GDM 2011
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Transcript of 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
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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.
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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.
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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:
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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.
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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
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RISK FACTORS OF GDM
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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
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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
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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
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Screening
Source : CPG MX of DM 4th edition
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)
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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
Source : CPG MX of DM 4th edition
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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
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Targets
Timing Level (mmol/l)
Pre breakfast 3.5 – 5.9
Pre prandial 3.5 – 5.9
Post prandial < 7.8
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Source : CPG MX of DM 4th edition
The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study
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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
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Definition of Diabetes and Pregnancy
Known case of diabetes patient if pregnant is not known as GDM
Diabetes mellitus and pregnancy
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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
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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
26Source: NICE guideline 2008-DM in Pregnancy
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.
27Source: NICE guideline 2008-DM in Pregnancy
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
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ROLE OF ORAL ANTIDIABETIC IN PREGNANCY
The American College of Obstetricians and Gynecologists has not recommended these agents during pregnancy
Glyburide/ GlibenclamideMetformin
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Timing of Delivery
Diet control allow up to EDD and then IOL
Insulin therapyIOL at 38 weeksIf complications anticipated---ELLSCS
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Intrapartum Management
On diet control manage as normal labour
On insulin therapy insulin infusion sliding scale +
dextrose/potassium maintenance
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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
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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
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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)
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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.
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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
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Complications – intrapartum
MOTHER
Polyhydramnions Obstructed labour Increase risk of
operative interventions
FETUS
Macrosomic baby birth injury Polyhydramnions unstable lie abruptio placenta
during ROM
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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
Hospital Pakar Sultanah Fatimah 2011 42
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.
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NICE Clinical Guideline. Diabetes in Pregnancy March 2008 Gestational Diabetes Mellitus: NICE for the U.S.? Diabetes Care 33:34–37, 2010
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thank you…Hospital Pakar Sultanah Fatimah 2011 45