Gestational Diabetes By: Kevin Rabey
Jan 17, 2016
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???