Post on 11-Apr-2017
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS
CONTENTS Definition Screening Diagnosis Risk assessment Medical Nutrition Therapy Insulin Therapy Intrapartum management Follow up Contraception
DEFINITION Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.
Pregestational or overt DM Gestational DM
SCREENING
Selective screening ADA NICE IADPSG
Universal screening
DIPSI
RISK ASSESSMENT
LOW RISK Member of an ethnic group with low prevalence of
GDM.No known diabetes in first degree relative.Age < 25yrs.Normal weight before pregnancy.No h/o abnormal glucose metabolism.
Blood glucose screening not routinely required
AVERAGE RISKMember of an ethnic group with high
prevelance of GDM.Diabetes in a first degree relative.Age > 25yrs.Overweight before pregnancy.
Blood glucose testing at 24 – 28 weeks
HIGH RISKMarked obesity.
Strong family history of type II DM.
Previous h/o GDM,impaired glucose metabolism or glycosuria.
Glucose testing as soon as feasible.
SCREENING
ONE STEP SCREENINGCRITERIA FBS
mg/dl1 HRmg/dl
2 HRmg/dl
DIPSI(75 gm)
≥ 140
IADPSG and ADA(75gm)
≥ 92 ≥ 180 ≥ 153
WHO(75 gm)
≥ 125 mg/dl ≥ 140 mg/dl
• TWO STEP PROCEDURECRITERIA FBS
mg/dl
1 HR
mg/dl
2 HR
mg/dl
3 HR
mg/dl
GLUCOSE CHALLENGETEST(50 gms)
.>140mg/dl
CARPENTERAND COUSTON(100 gms)
≥95 ≥180 ≥155 ≥140
OVERT DM
FBS ≥ 126 mg/dl.
RBS ≥ 200 mg/dl.
HbA1c >6.5
Glycemic criteriaCriteria FPG mg/dl 2-hr PG mg/dl
Normal Glucose Tolerance (NTG)
<100 <140
Impaired Fasting Glucose (IFG)
100-125 -
Impaired Glucose Tolerance (IGT)
- 140-199
Diabetes Mellitus (DM) >126 > 200
Fasting plasma glucose or random plasma glucose or HbA1c
Fasting glucose > 126mg/dl
HbA1c > 6.5%
Random glucose > 200mg/dl
Confirm with Fasting glucose or HbA1c
Fasting plasma glucose > 92mg/dl but < 126mg/dl GDM
OVERT DIABETES
2-hour 75g OGTTFasting plasma glucose >92mg/dl 1-hour > 180mg/dl2-hour > 153mg/dl
Fasting glucose > 126mg/dl
One or more values > thresholds
All 3 values < thresholds
OVERT DIABETES
GDM
Normal
24-28 wks
IADPSG 2PHASE
STRATEGY
FBS < 90mg/dl
PPBS < 120 mg/dl
FBS >90mg/dlPPBS >120
mg/dl
Continue on diabetic diet
To do FBS ,PPBSUpto 28wks –mthly
once28-32 wks – once in
2wks> 32 wks upto delivery-
weekly once.
Start insulin
Monitor sugar levelsAccordingly to maintain
FBS≤ 95mg/dl1st hr PPBS ≤ 140mg/dl
2nd hr PPBS ≤ 120
DIABETIC DIET FOR 2WEEKS
GDM
MEDICAL NUTRITION THERAPY• To achieve normoglycemia ,prevent ketosis,provide
adequate weight gain and contribute to fetal well being.
Major nutritional components,Caloric allotmentCHO intakeCaloric distribution
• 3 meals with 3 snacks .
• Total caloric requirement calculated based on BMI.
CALORIE REQUIREMENT• Optimal total daily calorie intake will be between 2000- 2500 Kcal/day.
• CALORIE ALLOTMENT : 45% CHO ,20% Protein, 25- 30% Fats, < 10% saturated fat.
• CALORIE INTAKE :Break fast 25%,Lunch 30%,Dinner 30%
• CHO distribution 10 - 15% : Break fast 20- 30% : lunch 30- 40% : dinner 0- 10% : snacks
EXERCISE• Beneficial for the improvement of glucose
control as a result of enhanced insulin sensitivity due to,
↓ Intra abdominal fat ↑Insulin sensitive glucose transporters (GLUT 4) in muscle. ↑Blood flow to insulin sensitive tissues ↓ free fatty acid level• Brisk walking of 2.52 km in 1hr.
MONITORING GLYCEMIC CONTROL
• If MNT fails to achieve control ,insulin may be initiated.
• Till 28 wks - lab monitoring of both FBS and PPBS once a month.
• After 28 wks - once in 2 wks.• After 32 wks - once a week • High risk pregnancies- frequency of monitoring
may be intensified.
TARGET PLASMA GLUCOSE LEVELS
• FBS ≤ 95 mg/dl.• 1 hr PPBS ≤ 140 mg/dl• 2 hr ≤ 120 mg/ dl• Consistent elevations more than 4 times
over a two week period – insulin should be initiated.
ORAL HYPOGLYCEMIC AGENTS
GLYBURIDE ( micronised form of glybenclamide)• 2nd generation Sulphonylurea• Longer acting• Category B drug• Nonteratogenic• Starting dose is 2.5mg once or twice daily.
METFORMIN• Category B drug
• Biguanides
• Suppress hepatic gluconeogenesis by activation of an enzyme activated protein kinase.
INSULIN THERAPY• Cover the basal needs and elevation in blood
sugar that occurs after meals.
• Correction dose supplement to control sporadic elevations of blood sugar.
• Dose and type of insulin is decided based on the degree of hyperglycemia and obesity.
α αINSULIN RECEPTORS
β βOUTSIDE THECELL
INSIDE THECELL
Phosphorylation
Altered enzyme activity
protein
MECHANISM OF ACTION OF INSULIN
Cell membrane
ANALOGUE CHANGE IN AMINOACID
SEQUENCE TYPE
LISPRO 28-29 proline and lysine are interchanged.
Rapid
ASPART Proline at 28 substituted by aspartic acid
Rapid
GLARGINE Substitution of glycine for aspargine at 21 in α chain and addition of 2 arginine at 30 in β chain.
Long
DETEMIR β chain 30 threonine substituted by myristic acid
Long
TYPE OF INSULIN ONSET (hr) PEAK (hr) DURATION (hr)
Regular 0.5-1.0 2-3 6-8
Lispro 0.25-0.5 1-2 4-6
Aspart 0.25-0.5 1-2 4-6
NPH 1.0 4-8 10-14
Glargine 1.5 - 30
MIXED AND SPLIT DOSE OF INSULIN
Combination of short and intermediate acting insulin in the morning and evening.
2/3rd morning and 1/3rd evening.
Each combination of 1/3rd dose should be
regular and 2/3rd dose should be intermediate
acting insulin.
HOW TO START AN INSULIN?
Every 4th day increase 2 units till 10 units
If FPG remains > 90mg/dl ,6 units before break fast ; 4 units before dinner
Review with blood sugar test; adjust dose further.Total insulin dose /day
can be divided as 2/3rd in the morning and 1/3rd in the evening
Starting dose 4 units before break fast
OBSTETRIC MANAGEMENT
ANTEPARTUM .• Detailed anomaly scan -18 – 20 wks.• Growth scans at 28, 32 and 36 wks.• Non stress test and Biophysical profile.• Doppler – indicated when cases complicated
by preeclampsia and IUGR.
TIMING OF DELIVERY
• Depends upon the presence of maternal or fetal complications or poor glycemic control.
• Good glycemic control with nutritional therapy alone - wait till 40 wks and plan for IOL.
• High risk patients- plan for IOL at 38 weeks
• Elective caesarean section if estimated fetal weight 4.5kgs .
INSULIN MANAGEMENT DURING LABOUR
Usual dose of intermediate acting insulin is given at bed time.
Morning dose of insulin is withheld. Intravenous infusion of normal saline is begun.Once active labour begins or glucose levels decrease
to <70 mg/dl, infusion is changed from saline to 5% Dextrose,delivered at a rate of 100- 150ml/hr.
Short acting insulin is administered by IV infusion at a rate of 1.25U/hr if glucose level exceeds 100 mg/dl.
GDM
FPG or 75 gm, 2 hr OGTT at 6-12 wks postpartum
FBS ≥126 mg/dl2HR ≥ 200 mg/dl
DM
IMPAIRED FASTING GLUCOSE or IGT or BOTH
FBS 110-125 2HR 140-199
NORMALFBS < 110PPBS< 140
REFER FOR DIABETES
MANAGEMENT
• Consider referralWeight loss and physical activity
Counselling as neededConsider metformin if combined impaired
fasting glucose and IGT.Medical nutrition therapy.
Yearly assessment of glycemic status.
Assess glycemic status every 3yrsWeight loss and physical activity.Counselling as
needed.
POSTPARTUM FOLLOW UP
CONTRACEPTION
• Barrier methods
• Oral contraceptives
• IUCD
THANK YOU