A Doctors Prayer

GDM

Dear Lord, You are the greatest Healer, All life and health comes from You Without Your blessings and Your grace, There is nothing I can do, I thank You for this noble role, My service unto Thee, Stand by me with my patients, Til the work is done daily.

A Doctors Prayer

GDM

Give me knowledge, wisdom and skill To do the tasks at hand, Provide the best care needed For each persons best interest, stand Let me lend a helping hand To those who cannot pay, Bringing good health to all Send them fit for homewards way.

A Doctors Prayer

GDM

Protect with Your mighty angels, Those under my care, When their need of me is greatest, May I always be there. When my zeal is at its lowest, Tiredness meeting me at every turn, May you then be my Healer, Renewed joy and vigor earn.

A Doctors Prayer

GDM

All this I ask from You Lord, That I may a good doctor be, That in my life as a physician, May they see You in me. Amen.

Diabetes Mellitus in Pregnancy

GDM

Diabetes Mellitus

GDM

9th leading cause of death in the Philippines 1 out of 25 Filipinos 3.36 million Filipinos, 8 million in about 20 years. 2.8 million diagnosed DM (1997 Food and Nutrition
Research Institute survey, DOH)

2.1% deaths (1993 to 1997) 2.5 percent increase annually

Diabetes on the Rise among Filipinos, www.bio-medicine.org/medicinenews/Diabetes-on-the-Rise-among-Filipinos-15022-1/

GDM
Incidence (annual) of Gestational diabetes:
135,000 pregnant women every year 3-5% of pregnant women.

Incidence Rate for Gestational diabetes:

approx 1 in 2,014 0.05% 135,000 people in USA
Statistics by Country for Gestational diabetes, http://www.cureresearch.com/g/gestdiab/stats-country.htm
7

Country/Region

Extrapolated Incidence

Gestational diabetes in North America

USA Canada 145,748 16,134

GDM
293,655,4051 32,507,8742 8,174,7622 10,348,2762 60,270,708 for UK2 1,0246,1782 5,413,3922 5,214,5122 60,424,2132 10,647,5292 82,424,6092 293,9662 10,032,3752 33,4362
8

Population Estimated Used

Gestational diabetes in Europe

Austria Belgium Britain (United Kingdom) Czech Republic Denmark Finland France Greece Germany Iceland Hungary Liechtenstein 4,057 5,136 29,913 618 2,686 2,588 29,989 5,284 40,909 145 4,979 16

Country/Region Ireland Italy Luxembourg Monaco Netherlands (Holland) Poland Portugal Spain Sweden Switzerland United Kingdom Wales

Extrapolated Incidence 1,970 28,815 229 16 8,099 19,171 5,223 19,992 4,460 3,698 29,913 1,448

GDM
3,969,5582 58,057,4772 462,6902 32,2702 16,318,1992 38,626,3492 10,524,1452 40,280,7802 8,986,4002 7,450,8672 60,270,7082 2,918,0002

Population Estimated Used

Gestational diabetes in the Balkans

Albania Bosnia and Herzegovina Croatia 1,759 202 2,231 3,544,8082 407,6082 4,496,8692
9

Country/Region Macedonia Serbia and Montenegro

Extrapolated Incidence 1,012 5,373

Gestational diabetes in Asia

Bangladesh Bhutan China 70,150 1,084 644,648

GDM
2,040,0852 10,825,9002 141,340,4762 2,185,5692 1,298,847,6242

Population Estimated Used

East Timor
Hong Kong s.a.r. India Indonesia Japan Laos Macau s.a.r.

505
3,402 528,619 118,349 63,198 3,011 221

1,019,2522
6,855,1252 1,065,070,6072 238,452,9522 127,333,0022 6,068,1172 445,2862

Malaysia
Mongolia

11,674
1,365 42,803

23,522,4822
2,751,3142 86,241,6972
10

Philippines

Country/Region Papua New Guinea Vietnam Singapore Pakistan North Korea South Korea

Extrapolated Incidence 2,690 41,027 2,160 79,012 11,265 23,939

GDM
5,420,2802 82,662,8002 4,353,8932 159,196,3362 22,697,5532 48,233,7602

Population Estimated Used

Sri Lanka
Taiwan Thailand

9,879
11,291 32,194

19,905,1652
22,749,8382 64,865,5232

Gestational diabetes in Eastern Europe

Azerbaijan Belarus Bulgaria 3,905 5,117 3,731 7,868,3852 10,310,5202 7,517,9732

Estonia
Georgia Kazakhstan

665
2,329 7,516

1,341,6642
4,693,8922 15,143,7042
11

Country/Region Latvia Lithuania Romania Russia Slovakia Slovenia

Extrapolated Incidence 1,144 1,790 11,095 71,457 2,691 998

GDM
2,306,3062 3,607,8992 22,355,5512 143,974,0592 5,423,5672 2,011,473 2

Population Estimated Used

Tajikistan
Ukraine Uzbekistan

3,480
23,690 13,108

7,011,556 2
47,732,0792 26,410,4162

Gestational diabetes in Australasia and Southern Pacific

Australia New Zealand 9,883 1,982 19,913,1442 3,993,8172

Gestational diabetes in the Middle East

Afghanistan
Egypt Gaza strip

14,152
37,778 657

28,513,6772
76,117,4212 1,324,9912
12

Country/Region Iran Iraq Israel Jordan Kuwait Lebanon

Extrapolated Incidence 33,503 12,594 3,076 2,784 1,120 1,874

GDM
67,503,2052 25,374,6912 6,199,0082 5,611,2022 2,257,5492 3,777,2182

Population Estimated Used

Libya
Saudi Arabia Syria Turkey United Arab Emirates West Bank Yemen

2,795
12,803 8,942 34,193 1,252 1,147 9,938

5,631,5852
25,795,9382 18,016,8742 68,893,9182 2,523,9152 2,311,2042 20,024,8672

Gestational diabetes in South America

Belize Brazil 135 91,373 272,9452 184,101,1092
13

Country/Region Chile Colombia Guatemala Mexico Nicaragua Paraguay

Extrapolated Incidence 7,853 20,999 7,087 52,093 2,660 3,072

GDM
15,823,9572 42,310,7752 14,280,5962 104,959,5942 5,359,7592 6,191,3682

Population Estimated Used

Peru
Puerto Rico Venezuela

13,670
1,934 12,416

27,544,3052
3,897,9602 25,017,3872

Gestational diabetes in Africa

Angola Botswana Central African Republic 5,448 813 1,857 10,978,5522 1,639,2312 3,742,4822

Chad
Congo Brazzaville Congo kinshasa

4,734
1,487 28,944

9,538,5442
2,998,0402 58,317,0302
14

 MOST COMMON endocrine disorder in pregnancy

90 to 95%: GDM

GDM

MOST COMMON medical complication of pregnancy

In 2002, 131, 000 American women with pregnancies complicated by diabetes 3.3 % of all live births > 90% : Gestational diabetes
Textbook of Obstetrics 3rd edition, Sumpaico et al. Martin and colleagues, 2003, Williams Obstetrics.
15

Glucose Intolerance in Pregnancy

GDM

Prevalence of GDM 3 to 18 %
16

Normal Regulation of Plasma Glucose

Insulin secretion Hepatic insulin response

GDM
Muscle/fat insulin response
Controlled glucose clearance

Controlled glucose production

Glucose enters the blood

Normal plasma glucose

Glucose enters peripheral tissues

12

Hyperglycemia
The Defining Feature of Diabetes

GDM
Impaired glucose clearance

Excessive glucose production Hyperglycemia

Tissue injury
1

Pathogenesis of Type 1 Diabetes

One Defect
Absent insulin secretion

GDM
No muscle/fat insulin effect
Impaired glucose clearance

No hepatic insulin effect

Unrestrained glucose production

Hyperglycemia

More glucose enters the blood

Less glucose enters peripheral tissues

Glycosuria

13

Pathogenesis of GDM

Pregnancy is a state of INSULIN RESISTANCE

GDM

Insulin Resistance (IR), cell stimulation 50 to 70% lower (INSULIN ACTION) vs. healthy non-pregnant women
Butte, 2000: Williams Obstetrics

Normal pregnancy Mild fasting hypoglycemia Postprandial hyperglycemia Hyperinsulinemia

20

Pathogenesis of GDM

GDM

Increased basal level of insulin with unique responses to glucose ingestion: Prolonged hyperglycemia and hyperinsulinemia Suppression of glucagon
peripheral resistance to insulin

Sustained postprandial glucose supply to the fetus

Phelps and associates, 1981: Williams Obstetrics.
21

Pathogenesis of GDM

GDM

& Sustained glucose levels fasting plasma glucose & amino acids (alanine) Free FA, TG, Chol

ACCELERATED STARVATION
Pregnancy-induced switch of fuels from glucose to lipids Risk for Ketonemia
Freinkel and colleagues, 1985: Williams Obstetrics
22

Pathogenesis of GDM

GDM

Placental Diabetogenic Hormones: Progesterone and estrogen

Direct or indirect mediators

Cortisol GH Human Placental Lactogen (HPL)

Growth-hormone like action increased lipolysis with liberation of free fatty acids insulin resistance

Prolactin
Freinkel, 1980: Williams Obstetrics
23

Pathogenesis of GDM

GDM

Reduced Insulin Sensitivity up to 80% Impaired 1st phase insulin, Hyperinsulinemia Islet cell auto antibodies (2 to 25% cases) Glucokinase mutation in 5% of cases

www.drsarma.in

24

Fundamental Defect in GDM

GDM

The hormones of pregnancy cause IR They also cause direct hyperglycemia But, the basic defect is The maternal pancreatic cells are unable to compensate for this increased demand

25

Normal Glucose Tolerance

GDM

www.drsarma.in

26

Abnormal GT in GDM

GDM

www.drsarma.in

27

Natural History Of PreType 1 Diabetes

-Cell mass 100%
Putative trigger
Cellular autoimmunity Circulating autoantibodies (ICA, GAD65) Loss of first-phase insulin response (IVGTT) Glucose intolerance (OGTT)

GDM
Clinical onset only 10% of -cells remain

Genetic predisposition

Insulitis -Cell injury

Prediabetes

Diabetes

Time Eisenbarth GS. N Engl J Med. 1986;314:1360-1368

14

GDM - Definition

GDM

CARBOHYDRATE INTOLERANCE of variable severity with onset of first recognition during pregnancy. Regardless of:
insulin use or persistence after pregnancy.

Does not exclude unrecognized glucose intolerance antecedent to pregnancy

Textbook of Obstetrics 3rd

Williams Obstetrics edition, Sumpaico et al.

29

GDM - Definition

GDM

Distinguish GDM from Pre-gestational DM Abnormal Glucose Tolerance Onset (begins) with pregnancy or Detected first time during pregnancy No h/o of pre pregnancy DM Hb A 1 c is usually < 7.5 in GDM In DM + Pregnancy it is > 7.5 GDM is a forerunner of T2DM
30

Classification of Diabetes (Powers, 2001)

Type 1 Diabetes

GDM

ABSOLUTE INSULIN DEFICIENCY

DEFECTIVE INSULIN SECRETION OR DEFECTIVE INSULIN RESISTANCE

Type II Diabetes

31

Etiological Classification of Diabetes Mellitus Type 1 A Immune-mediated -cell destruction Type 1 B Idiopathic -cell destruction

GDM

Type 2

May range from predominantly insulin resistance to predominantly an insulin secretory defect with insulin resistance

Genetic mutations in -cell function Genetic defects in insulin action Genetic syndromesDown, Klinefelter, Turner Diseases of the exocrine pancrease.g., pancreatitis, cystic fibrosis

Endocrinopathiese.g., Cushing syndrome, pheochromocytoma, others Drug or chemical inducede.g., glucocorticosteroids, thiazides, -adrenergic agonists, others
Infectionse.g., congenital rubella, cytomegalovirus, coxsackievirus
Adapted from Powers 2001
32

Classification of Diabetes (Powers, 2001)

GDM

Insulin Dependent Diabetes Mellitus (IDDM)

Noninsulin-dependent Diabetes Mellitus (NIDDM) AGE

-cell destruction: ANY AGE Most common onset: < 30 years old 5 to 10%- >30 years old Type 2 diabetes- most typical with increasing age but also occurs in OBESE ADOLESCENTS
33

Classification During Pregnancy (ACOG, 1986)

Class 15

GDM
Diet Insulin
Therapy

Onset 2-hour Therapy % of women with GDMFasting Plasma exhibit FASTING HYPERGLYCEMIA. Glucose Postprandial Sheffield Glucose & co-workers, 1999

A1 A2
Class

Gestational < 105 mg/dL < 120 mg/dL Classes B to H: WHITE CLASSIFICATION (1978) -OVERT DIABETESmg/dL Gestational > 105 antecedent to pregnancy > 120 mg/dL -END-ORGAN DERANGEMENT
Age of Onset (yr) Duration (yr) Vascular Disease

B C D F R

Over 20 10 to 19 Before 10 Any Any

< 10 10 to 19 > 20

None None Benign retinopathy

Insulin Insulin Insulin Insulin

Proliferative Insulin A single classification based on the presence or absence of good retinopathy
* When diagnosed during pregnancy: 500 mg or more proteinuria per 24 hours measured before 20 weeks gestation.

REPLACED 1994, ACOG

Any Any

Nephropathy*

maternal metabolic control andAny presence or absence of maternal the H Any Heart Insulin diabetic vasculopathy is more helpful
34

Diagnosis: OVERT DIABETES

1. 2. 3. 4. 5.

GDM

CRITERIA FOR DIAGNOSIS (American Diabetes Association, 2004):

Fasting plasma glucose of >125 mg/dL Glucosuria Ketoacidosis Random plasma glucose level >200 mg/dL Presence of Classic signs & symptoms:

Polydypsia, Polyphagia, polyuria, unexplained weight loss

Strong family history, previous delivery of large infants, unexplained fetal losses, persistent glucosuria
35

6. High index of suspicion

Screening:
30 years of research

GDM

NO CONSENSUS regarding the OPTIMAL APPROACH to SCREENING

Issues:
UNIVERSAL SCREENING SELECTIVE SCREENING Plasma glucose level after 50-gm glucose testing
Bonomo and colleagues, 1998; Danilenko-Dizon and colleagues, 1999: Williams Obstetrics

36

Screening
Since 1980

GDM
Metzger and Coustan, 1998

4 international work-shop conferences Consensus statements on screening

37

Recommended Screening Strategy Based on Risk Assessment for Detecting Gestational Diabetes
(4th International Workshop- Conference on Gestational Diabetes)

GDM

Low Risk
Blood glucose testing NOT ROUTINELY required if all of the following characteristics are present: Member of ethnic group with a low prevalence for gestational diabetes (-) DM in first degree relatives Age < 25 years Weight normal before pregnancy No history of abnormal glucose metabolism No history of poor obstetrical outcome
Metzger and Coustan, 1998
Adopted from ADA guidelines
38

Recommended Screening Strategy Based on Risk Assessment for Detecting Gestational Diabetes
(4th International Workshop- Conference on Gestational Diabetes)

GDM

Average Risk
Blood glucose testing at 24 to 28 WEEKS using one of the following: AVERAGE RISK:
Woman of HISPANIC, AFRICAN, NATIVE AMERICAN, SOUTH OR EAST ASIAN GROUP

HIGH RISK:
Women with marked obesity, strong family history of type 2 diabetes, prior gestational diabetes, or glucosuria

Metzger and Coustan, 1998

Adopted from ADA guidelines

39

Recommended Screening Strategy Based on Risk Assessment for Detecting Gestational Diabetes
(4th International Workshop- Conference on Gestational Diabetes)

GDM

HIGH Risk
Perform blood glucose testing as soon as feasible. If gestational diabetes is not diagnosed, blood glucose testing should be repeated at 2428 weeks or at any time a patient has symptoms or signs suggestive of hyperglycemia

Metzger and Coustan, 1998

Adopted from ADA guidelines

40

Risk Stratification for GDM

GDM

High Risk Group (Indians mostly)

BMI 30; PCOD; Age > 35 years F h/o DM; Ethnic predisposition; Acanthosis Previous h/o GDM, IGT, Macrosomic baby

Low Risk Group

Age < 25, BMI < 23, No F h/o DM or IGT No bad obstetric history; No risk ethnicity

Intermediate Risk Group

Not falling in the above two classes
Adopted from ADA guidelines
41

Screening
1997 Workshop
SELECTIVE SCREENING

GDM

1. 24 to 28 weeks AOG 2. Women with no known glucose intolerance earlier in pregnancy 3. Do a 1-step or a 2-step procedure

42

Screening
ACOG, 2001

GDM

Selective screening in some clinical settings and universal screening in others

Brody and colleagues, 2003

Insufficient to recommend for or against screening.

43

Screening
1-step procedure

GDM

FBS 75-gm glucose Extract another blood sample 2 hours after glucose ingestion Diagnostic of GDM:
FBS > 105 mg% 2-hour postglucose value >140mg%
Textbook of Obstetrics 3rd edition, Sumpaico et al. Martin and colleagues, 2003, Williams Obstetrics.

44

Screening
2-step procedure

GDM

50-g OGTT followed by diagnostic 100g- OGTT if results exceed a predetermined plasma glucose level. Plasma glucose level is measured 1-hour after a 50-g OGTT without regard to TIME OF DAY or TIME OF LAST MEAL (GLUCOSE CHALLENGE TEST) >140 mg/dL (7.8 mmol/L)= identifies 80% of GDM 14 to 18%- positive test >130 mg/dL (7.2 mmol/L)= identifies 90% of GDM
20-25%- positive test
Textbook of Obstetrics 3rd edition, Sumpaico et al. Martin and colleagues, 2003, Williams Obstetrics.

45

GDM Two Step Screening

Two Step Screening

GDM

Do a Random Glucose Challenge Test (GCT) 50 grams of oral glucose any time of day 1 hour post test for plasma glucose (1 hr PG) Result > 180 mg% - Dx of GDM confirmed Result > 140 mg% - Dx of GDM suspected 140 to 180 We need OGTT (100 g) to confirm

One Step Screening

OGTT 3 hours after 100 g of oral glucose
46

Table 524. American College of Obstetricians and Gynecologists 2001 Criteria for Diagnosis of Gestational Diabetes Using the 100-g Oral Glucose Tolerance Test

GDM
National Diabetes Plasma Data Group mmol/L 5.8 10.6 9.2 8.0 105 190 165 145

Plasma/Serum Carpenter and Coustan Status Fasting 1- hour 2-hour 3-hour mg/dL 95 180 155 140 mmol/L 5.3 10.00 8.6 7.8

mg/dL

47

Glucose Challenge Test (GCT)

GDM
180+
GDM confirmed

< 140
No GDM repeat 24 wk

140 to 180
Need to do OGTT 3 hr

48

OGTT 100g 3 hour Test

Test sample timing Fasting (mg%) 1 hour (mg%) 2 hour (mg%) 3 hour (mg%)

GDM

Plasma Glucose value 95 180 155 140

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49

Please be specific

GDM

Do not use the loose word Blood Sugar Be specific to measure Plasma Glucose Always venous sample for OGTT No capillary blood testing for OGTT NaF to be added as anticoagulant to blood Centrifuge to separate plasma immediately Plasma glucose to be estimated a.s.a.p Glucometer can be used for monitoring
www.drsarma.in

50

Diagnosis:

GDM
Weiss and collegues, 1998

NO international agreement: optimal OGTT for definitive diagnosis of GDM

WHO, Europe
75-g 2-hour OGTT

US, ACOG, 2001

100g- 3 hour OGTT after an overnight fast remains the standard
51

Maternal & Fetal Effects

Adverse maternal effects:

GDM

Increased frequency of hypertension and cesarean section

Maternal deaths are uncommon but the risk is increased 10x. (Cousins, 1987)
Due to ketoacidosis, hypertension, preeclampsia and pyelonephritis.

52

Maternal Effects:
Diabetic Nephropathy

GDM

Leading cause of end-stage renal failure in the US 30% for type 1 diabetes and 4 to 20 %- type 2 diabetes 25% decrease in nephropathy for each 10% decrease in hemoglobin A1C levels. (Diabetes Control and Complications Trial, 2002)

53

Maternal Effects:
Diabetic Nephropathy

GDM

Clinically detectable nephropathy begins with MICROALBUMINURIA

30 to 300 mg/24 h of albumin manifest as early as 5 years after the onset of diabetes (Nathan, 1993).

OVERT PROTEINURIA
After another 5 to 10 years more than 300 mg/24 h of albumin Hypertension invariably develops

RENAL FAILURE
ensues typically in the next 5 to 10 years.
54

Maternal Effects:
Diabetic Nephropathy
5 % with diabetes are class F

GDM

Hanson and Persson, 1993; Siddiqi and associates, 1991)

increased preeclampsia and indicated preterm delivery Proteinuria >500 mg/day 38 percent developed preeclampsia. Microproteinuria >190 to 500 mg/day increased risk of preeclampsia. Chronic hypertension with diabetic nephropathy increased the risk of preeclampsia to 60 percent. Heavy proteinuria before 20 weeks Chronic renal insufficiency as well as were predictive of preeclampsia.
Gordon and associates (1996) 55

Maternal Effects:
Diabetic Retinopathy Diabetic Neuropathy Pre-eclampsia Ketoacidosis Infections

GDM

56

Neonatal Effects

GDM

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Macrosomia of the baby CPD Shoulder Dystocia Intrapartum Trauma Feto-maternal Congenital Anomalies, HCM Neonatal Hypoglycemia Neonatal Hypocalcemia Neonatal Hyperbilirubinemia Respiratory Distress Syndrome (RDS) Polycythemia (secondary) in the new born

57

Macrosomia

GDM

Birth weight > 4500 g - 90th percentile GA Intrapartum feto-maternal trauma Increased need for C- Section 20 30% of infants of GDM Macrosomic Maternal factors for Macrosomia
Uncontrolled Hyperglycemia Particularly postprandial hyperglycemia High BMI of mother Older maternal age, Multiparity
58

Macrosomic Newborn

GDM

59

Shoulder Dystocia
Erbs palsy

GDM

60

Macrosomia

GDM
GDM Non DM P value 3333 g < 0.05 40.4% 13.7% < 0.001

Birth Weight

3512 g

LGA

Macrosomia

32.0%

11.0%

< 0.01

Neonatal Hypoglycemia

GDM

Due to fetal hyperinsulinemia Neonatal plasma glucose < 30 mg% Poor glycemic control before delivery Increases perinatal morbidity Congenital anomalies 3 to 8 times more More if periconception hyperglycemia Assoc. maternal fasting hyperglycemia
62

Minor Adverse Health Effects

Normal GDM DM

GDM
P

Birth Wt (g)
Macrosomia(%) C-S

330364
8 5

364951
36 10

384972
47 14

<0.01
<0.01 <0.01

Hypoglycemia
Hypocalcemia

2
0

28
4 23

52
7 21

<0.01
<0.01 <0.01

Hyperbilirubinemia 15

Polycythemia
Cord C-Pep Cord Glu

0
1.180.1 1003.6

7
2.070.12 1032.9

11

<0.01

2.980.22 <0.01 1145.5 <0.01

Major Adverse Health Effects

Normal
CNS 6.4%

GDM
DM
18.4%

Congenital heart disease

Respiratory disease Intestinal atresia

7.5%
2.9% 0.6%

21.0%
7.9% 2.6%

Anal atresia
Renal & Urinary defect Upper limb deficiencies

1.0%
3.1% 2.3%

2.6%
11.8% 3.9%

Lower limb deficiencies

Upper + Lower spine Caudal digenesis

1.2%
0.1% 0.1%

6.6%
6.6% 5.3%

Neonatal Complications
DM
T. hypoglycemia(%) P. hypoglycemia(%) 52 6

GDM
Normal p-value
3 0 <0.01 <0.01

GDM
28 2

Hypocalcemia(%)

5
23 2

0
15 0

<0.01
<0.01 <0.01

Hyperbilirubinemia(%) 21 Trans tachypnea(%) 5

Polycythemia(%)
RDS(%) IUGR(%)

11
5 2

7
2 1

0
0 0

<0.01
<0.01 <0.05

Congenital Anomalies - DM Control

Maternal HbA1c levels < 7.2 7.2-9.1 Nil 14%

GDM

9.2-11.1
> 11.2

23%
25%

Critical periods - 3-6 weeks post conception

Need pre-conceptional metabolic care

Late effects on the offspring

Increased risk of IGT Future risk of T2DM Risk of Obesity

GDM

67

Management:
Insulin therapy Diet Exercise Oral anti-diabetic drugs

GDM

68

GDM Glycemic Targets

Recommended values for Pre-pregnancy Hb A1c Pregnancy values FPG 1 hr PPG 2 hr PPG

GDM

Glycemic Targets 7.00 (if possible 6.00) Range 70 - 95 100 140 90 120

Hb A1c

6.00
69

GDM
American Diabetes Association (2000) nutritional counseling with individualization based on height and weight average of 30 kcal/kg/d based on prepregnant body weight for nonobese women. obese women with a body mass index greater than 30 kg/m2 may benefit from a 30- to 33-percent caloric restriction. Monitored weekly tests- ketonuria
maternal ketonemia has been linked with impaired psychomotor development in the offspring (Rizzo and colleagues, 1995). 70

Body Mass Index and Recommended Weigh Gain

Pre-pregnant weight status A. Twin Pregnancy Recommended range of weight gain 35-45 lbs

GDM

B.Underweight (BMI<18.5) C.Normal Weight (BMI 18.5 to 24.9)

D.Overweight (BMI 25.0 to 29.9)

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

E. Obese (BMI > 30.0) 15 lbs

71

GDM and MNT

GDM

Two weeks trial of Medical Nutrition Therapy Pre-pregnancy BMI is a predictor of the efficacy If target glycemia is not achieved initiate insulin MNT extra 300 calories in 2 and 3rd trimesters Calories 30 kcal/kg/day = 1800 kcal for 60 kg If BMI > 30; then only 25 kcal/kg/day 3 meals and 3 snacks avoid hypoglycemia 50% of total calories as CHO, 25% protein & fat Low glycemic, complex CHO, fiber rich foods
72

Diet therapy in GDM

Small, frequent meals Avoid eating for two

GDM

Avoid fasts and feasts

Avoid health drinks

Eat a bedtime snack

Tips for diet management

GDM

Small breakfast Mid morning snack

High protein lunch

Mid afternoon snack Usual dinner Bed time snack

GDM and Exercise

GDM

Recumbent bicycle Upper body egometric exercises Moderate exercises Mother to palpate for uterine contractions Walking is the simplest and easiest Continue pre pregnancy activity Do not start new vigorous exercise
75

Insulin Therapy

GDM

Usually recommended when standard dietary management does not consistently maintain:
FBS at <105 mg/dL
2-hour postprandial plasma glucose <120mg/dL

ADA, 1999
Diet alone fails to maintain:
FBS <95 mg/dL 2-hour postprandial plasma glucose <120mg/dL
76

GDM and Insulins

GDM

In 10 to 15% of GDM, MNT fails Start on insulin Good glycemic control No increased risk Human Insulins only Not Analogs Daily SMBG up to 7 times! Insulin Glargine (Lantus) Not to be used at all Insulin Lispro tested and does not cross placenta Insulin Aspart not evaluated for safty CSII may be needed in some cases Oral drugs not recommended (SU?, Metformin?)
77

Insulin Regimen

GDM

If MNT fails after 2 - 4 weeks of trial Initiate Insulin + Continue MNT Dose: 0.7, 0.8 and 0.9 u/kg 1, 2 & 3 trim. Eg. 1st trim 64 kg = 0.7 x 64 = 45 units Give 2/3 before BF = 30 units of 30:70 mix Give 1/3 before supper = 15 u of 50:50 mix Increase total dose by 2-4 units based on BG After BG levels stabilize monitor till term
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78

GDM and Delivery

GDM

Delivery until 40 weeks is not recommended Delivery before 39th week assess the pulmonary maturity by phosphatase test on amniocentesis fluid C - Section may be needed (25 -30%) Be prepared for the neonatal complications Assess the mother after delivery for glycemia May need to continue insulin for a few days Pre-gestational DMInsulin (30% less) or OAD
79

Thank You!

GDM

80