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    GDMA Doctors PrayerDear Lord, You are the greatest Healer,

    All life and health comes from YouWithout Your blessings and Your grace,

    There is nothing I can do,

    I thank You for this noble role,

    My service unto Thee,Stand by me with my patients,

    Til the work is done daily.

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    GDMA Doctors PrayerGive me knowledge, wisdom and skill

    To do the tasks at hand,Provide the best care needed

    For each persons best interest, stand

    Let me lend a helping hand

    To those who cannot pay,Bringing good health to all

    Send them fit for homewards way.

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    GDMA Doctors PrayerProtect with Your mighty angels,

    Those under my care,When their need of me is greatest,

    May I always be there.

    When my zeal is at its lowest,

    Tiredness meeting me at every turn,May you then be my Healer,Renewed joy and vigor earn.

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    GDMA Doctors PrayerAll this I ask from You Lord,That I may a good doctor be,

    That in my life as a physician,May they see You in me.

    Amen.

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    GDM

    Diabetes Mellitus

    in Pregnancy

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    GDMDiabetes Mellitus 9th leading cause of death in the Philippines

    1 out of 25 Filipinos

    3.36 million Filipinos, 8 million in about 20

    years.

    2.8 million diagnosed DM (1997 Food and NutritionResearch Institute survey, DOH)

    2.1% deaths (1993 to 1997) 2.5 percent increase annually

    Diabetes on the Rise among Filipinos, www.bio-medicine.org/medicine-news/Diabetes-on-the-Rise-among-Filipinos-15022-1/6

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    GDM Incidence (annual) of Gestational

    diabetes:

    135,000 pregnant women every year

    3-5% of pregnant women.

    Incidence Rate for Gestational diabetes:

    approx 1 in 2,014

    0.05%

    135,000 people in USA

    Statistics by Country for Gestational diabetes,

    http://www.cureresearch.com/g/gestdiab/stats-country.htm7

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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Gestational diabetes in North America

    USA 145,748 293,655,4051

    Canada 16,134 32,507,8742

    Gestational diabetes in EuropeAustria 4,057 8,174,7622

    Belgium 5,136 10,348,2762

    Britain (United Kingdom) 29,913 60,270,708 for UK2

    Czech Republic 618 1,0246,1782

    Denmark 2,686 5,413,3922

    Finland 2,588 5,214,5122

    France 29,989 60,424,2132

    Greece 5,284 10,647,5292

    Germany 40,909 82,424,6092

    Iceland 145 293,9662

    Hungary 4,979 10,032,3752

    Liechtenstein 16 33,43628

    http://www.cureresearch.com/risk/geography.htmhttp://www.cureresearch.com/risk/geography.htm
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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Ireland 1,970 3,969,5582

    Italy 28,815 58,057,4772

    Luxembourg 229 462,6902

    Monaco 16 32,2702

    Netherlands (Holland) 8,099 16,318,1992

    Poland 19,171 38,626,3492

    Portugal 5,223 10,524,1452

    Spain 19,992 40,280,7802

    Sweden 4,460 8,986,4002

    Switzerland 3,698 7,450,8672

    United Kingdom 29,913 60,270,7082

    Wales 1,448 2,918,0002

    Gestational diabetes in the Balkans

    Albania 1,759 3,544,8082

    Bosnia and Herzegovina 202 407,6082

    Croatia 2,231 4,496,86929

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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Macedonia 1,012 2,040,0852

    Serbia and Montenegro 5,373 10,825,9002

    Gestational diabetes in AsiaBangladesh 70,150 141,340,4762

    Bhutan 1,084 2,185,5692

    China 644,648 1,298,847,6242

    East Timor 505 1,019,2522

    Hong Kong s.a.r. 3,402 6,855,1252

    India 528,619 1,065,070,6072

    Indonesia 118,349 238,452,9522

    Japan 63,198 127,333,0022

    Laos 3,011 6,068,1172

    Macau s.a.r. 221 445,2862

    Malaysia 11,674 23,522,4822

    Mongolia 1,365 2,751,3142

    Philippines 42,803 86,241,697210

    http://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htm
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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Papua New Guinea 2,690 5,420,2802

    Vietnam 41,027 82,662,8002

    Singapore 2,160 4,353,8932

    Pakistan 79,012 159,196,3362

    North Korea 11,265 22,697,5532

    South Korea 23,939 48,233,7602

    Sri Lanka 9,879 19,905,1652

    Taiwan 11,291 22,749,8382

    Thailand 32,194 64,865,5232

    Gestational diabetes in Eastern Europe

    Azerbaijan 3,905 7,868,3852

    Belarus 5,117 10,310,5202

    Bulgaria 3,731 7,517,9732

    Estonia 665 1,341,6642

    Georgia 2,329 4,693,8922

    Kazakhstan 7,516 15,143,704211

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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Latvia 1,144 2,306,3062

    Lithuania 1,790 3,607,8992

    Romania 11,095 22,355,5512

    Russia 71,457 143,974,0592

    Slovakia 2,691 5,423,5672

    Slovenia 998 2,011,473 2

    Tajikistan 3,480 7,011,556 2

    Ukraine 23,690 47,732,0792

    Uzbekistan 13,108 26,410,4162

    Gestational diabetes in Australasia and Southern Pacific

    Australia 9,883 19,913,1442

    New Zealand 1,982 3,993,8172

    Gestational diabetes in the Middle East

    Afghanistan 14,152 28,513,6772

    Egypt 37,778 76,117,4212

    Gaza strip 657 1,324,991212

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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Iran 33,503 67,503,2052

    Iraq 12,594 25,374,6912

    Israel 3,076 6,199,0082

    Jordan 2,784 5,611,2022

    Kuwait 1,120 2,257,5492

    Lebanon 1,874 3,777,2182

    Libya 2,795 5,631,5852

    Saudi Arabia 12,803 25,795,9382

    Syria 8,942 18,016,8742

    Turkey 34,193 68,893,9182

    United Arab Emirates 1,252 2,523,9152

    West Bank 1,147 2,311,2042

    Yemen 9,938 20,024,8672

    Gestational diabetes in South America

    Belize 135 272,9452

    Brazil 91,373 184,101,109213

    http://www.cureresearch.com/risk/south_america.htmhttp://www.cureresearch.com/risk/south_america.htm
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    GDMCountry/Region Extrapolated Incidence Population Estimated Used

    Chile 7,853 15,823,9572

    Colombia 20,999 42,310,7752

    Guatemala 7,087 14,280,5962

    Mexico 52,093 104,959,5942

    Nicaragua 2,660 5,359,7592

    Paraguay 3,072 6,191,3682

    Peru 13,670 27,544,3052

    Puerto Rico 1,934 3,897,9602

    Venezuela 12,416 25,017,3872

    Gestational diabetes in Africa

    Angola 5,448 10,978,5522

    Botswana 813 1,639,2312

    Central African Republic 1,857 3,742,4822

    Chad 4,734 9,538,5442

    Congo Brazzaville 1,487 2,998,0402

    Congo kinshasa 28,944 58,317,030214

    http://www.cureresearch.com/risk/africa.htmhttp://www.cureresearch.com/risk/africa.htm
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    GDM MOST COMMON endocrine disorder in

    pregnancy

    90 to 95%: GDM

    MOST COMMON medical complicationof pregnancy

    In 2002, 131, 000 American women with

    pregnancies complicated by diabetes 3.3 % of all live births

    > 90% : Gestational diabetes

    Textbook of Obstetrics 3rd

    edition, Sumpaico et al.Martin and colleagues, 2003, Williams Obstetrics.15

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    GDMGlucose Intolerance in Pregnancy

    16

    Prevalenceof GDM 3 to 18 %

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    GDMNormal Regulation of PlasmaGlucose

    Hepaticinsulin response Muscle/fatinsulin response

    Controlled

    glucose production

    Controlled

    glucose clearance

    Insulinsecretion

    Normalplasma glucose

    12

    Glucose enters

    peripheral tissues

    Glucose enters

    the blood

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    GDMHyperglycemiaThe Defining Feature of Diabetes

    Hyperglycemia

    Excessive

    glucose productionImpaired

    glucose clearance

    Tissue injury

    1

    g

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    GDM

    Hyperglycemia

    a ogenes s o ypeDiabetesOne Defect

    Unrestrained

    glucose production

    Impaired glucose

    clearance

    No hepatic

    insulin effect

    No muscle/fat

    insulin effect

    Absentinsulinsecretion

    Glycosuria 13

    More glucose enters

    the blood

    Less glucose enters

    peripheral tissues

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    GDMPathogenesis of GDM Pregnancy is a state of INSULIN

    RESISTANCE Insulin Resistance (IR), cell stimulation

    50 to 70% lower (INSULIN ACTION) vs. healthynon-pregnant women

    Butte, 2000: Williams Obstetrics

    Normal pregnancy

    Mild fasting hypoglycemia Postprandial hyperglycemia

    Hyperinsulinemia

    20

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    GDMPathogenesis of GDM Increased basal level of insulin with

    unique responses to glucose ingestion:

    Prolonged hyperglycemia andhyperinsulinemia

    Suppression of glucagonperipheral resistance to insulin

    Sustained postprandial glucose supplyto the fetus

    Phelps and associates, 1981: Williams Obstetrics.

    21

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    GDMPathogenesis of GDM & Sustained glucose levels

    fasting

    plasma glucose & amino acids (alanine)

    Free FA, TG, Chol

    ACCELERATED STARVATION

    Pregnancy-induced switch of fuels fromglucose to lipids

    Risk for Ketonemia

    Freinkel and colleagues, 1985: Williams Obstetrics22

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    GDMPathogenesis of GDM

    Placental Diabetogenic Hormones:

    Progesterone and estrogen Direct or indirect mediators

    Cortisol

    GH

    Human Placental Lactogen (HPL) Growth-hormone like action increased lipolysis

    with liberation of free fatty acids insulinresistance

    Prolactin Freinkel, 1980: Williams Obstetrics 23

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    GDMPathogenesis of GDM Reduced Insulin Sensitivity up to 80%

    Impaired 1st phase insulin,Hyperinsulinemia

    Islet cell auto antibodies (2 to 25% cases)

    Glucokinase mutation in 5% of cases

    www.drsarma.in 24

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    GDMFundamental Defect in GDM

    The hormones of pregnancy cause IR

    They also cause direct hyperglycemia

    But, the basic defect is The maternal pancreatic cells are unable

    to compensate for this increased demand

    25

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    GDMNormal Glucose Tolerance

    www.drsarma.in 26

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    GDMAbnormal GT in GDM

    www.drsarma.in 27

    N t l Hi t Of P T 1

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    GDMPutativetrigger

    Circulating autoantibodies (ICA, GAD65)

    Cellular autoimmunity

    Loss of first-phaseinsulin response (IVGTT)

    Glucose intolerance(OGTT)

    Clinicalonsetonly10% of

    -cellsremain

    Time

    -Cellmass 100%

    Pre-diabetes

    Geneticpredisposition

    Insulitis-Cell injury

    Eisenbarth GS. N Engl J Med. 1986;314:1360-1368

    Diabetes

    Natural History Of PreType 1Diabetes

    14

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    GDMGDM - Definition CARBOHYDRATE INTOLERANCE of

    variable severity with onset of firstrecognition during pregnancy.

    Regardless of:

    insulin use or

    persistence after pregnancy.

    Does not exclude unrecognized glucoseintolerance antecedent to pregnancy

    Williams ObstetricsTextbook of Obstetrics 3rd edition, Sumpaico et al. 29

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    GDMGDM - Definition Distinguish GDM from Pre-gestational DM

    Abnormal Glucose Tolerance

    Onset (begins) with pregnancy or Detected first time during pregnancy

    No h/o of pre pregnancy DM

    Hb A 1 c is usually < 7.5 in GDM In DM + Pregnancy it is > 7.5

    GDM is a forerunner of T2DM

    30

    Cl ifi ti f Di b t

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    GDMClassification of Diabetes(Powers, 2001)

    ABSOLUTE INSULIN DEFICIENCY

    Type 1 Diabetes

    DEFECTIVE INSULIN SECRETION

    OR

    DEFECTIVE INSULIN RESISTANCE Type II Diabetes

    31

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    GDMEtiological Classification of Diabetes Mellitus

    Type 1 A Immune-mediated -cell destruction

    Type 1 B Idiopathic -cell destruction

    Type 2 May range from predominantly insulin resistance topredominantly an insulin secretory defect with insulin resistance

    Genetic mutations in -cell function

    Genetic defects in insulin action

    Genetic syndromesDown, Klinefelter, Turner

    Diseases of the exocrine pancrease.g., pancreatitis, cystic fibrosis

    Endocrinopathiese.g., Cushing syndrome, pheochromocytoma, others

    Drug or chemical inducede.g., glucocorticosteroids, thiazides, -adrenergicagonists, others

    Infectionse.g., congenital rubella, cytomegalovirus, coxsackievirus

    Adapted from Powers 2001 32

    Cl ifi ti f Di b t

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    GDMClassification of Diabetes(Powers, 2001)

    Insulin Dependent Diabetes Mellitus(IDDM)

    Noninsulin-dependent Diabetes Mellitus(NIDDM)

    AGE

    33

    -cell destruction: ANY AGEMost common onset: < 30 years old

    5 to 10%- >30 years oldType 2 diabetes- most typical with increasing age but

    also occurs in OBESE ADOLESCENTS

    Cl ifi ti D i P

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    GDMClassification During Pregnancy(ACOG, 1986)

    Class Onset Fasting PlasmaGlucose

    2-hourPostprandial

    Glucose

    Therapy

    A1 Gestational < 105 mg/dL < 120 mg/dL Diet

    A2 Gestational > 105 mg/dL > 120 mg/dL Insulin

    Class Age of Onset (yr) Duration(yr)

    Vascular Disease Therapy

    B Over 20 < 10 None Insulin

    C 10 to 19 10 to 19 None Insulin

    D Before 10 > 20 Benign

    retinopathy

    Insulin

    F Any Any Nephropathy* Insulin

    R Any Any Proliferativeretinopathy

    Insulin

    H Any Any Heart Insulin

    * When diagnosed during pregnancy: 500 mg or more proteinuria per 24 hoursmeasured before 20 weeks gestation. 34

    REPLACED1994, ACOGA single classification based on the presence or absence of good

    maternal metabolic control and the presence or absence of maternaldiabetic vasculopathy is more helpful

    15 % of women with GDM exhibit FASTING HYPERGLYCEMIA.Sheffield & co-workers, 1999

    Classes B to H: WHITE CLASSIFICATION (1978)-OVERT DIABETES antecedent to pregnancy

    -END-ORGAN DERANGEMENT

    Di i

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    GDMDiagnosis:OVERT DIABETES

    CRITERIA FOR DIAGNOSIS (AmericanDiabetes Association, 2004):

    1. Fasting plasma glucose of >125 mg/dL

    2. Glucosuria

    3. Ketoacidosis

    4. Random plasma glucose level >200 mg/dL

    5. Presence of Classic signs & symptoms: Polydypsia, Polyphagia, polyuria, unexplained weight loss

    6. High index of suspicion Strong family history, previous delivery of large infants,

    unexplained fetal losses, persistent glucosuria

    35

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    GDMScreening: 30 years of research

    NO CONSENSUS regarding the OPTIMALAPPROACH to SCREENING

    Issues:

    UNIVERSAL SCREENING

    SELECTIVE SCREENING

    Plasma glucose level after 50-gm glucosetesting

    36Bonomo and colleagues, 1998; Danilenko-Dizon and colleagues, 1999:

    Williams Obstetrics

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    GDMScreening Since 1980

    4 international work-shop conferences

    Consensus statements on screening Metzger and Coustan, 1998

    37

    R d d S i S B d Ri k

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    GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

    Low Risk Blood glucose testing NOT ROUTINELY required if

    all of the following characteristics are present:

    Member of ethnic group with a low prevalence forgestational diabetes

    (-) DM in first degree relatives

    Age < 25 years

    Weight normal before pregnancy No history of abnormal glucose metabolism

    No history of poor obstetrical outcome

    38Adopted from ADA guidelinesMetzger and Coustan, 1998

    R d d S i St t B d Ri k

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    GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

    Average Risk Blood glucose testing at 24 to 28 WEEKS using one of

    the following:

    AVERAGE RISK: Woman of HISPANIC, AFRICAN, NATIVE

    AMERICAN, SOUTH OR EAST ASIAN GROUP

    HIGH RISK:

    Women with marked obesity, strong family history oftype 2 diabetes, prior gestational diabetes, or glucosuria

    Metzger and Coustan, 1998 39Adopted from ADA guidelines

    R d d S i St t B d Ri k

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    GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

    HIGH Risk

    Perform blood glucose testing as soon asfeasible.

    If gestational diabetes is not diagnosed, bloodglucose testing should be repeated at 2428weeks or at any time a patient has symptoms

    or signs suggestive of hyperglycemia

    Metzger and Coustan, 1998 40Adopted from ADA guidelines

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    GDMRisk Stratification for GDM

    High Risk Group (Indians mostly)

    BMI 30; PCOD; Age > 35 years

    F h/o DM; Ethnic predisposition; Acanthosis

    Previous h/o GDM, IGT, Macrosomic baby

    Low Risk Group

    Age < 25, BMI < 23, No F h/o DM or IGT

    No bad obstetric history; No risk ethnicity

    Intermediate Risk Group

    Not falling in the above two classes41Adopted from ADA guidelines

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    GDMScreening 1997 Workshop

    SELECTIVE SCREENING

    1. 24 to 28 weeks AOG

    2. Women with no known glucose intoleranceearlier in pregnancy

    3. Do a 1-step or a 2-step procedure

    42

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    GDMScreening ACOG, 2001

    Selective screening in some clinical settingsand universal screening in others

    Brody and colleagues, 2003

    Insufficient to recommend for or against

    screening.

    43

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    GDMScreening 1-step procedure

    FBS

    75-gm glucose

    Extract another blood sample 2 hours afterglucose ingestion

    Diagnostic of GDM:

    FBS > 105 mg% 2-hour postglucose value >140mg%

    Textbook of Obstetrics 3rd edition, Sumpaico et al.

    Martin and colleagues, 2003, Williams Obstetrics.44

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    GDMScreening 2-step procedure

    50-g OGTT followed by diagnostic 100g- OGTT ifresults exceed a predetermined plasma glucose level.

    Plasma glucose level is measured 1-hour after a 50-gOGTT without regard to TIME OF DAY or TIME OFLAST MEAL (GLUCOSE CHALLENGE TEST)

    >140 mg/dL (7.8 mmol/L)= identifies 80% of GDM

    14 to 18%- positive test >130 mg/dL (7.2 mmol/L)= identifies 90% of GDM

    20-25%- positive test

    45

    Textbook of Obstetrics 3rd edition, Sumpaico et al.

    Martin and colleagues, 2003, Williams Obstetrics.

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    GDMGDM Two Step Screening Two Step Screening

    Do a Random Glucose Challenge Test (GCT)

    50 grams of oral glucose any time of day

    1 hour post test for plasma glucose (1 hr PG)

    Result > 180 mg% - Dx of GDM confirmed

    Result > 140 mg% - Dx of GDM suspected

    140 to 180 We need OGTT (100 g) to confirm

    One Step Screening

    OGTT 3 hours after 100 g of oral glucose

    46

    Table 524. American College of Obstetricians and Gynecologists 2001

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    GDMg y g

    Criteria for Diagnosis of Gestational Diabetes Using the 100-g OralGlucose Tolerance Test

    Plasma/SerumCarpenter and Coustan

    National DiabetesPlasma Data Group

    Status mg/dL mmol/L mg/dL mmol/L

    Fasting 95 5.3 105 5.8

    1- hour 180 10.00 190 10.6

    2-hour 155 8.6 165 9.2

    3-hour 140 7.8 145 8.0

    47

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    GDMGlucose Challenge Test (GCT)

    < 140

    No GDMrepeat 24 wk

    140 to 180

    Need to doOGTT 3 hr

    180+

    GDM

    confirmed

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    GDMOGTT100g3 hour Test

    Test sample timing Plasma Glucose value

    Fasting (mg%) 95

    1 hour (mg%) 180

    2 hour (mg%) 155

    3 hour (mg%) 140

    www.drsarma.in 49

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    GDMPlease be specific Do not use the loose word Blood Sugar

    Be specific to measure Plasma Glucose

    Always venous sample for OGTT No capillary blood testing for OGTT

    NaF to be added as anticoagulant to blood

    Centrifuge to separate plasma immediately Plasma glucose to be estimated a.s.a.p

    Glucometer can be used for monitoring

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    GDMDiagnosis: NO international agreement: optimal

    OGTT for definitive diagnosis of GDM

    WHO, Europe

    75-g 2-hour OGTTWeiss and collegues, 1998

    US, ACOG, 2001 100g- 3 hour OGTT after an overnight fast

    remains the standard

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    GDMMaternal & Fetal Effects Adverse maternal effects:

    Increased frequency of hypertension and cesareansection

    Maternal deaths are uncommon but the risk isincreased 10x. (Cousins, 1987)

    Due to ketoacidosis, hypertension, preeclampsia andpyelonephritis.

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    GDMMaternal Effects: Diabetic Nephropathy

    Leading cause of end-stage renal failure inthe US

    30% for type 1 diabetes and 4 to 20 %- type 2diabetes

    25% decrease in nephropathy for each 10%

    decrease in hemoglobin A1Clevels. (DiabetesControl and Complications Trial, 2002)

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    GDMMaternal Effects: Diabetic Nephropathy

    Clinically detectable nephropathy begins withMICROALBUMINURIA

    30 to 300 mg/24 h of albumin manifest as early as 5 years after the onset of diabetes

    (Nathan, 1993).

    OVERT PROTEINURIA After another 5 to 10 years

    more than 300 mg/24 h of albumin

    Hypertension invariably develops

    RENAL FAILURE ensues typically in the next 5 to 10 years.

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    GDMMaternal Effects: Diabetic Nephropathy

    5 % with diabetes are class FHanson and Persson, 1993; Siddiqi and associates, 1991)

    increased preeclampsia and indicated preterm delivery

    Proteinuria >500 mg/day

    38 percent developed preeclampsia.

    Microproteinuria >190 to 500 mg/day

    increased risk of preeclampsia.

    Chronic hypertension with diabetic nephropathy increased the risk of preeclampsia to 60 percent.

    Heavy proteinuria before 20 weeks

    Chronic renal insufficiency as well as were predictive ofpreeclampsia.

    Gordon and associates (1996)55

    G

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    GDMMaternal Effects: Diabetic Retinopathy

    Diabetic Neuropathy

    Pre-eclampsia Ketoacidosis

    Infections

    56

    GDM

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    GDMNeonatal Effects Macrosomia of the baby

    CPD Shoulder Dystocia

    Intrapartum Trauma Feto-maternal Congenital Anomalies, HCM

    Neonatal Hypoglycemia

    Neonatal Hypocalcemia Neonatal Hyperbilirubinemia

    Respiratory Distress Syndrome (RDS)

    Pol c themia secondar in the new bornwww.drsarma.in 57

    GDM

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    GDMMacrosomia Birth weight > 4500 g - 90th percentile GA

    Intrapartum feto-maternal trauma

    Increased need for C- Section

    20 30% of infants of GDM Macrosomic

    Maternal factors for Macrosomia

    Uncontrolled Hyperglycemia Particularly postprandial hyperglycemia

    High BMI of mother

    Older maternal age, Multiparity58

    GDM

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    GDMMacrosomic Newborn

    59

    GDM

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    GDMShoulder Dystocia

    60

    Erbs palsy

    GDMM i

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    GDMMacrosomia

    GDM Non DM P value

    Birth Weight 3512 g 3333 g < 0.05

    LGA 40.4% 13.7% < 0.001

    Macrosomia 32.0% 11.0% < 0.01

    GDM

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    GDMNeonatal Hypoglycemia Due to fetal hyperinsulinemia

    Neonatal plasma glucose < 30 mg%

    Poor glycemic control before delivery Increases perinatal morbidity

    Congenital anomalies 3 to 8 times more

    More if periconception hyperglycemia Assoc. maternal fasting hyperglycemia

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    GDM

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    GDMMinor Adverse Health Effects

    Birth Wt (g) 330364 364951 384972

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    GDMCNS 6.4% 18.4%

    Congenital heart disease 7.5% 21.0%

    Respiratory disease 2.9% 7.9%

    Intestinal atresia 0.6% 2.6%

    Anal atresia 1.0% 2.6%

    Renal & Urinary defect 3.1% 11.8%

    Upper limb deficiencies 2.3% 3.9%Lower limb deficiencies 1.2% 6.6%

    Upper + Lower spine 0.1% 6.6%

    Caudal digenesis 0.1% 5.3%

    Normal DM

    Major Adverse Health Effects

    GDMC

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    GDMNeonatal Complications

    T. hypoglycemia(%) 52 28 3

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    GDMCongenital Anomalies - DM Control

    Maternal HbA1c levels

    < 7.2 Nil

    7.2-9.1 14%9.2-11.1 23%

    > 11.2 25%

    Critical periods - 3-6 weeks post conception

    Need pre-conceptional metabolic care

    GDML t ff t th ff i

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    GDMLate effects on the offspring Increased risk of IGT

    Future risk of T2DM

    Risk of Obesity

    67

    GDMM t

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    GDMManagement: Insulin therapy

    Diet

    Exercise Oral anti-diabetic drugs

    68

    GDMGDM Gl i T t

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    GDMGDM Glycemic Targets

    Recommended values for Glycemic Targets

    Pre-pregnancy Hb A1c 7.00 (if possible 6.00)

    Pregnancy values Range

    FPG 70 - 95

    1 hr PPG 100 140

    2 hr PPG 90 120

    Hb A1c 6.00

    69

    GDM

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    GDM American Diabetes Association (2000)

    nutritional counseling with individualization basedon height and weight

    average of 30 kcal/kg/d based on prepregnant bodyweight for nonobese women.

    obese women with a body mass index greater than 30kg/m2

    may benefit from a 30- to 33-percent caloricrestriction.

    Monitored weekly tests- ketonuria maternal ketonemia has been linked with impaired

    psychomotor development in the offspring

    (Rizzo and colleagues, 1995).70

    GDMB d M I d d

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    GDM

    71

    Body Mass Index andRecommended Weigh Gain

    Pre-pregnant weight

    statusRecommended

    range of weight gain

    A. Twin Pregnancy 35-45 lbs

    B.Underweight(BMI 30.0) 15 lbs

    GDMGDM d MNT

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    GDMGDM and MNT Two weeks trial of Medical Nutrition Therapy

    Pre-pregnancy BMI is a predictor of the efficacy

    If target glycemia is not achieved initiate insulin

    MNT extra 300 calories in 2 and 3rd trimesters

    Calories 30 kcal/kg/day = 1800 kcal for 60 kg

    If BMI > 30; then only 25 kcal/kg/day

    3 meals and 3 snacks avoid hypoglycemia 50% of total calories as CHO, 25% protein & fat

    Low glycemic, complex CHO, fiber rich foods

    72

    GDMDi t th i GDM

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    GDMDiet therapy in GDM

    Small, frequent meals

    Avoid eating for two Avoid fasts and feasts

    Avoid health drinks

    Eat a bedtime snack

    GDMTi f di t t

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    GDMTips for diet management

    Small breakfast

    Mid morning snack

    High protein lunch

    Mid afternoon snack

    Usual dinner Bed time snack

    GDMGDM and E ercise

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    GDMGDM and Exercise Recumbent bicycle

    Upper body egometric exercises

    Moderate exercises

    Mother to palpate for uterine contractions

    Walking is the simplest and easiest

    Continue pre pregnancy activity Do not start new vigorous exercise

    75

    GDMInsulin Therapy

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    GDMInsulin Therapy Usually recommended when standard

    dietary management does not consistentlymaintain:

    FBS at

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    GDMGDM and Insulins In 10 to 15% of GDM, MNT fails Start on insulin

    Good glycemic control No increased risk

    Human Insulins only Not Analogs

    Daily SMBG up to 7 times! Insulin Glargine (Lantus) Not to be used at all

    Insulin Lispro tested and does not cross placenta

    Insulin Aspart not evaluated for safty CSII may be needed in some cases

    Oral drugs not recommended (SU?, Metformin?)

    77

    GDMInsulin Regimen

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    GDMInsulin Regimen If MNT fails after 2 - 4 weeks of trial

    Initiate Insulin + Continue MNT

    Dose: 0.7, 0.8 and 0.9 u/kg 1, 2 & 3 trim.

    Eg. 1st trim 64 kg = 0.7 x 64 = 45 units

    Give 2/3 before BF = 30 units of 30:70 mix

    Give 1/3 before supper = 15 u of 50:50 mix

    Increase total dose by 2-4 units based on BG

    After BG levels stabilize monitor till term

    www.drsarma.in 78

    GDMGDM and Delivery

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    GDMGDM and Delivery Delivery until 40 weeks is not recommended

    Delivery before 39th week assess thepulmonary maturity by phosphatase test on

    amniocentesis fluid C - Section may be needed (25 -30%)

    Be prepared for the neonatal complications

    Assess the mother after delivery for glycemia May need to continue insulin for a few days

    Pre-gestational DMInsulin (30% less) or OAD

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    GDMThank You!

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    GDMThank You!