained high ◦ Fetal macrosoma, and IUFD were the causes. ◦ Early delivery & C/S were the antidote. ◦ Late IUFD was still a problem.  1930 White classification.

5.  1930 White classification, fetal risk was proportional to severity of mat diabetes,this permitted individualized timing of delivery and perinatal survival =85%.  TODAY, refinement in management has reduced PM to near that of normal pregnancy, except for cong. abnormality.

6.  Overt DM, chronic,10%.Type 1or type 2  Gest. DM. 90%.  Carbohydrate intolerance of varying severity with onset or first recognition in preg.  Change in glucose metabolism  Type 2 unmasked in preg.

7. Defined as carbohydrate intolerance that begins or is first recognized during pregnancy Important because it impacts maternal health care both during and after pregnancy Incidence varies, but most often reported as 5-7% of pregnant women; may be greater in some high-risk populations Underlying risk factors include increased maternal age, obesity, h/o GDM in prior pregnancy, h/o large babies

8. Insulin Resistance Insulin Output 12 24 36 Gestational Age (weeks) Normal pregnancy OVERVIEW

9. Insulin Resistance Insulin Output 12 24 36 Gestational Age (weeks) Gestational diabetes OVERVIEW Cont

10.  Reduced insulin sensitivity.  Increased fasting insulin  Increased diabetogenic hormones(human placental lactogen, placental insulinase, cortisol, oestrogens and Progesterone)  Increased insulinase  In diabetics, insulin requirement increases in preg.

11.  More difficult to control  Proliferative retinopathy may worsen but the course of background retinopathy and nephropathy does not change,instead it is nephropathy assoc with HT and proteinuria that worsen pregnancy outcome.  No other long term effect of preg on DM.

12.  Spont.abortion  Cong. Abnormality  Fetal death  Macrosomia, Obstructed labour, instrumental delivery, shoulder dystocia  Perinatal mortality  Preterm delivery  polyhydramnios

13.  Infections ( candidiasis, UTI)  PIH.  Preterm labour.

14. Maternal hyperglycemia Fetal hyperglycemia Fetal hyperinsulinemia Pederson Hypothesis (1952) OVERVIEW Cont

15.  May be assymptomatic  SYMPTOMS & SIGNS: polyuria, polydipsia  SCREENING ◦ FBS,2HPP. RBS ◦ 50% glucose oral challenge, 1hr glucose 140mg/dl. 130mg/dl ◦ Universal or selective. ◦ Timing of screening.

16.  75g glucose OGTT (WHO)  100g OGTT (ACOG) 3hr monitoring

17. Do risk assessment at first visit, with no screening for low risk Low-risk ethnicity (Caucasian, European) Age < 25 BMI < 25 No known diabetes in first degree relative No h/o glucose intolerance No h/o obstetric complications usually associated with GDM 4 th International Workshop- Conference on Gestational Diabetes Mellitus, ADA, ACOG

18. High risk patients should be screened as early as possible and repeated at 24-28 weeks if screening negative..Strong family history of diabetes.Prior history of GDM.Morbid obesity.Other manifestations of glucose intolerance. glycosuria 4 th International Workshop- Conference on Gestational Diabetes Mellitus, ADA, ACOG

19. Recommended screening is 2-step approach, with 50-g 1-hr GCT followed by 2-hr or 3-hr 100-g OGTT Threshold value for 1-hr GCT is 130 or 140 – either is acceptable Threshold values for 2-hr OGTT are 95, 180, 155, 140, respectively; 2 values must be abnormal to diagnose GDM 4 th International Workshop- Conference on Gestational Diabetes Mellitus, ADA, ACOG

20. WHO advocates universal screening utilizing a one-step 2-hr 75-g OGTT Patient is diagnosed with GDM if fasting > 126 or 2-hr > 140 5 th International Workshop-Conference on Gestational Diabetes Mellitus did not change recommendations set forth by 4 th International Workshop-Conference on Gestational Diabetes Mellitus

22. Measure of glycemiaThreshold Fasting glucose> 126 mg/dl A1C> 6.5% Random glucose> 200 mg/dl To diagnose overt diabetes (preexisting) at any point in pregnancy Summary for IADPS International Association of Diabetes and Pregnancy Study Groups, 2009

23. Glucose measureGlucose threshold FPG92 mg/dl 1-hr plasma glucose180 mg/dl 2-hr plasma glucose153 mg/dl Diagnosis of GDM (75g- OGTT) *one or more of these values must be met or exceeded for diagnosis of GDM International Association of Diabetes and Pregnancy Study Groups, 2009

24.  First prenatal visit ◦ Measure FBS, A1C, or random glucose on only high-risk women  If results indicate overt diabetes as per Table above, treat and f/u as for preexisting diabetes  If results are not diagnostic of overt diabetes and FPG > 92 but < 126, diagnose as GDM; if FPG < 92, test for GDM at 24-28 weeks  24-28 weeks ◦ 2-hr 75-g OGTT after overnight fast on all women not previously found to have overt diabetes or GDM ◦ Overt diabetes if FPG > 126 ◦ GDM if one or more values equals or exceeds thresholds ◦ Normal if all values on OGTT less than thresholds International Association of Diabetes and Pregnancy Study Groups, 2009

25.  Screening/diagnosis ◦ WHO endorses universal screening with single step, arguing that the 2-step process introduces additional barrier to care ◦ Discussions continue around use of fasting, random glucose, or A1C at initial visit, but no consensus at present

26.  Pre pregnancy clinic  Combined management  Early booking and dating  More frequent visits  Admit for stabilization  Dietary control (fasting<105mg/dl)(2hr pp <120)  Mild exercise  Preferably use insulin(oral hypoglyceamics)  Various insulin regime(Post prandial surveillance)

27.  Medical management of GDM includes following: ◦ Dietary therapy. ◦ Exercise ◦ Self-monitoring of glucose at home ◦ If diet and exercise fail, oral hyperglycemic agent or insulin  metformin safe  Short-acting insulin analogs should be standard, and long-acting analogs not far behind.  Counsel on hypoglycemic symptoms ◦ Goal: Euglycemia!!

28. .Avoid sugar and foods high in sugar.High fiber diet with correct caloric intake.30-35 kcal/day with no patient receiving less than 1800 or more than 2800 calories/day Diet composed of: 1. Carbohydrate 45% 2. Protein 25% 3. Fats 30% If euglycemia is not achieved with diet within 1-2 weeks, use S/C insulin is recommended. Emphasize complex carbohydrates, such as starchy vegetables (such as potatoes, corn, beans and peas), grains, fruit and other starchy foods.

29.  Physical activity increases insulin receptor sensitivity by counteracting the hormonal changes that accompany pregnancy.  Performing 15 to 20 minutes of armchair exercises daily during routine sedentary activities, such as watching television or reading.  Taking a walk up and down a street.  Can help a pregnant woman reduce hyperglycemia without increasing the risk of inducing uterine contractions.

30.  Alpha fetoprotein  USS at 20 weeks  Value of antenatal testing.  Timing& mode of delivery  Insulin management in labour.  Avoid prolong labour  1-2hourly glucose measurement.  Intraprtum monitoring.  SHOULDER DYSTOCIA

31.  Fetal surveillance with GDM ◦ Increased surveillance of fetal well-being suggested if oral agent or insulin necessary, or abnormal fetal growth evident on ultrasound ◦ Optimal timing of delivery remains uncertain, but would consider delivery by 39 weeks if evidence of poor glucose control and/or abnormal fetal growth noted ◦ Allow usual indications for delivery management if diet controlled with normal growth and well- being

32. . Oral hypoglycaemics are contraindicated during early pregnancy, labour and early puerperium as they are not adequate for controlling diabetes, have teratogenic effects and may result in neonatal hypoglycaemia.  - Doses of insulin tend to increase in the first half of pregnancy, then stabilize and finally rise in the last quarter, to be decreased again postpartum.  - Twice daily ( before breakfast and before dinner)

33.  injections of a combination of short and intermediate acting insulin sufficient otherwise a subcutaneous insulin pump is used.  - Mono component insulin Actrapid" (short acting) and " Mixtard“ (intermediate acting).  - The total first dose of insulin is calculated by starting with a low dose of 20 units combined insulin then increase it according to the blood sugar.  OR according to the patient’s weight as follow:  In the first trimester............patient’s  weight x 0.7  In the second trimester.........patient’s  weight x 0.8  In the third trimester............patient’s  weight x 0.9

34.  In higher doses, 2/3 the dose is given in the morning with the same ratio and 1/3 the dose is given in the evening in a ratio 1:1.  Day of delivery, reduce insulin dosage by 25% and avoid intermediate acting or  5% glucose infusion in a rate of 125 ml/hour + short acting insulin 1-2 units/hour.

35.  MACROSOMIA : early feeding, RBS, HB, b1b2.  RDS  Hypoglycaemia  Hypocalaemia  Hyperbilirubin  Polycytaemia  Perinatal mortality=2-4%( cong abn,unexp IUFD)  cardiac hypertrophy.  1-3% inheritance.

36. ◦ Assess fasting and/or 2-hr PP in first day or two after delivery – no further treatment necessary if normal (majority of GDM) ◦ If fasting and/or 2-hr PP abnormal, continue oral agent or insulin ◦ Screen for Type 2 diabetes at 6-week postpartum visit ◦ Counsel patients regarding dietary and behavioral changes necessary to minimize risk of developing overt diabetes later in life. ◦ Contraception.

37. TimeTestPurpose Post-delivery (1-3 d) Fasting or random glucoseDetect persistent, overt diabetes Postpartum visit 75-g 2-h OGTTPP classification of glucose metabolism per ADA 1 year postpatum 75-g 2-h OGTTAssess glucose metabolism Annually Fasting plasma glucoseAssess glucose metabolism Tri-annually 75-g 2-h OGTTAssess glucose metabolism Prepregnancy 75-g 2-h OGTTAssess glucose metabolism 5 th Annual Workshop-Conference on GDM

38.  Gestational Diabetes should be considered a pre-diabetes condition  Women with gestational diabetes have a 7- fold future risk of type 2 diabetes vs.women with normoglycemic pregnancy Lancet, 2009, 373(9677): 1773-9

39.  THANK YOU