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DIABETES CARE OF MOTHER

BYHemant K Satpathy, MD, FACOGMFMMethodist Women HospitalOmaha, NE, USA

GDM

Pregestational

DM-1

DM-II

CLASSIFICATION

GDM

Gestational diabetes mellitus is a condition in which carbohydrate intolerance first recognized or diagnosed during pregnancy.

DEFINITION

Diabetes in pregnancy 6-9%

GDM 90%

INCIDENCE

{ {MATERNAL

PIH Polyhydramnios CD Shoulder dystocia PTD Operative delivery Diabetes Metabolic syndrome Cardiovascular disease

FETAL

IUFD

Macrosomia

Birth trauma

Hypoglycemia

Insulin resistance

Obesity

COMPLICATIONS

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In 2014, the U.S. Preventive Services Task Force made a recommendation to screen all preg-nant women for GDM at or beyond 24 weeks of gestation

DIAGNOSIS

Early pregnancy screening for undiagnosed type 2 diabetes, preferably at the initiation of prenatal care, is suggested in over- weight and obese women with additional diabetic risk factors, including those with a prior history of GDM

DIAGNOSIS

In women who have positive 50-g screening test results, but negative follow- up test results early in pregnancy, it is common to use the follow-up test at 24–28 weeks of gestation without repeating the 50-g screening test.

DIAGNOSIS

DIAGNOSIS

GDM diagnosed <20 weeks, counseling and management should be as for pregestational diabetes.

DIAGNOSIS

Two step GCT

100 g OGTT

One step 75 g OGTT

**No trial has evaluated the efficacy of any therapy based on these new values, and so the one step screening cannot be used yet for clinical care.

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in 2010, the International Association of Diabetes and Pregnancy Study Group (IADPSG) recommended that a universal 75-g, 2-hour OGTT be performed during pregnancy

In 2011, the ADA endorsed these criteria while acknowledging that adopting these cutoffs would significantly increase the prevalence of GDM

DIAGNOSIS

In 2013, a NICHD Consensus Development Conference on Diagnosing Gestational Diabetes recommended that obstetricians and obstetric care providers continue to use a two-step approach to screen for and diagnose GDM.

As of 2017, the ADA continues to recognize that there is an absence of clear evidence that supports the IADPSG-recommended approach versus the more traditional two-step screening approach

ACOG supports the two-step process

DIAGNOSIS

STEP ONE:

ACOG recommends choosing 135 mg/dL or 140 mg/dL as the cutoff.

More than 80% of women with values ≥200 mg/dL will fail the three-hour glucose tolerance test (GTT), so many use this cutoff as meeting the diagnosis of GDM

DIAGNOSIS

In the absence of clear comparative trials, one set of diagnostic criteria for the 3-hour OGTT cannot be clearly recommended over the other.

The Carpenter–Coustan stricter criteria increase by about 50% the number of women with a diagnosis of GDM compared to the NDDG criteria, and these pregnancies have elevated incidences of macrosomia and neonatal insulinemia

DIAGNOSIS

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Women who have even one abnormal value on the 100-g 3-hour OGTT have a significantly increased risk of adverse perinatal outcomes compared with women with no GDM.

DIAGNOSIS

ANTEPARTUM TREATMENT

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INSULIN

30% end up needing medications

Oral antidiabetic medications (e.g., metformin and glyburide) increasingly are being used among women with GDM, despite the fact that they have not been approved by the U.S. Food and Drug Administration for this indication and even though insulin continues to be the ADA-recommended first-line therapy.

ANTEPARTUM TREATMENT

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METFORMIN may be a reasonable second-line approach to

treat gestational diabetes after Insulin

Limitations of Metformin

-increased preterm birth

-placental transfer of the drug

-lack of long-term data in exposed offspring.

-between 26% and 46% of women who took metformin alone eventually required insulin

ANTEPARTUM TREATMENT

METFORMIN

Check baseline renal function

Starting dose 500 mg with meal

Maximum dose 3000 mg

Common side effects involve GI tract

In women whose total insulin dose is ≥1.12 IU/kg, the addition of metformin has been shown to improve glycemic control, decrease maternal hypoglycemia, reduce neonatal hypoglycemia and decrease NICU admission

ANTEPARTUM TREATMENT

METFORMIN

In women with polycystic ovary syndrome, metformin is often continued until the end of the first trimester, despite only limited evidence to suggest that such use decreases the risks of adverse pregnancy outcomes, including first-trimester loss

ANTEPARTUM TREATMENT

GLYBURIDE

This drug should NOT be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin or metformin

ANTEPARTUM TREATMENTGlibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis.

GLYBURIDE

Avoid in patients with sulfa allergy

Dose 2.5-20 mg/day

4-16% treatment failure

ANTEPARTUM TREATMENT

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ANTEPARTUM TESTING

Initiate at 32 weeks

Indicated for GDMA2 and pregestational DM

FETAL GROWTH US in late third trimester

ANTEPARTUM TREATMENT

Timing of delivery

GDMA1 39-41 weeks

GDMA2 39-39 6/7 weeks

Uncontrolled GDM/DM 34-39 weeks

ANTEPARTUM TREATMENT

CESAREAN FOR MACROSOMIA

it appears reasonable to recommend that women with GDM should be counseled regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 gm or more

INDUCTION FOR MACROSOMIA

ACOG does not recommend induction prior to 39 weeks for suspected fetal macrosomia.

ANTEPARTUM TREATMENT

PTL

Avoid beta-mimetic as tocolytic

Steroids for FLM up to 37 weeks

Wait 7 days prior to offering GCT

ANTEPARTUM TREATMENT

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Glucose monitoring in GDMA2 Q 4-6 hrs

Unlike in DM-I, Insulin gtt not necessary in most patients with GDM

Target intrapartum glucose 70-120 mg/dl

INTRAPARTUM CARE

SCHEDULED CESAREAN SECTIONS

Schedule in the morning

Only reduce the nighttime long acting Insulin dose by 50%

Hold Insulin or oral hypoglycemic in the morning

Avoid D5 bolus prior to regional block

1/3 dose of long/intermediate acting insulin given in the morning with D5 gtt if surgery scheduled in the afternoon

INTRAPARTUM CARE

Induction of labor

Schedule in morning

Use 50% of nighttime dose of long acting insulin

Light breakfast

Reduce morning insulin dose by 50%

INTRAPARTUM CARE

Encourage early breast feeding

Check FBS for 24-72 hours

Avoid BS >180 mg/dl

Don’t need insulin or oral hypoglycemic

75 g OGTT/FBS/A1C at 4-12 weeks postpartum visit

POSTPARTUM CARE

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Thanks