the primary care physician's guide to management of pregnancy diabetes
TRANSCRIPT
DIABETES IN PREGNANCY
All You Need To Know About The Management Of
Gestational Hyperglycaemia
1
by Associate Professor Dr Hanifullah Khan
What is DM? A metabolic condition characterized by chronic hyperglycemia as a result
of defective insulin secretion, insulin action
or both
3
• Type 1(IDDM) • Type 2(NIDDM) • Gestational diabetes • Others -genetic defects in insulin processing or action -endocrinopathies -drugs -exocrine pancreatic defects -genetic syndromes associated with DM
Pregnancy predisposes to persistent hyperglycaemia
• Glucose is made available to the fetus – ↑ placental hormones – ↑ plasma cortisol – A state of insulin resistance – Further aggravated by ↑
body weight and ↑ caloric intake during pregnancy
4
• Pregestational diabetes becomes worse during pregnancy
• GDM develops when the pancreas cannot overcome the effect of these hormones
Diabetes & Pregnancy
the prevalence of women with preexisting T2DM getting pregnant (diabetic pregnancies) seems to be rising
5
nowadays, more and more women go into pregnancy with increased body weight and caloric intake
This prevalence
is increasing
• Glucose intolerance of variable severity with onset or first identification during the pregnancy
– Generally occurs in the latter half of pregnancy
– Previously, found to constitute 90% of diabetes in pregnancy
6
• resolving after delivery
Important facts
To understand the effects of hyperglycaemia on the fetus, it should be remembered that glucose crosses the
placenta freely but maternal insulin does not
7
Thus, maternal hyperglycaemia leads to fetal hyperglycaemia with a consequent rise in fetal insulin
secretion
Pregnancy is a state of insulin resistance, especially towards term
Pathogenesis of tissue injuryHyperglycaemia leads to the production of reactive oxygen species (ROS)
ROS lead to tissue damage through various mechanisms
This ultimately leads to micro- and macrovascular complications
9
Giacco F. Circulation Research, 2010
Maternal Complications - antenatal
• Pre-eclampsia
• Recurrent infection-vaginal candidiasis,UTI
• Polyhydramnios—PPROM, discomfort
• Anomalies & abortions
• Sudden IUD
10
Maternal Complications - delivery
• Increased instrumental rates
• Birth trauma
• Operative delivery
11
• Polyhydramnios—premature membrane rupture, cord prolapse
Maternal Complications - postpartum
Increased risk of developing DM later in life
12
Past history of GDM increases the risk of recurrence in subsequent pregnancies
Retnakaran R. Diabetes Care, 31, 1275–1281
Maternal Complications - Medical
• Retinopathy
• Nephropathy
• Neuropathy
• Micro/macroangiopathy
13
Fetal complicationsCongenital anomalies (4 fold) - sacral agenesis, NTD, cardiac and renal anomaliesMacrosomiaMalpresentationShoulder dystocia
PrematurityRespiratory distress syndromeHypoglycemiaPolycythemic -jaundice
14
“strong continuous associations of several perinatal outcomes with maternal glucose levels below those diagnostic of diabetes”
HAPO study 2008
future development of T2DM
The significance of GDM
mothers are at risk of
adverse obstetrical outcomes
- esp. fetal overgrowth
19
growth restriction
The significance of pregestational DM
Most of the risk is to the fetus
complications during
organogenesis20
+ complications similar to GDM
Pregestational diabetic pregnancies
• carry a graver consequence
• should be managed immediately once identified
• Ideally, evaluation for DM should occur before pregnancy
• to prevent complications during organogenesis (1st trimester)
21
Hyperglycaemia in the 1st trimester
confers a significantly increased risk of major malformations
22
Type of Diabetes
in pregnancy
T1DM(n=221)
T2DM(n=317)
GDM(n=1822)
Risk of Major
congenital abnormality
(%)
5.9 4.4 1.4Farrel T 2002
Fetal malformations & Glycaemic control
• HAPO study
• a continuum of increasing risk of perinatal outcomes as glucose levels increase
• even within levels that were previously defined as normal
23HAPO study. NEJM 2008
Hyperglycaemia later in pregnancy
• High blood glucose increases fetal growth
• Postprandial normoglycemia can reduce the rate of macrosomia
FBG>5mmol/L, HbA1c>5.3% MACROSOMIA!
24HAPO study. NEJM 2008
Issues of concern
1. The frequently undiagnosed nature of T2DM before pregnancy
25
2. Lack of preconception care
3. The increase in complications of pregnancy due to the coexistence of obesity and T2DM
Difference between GDM & DM
• GDM– early pregnancy BS normal – Usually no effect on
organogenesis – less likely to have congenital
defects – diabetes disappears after
delivery – macrosomia more likely
• DM + Pregnancy– elevated BS since before
pregnancy – effect during organogenesis – more likely to have
congenital fetal defects (up to 8x more than normal pregnancy)
– fetes may be growth restricted
26
overall though, perinatal outcomes are worse whatever the cause of the hyperglycaemia
Pregnant women with DM are
frequently asymptomatic
They need to be identified before harm can come to the fetus
28
Screening
• this process of looking for asymptomatic diabetics is termed screening
elevations of maternal blood glucose are deemed harmful to the fetus
• during antenatal check-ups, mothers with unknown elevations of blood glucose need to be identified
29
• The benefits and importance of screening for GDM have been proven (ACHOIS & HAPO study)
Crowther NEJM 2005
In Malaysiawe base our screening strategy on
30
• screen selectively those considered high risk (1-step testing)
Added criteria• In recent time, this list has been expanded
• Include factors such as
• physical inactivity
• certain dietary patterns
• polycystic ovarian syndrome (PCOS)
• biochemical markers such as adiponectin & C-reactive protein
32
Retnakaran R. Clin Endocrinol 2007 Lo JC. Diabetes Care, 2006
PCOS• Ex-GDM mothers investigated for PCOS
• A majority of them displayed characteristic polycystic ovarian morphology
33
Kousta E. Clin Endocrinol, 2000
What is done now• At booking - assess risk
• if risk present, do OGTTCurrent'screening'protocol'
First Obstetric Visit - check risk status '
Risk Factors
Absent
Present
Consider'normal'
Risk Factors •Age >=40 yrs •Unexplained SB •P/H recurrent miscarriages •P/H BW >=4.0 kg •Weight >100 kg •P/H oligomenorrhoea •Strong maternal/sibling F/H
Note: OGTT not performed in: Known pre-existing DM cases & Cases with P/H of GDM
OGTT performed after 24 weeks
gestation
Consider'GDM'if'diagnostic'criteria'met'
34
Schedule for screeningBetween 24-28 weeks of gestation
or earlier if there are stronger indications
If the glucose tolerance remains
normal at 34 weeks, stop testing
If the original OGTT is negative, recommend periodic repeat testing (may be required
until 34 weeks of gestation)
35
Recent Recommendations• Based on HAPO study data - even the slightest
hypoglycaemia increases pregnancy adversity
• IADPSG formulated recommendations
36IADPSG. Diabetes Care 2010
• In a bid to achieve international consensus
• Try to catch as many patients with pregnancy hyperglycaemia as possible
IADPSG screen
• 1st phase - early pregnancy• aimed at detecting previously undiagnosed overt diabetes
• HbA1c or plasma glucose (fasting or random) measurements
• carried out on high-risk women (adult non-pregnant criteria)
38
2 discrete phases
• 2nd phase - 24-28 weeks
• if 1st phase normal
• 2-hour 75 g OGTTIADPSG. Diabetes Care 2010
OGTT• The first-line diagnostic test
• Initially developed to identify the diabetic in the general population
because of the many controversies surrounding this topic, numerous
iterations of the OGTT abound with different criteria for diagnosis
41
O’Sullivan, Mahan. Diabetes 1964.
Procedure for OGTT
42
IADPSG. Diabetes Care 2010
75 grams of oral glucose is given 3 readings -fasting glucose level, 1 hr and 2 hr post glucose
Diagnostic Values
5 4 5 4
Table 1: Values for Diagnosis
Fasting Random
Venous Plasma Glucose ≥ ≥ 11.1 mmol/L
Table 2: Diagnostic values for Type 2 Diabetes Mellitus/Glucose Intolerance – oral glucose tolerance test (OGTT) [IDF 2005] 5 (Level III)
OGTT Plasma Glucose Values (mmol/L)
Category 0-hour 2-hour
DM ≥ ≥ 11.12
Recommendations: Screening and Diagnosis
in those with risk factors and those ≥30 years. [Grade C]
initiated at 10 years old or at onset of puberty if puberty occurs at a younger age. [Grade C]
3. More frequent and/or earlier testing with either a FPG or 2-hour plasma glucose in
[Grade C]
≥6.1 to 6.9 mmol/L in order to identify individuals with IGT or diabetes. [Grade C]
screening for other cardiovascular risk need to be done or planned. [Grade C]
43
More recent diagnostic criteria
Commonly referred to diagnostic criteria for the 75 gram OGTT include the WHO and the ADA criteria
More recently, the IADPSG have adopted stringent criteria based on the HAPO study
44
IADPSG. Diabetes Care 2010
23
12:20:10
Postpartum considerationsPostpartum considerationsP/H GDM woman
Postpartum oGTT
Normal GTAbnormal GT
IGT/DM
Manage as appropriate
Diet & exerciseF/U Blood Glucose
Stable glucose
75g oGTTDiet & exercise
F/U Blood Glucose
Raised glucose
Normal GT
45
Should be carried out after 2 months
postpartum
Yes, but…
• Only in early pregnancy
• Glycated haemoglobin (HbA1c) and plasma glucose (random or fasting)
• HbA1c has been validated for the diagnosis of DM outside of pregnancy (≥6.5%) with many authorities favouring its use in pregnancy as well
47
International Expert Committee. Diabetes Care 2009
HbA1c limitations•costs•unavailability• inaccuracy in anaemia
Plasma glucose
• Fasting or random
• FPG level of ≥7.0 mmol/L is diagnostic of overt diabetes
• RPG of ≥11.1 mmol/L has to be confirmed with either an FPG or A1c value ≥ the threshold
48
Strategy
• Rapid normalisation of blood glucose
• Limited weight gain
• Monitoring for anomalies and complications
• Avoiding macrosomia
• Planned delivery
50
Optimization of metabolic control
• BS control dependant upon diet modification, exercise and hypoglycaemic medications
51
• Lifestyle modification (dietary advice & appropriate exercise) should be the primary interventions considered
• Resort to medications only when these fail to achieve the desired targets
Less weight gain
• In overweight or obese mothers
• No specific guidelines for women with diabetes
• Less weight gain is safe and has a beneficial effect on perinatal outcomes in obese women
• Access to dietitian
53
Individualised counselling• From a registered dietician experienced with pregnancy
and diabetes
• Basic plan - based on dietary recommendations for all pregnant women, adjusted to the individual needs of the patient
54
• Carbohydrate and caloric contents - modified based on the woman’s height, weight, and degree of glucose intolerance
Caloric restriction• A 33% reduction of calories results in clinically relevant
improvement in glycemic parameters
• 30-35 kcal/kg/day = 1200 Kcal/d is safe
• 50% of these calories should be from complex carbs
• Exact amount unknown - carbohydrates, like calories, should be determined based on individual needs
• mother’s weight, activity, home & personal circumstances
• Base calculations on home blood glucose levels
55
Specific targets• Avoid concentrated sweets and highly processed foods -
contribute to unwanted weight gain
• soft drinks, ice cream, cakes and sweets
• restrict CHO to those found in vegetables and dairy products like cheese and cottage cheese
56
Hone J. J Clin Endocrinol Metab 2010
• Small frequent meals (4 hourly) instead of fewer larger meals
• reduces the amount of insulin needed at any one time, resulting in lower glucose excursions
• also reduce hunger and prevent overeating
Some more targets• Breakfast should be especially small and low in carbs because
insulin resistance is highest in the morning
• High-fiber and low-GI foods should be substituted wherever possible for simple sugars
• higher fiber/low GI may assist in delaying absorption of food, thus allowing the insulin peak to “catch up”
• Foods rich in antioxidants have a role in reducing the incidence of fetal anomalies
• fruits and vegetables are recommended
57
Folic acid
• Supplemental
• Proven to reduce the risk of neural tube defects
• The prescription should begin at least 3 months preconceptionally and through the first trimester
• Minimum dose of 4 mg daily
58
Medical
Nutritional
Therapy -
MNTIf MNT
doesn't work?
Medication is implemented if 2 or more glucose values are elevated after 1 wk of
lifestyle management
59
Oral medication?
• Previously, next step would be insulin therapy
• because oral medications were thought unsafe, ineffective & teratogenic
• enough data to show the utility and safety of oral hypoglycaemic agents (OHAs) in pregnancy
61
When to start OHAs?
• When fasting or premeal BS values constantly exceed 5.5 mmol/L
• OHAs should be started without hesitation whilst encouraging dietary and exercise efforts
62
Glibenclamide
• The first OHA to have proven efficacy and safety in pregnancy
• At a dose of 2.5 mg daily to a maximum of 20 mg per day
• Similar birth outcomes can be achieved when comparing glibenclamide use to insulin initiation in pregnancy
63
Langer et al. N Eng J Med 2000
Metformin• The starting dose is 500 mg once daily & increasing to
500 mg tds
• Similar outcomes between metformin and insulin initialisation
• Although 46% of mothers on metformin required additional insulin supplementation for blood sugar optimisation
• An early indicator that metformin therapy alone might be inadequate to achieve target values is a higher fasting glucose
64
Rowan et al. N Eng J Med 2008
General considerations• OHA dosage should be increased every 4-5 days to
achieve the desired blood sugar target values
65
Rowan et al. N Eng J Med 2008
• Although both metformin and glibenclamide cross the placenta, there have been no reports of fetal adversity so far
• The long term effects of these OHAs are still under study but there is optimism that their safety will be proven
• decreased overall weight gain has been noted in pregnant mothers on metformin
An example of a therapy guide
68
14
lifestyle, and personal circumstances. Food intake should be adequate to maintain maternal and foetal nutrition. An energy prescription of 30-35 kcal/kg pre-pregnant ideal body weight is recommended, though this should be flexible to correct for any alteration in activity levels. Those women whose body weight exceeds 120% of their ideal body weight may require a lower energy intake per kilogram in order to limit their weight gain during pregnancy. Frequent small meals may facilitate improved blood glucose control. Complex carbohydrates should provide about 50% of the total calories. This should be distributed in the form of 10-gram exchanges as regular main meals and snacks throughout the day. Levels of dietary fibre of 30-50g per day should be advised. Foods rich in antioxidants - fresh fruits and vegetables - may have aa role in reducing malformations. All foods containing refined sugars, eg cakes, ice cream, sweets, soft drinks, should be strictly avoided preferably by all pregnant women irrespective of their carbohydrate metabolism status. Foliate supplements (4 mg/day) should be routinely prescribed preconceptionally and in the first trimester to reduce the risk of neural tube defects. Exercise helps maintain control and women should be encouraged to walk for about 30 minutes per day. Hypoglycaemic agents need to be introduced when lifestyle and dietary measures fail to control the glycaemia. In cases of GDM, it is appropriate to consider starting oral hypoglycaemic agents in the first instance whenever the fasting or pre-meal blood glucose levels consistently exceed 5.5 mmol/l, definitely if the value exceeds 7.0 mmol/l. Recent research has confirmed the safety and clinical efficacy of glibenclamide [gliburide] during pregnancy. Glibenclamide should be started at 2.5 mg daily with the dose increased every 4-5 days to a maximum of 20 mg/day. If control is not achieved, then the sulphonylurea should be replaced by insulin. An alternative oral hypoglycaemic agent if metformin, though the use of this is still under investigation. This should be started as a 500 mg daily dose, increasing the dose to 500 mg t.d.s. depending on gastrointestinal symptoms.
Class Fasting/preprandial Blood glucose
2-hour postpradial Blood glucose
Management option
A1 Always <5.1 mmol/l Always <6.7 mmol/l Diet alone A2 5.1-7.0 mmol/l 6.7-7.0 mmol/l Diet +/-
pharmacological Rx B1 >7.0 mmol/l >7.0 mmol/l Diet + Insulin
Management options
Savonna-Ventura. UMMS Malta 2011
Insulins
• Each type of insulin has an onset time, a peak and duration of action
• The onset time is delineates how soon the blood glucose lowering action comes into effect and is commonly used to classify this class of medications
• either rapid-, short-, intermediate- or long-acting
70
A basic understanding of the dynamics and actions
Development of Insulins• Originally, from animals
• Biosynthetic preparations in the 1970s - more effective and cheaper preparations
• The first such insulins - regular insulin (or “human” insulins)
• classed as short-acting,
• mainstay of diabetes treatment in pregnancy in the 1980s
• not fully satisfactory due to a late peak (2-3 h after injection) - not very effective for postprandial control
• too long duration of action - tending to cause hypoglycaemia
71
Insulin analogues• They provide more optimal glucose control during pregnancy
• technically not insulin, but something similar that retains the hormone’s glucose lowering function
• They are considered safe for pregnancy use - no teratogenic or embryotoxic effects have ever been demonstrated
• They act rapidly, peak in about 1 hour with a duration of action between 2-4 hours.
• The first such insulin developed was insulin lispro followed soon after by insulin aspart
72
NPH insulin
• An intermediate acting insulin originally developed in the 1930’s
• now synthetically produced to give better absorption rates when injected subcutaneously
• May be mixed with shorter acting ones in the same syringe to complement its longer duration of action and to allow for better dosing and blood sugar control
• NPH remains in the market today specifically for the reason that it can be marketed in premixed formulations for ease of use
73
More recent insulin analogues
• Insulin glargine and detemir
• Absorbed more steadily after injection, providing a “peakless” mode of action, followed by a rapid decline and all the while producing a more constant glucose lowering effect
• Duration of action is approximately 24 hours, thus needing only once-daily administration - long-acting insulins
• also induce less hypoglycaemia and weight gain compared to conventional insulins
• Despite these attractive features, they are currently unlicensed for pregnancy use due to lack of systematic data although several reports have not demonstrated any adverse effects or teratogenicity.
74
Summary of insulins
75
Table&1&Commonly&used&insulins&and&their&properties&
Type&of&insulin&
Generic&name& Onset& Peak& Duration&
!
Rapid'acting!!
!
Insulin!lispro!
15!minutes!30'90!minutes!
3'5!hours!Insulin!aspart!
!Short'acting!
!
Regular!
insulin!
30'60!
minutes!2'4!hours! 5'8!hours!
Intermediate!acting!
!
NPH!insulin! 1'3!hours! 8!hours! 12'16!hours!
Long'acting!
Insulin!
glargine!1!hour! Peakless!! 20'26!hours!
Insulin!detemir!
!
!Modes&of&administration&
By! dint! of! being! protein! in! origin,! insulin!medications! cannot! be! taken!
orally! and! have! to! be! injected.! The! most! frequent! mode! of! parenteral!administration!is!via!subcutaneous!injection!using!repeat'use!insulin!pens!with!
fine! needles.! Intravenous! administration! is! frequently! seen! in! intensive! care!settings.!Of! late,! insulin!pumps!have!been!providing! fine'tuned! insulin!delivery!
and!consequent!better!blood!glucose!control.!This!mode!of!insulin!delivery!may!
supersede! others! once! financial! and! a! host! of! technical! considerations! can! be!overcome.!
&Regimes&&
The!philosophy!behind!insulin!delivery!is!to!mimic!physiologic!secretion!
of!insulin!by!the!pancreas!as!close!as!possible.!In!pregnancy,!this!entails!multiple!injections! of! various! combinations! of! rapid,! short! and! intermediate'acting!
insulin.!!
To! limit! the! effects! of! persistent! hyperglycaemia! on! the! fetus,! insulin!should! be! instituted! as! early! as! possible! once! failure! of! nutritional! and! OHA!
therapy! is! recognized.! A! tried! and! tested! insulin! combination! is! a! rapid'acting!and!NPH!one.!!
The! daily! insulin! requirement! of! the! pregnant! mother! is! based! on! her!
weight!and!gestation!as!follows:!first!trimester!,!0.7!U/kg/day;!second!trimester!0.8!U/kg/day;!third!trimester!(wk!29!–34),!0.9!U/kg/day;!and!term!(wk!35–39),!
1.0!U/kg/day.!Jovanovic&L,&Peterson&CM.&1982!Optimal!insulin!delivery!for!the!pregnant! diabetic! patient.! Diabetes! Care! 5! (Suppl! 1):24–37.! LapollaA,&DiCianniG,&BruttomessoD,&Dalfra`MG,& FresaR,&MelloG,&Napoli&A,&Romanelli&T,&Sciacca&L,&Stefanelli&G,&Torlone&E,&Mannino&D.&2009!Use!of!insulin!detemir!in!pregnancy:! a! report! on! 10! type! 1! diabetic!women.!Diabet!Med! 26:1181–1182.!
Slightly! higher! starting! doses! may! be! used! for! obese! patients.! It! must! be!
remembered!that!these!values!are!a!safe!guide!to!insulin!initiation!and!must!be!
Modes of administration
• The most frequent mode of parenteral administration is via subcutaneous injection
• using repeat-use insulin pens with fine needles
• Intravenous administration - in intensive care settings
• Insulin pumps provide fine-tuned insulin delivery & consequent better blood glucose control
• financial & technical considerations
76
Philosophy behind insulin• Mimic physiologic secretion of insulin as close as
possible
• In pregnancy, this entails multiple injections of various combinations of rapid, short and intermediate-acting insulin
78
A tried and tested insulin combination is a rapid-acting and NPH one
Starting values
• Slightly higher starting doses may be used for obese patients
• These values are a safe guide to insulin initiation
• Must be optimised rapidly to achieve the target blood glucose values by using (home blood glucose monitoring) HBGM
79
Starting dose calculationTime of pregnancy Dose
Prepregnancy 0.6 U/kg/day
First trimester 0.7 U/kg/day
Second trimester 0.8 U/kg/day
Third trimester (29-34 wks) 0.9 U/kg/day
Term (35-39 wks) 1.0 U/kg/day
80
Jovanovic. Diab Care 1982Lapolla et al. Diab Med 2009
Starting doses• The regimens are based on predicted total daily insulin
requirements - based on current weight and stage of pregnancy
• 50% of the total dose is given as a basal dose using NPH insulin (intermediate-acting)
• at bedtime or bedtime+breakfast time
• the other 50% of the total dose - given as boluses before meals using insulin analogues (rapid-acting)
• before meals (within 15 minutes) in divided doses (1/6 of the total dose per meal)
81
Adjustments
• These doses are starting doses only
• Necessary to rapidly adjust dose to achieve glucose goals using HBGM data & A1C testing
• Serial blood sugars - carried out between 3-7 days after starting & the dosage of insulin adjusted commensurately
82
Pillar of assessment
• Glycaemic adequacy is assessed through regular blood glucose estimations
• Tight glucose control achieved through dietary, physical and pharmaceutical interventions
84
Adequate BS control is proven beneficial to the pregnancy. Despite this, no clearly established
glucose targets exist.
Crowther et al. N Eng J Med 2005
Techniques of assessment
• 2 techniques of assessment - HBGM & HbA1c
• Most data regarding target values in pregnancy - derived from pregnant T1DM & T2DM patients
85
Kitzmiller et al. Diab Care 2008
Target Values - FPG
• FPG of ≤5.0 mmol/L
• Associated with a reduction in the risk of macrosomia, neonatal hypoglycemia, and maternal preeclampsia in GDM during the third trimester
86
Prutsky et al. JCEM 2013
Target Values - FPG & postprandial
• FPG of ≤4.9 mmol/L & and 2-hour postprandial glucose between 5.9–6.4 mmol/L
• risk of birthweight greater than 4 kg, prematurity, neonatal hypoglycaemia & preeclampsia are all lowered
87
Rowan et al. Diab Care 2010
Target Values - HbA1C
Amongst pregnant Type 1 diabetic mothers, maintaining HbA1c levels to less than 6% before and during pregnancy
predicated outcomes similar to non-diabetic pregnant mothers
88
Wyatt et al. Diab Med 2005
Recommendations
89
Timing Glucose Level
Premeal, bedtime, overnight 3.3–5.4 mmol/L
Postprandial 5.4-7.1 mmol/L
HbA1c 6.0%
ADA.Diabetes Care 2013
Monitoring • Regular blood glucose monitoring - mainstay of objective
optimization of metabolic control
• between 3-4 times a day
• a prebreakfast and postprandial (2 hours post-lunch and dinner) and/or night test
• Initially, clinic attendance - primarily for patient education purposes
• Subsequently, self-monitoring of blood glucose is the optimum
• Assessment of long-term control and further optimization - 4-6 weekly by measuring HbA1c levels
90
Postprandial blood glucose monitoring
• Glycaemic control has been shown to be improved by limiting postprandial glucose excursions
• Postprandial glucose correlates well with HbA1C
• By measuring and controlling the postprandial and fasting sugars, the occurrence of neonatal hypoglycaemia and macrosomia may be reduced
91de Veciana M. NEJM 2013
Do This
Assessment of the pregnancy
The pregnancy must be treated as a whole
Take precise history - maternal well-being, FM
Examine for complications - remember; maternal, fetal & placental
Investigations - in order of priority
ultrasound scan, urine, blood tests, CTG
92
Patient complaints!
Do not manage the blood sugar, manage the patient!
93
Physical Examination!
Ultrasound scans!
You can if..• You routinely manage antenatal patients
• You know how to screen for & diagnose this condition
• You know how to implement & monitor treatment
• You know how to monitor for complications
95
Do not hesitate to seek help!
Case 1
• A 34-year-old Malay woman, known DM, who is in her second pregnancy and has had one live birth is seen for prenatal care at 8 weeks gestation
• Her weight is 96 kg, and her blood pressure is 130/80 mmHg. Uterine size is appropriate for gestational age. Her family history reveals that her mother has type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria and negative ketones
Q. What tests should be done to evaluate the patient's glucose tolerance?
Q. How is the diagnosis of GDM established?
Q. What would be the best treatment and follow-up strategy?
97
Case 2
• 25 year old G1P0 at 10 weeks gestation. No significant past medical, surgical or reproductive history. No family history of DM. A regular patient of the GP, antenatal booking bloods includes a diabetic screen utilizing HbA1c. HbA1c was 6.2%.
Q. Is this patient GDM?
Q. Does she need to be started on insulin
98
Case 3 • 35 year old G2P1 at 8 weeks gestation. Her first pregnancy –
delivered LSCS for obstructed labour 4 years prior – 3.6 kg baby girl. No contraception prior to this pregnancy.
• Routine ANC by GP – incorporate HbA1c – 8%. Diagnosed as DM with pregnancy. Based on local knowledge and guidelines, this patient requires insulin but patient refuses.
99
Q. What should the GP do next?
Q. Should this patient be started on oral medication immediately?
Case 4
• 38 year old G4P3 at 35 weeks, known DM diagnosed since last pregnancy, on metformin 850 mg bd. Since the patient is already on treatment, the GP has continued the oral medication. Regular serial sugar estimations are carried out – pre-breakfast, post-lunch and dinner – 6.2/7.7/7.8
• Maternal and fetal well-being established
Q. Should she be started on insulin now?
100