GESTATIONAL DIABETES

WHAT IS GESTATIONAL DIABETES?

Is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy.
"Gestational" diabetes implies that this disorder is induced by pregnancy, perhaps due to exaggerated physiological changes in glucose metabolism

DEFINITION

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy". This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether or not symptoms subside after pregnancy is also irrelevant to the diagnosis

GESTATIONAL DIABETES diabetes diagnosed during pregnancy

Undiagnosed

PDM during first half of

pregnancy GDM during the late part of gestation

OVERT DIABETES patients known to have diabetes even before pregnancy

What causes this?

No specific cause has been identified, but it is believed that the hormones produced during pregnancy reduce a woman's sensitivity to insulin, resulting in high blood sugar levels.

PATHOPHYSIOLOGY

Almost all women have some degree of impaired glucose intolerance during pregnancy as a result of hormonal changes that occur during pregnancy. That means that their blood sugar may be higher than normal, but not high enough to have diabetes. During the later part of pregnancy (the third trimester), these hormonal changes place pregnant woman at risk for gestational diabetes.

During pregnancy, increased levels of certain hormones made in the placenta (the organ that connects the baby by the umbilical cord to the uterus) help shift nutrients from the mother to the developing fetus. Other hormones are produced by the placenta to help prevent the mother from developing low blood sugar. They work by stopping the actions of insulin.

Over the course of the pregnancy, these hormones lead to progressive impaired glucose intolerance (higher blood glucose levels). To try to decrease the glucose levels, the body makes more insulin to shuttle glucose into cells.

Usually the mother's pancreas is able to produce more insulin (about three times the normal amount) to overcome the effect of the pregnancy hormones on glucose levels. If, however, the pancreas cannot produce enough insulin to overcome the effect of the increased hormones during pregnancy, glucose levels will rise, resulting in gestational diabetes.

PATHOPHYSIOLOGY

EPIDEMIOLOGY
Gestational diabetes affects 3-10% of pregnancies, depending on the population studied It occurs in between 5 and 10% of all pregnancies (between 1-14% in various studies).

RISK FACTORS
A

previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia A family history revealing a first degree relative with type 2 diabetes Maternal age - a woman's risk factor increases the older she is (especially if older than 35 years of age)

Ethnic background (those with higher risk factors include African-Americans, North American native peoples and Hispanics) Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively. Previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g) Previous poor obstetric history

SIGNS AND SYMPTOMS

Frequently women with gestational diabetes exhibit no symptoms However, possible symptoms include
increased

thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision.

DIAGNOSIS

PregestationalDM (DM prior to pregnancy) Diagnosis:

FBS

> 126 mg/dl on 2 occasions or RBS > 200 mg/dl or 75 gm 2 hour OGIT > 200 mg/dl

. Gestational DM
A.

Screening test (at 24-28 weeks usually or earlier): 50 gm 1 hour Oral Glucose Challenge of > 140 mg/dl or 7.8mmol/L b. If (+) screening test do Gold Standard For Gestational DM Diagnosis: 100 gm 3 hour Oral Glucose Tolerance test (OGTT) after an overnight fast of 8-14 hours

DIAGNOSIS
TIMING OF MEASUREMENT Plasma Glucose mg/dL National Diabetes Group (1979)
105 190 165 145

Plasma Glucose mg/dL Carpenter and Coustan (1982)

95 180 155 140

Fasting 1 hour 2 hour 3 hour

If two values are above normal then the patient is + Gestational DM.

MATERNALCOMPLICATIONS
Increased risk for Cesarean Delivery Higher risk of Preeclampsia Diabetic ketoacidosis Coronary Artery Disease Nephropathy Retinopathy

FETAL COMPLICATIONS

Large for gestational age (macrosomic) Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) Problems during vaginal delivery (such as shoulder dystocia). Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia).

Potential Congenital Fetal Anomalies

1.CNS: spina bifida, anencephaly, holoprosencephaly, hydrocephalus 2.Cardiac (most common): transposition of the great vessels, ventricular septal defect, atrial septal defect, hypoplastic left heart, cardiac hypertrophy, anomalies of the aorta

3.GI: tracheoesophageal fistula, anal/rectal atresia

4.Genitourinary: renal agenesis, double ureter, cystic kidneys 5.Skeletal: caudal regression syndrome (most specific) 6.Situs inversus

GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation

PROGNOSIS
Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence

WHITE CLASSIFICATION
Named after Priscilla White who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes).

Emphasizes that end organ derangements, especially involving the eyes, kidneys, have significant effects on pregnancy outcomes

CLASS

ONSET

FASTING PLASMA GLUCOSE <105mg/dl

2 HOUR POST PRANDIAL GLUCOSE <120mg/dl

THERAPY

A1

Gestational

Diet

A2

Gestational

>105mg/dl

>120mg/dl

Insulin

CLASS

AGE OF ONSET Over 20 10 19 Before 10

DURATION VASCUALR THERAPY (YEARS) DISEAS E <10 10 19 >20 None None Benign Retinopathy Insulin Insulin Insulin

B C D

F R

Any Any

Any Any

Nephropathy Insulin Proliferative nephropathy Heart Insulin

Any

Any

insulin

MANAGEMENT

GENERAL
The patient with GDM is at higher risk of developing glucose intolerance later in life. Approximately 40% of women with GDM develop DM within 15 years. GDM may be an early manifestation of DM type 2 that is temporarily unmasked by the diabetogenic hormones of pregnancy.

Women with GDM are commonly treated on an outpatient basis. The primary focus for women with GDM is dietary control of glucose intake and adequate monitoring of glucose values. GDM is divided into two categories:

A1

(glucose control by diet alone) and A2 (glucose control with diet and insulin). If glucose levels cannot be controlled with diet alone, then insulin therapy should be started.

DIET

Diabetic Diet To provide the necessary nutrients for the mother and the fetus To control glucose levels To prevent starvation ketosis

CURRENT WEIGHT IN RELATION TO IDEAL BODY WEIGHT

RECOMMENDED DAILY CALORIC INTAKE AND PREGNANCY WEIGHT GAIN IN WOMEN WITH GESTATION DM
DAILY CALORIC INTAKE (Kcal/Kg)

RECOMMENDED PREGNANCY WEIGHT GAIN (LBS)

<80-90%
80-120% (ideal) 120-150% >150%

36-40
30 24 12-18

28-40
25-35 15-25 15-25

DIABETIC DIET
Ideal Body Weight = [(Height in inches X 2.54) - 100] - 10% (if female) Ideal Body Weight X 35 cal/Kg = Total calories/day

SAMPLE DIET
Total calories = 1800-2400 cal/day 60% Carbohydrate: Total cal/day X 0.60 = 1200 cal /4 = 300gm carbo 20% Protein: Total cal/day X 0.20 = 400 cal / 4 = 100 gm protein 20% Fat: Total cal/day X 0.20 = 400 cal / 9 = 45 gm fat

PRECONCEPTUAL AND PREGNANCY WORKUP

The patient should have a preconceptual history and physical examination, an ophthalmologic examination, and measurement of an ECG.. The patient should be advised to maintain tight glucose level control. Measurement of HbA1C may be helpful in evaluating glucose control and assessing risk of fetal malformations. HbA1C levels of 10% or higher are associated with significant risk of fetal malformations. If the HbA1C level is within the normal range, risk appears to be similar to that of nondiabetic women.

A 24-hour urine measurement of creatinine clearance and protein excretion should also be performed for evaluation of kidney function. The patient should be started on folate 400 g/day for spina bifida prophylaxis. The patient should be encouraged to maintain an appropriate activity level or exercise program.

FETAL MONITORING
FIRST TRIMESTER minimal fetal monitoring is required (i.e., assessment for heart tones by Doppler ultrasonography at each visit during the latter portion of the first trimester).

SECOND TRIMESTER

Measurement of maternal serum alphafetoprotein levels, along with levels of unconjugated estriol and human chorionic gonadotropin, represents the triple screen, which is typically performed at 1618 weeks' gestation. Ultrasonography (usually at 1820 weeks) helps to date the pregnancy and evaluate the fetus for genetic abnormalities and other congenital anomalies that may be present. Fetal cardiac anomalies are the most common congenital anomalies with PDM, and so a fetal echocardiogram is recommended at 1922 weeks' gestation.

THIRD TRIMESTER

Regular fetal surveillance should be initiated for all pregnancies in insulin-requiring diabetic women. Fetal surveillance should be performed frequently in the presence of maternal vascular disease, hypertension, ketoacidosis, pyelonephritis, preeclampsia, and poor patient compliance. In well-controlled DM without associated complications of hypertension and vascular disease, minimal ongoing evaluation of the fetus may be required.

In poorly controlled or complicated DM, the incidence of fetal compromise and death is much higher, and therefore frequent fetal evaluation is required.

Repeat obstetrical ultrasonographic examinations for fetal growth may be considered at 2830 weeks and then at 3638 weeks. If the patient has evidence of microvascular disease, monthly ultrasonographic examinationS starting at 2426 weeks may be necessary to closely follow fetal growth to assess for intrauterine growth restriction (IUGR). Tests commonly used for fetal assessment are the nonstress test, biophysical profile, and contraction stress test.

MEDICAL TREATMENT

INSULIN TREATMENT
Do not give oral hypoglycemic agents. These are contraindicated during pregnancy Sample Insulin Regimen:

i.Humulin

N (intermediate) or Humulin U (Ultralente - long acting ) OD in a.m. ii.Humulin N & R combination (intermediate & short acting) at 6 a.m. and 6 p.m.

(2/3 of daily dosage to be given at 6 AM and 1/3 of daily dosage at 6 p.m.) Note: Aim for normal blood glucose (FBS =105 and Two-hour postprandial blood glucose of < 140 mg/dl.

Insulin requirements increase throughout gestation, from approximately

0.7

U/kg (body weight)/day during weeks 618, to 0.8 U/kg/day during weeks 1826, to 0.9 U/kg/day during weeks 2636, and to 1.0 U/kg/day during weeks 3640.

GOALS FOR GLUCOSE CONTROL

Fasting: 6090 mg/dL Premeal: less than 100 mg/dL 1 hour postprandial: less than 140 mg/dL 2 hours postprandial: less thAn 120 mg/dL Bedtime: less than 120 mg/dL 26 am: 6090 mg/dL

TREATMENT

Control diabetes at first 6 weeks AOG to prevent birth defects Deliver baby ideally at 36-37 weeks AOG

POSTPARTUM EVALUATION

In the postpartum period, a woman with GDM (A1 and A2) should have a follow-up GTT at 6 12 weeks postpartum to assess for possible PDM. The recommended test to further evaluate for overt DM is as follows:
a a a If

fasting blood glucose value is taken, then 75-g oral glucose load is administered, then 2-hour glucose level is measured. the threshold values are met or exceeded in followup testing, the patient should then be followed and treated for overt DM.

TIME SINCE 75g GLUCOSE LOAD

NO DM

IMPAIRED GLUCOSE TOLERANCE

OVERT DM

FASTING

< 110 mg/dl 110 125 mg/dl < 140 mg/dl 140 199 mg/dl

> OR EQUAL TO 125 mg/dl > OR EQUAL TO 200 mg/dl

2 HOUR

Patient should be placed back on an ADA diet (with increased soluble fiber and reduced fat). She should do a lifestyle assessment and attempt to keep her weight near ideal for her height. Weight reduction is generally necessary, and thus, if the patient is not breastfeeding, calories are reduced to 12001500 kcal with repeat dietary instruction, and the same calorie ADA diet is continued as the patient is breastfeeding. The caloric demand of breastfeeding increases with neonatal size but can reach 8001200 kcal per day. Exercise equivalent to expend the energy is to run hard for 1 hour (900 kcal). It takes 3500 kcal expended to reduce weight by 1 pound! She should enter a regular exercise program.

THANK YOU!!!