GDM presetation

8/13/2019 GDM presetation

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Current Recommendations

Regarding Gestational

Diabetes

By Brandon Ernst

UNMC PharmD Candidate 2007Friday, January 26


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Objectives for Today

Define gestational diabetes mellitus (GDM)

Indicate possible adverse effects of GDM

Discuss diagnosing GDM

Evaluate monitoring and treatment possibilities

Reassess mother and offspring postpartum

Briefly discuss the results of the Australian

Carbohydrate Intolerance Study in PregnantWomen (ACHOIS)


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What is Gestational Diabetes?1

Gestational Diabetes Mellitus (GDM) is

glucose intolerance usually recognized

during pregnancy

GDM is thought to occur in about 7% of all

pregnancies

- Hispanic, Native, African, Asian-Americans,

and Pacific Islanders are at highest risk


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Why may GDM occur? The

Thought is that:2

1. The placenta supports the fetus as it grows byproviding hormones for development

2. These hormones block the action of themothers insulin, causing insulin resistance (3x

more insulin)3. Mothers body is unable to lower BGL, causing

hyperglycemia

4. The high BGLs remain in the blood stream,

cross the placenta, and cause the fetusspancreas to produce more insulin to regulateits own hyperglycemic environment

5. Therefore, leading to possible adverse effects


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Possible Problems in GDM2

As the baby continues in this high glycemicenvironment:- Higher glucose gives more energy than needed for

growth, causing fat storage

- Macrosomia (large body size) increases the risk ofdamage to shoulders and limbs during delivery

- Increased pancreas/insulin use in baby may causelow BGL and breathing problems at birth

- Cesarean delivery

- Risk of children developing obesity and adults withtype 2 diabetes

- Jaundice, polycythemia, and hypocalcemia at birth


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Possible Problems in GDM2

The mothers possible complications

include:

- Increased chance of cesarean delivery

- Increased frequency of maternal hypertensive

disorders

- Increase risk of developing diabetes after

pregnancy, typically type 2


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Diagnosing GDM3

Risk assessment should always be done

at first prenatal visit, especially with:

- Obese patients

- Personal history of GDM

- Glycosuria

- Strong family history

- High risk ethnic groups


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Diagnosing GDM3

All women, unless low risk, should be

tested for GDM at 24-28 weeks.

- Low risk must meet all criteria:


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Diagnosing GDM3,4

Two Different Approaches

One step approach

1. Perform a diagnostic 75 g or 100 gOGTT without any prior plasma test

This may be best for patients that cant

afford more tests or in patients that are

already at high risk


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Diagnosing GDM3,4

Two Different Approaches

Two step approach

1. Perform screen using 50 g oral glucose load

(OGL) and check BGL at 1 hour

2. If >130 mg/dL at 1 hour, retest for diagnoses

using 75 g or 100 g OGTT


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Diagnosing GDM3

The OGTT diagnosis criteria

Patient must be above the BGL at the time

interval measured

Positive result must be confirmed on a

following occasion


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Monitoring of GDM3,4

Daily self monitoring of blood glucose (SMBG)is best- Either Pre or Post -prandial testing is best for

obtaining levels (according to ACOG and ADA)

Screen urine for glucose, ketones, and proteins

Monitor blood pressure

Monitor for fetal demise when pregnancy goes

past term Check for asymmetric fetal growth using

ultrasound


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Treatment Options in GDM3

All women should receive diet andnutrition counseling regarding pregnancy

- If BMI > 30 kg/m2:

Lower caloric intake to 25 kcal/kg/day Lower carbohydrate intake to only 25-30% of total

calories

Moderate exercise should be done with

physicians consent Delivery during or before the 38thweek is

encouraged, as is breast-feeding


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When to Add Insulin3,4

If medical nutritional therapy (MNT) fails then

add insulin when BGL are:

ADA ACOG

Fasting 105 mg/dL 95 mg/dL

1-H postprandial 155 mg/dL 130-140 mg/dL

2-H postprandial 130 mg/dL 120 mg/dL


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Treatment Options in GDM3,5,6

Insulin treatment is best for blood glucose

control

- Human insulin should be used when

prescribed, due to lack of analogs studies

NPH or Regular

Humalog is catagory B, and is being used under

Dr. supervision


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Treatment Options in GDM3,5,6

Oral agents are still questionable

- Glyburide (category B), and insulin were compared in

a trial and found to be similar in outcomes- Metformin (category B), shows some good evidence

toward its use in PCOS. Its currently being studied in

GDM and following up with offspring

- Glyburide and Metformin are still not FDA approvedfor GDM


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Treatment Options in GDM

Do not use in pregnancy:

- Aspirin (D)

- Statins (X)

- ACE Inhbitors (D)

- ARBs (D)


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Delivery Time2

During Labor:- Active labor lowers insulin needs for about 24-72

hours after delivery

After Delivery:- May have better BGL control for a few weeks

- Still could have unpredictable BGL swings

- Check BGLs more often during this time

- Breastfeeding is encouraged Have snack before or during nursing, and keep something

close to treat low BGLs

Drink fluids


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Reassessing Offspring2

Following delivery:

- Monitor newborn for any of the possible

abnormalities discussed earlier

- Monitor for development of obesity

- Evaluate for any irregularity in glucose

tolerance


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Reassessing Mother3,4

A mother having GDM:- Has a 50% chance of developing type 2 diabetes

- Should be have BGL evaluated at least 6 weeks

postpartum

If normoglycemic, then testing should be done every 3 years

If IFG or IGT, then testing should be repeated annually

If FPG 126mg/dL or 2-hr 200, then testing should be

repeated on a separate occasion for DM diagnosis

C


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The Australian Carbohydrate Intolerance

Study in Pregnant Women (ACHOIS)7

Randomized clinical trial

Wanted to determine whether treatingwomen with GDM reduced perinatal

complications One thousand women randomized

- Intervention group490 women, received

dietary advice, BGM, and insulin therapy- Routine group510 women

Weeks gestation - 24-34

Th A t li C b h d t I t l


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Primary endpoint

- Serious perinatal complications

death, shoulder dystocia, bone fracture, nerve

palsy, admit. neonatal nursery, jaundice, induct. oflabor, cesarean birth, anxiety, depression, health

Secondary endpoint

- Birth weights, large for gestational age,macrosomia, small for gestational age



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Primary outcome results (only clinicallysignificant):

- Any serious perinatal complication was

significantly lower in the treatment group Number needed to treat for benefit was 34

- Admission to the neonatal nursery was higherin the treatment group, but length of stay was

equal- Induction of labor was higher in the treatment

group



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Secondary outcome results (only clinicallysignificant)

- Birth weight was lower in the treatment

group

- There were higher rates of macrosomia

and large for gestational age in the

routine group


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Questions?


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References

1. Isley WL, Oki JC. Diabetes Mellitus. In: DiPiro JT, Talbert RL, Yee GC,Matzke GR, Well BG, Posey LM, eds. Pharmacotherapy: A Pathologicapproach. 5th ed. New York, NY: McGraw-Hill; 2002: 1335.

2. American Diabetes Association web site. Available at:http://www.diabetes.org/home.jsp/. Accessed January 23, 2007.

3. American Diabetes Association. Gestational Diabetes Mellitus. Diabetes

Care 2004;27:suppl 1: S88-S90.4. Clinical management guidelines for obstetrician-gynecologists. ACOG

practice bulletin no. 30. Washington, D.C.: American College ofObstetricians and Gynecologists, 2001.

5. American Diabetes Association. Gestational Diabetes Mellitus. DiabetesCare 2006;29:suppl 2: 485.

6. Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A

comparison of glyburide and insulin in women with gestational diabetesmellitus. New Engl J Med 2000;343:1134-1138 (Level 1)

7. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS.Effect of treatment of gestational diabetes mellitus on pregnancyoutcomes. N Engl J Med. 2005;352:2477-86.
http://www.diabetes.org/home.jsp/http://www.diabetes.org/home.jsp/http://www.diabetes.org/home.jsp/

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