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Diabetes mellitus during pregnancyHOW PREVALENT IS DM IN THE PREGNANT POPULATION?epidemiologyPrevalenceWorldwideApprox. 7% of all pregnancies complicated with gdmWestern pacific region7.6% of population have DM Type II (including gdm)Highest among other regions studied Philippines1.9% of pregnant women admitted in the last 5 years have gdm5.1% of women surveyed had type 2 diabetes mellitus or gdm Worldwide range: 1-14%; Western Pacific Region which includes the Philippines;Regions include South East Asia (6%), South and Central America, North America, Eastern Mediterranean, Middle East and African CountriesDiscrepancy in prevalence of GDM in data from the Philippines may be due to underreporting or regional differences in the country. The data was only taken in those institutions accredited by the POGS, which only includes 147 hospitals3Changes in glucose metabolism during normal pregnancyIncreased insulin secretionDecreased insulin sensitivityElevated postprandial glucose levels and prolonged glucose peakIncreased hepatic glucose production Increased carbohydrate use (by fetus)Accumulation of maternal fat stores in early pregnancyEnhanced fat mobilization in late pregnancyThis slide shows the changes in glucose metabolism during normal pregnancyThese changes occur during pregnancy to accommodate fetal nutritional requirements and ensure a continuous supply of nutrients to the growing fetus, despite intermittent maternal intakeIncreased insulin secretion and decreased insulin sensitivity could be attributed to increased levels of human chorionic sommatotropin, formerly called humal placental lactogen or HPL, which has a strong lypolytic and antiinsulin property. This directly leads to decreased insulin sensitivity which then leads to increased insulin secretion. Another direct effect would be elevated postprandual glucose levels and prolonged glucose peak.4

As a summary, this picture shows the fetal complications of diabetes mellitus in pregnancy which mainly includes MACROSOMIA and POLYHRAMNIOS. Other complications include early abortions, preterm labor and delivery and congenital malformations.5

On the other hand, this picture shows the different possible maternal complications of diabetes mellitus in pregnancy.6Diagnosis and screeningAs recommended by the POGS7Who should be screened?Universal screening for GDM is recommended for all Filipino gravidas! should be screened for type 2 diabetes mellitus in the first prenatal visit either using fasting blood sugar [FBS], glycosylated haemoglobin [Hba1c] or random blood sugar [RBS])

Filipino gravidas are considered high risk by race or ethnic group, as shown in the epidemiology part awhile ago9Diagnosis and screeningDiabetes mellitus recognized during pregnancy should now be classified as either gestational diabetes mellitus (GDM) or Overt diabetes mellitus based on plasma glucose levelsA diagnosis of overt diabetes mellitus is given among women with any of the following results in their first visit:Fbs >= 126 mg/dl (7 mmol/L)RBS >= 200 mg/dl (11.1 mmol/L)HbA1C >= 6.5%2 hour 75 g oral glucose tolerance test (OGTT) > 200mg/dl (11.1 mmol/L)

A diagnosis of gdm is made if any one of the following plasma values are exceeded:FBS > 92 mg/dl1 hour >180mg/dl2 hours >153 mg/dl

For Filipino pregnant women, pogs cpg consensus panel recommends the following cut-off values for the diagnosis of gdm:Fbs >92 mg/dl2 hours >140 mg/dlFor Filipino gravidas with no other risk factors aside from race or ethnicity and the initial test (fbs or hba1c or rbs) is normal:screening for gdm should be repeated at 24-28 weeks using a 2 hours 75g ogttIf there are other risk factors identified:initial screening should proceed immediately to 2 hour 75g ogtt

If the ogtt at 24-28 weeks is normal, should be re-tested at 32 weeks or earlier if clinical signs and symptoms of hyperglycemia are present in the mother and the fetusThe ogtt should be performed in the morning after an overnight fast of 8 hours following the general instructions for the test

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200mg/dl: OVERT ; 140mg/dl: GDM16Preconception counselling and managementWoman who are diabetic and are contemplating pregnancy should be evaluated and if indicated, should be screened and treated for retinopathy, nephropathy and cardiovascular diseaseMedications taken by such women should be evaluated prior to conceptionHba1c levels should be as close as possible ( high glycemic index

HOW ABOUT THE USE OF SUGAR SUBSTITUTES?Intake of sugar substitutes such as acesulfame potassium, aspartate and sucralose = acceptable during pregnancy and lactation Saccharin and cyclamates are not recommended during pregnancyAn estimate how much each gram of availablecarbohydrate(total carbohydrate minusfiber) in a food raises a person's blood glucose level following consumption of that food25Lifestyle changesStop alcohol consumptionsmoking cessationsufficient level of physical activity and exerciseLifestyle changes should be advised so as to improve glucose control, reduce cvd risk, contribute to weight management goals, and over-all well being

26Antepartum blood glucose controlinstituted once diet and exercise have failed as evidenced by abnormality in more than half of self-monitored glucose or an abnormal value In those women tested weeklyInsulin = traditional drug of choiceTotal insulin needs maybe computed as follows:0.7 to 0.8 U/kg actual body weight in the first trimester1.0 u/kg actual body weight in the second trimester1.2 u/kg actual body weight In the third trimester

Insulin administration should be individualized to achieve the glycemic goals. Human regular insulin or rapid-acting insulin analogues (if postprandial levels are high) or neutral protamine hagedorm (nph) insulin may be used for control of basal insulin needs (if fbs levels are high)

27Guidelines for outpatient glucose monitoring and targets for pregnant diabetics:For GDM, treatment goals are:Preprandial glucose concentration of 35 yearsIn healthy populationEpid Studies on current or previous coc-users not established an increased risk of dmshort term studies found no clinically relevant damaging effect on lipid metabolismCOC contain ESTROGEN and PROGESTIN ; Most widely used type of hormonal contraceptionESTROGEN ( ETHINYL ESTRADIOL)- no effect on glucose tolerance and sensitivity; increases TG and cholesterol levels; increase thrombosis risk and BPPROGESTIN: generally antagonizes the effect of estrogen, but may increase glucose tolerance and sensitivity64women with prior gdm likely fall in low absolute risk of cardiovascular and venous thrombotic events, hence:low-dose coc can be prescribed taking into account that: absolute risks increase with age periodic risk assessment of cardiovascular risk factors in women with prior gdm should be done

The magnitude of other risk factors and family history of thrombosis increase the odds for arterial and venous thrombotic events by 2 to 12 fold in coc users

When hypertension or migraines are present in women with prior gdm, it would be most cautious not to prescribe a coc

In all cases, the lowest ethinyl estradiol with newer progestins should be prescribed and close attention should be paid to increases in blood pressure and weightRisk factors (i.e. hypertension, migraine, smoking, hyperlipidemia, coagulation disorders) and family history of thrombosis [presence of leiden v factor mutation]) 66All women should receive nutritional counsellingbe encouraged to exercise dailyachieve a healthy weightreceive appropriate medical therapy to control blood pressure and/or lipids if lifestyle interventions fail

Non oral combination hormonal methods (Not yet available locally)can be administered as a monthly injection or an intravaginal ringProgestin only oral contraceptives (pocs)taken continuously and contain low dose norethindrone, levonorgestrel or desogestrelPOCS: Less widely prescribed than cocs, largely because of their actual failure rates and breakthrough bleeding ratesSuited for those with type 1 diabetes mellitus where estrogen containing methods are contraindicated and for women with prior gdm who often have several cardiovascular risk factors, making estrogen-containing contraception favorable

68Long acting progestinscan be administered intramuscularly (IM)/ subcutaneously (sq) or as an implantoffer the same metabolic advantage as poc with no effect on maternal coagulation factors or blood pressure

to deliver long-acting and efficacious contraceptive protection

69Dmpa should be used with caution in breastfeeding women and those with elevated triglyceride levels (>150mg/dl)Close attention should be paid to weight gain, which also has been demonstrated to increase the risk of subsequent diabetesThe food and drug authority (FDA) cautions dmpa use for more than 2 years because of the associated decrease in bone mineral densityLong acting progestin methods are not a first line choice in women with prior gdm unless compliance with taking daily medication is a problemIf estrogen containing contraceptives are contraindicated, the poc would be the first choice hormonal method or either type of iud

Surgical sterilizationAn excellent choice for women who are no longer desirous of subsequent childbearing especially among parous women particularly those who deliver by caesarean sectionInfants of diabetic mothersMonitoring and management of hypoglycaemia after deliveryBlood sugar monitoring protocolTesting:Check blood sugar within 30 minutes of delivery, at 1, 2 hours of life, and thereafterInfant will need 4 stable blood sugars prior to discontinuing blood sugar checks.Treatment:Blood sugar >45mg/dl normal x 4 (consecutively), no further testing required!If blood sugar 30-45mg/dl: step-by-step procedure is done to increase blood sugar levelsBreastfeedingFormula feeding by cup or dropperTransfer to nursery intensive care unit (nicu) and give iv glucose infusion of d10w at 4ml/kg/hr and repeat blood sugar in 30 minutesIf blood sugar