Gestational Gestational DiabetesDiabetes

Gestational Gestational DiabetesDiabetes

DefinitionDefinition

Any degree of glucose intolerance Any degree of glucose intolerance with onset or 1with onset or 1stst recognition during recognition during pregnancy.pregnancy.

Diabetes Care, 2003 Jan:26(1):s103Diabetes Care, 2003 Jan:26(1):s103

prevalence 1.4 – 14%prevalence 1.4 – 14% UTD 11.2UTD 11.2

EtiologyEtiology

Early pregnancyEarly pregnancy estrogen-progesteron counterbalanceestrogen-progesteron counterbalance

22ndnd trimester trimester hPL, hPL, Cortisol, Cortisol, Prolactin Prolactin

Underlying Underlying cell defect cell defect Evidence-Based Diabetes Care Evidence-Based Diabetes Care

20012001

Risk FactorsRisk Factors

AgeAge +ve F Hx. of DM+ve F Hx. of DM Increasing obesity, Wt. gain in early Increasing obesity, Wt. gain in early

adulthoodadulthood EthnicityEthnicity

AsiansAsians5, Hispanics5, Hispanics2.5, African Americans2.5, African Americans22 Cigarette smoking Cigarette smoking

Evidence-Based Diabetes Care 2001Evidence-Based Diabetes Care 2001

Short Term Risk for The Short Term Risk for The FetusFetus

Macrosomia & possible birth traumaMacrosomia & possible birth trauma Neonatal hypoglycemiaNeonatal hypoglycemia JaundiceJaundice HypocalcemiaHypocalcemia PolycythemiaPolycythemia RDSRDS Myocardial hypertrophyMyocardial hypertrophy

Long Term Risks for The Long Term Risks for The OffspringsOffsprings

Susceptibility for glucose Susceptibility for glucose intoleranceintolerance

Insulin resistance during pubertyInsulin resistance during puberty

ObesityObesity

Mother’s RisksMother’s Risks

Long term risk for DMLong term risk for DM 50% diabetes, 75% any IGT50% diabetes, 75% any IGT Rarely DKA, RetinopathyRarely DKA, Retinopathy PreeclampsiaPreeclampsia PolyhydramniosPolyhydramnios Fetal macrosomiaFetal macrosomia Birth traumaBirth trauma Operative deliveryOperative delivery Perinatal mortalityPerinatal mortality

Risk Factors for Risk Factors for Progression to Progression to DiabetesDiabetes

Prepregnancy BMIPrepregnancy BMI Severity of glucose intolerance during Severity of glucose intolerance during

pregnancypregnancy• Earlier gestational age of onsetEarlier gestational age of onset• FPGFPG• Need for insulinNeed for insulin• Presence of higher glucose values on postpartum Presence of higher glucose values on postpartum

OGTTOGTT

ScreeningScreening

Selective ( ADA & ACOG )Selective ( ADA & ACOG ) Universal Universal

* * If screening had been selective, If screening had been selective, 10% of women with GDM have 10% of women with GDM have been missed been missed

Screening Screening (continued)(continued)

ScreeningScreeningGCT GCT

thresholdthresholdSensitivitySensitivity

Cost per Cost per case case

diagnoseddiagnosed

UniversalUniversal 130 130 mg/dlmg/dl 100%100% $ 249$ 249

UniversalUniversal 140 140 mg/dlmg/dl 90%90% $ 222$ 222

SelectiveSelective 140 140 mg/dl mg/dl 85%85% $ 192$ 192

Screening Screening (continued)(continued)

Low riskLow risk• Age<25 yrAge<25 yr• Nl weight before pregnancyNl weight before pregnancy• Member of an ethnic group with low prevalence of Member of an ethnic group with low prevalence of

GDMGDM• No known diabetes in 1No known diabetes in 1stst degree relatives degree relatives• No Hx. of abn. Glucose toleranceNo Hx. of abn. Glucose tolerance• No Hx. of adverse pregnancy outcomes often No Hx. of adverse pregnancy outcomes often

associated with GDMassociated with GDM

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ScreeningScreening(continued)(continued)

High RiskHigh Risk• Marked obesity (prepregnancy Wt. of 110% of IBW)Marked obesity (prepregnancy Wt. of 110% of IBW)• Personal Hx. of GDMPersonal Hx. of GDM• Strong F Hx. of diabetes Strong F Hx. of diabetes • GlycosuriaGlycosuria Diabetes Care, 2003 Diabetes Care, 2003

Jan:26(1):S34Jan:26(1):S34• Age>25 yrAge>25 yr• Hx. of abn. glucose toleranceHx. of abn. glucose tolerance• Previous large babyPrevious large baby• PCOPCO• Maternal low birth Wt.Maternal low birth Wt.• The mother was large at birthThe mother was large at birth• Member of an ethnic group with a higher than Nl rate of Member of an ethnic group with a higher than Nl rate of

type2 DMtype2 DM• Previous unexplained prenatal loss or birth malformed Previous unexplained prenatal loss or birth malformed

childchild UTD UTD

11.2 11.2

ScreeningScreening(continued)(continued)

TimingTiming• High risk : 1High risk : 1stst prenatal visit prenatal visit

If -veIf -ve• Mod. risk : between 24-28 wks Mod. risk : between 24-28 wks • Low risk : need no glucose testingLow risk : need no glucose testing

Diabetes Care, 2003 Jan:26(1):S34Diabetes Care, 2003 Jan:26(1):S34

UTD 11.2

UTD 11.2

ManagementManagement

Diet : Diet : in women who do not meet criteria for in women who do not meet criteria for gestational diabetes (abnormal gestational diabetes (abnormal GTTGTT) if they have ) if they have FPGFPG >90 mg/dL or an abnormal >90 mg/dL or an abnormal GCTGCT..

ExerciseExercise

Insulin : Insulin : ٭٭ when FPG >90 mg/dl when FPG >90 mg/dl &&

1hr PP blood sugar >120 mg/dl1hr PP blood sugar >120 mg/dl

1515 ٭٭ % of women with GDM require % of women with GDM require insulin Rx.insulin Rx.

Management Management (continued)(continued)

Caloric AllotmentCaloric Allotment •• 30 kcal per present weight in kg per day in pregnant 30 kcal per present weight in kg per day in pregnant

women who are 80 to 120 women who are 80 to 120 %% of of IBWIBW at the start of at the start of pregnancy.pregnancy.

•• 24 kcal per present weight in kg per day in 24 kcal per present weight in kg per day in overweight pregnant women (120 to 150 overweight pregnant women (120 to 150 %% of of IBWIBW).).

•• 12 to 15 kcal per present weight in kg per day for 12 to 15 kcal per present weight in kg per day for morbidly obese pregnant women (>150 morbidly obese pregnant women (>150 %% of of IBWIBW).).

•• 40 kcal per present weight in kg per day in pregnant 40 kcal per present weight in kg per day in pregnant women who are women who are << 80 80 %% of of IBWIBW..

Management Management (continued)(continued)

Insulin RegimenInsulin Regimen

if if ↑↑FPG :FPG : NPH 0.15 IU/kg before bedtime NPH 0.15 IU/kg before bedtime

if if ↑↑PP blood glucose :PP blood glucose : Insulin regular or lispro Insulin regular or lispro

1.5 IU/10gr CHO before breakfast 1.5 IU/10gr CHO before breakfast &&

1 IU/10gr CHO before lunch and dinner 1 IU/10gr CHO before lunch and dinner meals.meals.

Management Management (continued)(continued)

if both if both ↑↑FPG & FPG & ↑↑PP blood glucose :PP blood glucose : four- four-injection per day regimen should be initiated :injection per day regimen should be initiated :

NPH 45% Regular 55%NPH 45% Regular 55%

30% breakfast 22% breakfast30% breakfast 22% breakfast

15% bedtime 16.5% lunch15% bedtime 16.5% lunch

16.5% dinner 16.5% dinner

Insulin Insulin requirementrequirement

Week of Week of gestationgestation

0.7 IU/kg0.7 IU/kg 6-186-18

0.8 IU/kg0.8 IU/kg 19-2619-26

0.9 IU/kg0.9 IU/kg 27-3627-36

1 IU/kg1 IU/kg 37 to 37 to termterm

Management Management (continued)(continued)

Goal of glucose concentrationGoal of glucose concentration

FPG <90 mg/dlFPG <90 mg/dl

BS 1hr PP <140 mg/dlBS 1hr PP <140 mg/dl PlasmaPlasma

BS 2hr PP <120 mg/dlBS 2hr PP <120 mg/dl

Management Management (continued)(continued)

Postpartum F/UPostpartum F/U1/31/3 ٭٭ to 2/3 of women will have gestational diabetes in a to 2/3 of women will have gestational diabetes in a

subsequent pregnancy.subsequent pregnancy. As many as 20 % of women with GDM have IGT during the As many as 20 % of women with GDM have IGT during the ٭٭

early postpartum period.early postpartum period. The risk of type 2 diabetes is also importantly affected by The risk of type 2 diabetes is also importantly affected by ٭٭

body weight, being 50 to 75 % in obese women versus < 25 % body weight, being 50 to 75 % in obese women versus < 25 % in women who achieve IBW after delivery.in women who achieve IBW after delivery.

GDM is also a risk factor for the development of type 1 GDM is also a risk factor for the development of type 1 ٭٭ diabetes. Specific HLA alleles (DR3 or DR4) may predispose diabetes. Specific HLA alleles (DR3 or DR4) may predispose to the development of type 1 diabetes postpartum, as does the to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies.presence of islet-cell autoantibodies.

Postpartum F/UPostpartum F/U

•• Immediately after delivery, FPG should be Immediately after delivery, FPG should be < 115 mg/dL & one-hour PP should be <140 < 115 mg/dL & one-hour PP should be <140 mg/dL.mg/dL.

•• ~~ 6-86-8 wks after delivery, or shortly after wks after delivery, or shortly after cessation of breast feeding, cessation of breast feeding, aa two-hour 75 gr two-hour 75 gr OGTTOGTT is recommended by the is recommended by the ADAADA and the and the 44thth International Workshop-Conference on International Workshop-Conference on GDMGDM. .