Gestational Diabetes

By:Kevin Rabey

Gestational Diabetes

Gestational Diabetes is Carbohydrate Intolerance

Carbohydrate Intolerance Begins/detected in pregnancy insulin resistance/hyperinsulinemia

during pregnancy.

Gestational Diabetes

Metabolic adaptations occur in normal pregnant women to ensure adequate fuel and nutrients to the fetus throughout the pregnancy

Placental secretions of diabetogenic hormones help facilitate insulin resistance growth hormone corticotropin-releasing hormone placental lactogen progesterone

Prevalence

United States prevalence is between 1.4 and 14 %

Higher in Black, Latino, Native American and Asian as compared to white women

Screening for Gestational Diabetes

American Diabetic Association (ADA)

American College of Obstetrics (ACOG)

United States Preventative Service Task Force (USPSTF)

Screening

At the Fourth International Workshop on Gestational Diabetes it was also recommended that further evaluation be conducted on any woman with: Random serum glucose >200 Fasting serum glucose >126

Screening

Carbohydrate loading for 3 days prior to the OGTT has been recommended but is probably not necessary.

should fast for 12 hours

Universal Screening

threshold of values for GCT and GTT

Effects of Gestational Diabetes

Preeclampsia PolyhydramniosFetal Macrosomia Birth TraumaOperative Delivery Perinatal Mortality

Neonatal Metabolic Complications Hypoglycemia Hyperbilirubinemia Hypocalcemia Erythremia

Development of obesity and diabetes in childhood

Treatment of Gestational Diabetes

Diet and exercise

Glucose Monitoring

Insulin Therapy

Oral Hypoglycemic agents

Diet Therapy

Goals of an Effective diet Normoglycemia prevent ketosis adequate wt gain good fetal health

Blood glucose concentrations fall about 20% during pregnancy Average FBS in a pregnancy is 56 and 1

hour never exceeded 105

Diet TherapyFBS > 95 is high in pregnancyFBS >90 with normal GTT: Studies showed a higher risk of an infant with macrosomiaThus treatment with small elevations in sugar should be consideredHigh maternal Glucose fetal hyperglycemia increased fetal growth even in the absence of gestational

diabetes

Diet Therapy

Calorie Allotment: wt dependent at initial presentation (Kg/Day) 30 kcal 80 – 120% ideal body 24 kcal 120 – 150% ideal body 12-15 kcal >150% ideal body 40 kcal < 80% of ideal body wt

Diet Therapy

Calories: Carbohydrate 40% (postprandial glucose) Protein 20% Fat 40%

75 to 80% gestational diabetes/glucose intolerance : normoglycemia

Complex carbohydrates (starches/veget) nutrient dense: less effect on postprandial sugars then simple sugars

Diet Therapy

Calorie distribution: 3 meals and 3 snacks Over wt: 3 meals no snacks Breakfast: very small meal (10% total

daily calories)

Higher postprandial glucose significantly increase the risk of macrosomiaRemaining calories: 30% lunch and dinner Remaining divided evenly between snacks

Glucose MonitoringGestational diabetes/glucose intolerance Measure glucose when wake in am

(FBS) Measure 2 hours after each meal/snack Diet diary

Two criteria to prevent macrosomia Fasting glucose <90 1 hour postprandial <120

Exercise Therapy

Gestational Diabetes Type 2 diabetes unmasked in

pregnancy exercise that diminishes peripheral

resistance to insulin would be beneficial: cardiovascular conditioning increase affinity and receptor binding

Reduction in both fasting and postprandial glucose may decrease need for other therapies

in Gestational Diabetes

Exercise Therapy

Safety and Exercise in pregnancy Increase CO and Bld volume

Exercise: divert oxygen and nutrients

Fetal bradycardia

Exercise Therapy

Safe exercise does not cause fetal distress low birth wt uterine contractions maternal hypertension

Teach woman to: palpate their uterus for contractions cease exercise should they occur Avoid exercise in supine position

Exercise therapy

Contraindications to exercise in Pregnancy Preg-induced HTN Premature rupture of membranes Preterm labor Incompetent cervix Persistent second or third trimester bleeding Intra-uterine growth retardation

Exercise Therapy

Exercises walking seem the most appropriate

Arm exercises against resistance are safe and effective

Study cardiovascular fitness program

Insulin therapy

Initiate insulin therapy when the following occur on 2 or more occasions in a 2 week period: (4th international work shop GDM) Fasting glucose >90 1 hour postprandial >120

The ADA and ACOG use 95 fasting and 2 hour >120Macrosomia decreased from 42% to 12% and C-Section decrease b/c of cephalopelvic dispropotion from 36% to 12%

Insulin therapy

Elevated Fasting glucose intermediate acting insulin such as

NPH given Qhs. Dose: 0.15 U/Kg

Elevated PostPrandial regular insulin or Lispro given before

meals. Dose: 1.5 U per 10 gms carbohydrate in breakfast and 1.0 U per 10 gms carbohydrate for lunch and dinner

Insulin Therapy

If both Fasting and Postprandial concentrations are high then 4 injections per day regimen: 0.7 U/Kg wks 6-18 0.8 U/Kg wks 19-26 0.9 U/Kg wks 27-36 1.0 U/Kg wks 37 to term

Insulin Therapy

Divide the injections: 55% preprandial Regular insulin

22% before breakfast 16.5% before lunch 16.5 before dinner

45% NPH 30% before breakfast 15% before bed

One study demonstrated that the 4 injection a day as compared to 2 injections a day improved glycemic control and perinatal outcome

Oral Hypoglycemic Agents

Further study required before Oral Hypoglycemic Agent may be usedSulfonylurea drug Fetal hyperinsulinemia

Macrosomia Neonatal hypoglycemia

Glyburide Does not pass placenta May be safe: on going studies

Metformin Preeclampsia and still birth

Peripartum Concerns: Fetal Surveillance

vasculopathy or significant potential fetal malformationsincreased risk of fetal malformations over the general population (1.5% vs 4.8%)Increased risk of prenatal complications Fasting hyperglycemia Poor metabolic control Macrosomia (affect mode of delivery) Overall pregnancy outcome Increased risk pre eclampsia

Peripartum Concerns

Fetal SurveillanceEarly DeliveryMacrosomia and C-SectionGeneral DeliveryNeonatal Issues

Peripartum Concerns: Fetal Surveillance

Well controlled gestational diabetes Decreased risk antepartum fetal demise Decreased third trimester neonatal mortality

Counting fetal movements is a simple way to assess fetal well beingFewer then 10 movements in 12 hours is associated with poor outcomeThe ACOG recommend fetal surveillance to be initiated in women with poor control, require insulin or have other complications of pregnancy

Peripartum Concerns: Fetal Surveillance

Nonstress tests (NSTs) or (BPP) 32 weeks of gestation with poor control 35 weeks with good control may increase to 2x / week if indicated may start as early as 26 weeks

complications/poor control

Non reassuring fetal testing Reversible problem Non reversible situations

Often pathologic heart patterns will revert to normal when maternal metabolic control is achieved

Peripartum Concerns: Early delivery

Ideally deliver at 39 or 40 weeksIndications for early delivery poor glycemic control fetal abnormalities

If early delivery is indicated Assess lung for maturity Delay delivery until lung maturity

Utilize steroids

Peripartum Concerns: Macrosomia and C-Section

Untreated GDM Macrosomia is 17 to 29% (10% in

general population) C-Section to prevent shoulder dystocia is

common for macrosomia

Ultra SoundElective C-Sections Estimated fetal wt is > 4.5 Kg fetal wts of 4.0 to 4.5 Kg are at risk for

shoulder dystocia

Peripartum Concerns: Delivery

Goals GDM proceed to term and have an

uneventful spontaneous vaginal deliver

Avoid maternal hyperglycemia

Insulin may be withheld during delivery and an IV of NS may be sufficient to maintain normoglycemia

Peripartum Concerns: Neonatal Issues

The degree of maternal hyperglycemia correlates to the adverse outcomesImmediate Hypoglycemia Hyperbilirubinemia Hypocalcemia Polycythemia

Long Term Possibly impaired glucose intolerance and

childhood obesity

PostPartum Care

Immediately after deliver glucose should be measured Fasting glucose should be < 110 and

1 hour post prandial <140

Resume regular diet but continue to measure and record bld sugars for several weeks after discharge6 to 8 weeks following delivery GCT; GTT

PostPartuum concerns and future Risk

After delivery nearly all postpartum women will become normoglycemic 1/3 to 2/3 will have recurrent GDM in subsequent

pregnancies 47 to 50% will develop DM within the first 5 years and is

correlated to the glucose intolerance on the postpartum GTT

20% of GDM will have impaired glucose intolerance in early postpartum period

GDM itself is a risk for development of DM. The HLA (DR3 DR4) may predispose to type 1 DM

Gestational Diabetes

Questions???