Gestational Diabetes 01

8/3/2019 Gestational Diabetes 01

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Gestationalestationaldiabetes mellitusiabetes mellitus

Dr. Mohammed AbdallaDr. Mohammed Abdalla

Egypt, Domiat General HospitalEgypt, Domiat General Hospital



Gestational diabetes and impaired glucoseGestational diabetes and impaired glucose

tolerance (IGT) in pregnancy affectstolerance (IGT) in pregnancy affects

between of all pregnancies andbetween of all pregnancies and

both have been associated with pregnancyboth have been associated with pregnancy

complications.complications.

2-3%



Fasting and 2 hours postprandialasting and 2 hours postprandial

venous plasma sugar duringenous plasma sugar during

pregnancy.regnancy.

Border line indicatesBorder line indicates

glucose tolerance test.glucose tolerance test.125-200 mg/dl.125-200 mg/dl.100-125 mg/dl100-125 mg/dl

DiabeticDiabetic>200 mg/ dl.>200 mg/ dl.>125 mg/ dl>125 mg/ dl

Not diabeticNot diabetic< 145mg/ dl.< 145mg/ dl.<100 mg/dl<100 mg/dl

ResultResult2h postprandial2h postprandialFastingFasting



Low-risk statusow-risk status requires no glucose testing, but thisrequires no glucose testing, but thiscategory is limited to those women meetingcategory is limited to those women meeting allall of theof thefollowing characteristics:following characteristics:

Age <25 years. Age <25 years. Weight normal before pregnancy .Weight normal before pregnancy . Member of an ethnic group with a low prevalence of Member of an ethnic group with a low prevalence of

gestational diabetes mellitus .gestational diabetes mellitus . No known diabetes in first-degree relatives .No known diabetes in first-degree relatives . No history of abnormal glucose tolerance .No history of abnormal glucose tolerance .

No history of poor obstetric outcome .No history of poor obstetric outcome .

Risk assessmentisk assessment




marked obesity.marked obesity.

personal history of gestational diabetespersonal history of gestational diabetes

mellitus.mellitus.

Glycosuria.Glycosuria.

a strong family history of diabetes .a strong family history of diabetes .

A high risk of gestational diabetes mellitus: A hig

h risk of gestational diabetes mellitus:



high risk patients should undergo glucosehigh risk patients should undergo glucose

testingtesting

A fasting plasma glucose levelA fasting plasma glucose level>125mg/dL>125mg/dL or a casualor a casual

plasma glucoseplasma glucose >200 mg/dL>200 mg/dL meets the threshold for themeets the threshold for the

diagnosis of diabetesdiagnosis of diabetes

In the absence of thisdegree of hyperglycemia,

evaluation for gestational

diabetes mellitus in

women with average or high-risk characteristics is

by glucose tolerance test .




5050--g oral glucose challengeg oral glucose challenge

The screening test for GDM, a 50-g oral glucoseThe screening test for GDM, a 50-g oral glucose

challenge, may be performed in the fasting orchallenge, may be performed in the fasting or

fed state. Sensitivity is improved if the test isfed state. Sensitivity is improved if the test is

performed in the fasting state .performed in the fasting state . A plasma value above A plasma value above one hourone hour

afterafter is commonly used as a threshold foris commonly used as a threshold for

performing a 3-hour OGTT.performing a 3-hour OGTT.

If initial screening is negative, repeat testing isIf initial screening is negative, repeat testing is

performed at 24 to 28 weeks.performed at 24 to 28 weeks.

130130--140140mg/dlmg/dl



33our Oral glucose tolerance testour Oral glucose tolerance test

Prerequisites:- Normal diet for 3 days before the test.

- No diuretics 10 days before.

- At least 10 hours fast.

- Test is done in the morning at rest.

Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally

Criteria for glucose tolerance test:The maximum blood glucose values during pregnancy:

- fasting 90 mg/ dl,

- one hour 165 mg/dl,

- 2 hours 145 mg/dl,

- 3 hours 125 mg/dl.

If any 2 or more of these values are elevated, the patient is considered to have

an impaired glucose tolerance test.



Monitoringonitoring

Urine glucose monitoring is not useful inUrine glucose monitoring is not useful in

gestational diabetes mellitus. Urinegestational diabetes mellitus. Urineketone monitoring may be useful inketone monitoring may be useful in

detecting insufficient caloric ordetecting insufficient caloric or

carbohydrate intake in women treatedcarbohydrate intake in women treatedwith calorie restriction.with calorie restriction.



Daily Daily self-monitoring of bloodself-monitoring of blood

glucose (SMBG) appears to beglucose (SMBG) appears to besuperior tosuperior to intermittent intermittent officeoffice

monitoring of plasma glucose.monitoring of plasma glucose.

Monitoringonitoring



For women treated with insulin,For women treated with insulin, preprandialpreprandial

monitoring ismonitoring is postprandialpostprandialmonitoring. However, the success of eithermonitoring. However, the success of either

approach depends on the glycemic targetsapproach depends on the glycemic targets

that are set and achieved.that are set and achieved.

Monitoringonitoring

superior tosuperior to



Glycosylated haemoglobin (Hb A1lycosylated haemoglobin (Hb A1(

It is normally accounts forIt is normally accounts for 5-6%5-6% of the totalof the totalhaemoglobin mass. A valuehaemoglobin mass. A value over 10%over 10% indicates poorindicates poordiabetes control in the previous 4-8 weeks.diabetes control in the previous 4-8 weeks.

If this is detected early in pregnancyIf this is detected early in pregnancy, there is a high risk , there is a high risk

of congenital anomalies .of congenital anomalies .If this is detected in late pregnancyIf this is detected in late pregnancy it indicates increasedit indicates increased

incidence of macrosomia and neonatal morbidity andincidence of macrosomia and neonatal morbidity andmortality.mortality.

MonitoringMonitoring



The mean glucose represented by the hemoglobinThe mean glucose represented by the hemoglobin

A1c level can be calculated using the "rule of A1c level can be calculated using the "rule of

8's." A value of 8 percent equals 180 mg/dl, and8's." A value of 8 percent equals 180 mg/dl, and

each 1 percent increase or decrease representseach 1 percent increase or decrease represents

± 30 mg/dl.± 30 mg/dl.

Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1((

Monitoringonitoring



Assessment for asymmetric fetal Assessment for asymmetric fetal

growth by ultrasonography,growth by ultrasonography,particularly in early third trimester,particularly in early third trimester,

may aid in identifying fetuses that canmay aid in identifying fetuses that can

benefit from maternal insulin therapybenefit from maternal insulin therapy

Monitoringonitoring



Maternal surveillance should includMaternal surveillance should includ

blood pressure and urine proteinblood pressure and urine protein

monitoring to detect hypertensivemonitoring to detect hypertensive

disorders.disorders.

Monitoringonitoring



There are insufficient data for any reliableThere are insufficient data for any reliable

conclusions about the effects of conclusions about the effects of

treatments for impaired glucose tolerancetreatments for impaired glucose tolerance

on perinatal outcome.on perinatal outcome.

FromFrom The Cochrane Library, Issue 4, 2003 The Cochrane Library, Issue 4, 2003



Medical nutrition therapy should include theMedical nutrition therapy should include theprovision of adequate calories andprovision of adequate calories andnutrients to meet the needs of pregnancynutrients to meet the needs of pregnancyand should be consistent with theand should be consistent with thematernal blood glucose goals that havematernal blood glucose goals that havebeen established. Noncaloric sweetenersbeen established. Noncaloric sweetenersmay be used in moderation.may be used in moderation.

1-medical nutrition

therapy



Diet therapy is critical to successful regulation of Diet therapy is critical to successful regulation of maternal diabetes. A program consisting of maternal diabetes. A program consisting of three meals and several snacks is used forthree meals and several snacks is used formost patients. Dietary composition should be :most patients. Dietary composition should be :

50 to 60 percent carbohydrate,50 to 60 percent carbohydrate, 20 percent protein,20 percent protein, 25 to 30 percent fat with less than 10 percent25 to 30 percent fat with less than 10 percent

saturated fats, up to 10 percentsaturated fats, up to 10 percentpolyunsaturated fatty acids, and the remainderpolyunsaturated fatty acids, and the remainderderived from monosaturated sourcesderived from monosaturated sources



insulin therapy is recommended when medical nutritioninsulin therapy is recommended when medical nutrition

therapy fails to maintain self-monitored glucose at thetherapy fails to maintain self-monitored glucose at thefollowing levels:following levels:

Fastingasting whole blood glucosewhole blood glucose <<95 mg/dL95 mg/dL

Fasting plasma glucoseFasting plasma glucose <<105 mg/dL105 mg/dL

oror1-hour postprandial-hour postprandial whole blood glucosewhole blood glucose <<140 mg/dL140 mg/dL

1-hour postprandial plasma glucose1-hour postprandial plasma glucose <<155 mg/dL155 mg/dL

oror

2-hour postprandial-hour postprandial whole blood glucosewhole blood glucose <<120 mg/dL120 mg/dL2-hour postprandial plasma glucose2-hour postprandial plasma glucose <<135 mg/dL135 mg/dL

2-insulin therapy



GOALOAL

Self-blood glucose monitoring combinedSelf-blood glucose monitoring combined

with aggressive insulin therapy haswith aggressive insulin therapy hasmade the maintenance of maternalmade the maintenance of maternal

normoglycemianormoglycemia

((fasting and premeal glucose betweenfasting and premeal glucose between50-80mg/dl and 1 hour postprandial50-80mg/dl and 1 hour postprandial

glucose <140mg/dlglucose <140mg/dl))

Insulin therapy Insulin therap y ……..cont..cont..




Twice daily ( before breakfast and beforeTwice daily ( before breakfast and before

dinner) injections of a combination of shortdinner) injections of a combination of short

and intermediate acting insulins are usuallyand intermediate acting insulins are usuallysufficient to control most patientssufficient to control most patients

otherwise a subcutaneous insulin pump isotherwise a subcutaneous insulin pump is

used.used.



The total first dose of insulin is calculatedThe total first dose of insulin is calculatedaccording to the patientaccording to the patient’’s weight as follow:s weight as follow:


In the first trimester .......... weight x 0.7In the first trimester .......... weight x 0.7

In the second trimester........ weight x 0.8In the second trimester........ weight x 0.8

In the third trimester........... weight x 0.9In the third trimester........... weight x 0.9



If the total dose of insulin is less than 50f the total dose of insulin is less than 50

units/ daynits/ day , it is given in a single morning dose withit is given in a single morning dose with

the ratiothe ratio:: Short acting (regular orShort acting (regular or Actrapid)/Intermediate (NPH or Monotard) = 1 : 2 Actrapid)/Intermediate (NPH or Monotard) = 1 : 2

In higher dosesn higher doses ,, As a general rule, the amount of As a general rule, the amount of intermediate-acting insulin will exceed the short-intermediate-acting insulin will exceed the short-

acting component by a 2:1 ratio. Patients usuallyacting component by a 2:1 ratio. Patients usually

receive two thirds their total dose with breakfast andreceive two thirds their total dose with breakfast and

the remaining third in the evening as a combinedthe remaining third in the evening as a combineddose with dinnerdose with dinner



Insulin Dose adjustmentInsulin Dose adjustment

Home glucose monitoring with a reflectanceHome glucose monitoring with a reflectancemeter by measuring fasting and preprandialmeter by measuring fasting and preprandialglucose values 4 times a day (30-40 min)beforglucose values 4 times a day (30-40 min)befor

each meal.each meal.preprandial glucose measuring allows addingpreprandial glucose measuring allows adding

additional regular insulin to compensate anyadditional regular insulin to compensate anyhyperglycemia already present before meals.hyperglycemia already present before meals.

All values are recorded in a daily log.All values are recorded in a daily log.

NEXT



Each time the fasting or premealEach time the fasting or premeal

glucose is measured, the patientglucose is measured, the patient

refers to therefers to the supplemental regularsupplemental regularinsulin scaleinsulin scale to determine if to determine if

additional regular insulin isadditional regular insulin is

neededneeded

NEXT




Preprandial glucosePreprandial glucose

mg/dlmg/dl Additional units (regular Additional units (regular

insulin)insulin)

<100<100 00

100-140100-140 22140-160140-160 33

160-180160-180 44

180-200180-200 55200-250200-250 66

250-300250-300 88

>300>300 1010

supplemental regular insulin scalesupplemental regular insulin scale

NEXT



When the pattern for additionalWhen the pattern for additional

regular insulin supplementation isregular insulin supplementation isidentified over 2-3 days, thatidentified over 2-3 days, that

amount of insulin can then beamount of insulin can then be

added to the planned daily dose.added to the planned daily dose.




In patients who are not well controlled, aIn patients who are not well controlled, a

brief period of hospitalization is oftenbrief period of hospitalization is often

necessary for the initiation of therapy.necessary for the initiation of therapy.Individual adjustments to the regimensIndividual adjustments to the regimens

implemented can then be made.implemented can then be made.

3-Hospitalisation



KETOACIDOSISKETOACIDOSIS



KETOACIDOSISETOACIDOSIS

As pregnancy is a state of relative insulin As pregnancy is a state of relative insulin

resistance marked by enhanced lipolysis andresistance marked by enhanced lipolysis and

ketogenesis, diabetic ketoacidosis may developketogenesis, diabetic ketoacidosis may develop

in a pregnant woman with glucose levels barelyin a pregnant woman with glucose levels barelyexceeding 200 mg/dl .exceeding 200 mg/dl .

Thus, DKA may be diagnosed during pregnancyThus, DKA may be diagnosed during pregnancy

with minimal hyperglycemia accompanied by awith minimal hyperglycemia accompanied by a

fall in plasma bicarbonate and a pH value lessfall in plasma bicarbonate and a pH value lessthan 7.30. Serum acetone is positive at a 1:2than 7.30. Serum acetone is positive at a 1:2

dilution.dilution.



clinical signs of volume depletion follow theclinical signs of volume depletion follow the

symptoms of hyperglycemia, whichsymptoms of hyperglycemia, which

includeinclude

polydipsia and polyuria.polydipsia and polyuria.

Malaise.Malaise.

Headache.Headache.

nausea.nausea.

Vomiting. Vomiting.




Occasionally, diabetic ketoacidosis may present inOccasionally, diabetic ketoacidosis may present inan undiagnosed diabetic woman receiving β-an undiagnosed diabetic woman receiving β-mimetic agents to arrest preterm labor.mimetic agents to arrest preterm labor.

Because of the risk of hyperglycemia and diabeticBecause of the risk of hyperglycemia and diabetic

ketoacidosis in diabetic women . Terbutaline andketoacidosis in diabetic women . Terbutaline andmagnesium sulfate has become the preferredmagnesium sulfate has become the preferredtocolytic for cases of preterm labor in these cases.tocolytic for cases of preterm labor in these cases.

Sometimes Administration of antenatalSometimes Administration of antenatalcorticosteroids to accelerate fetal lung maturationcorticosteroids to accelerate fetal lung maturationcan cause significant maternal hyperglycemia andcan cause significant maternal hyperglycemia andprecipitate DKA. In diabetic patients.precipitate DKA. In diabetic patients.




An intravenous insulin infusion will usually be An intravenous insulin infusion will usually berequired and is adjusted on the basis of frequentrequired and is adjusted on the basis of frequentcapillary glucose measurements.capillary glucose measurements.

Therapy hinges on the meticulous correction of Therapy hinges on the meticulous correction of metabolic and fluid abnormalities.metabolic and fluid abnormalities.

Every effort should therefore be made to correctEvery effort should therefore be made to correctmaternal condition before intervening andmaternal condition before intervening anddelivering a preterm infant.delivering a preterm infant.




ANTEPARTUM FETALNTEPARTUM FETAL

EVALUATIONVALUATION

antepartum fetal monitoring tests are nowantepartum fetal monitoring tests are now

used primarily to reassure the obstetricianused primarily to reassure the obstetrician

and avoid unnecessary prematureand avoid unnecessary prematureintervention.intervention.

These techniques have few false-negativeThese techniques have few false-negative

results, allowing the fetus to benefit fromresults, allowing the fetus to benefit fromfurther maturation in utero.further maturation in utero.



11--ltrasoundltrasound

Ultrasound is a valuable tool inUltrasound is a valuable tool in

evaluating fetal growth,evaluating fetal growth,

estimating fetal weight, andestimating fetal weight, anddetecting hydramnios anddetecting hydramnios and

malformations.malformations.



Ultrasoundltrasound……..cont..cont.

maternal serum α-fetoprotein (MSAFP) at 16maternal serum α-fetoprotein (MSAFP) at 16

weeks' gestation is often used inweeks' gestation is often used in

association with a detailed ultrasoundassociation with a detailed ultrasound

study during the second trimester in anstudy during the second trimester in anattempt to detect neural tube defects andattempt to detect neural tube defects and

other anomalies. Normal values of MSAFPother anomalies. Normal values of MSAFP

for diabetic women are lower than in thefor diabetic women are lower than in thenondiabetic population .nondiabetic population .



Ultrasoundltrasound…….cont.cont.

Ultrasound examinations should beUltrasound examinations should be

repeated at 4- to 6-week intervals torepeated at 4- to 6-week intervals to

assess fetal growth. The detection of assess fetal growth. The detection of fetal macrosomia, the leading risk fetal macrosomia, the leading risk

factor for shoulder dystocia, isfactor for shoulder dystocia, is

important in the selection of patientsimportant in the selection of patientswho are best delivered by cesareanwho are best delivered by cesarean

section.section.



22--Maternal assessment of fetal activityMaternal assessment of fetal activity

While the false-negative rate with maternalWhile the false-negative rate with maternal

monitoring of fetal activity is low (~1monitoring of fetal activity is low (~1

percent), the false-positive rate may be aspercent), the false-positive rate may be as

high as 60 percent.high as 60 percent.

Maternal hypoglycemia, while generallyMaternal hypoglycemia, while generally

believed to be associated with decreasedbelieved to be associated with decreased

fetal movement, may actually stimulatefetal movement, may actually stimulatefetal activity.fetal activity.



3--The nonstress test (NSTThe nonstress test (NST((

Done weekly at 28 weeks and TwiceDone weekly at 28 weeks and Twice

weekly at 34 weeksweekly at 34 weeks

remains the preferred method to assessremains the preferred method to assessantepartum fetal well-being in the patientantepartum fetal well-being in the patient

with diabetes mellituswith diabetes mellitus

If the NST is nonreactive, a biophysicalIf the NST is nonreactive, a biophysicalprofile (BPP) or contraction stress test isprofile (BPP) or contraction stress test is

then performed .then performed .



44--Doppler umbilical artery velocimetryDoppler umbilical artery velocimetry

Doppler umbilical artery velocimetry has been proposedDoppler umbilical artery velocimetry has been proposedas a clinical tool for antepartum fetal surveillance inas a clinical tool for antepartum fetal surveillance inpregnancies at risk for placental vascular disease.pregnancies at risk for placental vascular disease.

It is found that Doppler studies of the umbilical arteryIt is found that Doppler studies of the umbilical arterymay be predictive of fetal outcome in diabeticmay be predictive of fetal outcome in diabeticpregnancies complicated by vascular disease.pregnancies complicated by vascular disease. ElevatedElevated

placental resistance as evidenced by an increasedplacental resistance as evidenced by an increasedsystolic/diastolic ratio is associated with fetal growthsystolic/diastolic ratio is associated with fetal growthrestriction and preeclampsia in these high-risk restriction and preeclampsia in these high-risk patients.patients.



There isThere is very little evidenceery little evidence to supportto support

either elective delivery or expectanteither elective delivery or expectant

management at term in pregnant womenmanagement at term in pregnant women

with insulin-requiring diabetes. Limitedwith insulin-requiring diabetes. Limited

data from a single randomized controlleddata from a single randomized controlled

trial suggest that induction of labour intrial suggest that induction of labour in

women with gestational diabetes treatedwomen with gestational diabetes treated

with insulin reduces the risk of with insulin reduces the risk of macrosomia.macrosomia.

FromFrom The Cochrane Library, Issue 4, 2003 The Cochrane Library, Issue 4, 2003



When antepartumWhen antepartumtesting suggests fetaltesting suggests fetal

compromise, deliverycompromise, deliverymust be considered.must be considered.



Delivery by cesarean section usually isDelivery by cesarean section usually is

favored when fetal distress has beenfavored when fetal distress has been

suggested by antepartum heart ratesuggested by antepartum heart ratemonitoring.monitoring.

If a patient reachesIf a patient reaches 38 weeks'38 weeks' gestationgestation

with a mature fetal lung profile and is atwith a mature fetal lung profile and is atsignificant risk for intrauterine demisesignificant risk for intrauterine demise

because of poor control or a history of abecause of poor control or a history of a

prior stillbirth, an elective delivery isprior stillbirth, an elective delivery is

planned.planned.

l b f l hD i l b ti f t l h t



During labor, continuous fetal heartDuring labor, continuous fetal heartrate monitoring is mandatory.rate monitoring is mandatory.

Labor is allowed to progress asLabor is allowed to progress aslong as normal rates of cervicallong as normal rates of cervical

dilatation and descent aredilatation and descent are

documented.documented.arrest of dilatation or descent despitearrest of dilatation or descent despite

adequate labor should alert theadequate labor should alert thephysician to the possibility of physician to the possibility of cephalopelvic disproportion.cephalopelvic disproportion.



•• Usual dose of intermediate-acting insulin is given atUsual dose of intermediate-acting insulin is given atbedtime.bedtime.

•• Morning dose of insulin is withheld.Morning dose of insulin is withheld.

•• Intravenous infusion of normal saline is begun.Intravenous infusion of normal saline is begun.

•• Once active labor begins or glucose levels fall below 70Once active labor begins or glucose levels fall below 70mg/dl, the infusion is changed from saline to 5%mg/dl, the infusion is changed from saline to 5%dextrose and delivered at a rate of 2.5 mg/kg/min.dextrose and delivered at a rate of 2.5 mg/kg/min.

•• Glucose levels are checked hourly using a portableGlucose levels are checked hourly using a portable

meter allowing for adjustment in the infusion rate.meter allowing for adjustment in the infusion rate.•• Regular (short-acting) insulin in administered byRegular (short-acting) insulin in administered by

intravenous infusion if glucose levels exceed 140intravenous infusion if glucose levels exceed 140mg/dl.mg/dl.

Insulin Management during Labor and DeliveryInsulin Management during Labor and Delivery

Gestational Diabetes 01

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