Gestational diabetes

Gestational Gestational diabetesdiabetes

BYBYSohaib AhmedSohaib Ahmed

08-18308-183

DefinitionDefinition::It is a condition in which women without previously diagnosed

diabetes exhibit high blood glucose levels during pregnancy (especially during their

third trimester(.

http://en.wikipedia.org/wiki/Diabetes_mellitus

http://en.wikipedia.org/wiki/Hyperglycemia

http://en.wikipedia.org/wiki/Pregnancy

Prevalence:Prevalence: Gestational diabetes and impaired glucose Gestational diabetes and impaired glucose

tolerance (IGT) in pregnancy affects tolerance (IGT) in pregnancy affects between 2-3% of all pregnancies between 2-3% of all pregnancies

and both have been associated with and both have been associated with pregnancy complications. pregnancy complications.

Fasting and 2 hours postprandial Fasting and 2 hours postprandial venous plasma sugar during venous plasma sugar during

pregnancy.pregnancy.

Border l ine Border l ine indicates glucose indicates glucose tolerance test.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 statusLow-risk status requires no glucose testing, but this requires no glucose testing, but this category is limited to those women meetingcategory is limited to those women meeting all all of the of the following 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 assessment Risk assessment


marked obesity. marked obesity. personal history of gestational diabetes personal 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 high risk of gestational diabetes mellitus:

high risk patients should undergo glucose high risk patients should undergo glucose testingtesting

A fasting plasma glucose A fasting plasma glucose level level >125mg/dL>125mg/dL or a or a casual plasma glucose casual plasma glucose >200 mg/dL>200 mg/dL meets the meets the threshold for the threshold for the diagnosis of diabetes diagnosis of diabetes

In the absence of this degree 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 glucose The screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting or challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is fed 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 hour one hour afterafter is commonly used as a threshold for is commonly used as a threshold for performing a 3-hour OGTT. performing a 3-hour OGTT.

If initial screening is negative, repeat testing is If initial screening is negative, repeat testing is performed at 24 to 28 weeks.performed at 24 to 28 weeks.

130130 - - 140140 mg/dlmg/dl

33 hour Oral glucose tolerance testhour 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.

MonitoringMonitoring

Urine glucose monitoring is not useful in Urine glucose monitoring is not useful in gestational diabetes mellitus. Urine gestational diabetes mellitus. Urine ketone monitoring may be useful in ketone monitoring may be useful in

detecting insufficient caloric or detecting insufficient caloric or carbohydrate intake in women treated carbohydrate intake in women treated

with calorie restriction. with calorie restriction.

DailyDaily self-monitoring of blood self-monitoring of blood glucose (SMBG) appears to be glucose (SMBG) appears to be superior to superior to intermittentintermittent office office

monitoring of plasma glucose. monitoring of plasma glucose.


For women treated with insulin, For women treated with insulin, preprandial preprandial monitoring is monitoring is postprandial postprandial monitoring. However, the success of monitoring. However, the success of

either approach depends on the glycemic either approach depends on the glycemic targets that are set and achieved. targets that are set and achieved.


superior tosuperior to

Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 ((

It is normally accounts for It is normally accounts for 5-6%5-6% of the total haemoglobin of the total haemoglobin mass. A value mass. A value over 10%over 10% indicates poor diabetes indicates poor diabetes control in the previous 4-8 weeks.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 increased it indicates increased incidence of macrosomia and neonatal morbidity and incidence of macrosomia and neonatal morbidity and mortality.mortality.


The mean glucose represented by the hemoglobin The 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, and 8's." A value of 8 percent equals 180 mg/dl, and each 1 percent increase or decrease represents each 1 percent increase or decrease represents ± 30 mg/dl. ± 30 mg/dl.

Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 ((


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 can may aid in identifying fetuses that can benefit from maternal insulin therapy benefit from maternal insulin therapy


Maternal surveillance should include Maternal surveillance should include blood pressure and urine protein blood pressure and urine protein monitoring to detect hypertensive monitoring to detect hypertensive

disorders. disorders.


There are insufficient data for any reliable There are insufficient data for any reliable conclusions about the effects of conclusions about the effects of treatments for impaired glucose tolerance treatments for impaired glucose tolerance on perinatal outcome. on perinatal outcome.

Medical nutrition therapy should include the Medical nutrition therapy should include the provision of adequate calories and provision of adequate calories and nutrients to meet the needs of pregnancy nutrients to meet the needs of pregnancy and should be consistent with the and should be consistent with the maternal blood glucose goals that have maternal blood glucose goals that have been established. Noncaloric sweeteners been established. Noncaloric sweeteners may 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 for three meals and several snacks is used for most 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 percent 25 to 30 percent fat with less than 10 percent

saturated fats, up to 10 percent saturated fats, up to 10 percent polyunsaturated fatty acids, and the remainder polyunsaturated fatty acids, and the remainder derived from monosaturated sources derived from monosaturated sources

insulin therapy is recommended when medical nutrition insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the therapy fails to maintain self-monitored glucose at the

following levels:following levels:FastingFasting whole blood glucose whole blood glucose <<95 mg/dL 95 mg/dL Fasting plasma glucose Fasting plasma glucose <<105 mg/dL105 mg/dL oror1-hour postprandial1-hour postprandial whole blood glucose whole blood glucose <<140 mg/dL 140 mg/dL 1-hour postprandial plasma glucose 1-hour postprandial plasma glucose <<155 mg/dL155 mg/dL oror2-hour postprandial2-hour postprandial whole blood glucose whole blood glucose <<120 mg/dL 120 mg/dL 2-hour postprandial plasma glucose 2-hour postprandial plasma glucose <<135 mg/dL 135 mg/dL

2-insulin therapy

GOAL GOAL Self-blood glucose monitoring combined Self-blood glucose monitoring combined

with aggressive insulin therapy has with aggressive insulin therapy has made the maintenance of maternal made the maintenance of maternal

normoglycemia normoglycemia ((fasting and premeal glucose between fasting and premeal glucose between

50-80mg/dl and 1 hour postprandial 50-80mg/dl and 1 hour postprandial glucose <140mg/dlglucose <140mg/dl))

Insulin therapyInsulin therapy ……..cont..cont..


Twice daily ( before breakfast and before Twice daily ( before breakfast and before dinner) injections of a combination of short dinner) injections of a combination of short

and intermediate acting insulins are and intermediate acting insulins are usually sufficient to control most patients usually sufficient to control most patients

otherwise a subcutaneous insulin pump is otherwise a subcutaneous insulin pump is used. used.

The total first dose of insulin is calculated The total first dose of insulin is calculated according 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 0.7In the second trimester........ weight x 0.8In the second trimester........ weight x 0.8In the third trimester........... weight x 0.9In the third trimester........... weight x 0.9

If the total dose of insulin is less than 50 If the total dose of insulin is less than 50 units/ dayunits/ day ,, it is given in a single morning dose with it is given in a single morning dose with the ratiothe ratio: : Short acting (regular or Short acting (regular or Actrapid)/Intermediate (NPH or Monotard) = 1 : 2Actrapid)/Intermediate (NPH or Monotard) = 1 : 2

In higher dosesIn 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 usually acting component by a 2:1 ratio. Patients usually receive two thirds their total dose with breakfast and receive two thirds their total dose with breakfast and the remaining third in the evening as a combined the remaining third in the evening as a combined dose with dinnerdose with dinner

Insulin Dose adjustmentInsulin Dose adjustmentHome glucose monitoring with a reflectance Home glucose monitoring with a reflectance

meter by measuring fasting and preprandial meter by measuring fasting and preprandial glucose values 4 times a day (30-40 min)befor glucose values 4 times a day (30-40 min)befor each meal. each meal.

preprandial glucose measuring allows adding preprandial glucose measuring allows adding additional regular insulin to compensate any additional regular insulin to compensate any hyperglycemia 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.

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Each time the fasting or premeal Each time the fasting or premeal glucose is measured, the patient glucose is measured, the patient

refers to the refers to the supplemental regular supplemental regular insulin scaleinsulin scale to determine if to determine if additional regular insulin is additional regular insulin is

neededneeded

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Insulin Dose adjustmentInsulin Dose adjustment

Preprandial Preprandial glucose mg/dlglucose mg/dl

Addit ional units Addit ional units (regular insulin)(regular insulin)

<100<100 00

100-140100-140 22

140-160140-160 33

160-180160-180 44

180-200180-200 55

200-250200-250 66

250-300250-300 88

>300>300 1010

supplemental regular insulin scalesupplemental regular insulin scale

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When the pattern for additional When the pattern for additional regular insulin supplementation is regular insulin supplementation is

identified over 2-3 days, that identified over 2-3 days, that amount of insulin can then be amount of insulin can then be

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

Insulin Dose adjustmentInsulin Dose adjustment

In patients who are not well controlled, a In patients who are not well controlled, a brief period of hospitalization is often brief period of hospitalization is often necessary for the initiation of therapy. necessary for the initiation of therapy. Individual adjustments to the regimens Individual adjustments to the regimens

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

3-Hospitalisation

KETOACIDOSISKETOACIDOSIS


As pregnancy is a state of relative insulin As pregnancy is a state of relative insulin resistance marked by enhanced lipolysis and resistance marked by enhanced lipolysis and

ketogenesis, diabetic ketoacidosis may develop ketogenesis, diabetic ketoacidosis may develop in a pregnant woman with glucose levels barely in a pregnant woman with glucose levels barely

exceeding 200 mg/dl .exceeding 200 mg/dl . Thus, DKA may be diagnosed during pregnancy Thus, DKA may be diagnosed during pregnancy

with minimal hyperglycemia accompanied by a with minimal hyperglycemia accompanied by a fall in plasma bicarbonate and a pH value less fall in plasma bicarbonate and a pH value less than 7.30. Serum acetone is positive at a 1:2 than 7.30. Serum acetone is positive at a 1:2

dilution.dilution.

clinical signs of volume depletion follow the clinical signs of volume depletion follow the symptoms of hyperglycemia, which symptoms of hyperglycemia, which include include

polydipsia and polyuria. polydipsia and polyuria. Malaise.Malaise. Headache.Headache. nausea.nausea. Vomiting. Vomiting.


Occasionally, diabetic ketoacidosis may present Occasionally, diabetic ketoacidosis may present in an undiagnosed diabetic woman receiving β-in 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 diabetic Because of the risk of hyperglycemia and diabetic ketoacidosis in diabetic women . Terbutaline and ketoacidosis in diabetic women . Terbutaline and magnesium sulfate has become the preferred magnesium sulfate has become the preferred tocolytic for cases of preterm labor in these tocolytic for cases of preterm labor in these cases. cases.

Sometimes Administration of antenatal Sometimes Administration of antenatal corticosteroids to accelerate fetal lung maturation corticosteroids to accelerate fetal lung maturation can cause significant maternal hyperglycemia and can cause significant maternal hyperglycemia and precipitate DKA. In diabetic patients.precipitate DKA. In diabetic patients.


An intravenous insulin infusion will usually be An intravenous insulin infusion will usually be required and is adjusted on the basis of frequent required and is adjusted on the basis of frequent capillary 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 correct Every effort should therefore be made to correct

maternal condition before intervening and maternal condition before intervening and delivering a preterm infant.delivering a preterm infant.


There is There is very l i t t le evidencevery l i t t le evidence to support to support either elective delivery or expectant either elective delivery or expectant management at term in pregnant women management at term in pregnant women with insulin-requiring diabetes. Limited with insulin-requiring diabetes. Limited data from a single randomized controlled data from a single randomized controlled trial suggest that induction of labour in trial suggest that induction of labour in women with gestational diabetes treated women with gestational diabetes treated with insulin reduces the risk of macrosomiwith insulin reduces the risk of macrosomi

When antepartum When antepartum testing suggests fetal testing suggests fetal compromise, delivery compromise, delivery must be considered. must be considered.

Delivery by cesarean section usually is Delivery by cesarean section usually is favored when fetal distress has been favored when fetal distress has been suggested by antepartum heart rate suggested by antepartum heart rate

monitoring. monitoring. If a patient reaches If a patient reaches 38 weeks'38 weeks' gestation gestation with a mature fetal lung profile and is at with a mature fetal lung profile and is at significant risk for intrauterine demise significant risk for intrauterine demise because of poor control or a history of because of poor control or a history of a prior stillbirth, an elective delivery is a prior stillbirth, an elective delivery is

planned.planned.

During labor, continuous fetal heart During labor, continuous fetal heart rate monitoring is mandatory. Labor rate monitoring is mandatory. Labor

is allowed to progress as long as is allowed to progress as long as normal rates of cervical dilatation normal rates of cervical dilatation

and descent are documented. and descent are documented. arrest of dilatation or descent despite arrest of dilatation or descent despite

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

•• Usual dose of intermediate-acting insulin is given at Usual dose of intermediate-acting insulin is given at bedtime. 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 Once active labor begins or glucose levels fall below

70 mg/dl, the infusion is changed from saline to 5% 70 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 portable Glucose 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 by Regular (short-acting) insulin in administered by intravenous infusion if glucose levels exceed 140 intravenous infusion if glucose levels exceed 140 mg/dl. mg/dl.

Insulin Management during Labor and DeliveryInsulin Management during Labor and Delivery

Gestational diabetes

Health & Medicine

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