Diabetes in Pregnancy

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Diabetes in Pregnancy. Ass. Pro. : S. Rouholamin. Objectives. Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM in Pregnancy Discuss long term followup of Gestational Diabetes Mellitus (GDM) Discuss needs of pre-existing diabetes in pregancy. - PowerPoint PPT Presentation

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  • Diabetes in PregnancyAss. Pro. : S. Rouholamin

  • ObjectivesDiscuss Gestational Diabetes Mellitus (GDM) and TreatmentRecognize common problems of GDM in PregnancyDiscuss long term followup of Gestational Diabetes Mellitus (GDM)Discuss needs of pre-existing diabetes in pregancy

  • Gestational Diabetes Mellitus

  • Gestational DiabetesReduced sensitivity to insulin in 2nd and 3rd trimestersDiabetogenic State when insulin production doesnt meet with increased insulin resistanceHod and Yogev Diabetes Care 30:S180-S187, 2007Crowther, et al NEJM 352:24772486, 2005 Langer, et al Am J Obstet Gynecol 192:989997, 2005

  • Gestational DiabetesHuman placental lactogen, leptin, prolactin, and cortisol result in insulin resistanceLack of diagnosis and treatment-increased risk of perinatal morbidities

    Hod and Yogev Diabetes Care 30:S180-S187, 2007Crowther, et al NEJM 352:24772486, 2005 Langer, et al Am J Obstet Gynecol 192:989997, 2005

  • Gestational Diabetes

    Occurs in 2-9% of pregnancies

    ~135,000 cases in U.S. annually

    Management can include insulin (usually preferred, better efficacy) or sulfonylureas (in very select cases)

    Am J Obstet Gynecol 192:17681776, 2005Diabetes Care 31(S1) 2008 Diabetes Care 25:1862-1868, 2002

  • Gestational Diabetes and Type 2 Diabetes RiskGestational Diabetes should be considered a pre-diabetes conditionWomen with gestational diabetes have a 7-fold future risk of type 2 diabetes vs.women with normoglycemic pregnancyLancet, 2009, 373(9677): 1773-9

  • Gestational Diabetes-ScreeningScreen all very high risk and high riskVery high risk: Previous GDM, strong FH, previous infant >9lbsHigh risk: Those not in very high risk or low risk category

  • Gestational Diabetes-ScreeningLow Risk (all of following)Age
  • Low Risk (all of following)(contd)No known diabetes in first-degree relativesNo history of abnormal glucose toleranceNo history of poor obstetrical outcomeGestational Diabetes-ScreeningDiabetes Care 31(S1) 2008

  • Gestational Diabetes Screening2 step approach oral glucose tolerance test (OGTT)1) 50gm 1 hour OGTT

    2) 100gm 2 hour OGTT

  • Gestational Diabetes-ScreeningGDM screening at 2428 weeks:

    Two-step approach: 1) Initial screening: plasma or serum glucose 1 h after a 50-g oral glucose load

    Glucose threshold 140 mg/dl identifies 80% of GDM130 mg/dl identifies 90% of GDM

    Diabetes Care 31(S1) 2008

  • Gestational Diabetes-ScreeningGDM screening at 2428 weeks: Two-step approach (contd)2) 3 hour OGTT* (100g glucose load) Fasting: >95 mg/dl (5.3 mmol/l) 1 h: >180 mg/dl (10.0 mmol/l) 2 h: >155 mg/dl (8.6 mmol/l) 3 h: >140 mg/dl (7.8 mmol/l) *2 of 4 Diabetes Care 31(S1) 2008

  • Gestational Diabetes ManagementDieticianDiabetes EducatorConsider referral to Diabetologist or EndocrinologistModerate Physical Activity ~30 minutes daily when appropriateSummary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care 30:S251-S260, 2007

  • Glucose Control in GDMPreprandial:
  • Gestational Diabetes-MedicationsPatients who do not meet metabolic goals within one week or show signs of excessive fetal growthInsulin has been the usual first choiceSulfonylureas (glyburide) may be used in select patientsOther diabetes medications not recommended in GDM

    Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care 30:S251-S260, 2007 Langer et al N Engl J Med 343:11341138, 2000

  • Diabetes MedicationsInsulins-SafetyAspart, Lispro, NPH, R, Lispro protamine all Category B and used in pregnancyAll other insulins Category C

    Human Insulins-Least ImmunogenicBreastfeed-All insulins considered safe

    Data from Package Inserts

  • Gestational Diabetes-ManagementFasting, pre-meal, 2-hour post-prandial blood glucose probably all importantMean blood glucose >105-115, greater perinatal mortalityA1C in GDM probably not importantAm J Obstet Gynecol 192:17681776, 2005ADA Position StatementPettit, et al Diabetes Care 3:458464, 1980 Karlsson, Kjellmer Am J Obstet Gynecol 112:213220, 1972Langer, et al Am J Obstet Gynecol 159:14781483, 1988

  • Insulin Dosing-GDMInsulin dosing:Can use usual weight based dosing (i.e., 0.5 u/kg)Practical dosing can be to start 10 units NPH with evening mealMost will titrate to BID, with eventual addition of Regular or Rapid Acting BID

  • Alternate Insulin Dosing in GDMRegular or rapid acting (lispro or aspart) with meals, NPH at bedtimeNPH + Regular or rapid acting in AM, regular or rapid acting at supper, NPH at bedtimeTitrate insulin based on SBGM values, tested fasting, pre-meal, 2 hour post-meal, bedtime, occasional 3 AM.

  • GDM ComplicationsMacrosomia Fractures Shoulder dystociaNerve palsies (Erbs C5-6)Neonatal hypoglycemiaPregnancy outcomes can be very poor with HTN/nephropathy

    Gabbe, Obstetrics: Normal and Problem Pregnancies 2002

  • Gestational Diabetes: Post-natalFasting glucose rechecked 6-12 weeks following delivery Every 6 months thereafter to be screened for type 2 diabetes Higher risk of developing Type 2 Diabetes

    Kitzmiller, et al Diabetes Care 30:S225-S235, 2007

  • Metabolic changes in pregnancyLipid metabolism:Increased lipolysis (preferential use of fat for fuel, in order to preserve glucose and protein)

    Glucose metabolism:Decreased insulin sensitivity Increased insulin resistance

  • Metabolic changes in pregnancyIncreased insulin resistanceDue to hormones secreted by the placenta that are diabetogenic: Growth hormoneHuman placental lactogenProgesteroneCorticotropin releasing hormoneTransient maternal hyperglycemia occurs after meals because of increased insulin resistance

  • Diabetes in Pregnancy:Clinical implicationsFetal macrosomiaShoulder dystocia

  • Diabetes in Pregnancy: Clinical ImplicationsObstetric complications (contd.):Preterm deliveryIntrauterine fetal demiseTraumatic delivery (e.g., shoulder dystocia)Operative vaginal delivery vacuum-assisted forceps-assisted

  • Diabetes in Pregnancy: Clinical ImplicationsFetal macrosomiaDisproportionate amount of adipose tissue concentrated around shoulders and chestRespiratory distress syndromeNeonatal metabolic abnormalities:HypoglycemiaHyperbilirubinemia/jaundiceOrganomegalyPolycythemiaPerinatal mortalityLong term predisposition to childhood obesity and metabolic syndrome

  • GDM: Risk factorsMaternal age >25 yearsBody mass index >25 kg/m2Race/EthnicityLatinaNative AmericanSouth or East Asian, Pacific Island ancestryPersonal/Family history of DMHistory of macrosomia

  • GDM: DiagnosisFasting blood glucose >126mg/dL or random blood glucose >200mg/dL

    100 gm 3-hour glucose tolerance test (GTT) with 2 or more abnormal values

    Carpenter and CoustanNational Diabetes and Data Group Fasting 95 mg/dL105 mg/dL1 hour180 mg/dL190 mg/dL2 hour155 mg/dL165 mg/dL3 hour140 mg/dL145 mg/dL

  • Management:Glycemic controlGlycosylated Hemoglobin A1C (Hgb A1C) level should be less than or equal to 6%Levels between 5 and 6% are associated with fetal malformation rates comparable to those observed in normal pregnancies (2-3%)Goal of normal or near-normal glycosylated hemoglobin (Hgb A1C) level for at least 3 months prior to conceptionHgb A1C concentration near 10% is associated with fetal anomaly rate of 20-25%

  • Management:Overview Nutrition therapy Home self glucose monitoring Medical therapy if glycemic control not achieved with diet/exerciseSubcutaneous insulin Oral hypoglycemic agents (Glyburide, Metformin) Antenatal monitoring

  • Management: Glycemic ControlBlood glucose goals during pregnancy Fasting < 95mg/dL1-hr postprandial < 130-140mg/dL2-hr postprandial am < 120mg/dL2 am < 120mg/dLNocturnal glucose level should not go below 60 mg/dLAbnormal postprandial glucose measurements are more predictive of adverse outcomes than preprandial measurements

  • Management:NutritionCaloric requirements:Normal body weight - 30-35 kcal/kg/dayDistributed 10-20% at breakfast, 20-30% at lunch, 30-40% at dinner, up to 30% for snacks (to avoid hypoglycemia)Caloric composition:40-50% from complex, high-fiber carbohydrates20% from protein30-40% from primarily unsaturated fats

  • Management:Subcutaneous Insulin TherapyInsulin requirements increase rapidly, especially from 28 to 32 weeks of gestation1st trimester: 0.7-0.8 U/kg/d2nd trimester: 0.8-1 U/kg/d3rd trimester: 0.9-1.2 U/kg/d

  • Management:Oral Hypoglycemic AgentsGlitazones (Avandia, Actos)Sensitize muscle and fat cells to accept insulin more readilyDecrease insulin resistanceSulfonylureasAugment insulin release1st generationConcentrated in the neonate hypoglycemia2nd generation (Glyburide)Low transplacental transferBiguanide (Metformin, aka Glucophage)Increases insulin sensitivityCrosses placenta

  • Management Summary:Pregestational DiabetesReferral to perinatologist and/or endocrinologistMultidisciplinary approachRegular visits with nutritionistHgb A1C every trimesterFetal EchocardiogramLevel II ultrasoundOpthamologistBaseline kidney and liver function tests

  • Management Summary:Pregestational DiabetesOptimize glycemic control frequent insulin dose adjustmentsType 1: often have insulin pumpType 2: subcutaneous insulinFetal monitoring starting at 28-32 weeks, depending on glycemic controlUltrasound to assess growth at 36 weeksDelivery at 38-39 weeks

  • Management Summary:GDMBegin with die