GDM 2011

DIABETES IN

PREGNANCY

PRESENTER : DR LEONG YUH YANG (MD UKM)SUPERVISOR : DR NORAZA AZMEERA

Diabetes in Pregnancy

Diabetes and Pregnancy

Gestational Diabetes mellitus

Hospital Pakar Sultanah Fatimah 2011 2

CLASSIFICATION

DEFINITION OF GDM

GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.

The definition applies regardless of whether insulin or only diet modification is used for treatment or whether the condition persists after pregnancy.

It does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy.


Source: American Diabetes Association 2009

GLOBAL SCENARIO OF GDM

GDM complicates ∼4% of all pregnancies in the U.S., resulting in ∼135,000 cases annually.

The prevalence may range from 1 to 14% of pregnancies, depending on the population studied.

GDM represents nearly 90% of all pregnancies complicated by diabetes.

Deterioration of glucose tolerance occurs normally during pregnancy, particularly in the 3rd trimester.


Source: American Diabetes Association 2009

MALAYSIA SCENARIO OF GDM Diabetes prevalence had increased from 8.3%

(1996) to 14.9% (2006) (NHMS III 2006).

Diabetes admission based on type of diabetes (1994-2004): GDM represent ≈ 30% of total admission (Ministry of Health Malaysia 2007).

Prevalence of GDM:


Year Author Study Location

Prevalence of GDM (%)

1993 Chan UMMC 12.72001 Shamsuddin et

al.UKMMC 24.9

2009 Idris et al. Alor Setar 18.3

Demographic Data of Patients with GDM

6

85.1%

10.4%3.0% 1.5%

Malay Chinese Indian Others

GDM & ETHNICITY

3.0%46.3%50.7%

Less than 25 25-34 35 & above

GDM & AGE (YEARS)

Figures modified from Idris et al. (2009)

MALAYSIA SCENARIO OF GDM (2)

7

19.4%

76.1%

4.5%

Nulliparious Parity 1-4

Parity 5 & above

GDM & PARITY

Demographic Data of Patients with GDM

Figure modified from Idris et al. (2009)

MALAYSIA SCENARIO OF GDM (3)

PATHOPHYSIOLOGY

levels of placental steroid and peptide hormones (eg, estrogens, progesterone, and chorionic somatomammotropin) rise linearly throughout the second and third trimesters.

insulin resistance increases and the demand for increased insulin secretion with feeding escalates progressively during pregnancy.

Twenty-four–hour mean insulin levels are 50% higher in the third trimester compared to the nonpregnant state.


Inadequate maternal pancreatic insulin response

fetal hyperglycemia results - manifests as recurrent postprandial hyperglycemic episodes.

These postprandial episodes are most significantly accountable for the accelerated growth exhibited by the fetus.

Reflex hyperinsulinaemia by the fetus – promoting excess nutrient storage

macrosomiaHospital Pakar Sultanah Fatimah 2011 9

Antenatally

Identify risk factorsScreeningDiagnosisMonitoring Targets Other screening tests


RISK FACTORS OF GDM


BMI >27kg/m2Previous macrosomic baby weighing

4kg or abovePrevious gestational diabetes

mellitus (GDM)First-degree relative with diabetesBad obstetric historyGlycosuria at the first prenatal visit

Current obstetric problems (essential hypertension, pregnancy

induced hypertension, polyhydramnios and

current use of steroids)

Age above 25


Source : CPG MX of DM 4th edition

2-hour 75 g oral glucose tolerance test (OGTT) Malaysia At least once at or more than 24

weeksScreening at an earlier stage of gestation depends on the degree ofsuspicion and at the physician’s/obstetrician’s request

WHO Screen high-risk populationgroups during the first trimester of pregnancy in order to detect previously undiagnoseddiabetes mellitus. Women at high risk who screen negatively and average risk womenshould be tested between 24 and 28 weeks of gestation


Screening

2-hour 75 g oral glucose tolerance test (OGTT) (Malaysia)

Fasting 6.1 / 5.6 (ADA) mmol/l

2 hours 7.8 mmol/l


Screening


ScreeningADA/WHO ACOG NICE

High risk women should be screened as soon as feasible

screen allpregnant women (universalscreening)

16–18weeks if prior GDM; 24–28weeks if risk factors

If normal, to repeat at 24 – 28 weeks

100 g glucose 100 g glucose 75 g glucose

(2 or more elevated) (2 or more elevated) 1 or more elevated

Fasting 5.3 mmol/l1-h 10.0 mmol/l2-h, 8.6 mmol/l (only 2 h if 75-gglucose used)3-h, 7.8 mmol/l

Fasting 5.3 mmol/l1-h 10.0 mmol/l2-h, 8.6 mmol/l (only 2 h if 75-gglucose used)3-h, 7.8 mmol/l

Fasting 7.0 mmol/l2-h 7.8 mmol/l

15

Frequency of Monitoring

Frequency should be individualized Ideal to have self blood glucose

monitoring(SBGM)

On diet control: pre-breakfast,1 hour PPG levels (weekly – fortnightly)


On insulin therapy: premeal (breakfast, lunch, dinner)

and pre-bed glucose levels (weekly – fortnightly). Once premeal glucose levels are

achieved, PPG testing is recommended for fine-tuning of

insulin dose. 17



WHO MALAYSIA CPG

Hba1c can be falsely altered (increased or decreased) in patients with haemoglobinopathies/ recent blood loss

4-6 weekly

Fructosamine Not an adequate substitute for HbA1c, but fulfilssome of the same functions.

It may be used when there is -- coexisting haemoglobinabnormalities falsely affecting the level of HbA1c (i.e. thalassemia)

- during pregnancyfor early detection of deteriorations in glycaemic control

Reflect control in the past 2-3 weeks

Hba1c Vs Fructosamine

Fructosamine(µmol)

HbA1c%

200 5

258 6

288 6.5

317 7

346 7.5

375 8

435 9

494 10

552 11

611 12


Targets

Timing Level (mmol/l)

Pre breakfast 3.5 – 5.9

Pre prandial 3.5 – 5.9

Post prandial < 7.8



The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study


Other screenings for pregnancy with diabetes mellitus

Detail scan at 18 – 20 weeks of gestation

Regular US scan to monitor fetal growth and amniotic fluid index


Definition of Diabetes and Pregnancy

Known case of diabetes patient if pregnant is not known as GDM

Diabetes mellitus and pregnancy


Pre Conception Care

Counseling is importantPregnancy should be plannedAchieve good glycaemic control

before conception, aim for HbA1c <6.5%

Insulin therapy may be necessary before conception


Measures significance

Joint clinic (obstetrician and physician)

Better control of pre morbidities

Good glycaemic control preconception and throughout pregnancy

-reduces risk of complications-Assessed by Hba1c level( Hba1c < 6.1% reduces risk of congenital malformation)

Avoid unplanned pregnancies -risks associated with pregnancies complicated by diabetes increase with the duration of diabetes

-glycaemic targets, monitoring, medications for diabetes and medications for complications of diabetes will need to be reviewed before and during pregnancy

25Source: NICE guideline 2008-DM in Pregnancy

Measures Significance

Role of diet, exercise, body weight -To refer dietician-reduce weight if preconception BMI > 27kg/m2 -medical nutrition therapy-T.folate 5mg OD for 1st trimester

Assessment for diabetic nephropathy

-Serum creatinine > 120 umol/l-Total protein excretion > 2g/ day-Estimated GFR < 45 ml/min*to refer nephrologist **if already pregnant, eGFR is not used

- Thrombophylaxis needed if excretion > 5g/day


Significance

Assessment for diabetic retinopathy- Preconception and during pregnancy

-Retinopathy tends to get worsen during pregnancy

-assessment by digital imaging with mydriasis following first antenatal clinic appointment and again at 28 weeks if the first assessment is normal.

-If any diabetic retinopathy is present, an additional retinal assessment should be performed at 16–20 weeks.

-pre proliferative diabetic retinopathy diagnosed during pregnancy should have ophthalmological follow-up for at least 6 months following the birth

-should not be considered a contraindication to vaginal birth.


General management

Diet control and lifestyle modification for all

-Medical Nutrition Therapy -moderate amount of exercise If conservative mx fails to maintain

satisfactory blood sugar profile after 1-2 weeks

Insulin commencement-insulin needs variable-Requirements increase through

pregnancy

28

-average 0.8 units/kg/day first trimester 1.0 unit/kg/day second trimester 1.2 units/kg/day third trimester

s/c Humulin R tdss/c Humulin N on

Source :http/ /bestpractice.bmj.com

29


ROLE OF ORAL ANTIDIABETIC IN PREGNANCY

The American College of Obstetricians and Gynecologists has not recommended these agents during pregnancy

Glyburide/ GlibenclamideMetformin


Timing of Delivery

Diet control allow up to EDD and then IOL

Insulin therapyIOL at 38 weeksIf complications anticipated---ELLSCS


Intrapartum Management

On diet control manage as normal labour

On insulin therapy insulin infusion sliding scale +

dextrose/potassium maintenance


Investigations 4 Houly urine ketoneHourly GM baseline BUSE and then 4 Hly

NBM Maintain 1 pint D5% + 1 g KCl (100

mls/H) Insulin infusion sliding scale


Post Partum (maternal)

Insulin requirement drops immediately after delivery by 60 -75%

In breast-feeding, if glycaemic control is inadequate with diet therapy alone, insulin

therapy should be continued at a lower dose.

In non-breast-feeding mothers, OAD agents can be continuedHospital Pakar Sultanah Fatimah 2011 35

If GDM off insulin therapy and then monitor GM regularly

If pre existing diabetes to continue pre-pregnancy insulin/OAD

Repeat OGTT 6/ 52 post delivery - DM/IFG/IGT


Post Partum (Baby)

Blood glucose testing should be carried out routinely in babies of women with diabetes at 2–4 hours after birth.

should feed as soon as possible after birth (within 30 minutes) and then at frequent intervals (every 2–3 hours)


If blood glucose values are below 2.0 mmol/l on two consecutive readings despite maximal support for feeding, if there are abnormal clinical signs or if the baby will not feed orally effectively, additional measures such as tube feeding or intravenous dextrose should be given.


Complications – antenatally

MOTHER

Miscarriage Stillbirths Pre eclampsia Pre term Polyhydramnions Prone to infections Deterioration of

diabetic retinopathy/nephropathy

FETUS

Fetal malformations Growth accelerations/

restrictions Macrosomic baby



Complications – intrapartum

MOTHER

Polyhydramnions Obstructed labour Increase risk of

operative interventions

FETUS

Macrosomic baby birth injury Polyhydramnions unstable lie abruptio placenta

during ROM


Complications – post partum

MOTHER

PPH Risk of future type 2

DM

FETUS

Birth injury Respiratory distress

syndrome Hypoglycaemia Hypocalcemia Hypomagnesaemia Polycythaemia Hyperbilirubinaemia Risk of metabolic

syndrome


REFERENCES

American Diabetes Association. 2009. Diagnosis and classification of diabetes mellitus. Diabetes Care 32 (supplement 1):88-90.

Kulenthran, A. 2006. A practical approach to obstetric problems for the undergraduate. Third edition. Page 87.

Ministry of Health Malaysia. Diabetes Mellitus. The Third National Health and Morbidity Survey, 2006 (NHMS III): Executive Summary. Kuala Lumpur: Institute of Public Health (IPH), Malaysia; 2008, p. 55-7.

Ministry of Health Malaysia. Diabetes Admission and Death by Type of Diabetes for Malaysia. Putrajaya: Ministry of Health Malaysia; 2007, p. 18.

Chan S. Prevalence of GDM in Malaysia. ASGODIP Report: ASEAN, 7th Congress of ASEAN Federation of Endocrine Society, 1993.

Shamsuddin K, Mahdy ZA, Rafiaah SI, Jamil MA. Risk Factor screening for abnormal glucose tolerance in pregnancy. International Journal of Gynecology and Obstetric 2001;75:27-32.

Idris N, Che Hatikah CH, Murizah MZ, Rushdan MN. Universal versus selective screening for detection of gestational diabetes mellitus in a Malaysian population. Malaysian Family Physician. 2009;4(2&3):83-87.

Siti Rohana, S. 2010. Risk factors of gestational diabetes mellitus in Gombak district, Selangor- A case-control study. Paper presented in 5th International Case-mix Conference Malaysia in Park Royal Hotel, Kuala Lumpur, Malaysia, December 2010.


NICE Clinical Guideline. Diabetes in Pregnancy March 2008 Gestational Diabetes Mellitus: NICE for the U.S.? Diabetes Care 33:34–37, 2010


thank you…Hospital Pakar Sultanah Fatimah 2011 45

GDM 2011

Documents

g glucose

mmoll source

gdm parity

prior gdm

gdm ethnicity3

premeal glucose levels

diabetes prevalence

ada mmoll