CURRENT CONCEPTS IN MANAGEMENT OF GDM

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CURRENT CONCEPTS IN MANAGEMENT OF GDM
Dr SANJAY KALRA, D.M. AIIMS
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OUR VISIONTo be a globally-acknowledged centre
of excellence for clinical care,
education training, and research
in diabetology and endocrinology.
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Diabetes and pregnancy

• One of the most challenging aspects of diabetes
  practice
• Seemingly easy Practically difficult
• Needs a lot of commitment on part of doctor,
  patient and family
• Success can be achieved if we try together

Lets begin by staying awake for the next 30
minutes
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Women and diabetes

• Diabetes no longer means
• Abstinence
• Amenorrhea
• Inability to conceive
• Inability to deliver healthy children
• Death during pregnancy

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Diabetes and fertility

• Delayed menarche in T1
• Menstrual abnormalities
• Premature Ovarian Failure
• PCOD
• Only 1 diabetic pregnancy out of 35 000
  deliveries in London in 1920s

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Classification

• Type 1
• Type 2
• GDM any degree of glucose intolerance, with
  onset or first recognition during pregnancy
• 2-12 in various studies
• 17 in Indian studies
• 22/170 13 in Karnal

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Total Deliveries - 170
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HIGHEST G 10 Highest A 4,4,4
History of Diabetic Cases
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Metabolism in normal pregnancy

• Decreased FBG nadir at 12 wks, partly due to
  increased renal clearance
• Increased PPBG facilitated anabolism for
  foetus
• Increased insulin levels, both F and PP peak at
  18-20 wks
• beta-cell hypertrophy and hyperplasia
• Decreased insulin sensitivity by 50, in late
  2nd and 3rd trimesters
• Enhanced lipolysis spares glucose for
  utilization by foetus accelerated starvation
  due to placental hormones
• Due to progesterone, hPL, leptin, TNF-?, other
  inflammatory and stress-related markers
  Radaelli, 2004

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Diabetes and pregnancy

• Placental structure and function is affected
• Early IUGR as high BG inhibits trophoblast
  proliferation
• Hypertension, renal disease more frequent
• High glycogen content in placenta

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Diabetes and embryogenesis

• Early fetal loss due to apoptosis of blastocyst,
  modulated by regulatory gene Bax, which is
  stimulated by high BG
• Malformation rate 3X higher 4-10
• High BG reduces total cell mass and number of
  blastocysts, esp in inner cell layer

• Cardiac 4x
• Anencephaly 5x
• Spina bifida 3x
• Caudal regression syn 212x
• Arthrogryposis 28x
• Cleft lip/palate 1.5x
• Ureteric duplication 23x
• Renal agenesis 5x
• Pseudohermaphroditism 11x
• Anorectal atresia 4x

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Diabetes and fetal growth

• Maternal diabetes
• Incr nutrient transfer to foetus
• Foetal hyper-insulinemia wk 9 onwards
• Incr IGF-1 because of changes in IGFBP-1 affinity

• Incr adipose tissue
• Accel skeletal maturation
• Incr hepatic glycogen content
• Organomegaly liver, spleen, heart
• Delayed pulmo maturation
• Delay in switch from HbF to HbA
• Polycythemia

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Stillbirths in diabetes

• Fetal hypoxia as O2 is diverted to non-visceral
  tissues, acidosis
• Hypokalemia
• Placental dysfunction
• Hypoglycemia
• Oxidative stress
• Impaired O2 delivery to foetus as GHb has higher
  O2 affinity

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Diabetes in future life

• LGA
• IUGR
• Maternal history
• T2 more common than T1
• Programming effect of intrauterine environment on
  insulin sensitivity

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Screening for GDM

• WHO FBG and 2h PPBG or 2h post-75 g glucose BG
• 1 h post- 50 g glucose load BG GCT
• ADA FBG, 1 h, 2 h, 3 h post- 75 or 100 g glucose
  BG
• One-step or two-step protocol
• At first visit reassess at 24 28 weeks

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Screening for GDM

• 1 hr GCT
• 140 mg
• 130 mg
• 75 g GTT
• 2 h 155 mg

• 100 g GTT
• 1 h 180 mg
• 2 h 155 mg
• 3 h 140 mg

Any time of day No regards to meals
All venous samples. Normal meals x 3 days No
smoking Patient seated 8 14 hrs fasting
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Diagnosis of GDM
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Treatment

• Medical nutrition therapy
• Exercise
• Insulin
• Glibenclamide
• Metformin

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Treatment of Diabetic Cases
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MNT

• 6 meal pattern
• Substantial night snack light breakfast
• Encourage complex carbohydrates, fruits
• 30 cal/kg/day 1500 cal for a 50 kg lady
• Avoid starvation/ketosis
• Increase intake in 3rd trimester
• Weight reduction if BMI gt 27

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Exercise

• Upper limb exercises
• Avoid resistance exercises
• Walking swimming Breathing exercises
• Avoid jogging
• Pelvic floor exercises

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INSULIN

• Be dynamic
• Choose regime acc to BG profile
• Usually FBG is easy to control, PPBG is difficult
• Prefer human insulin use analogs only if esential

• Basal-bolus regime
• Regular- regular- premixed
• Premixed 50 premixed 30
• Premixed b.d.
• Premixed o.d.
• NPH o.d.

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Treatment of Diabetic Cases
6 to 120 U/day dose variation
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OHAs

• GLIBENCLAMIDE does not cross placental barrier
• Recent reports suggest no increase in foetal
  malformation rate
• Risk of maternal hypoglycemia
• Stop as soon as patient comes to you

• METFORMIN used extensively in South Africa in
  pregnancy
• Being used extensively for PCOD, infertility
• Reports suggest beneficial results in ist
  trimester continuation rate
• Stop as soon as pregnancy is diagnosed/at 12
  weeks

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First trimester

• Early USG for dating, to r/o CMF
• CRL may lag behind dates is associated with 7x
  CMF
• Tight glycemic control F 95, 1hPP 140, 2hPP 120
  mg
• Prefer basal-bolus regime may use analogues
• Preempt hypoglycemia if nausea, vomiting are
  present check ketones
• Supplement folic acid till 12 wks

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Blood glucose goals

• FBG lt 95 in whole blood, lt 105 in plasma
• 1 h PP lt 140, 155
• 2 h PP lt 120, 130 ADA
• Mean FBG 56 , MBG 74.7, 1 h PP lt 105 mg
  Paretti, 2001 in healthy 3rd trimester

• MBG lt 86 IUGR
• MBG gt 105 LGA
• MBG gt 110 neonatal metabolic and respiratory
  complications Langer,1998
• Desired BG 63 100 mg Tamas, 1981

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Second trimester

• Monitor glucose, HbA1c/fructosamine
• Insulin dose may double by end of
  2nd trimester
• highest glucose levels between BF and lunch
• Monitor B.P., renal and retinal problems
• Encourage upper limb exercise

• USG at 18-20 wks
• Fetal echo at 20-24 wks
• Doppler at 20 wks -ve predictive value for PIH
  is 90 ve 30
• USG for foetal growth, liquor volume regularly
  after 26 wks
• Watch for candidiasis, UTI, carpal tunnel
  syndrome

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Screening for chr anomalies

• Amniocentesis
• Triple marker test gestational age, mothers
  age, blood uE3, AFP,hCG from 16-22 wks
  identifies 60-70 abn pregnancies
• AFP, uE3 levels are lower in diabetic
  pregnancies
• USG increased fetal nuchal lucency at 10-14 wks
  may point to Downs

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Third trimester

• Insulin req increases till 34-36 wks, then
  plateaus or falls
• USG for FAC, liquor volume. Estimated foetal
  weight may be inaccurate
• Watch for PIH, preterm labour, IUGR, IUD

• asymmetrical growth restriction is a feature of
  nephropathy/retinopathy, PIH
• is due to uteroplacental insufficiency which
  spares brain growth at expense of reduced liver
  glycogen and SC fat
• is ass with IUD, intrapartum hypoxia, NEC

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Third trimester

• Delaying delivery beyond 38 wks increases risk of
  perinatal death
• May have to deliver at 36-37 wks
• Give betamethasone, ritodrine under insulin cover

• NST/ CTG
• Biophysical profile
• Umbilical artery resistance index
• Aspirin reduces risk of PIH by 15 may be
  offered to all diabetics

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Maternal Complication
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Labour and delivery

• Insulin requirements are low in labour
• Give GIK infusion may use 10 dextrose 100
  ml/hr 40 cals/hr
• Watch for ketosis
• Insulin req falls further after delivery

• Intermittent CTG
• LSCS vs NVD
• Epidural
• Paediatrician must be present
• Breastfeeding
• 24 hr milk 50 g carbohydrates

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Time and Method of Delivery
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The neonate

• Hypoglycemia
• Polycythemia
• Hyperviscosity syndrome
• NEC
• RDS
• TTN
• Transient HCMP

• Hypocalcemia
• Hypomagnesemia
• Hyperbilirubinemia
• Prematurity
• Congenital malformations

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Birth Weight
Max birth weight 4.25 kg at 41 wks gestation
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Neonatal Complication
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Gender ratio

• Distt Karnal 800 females for 1000 males
• Diabetic pregnancies 12 daughters, 11 sons

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Post partum management

• GTT at 6 wks
• Contraception
• Counselling for future pregnancies
• 5-10 may develop T1DM GAD ve
• T2DM in obese, pts with high insulin req, wt gain
  postpartum, maternal h/o DM

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Post partum follow up at 6 weeks
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Management

• Specialized diabetes antenatal care
• Education
• Self-monitoring
• 10-30 need insulin esp at 30 wks
• Serial USG for FAC
• Induction of labour on obstetric grounds
• May need GIK infusion if labour is long
• Stop insulin after delivery