diabetes in pregnancy
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TRANSCRIPT
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MARGARITA ISABEL AMOROSO-ARTES, M.D.
DEPARTMENT OF OBSTETRICS & GYNECOLOGY
DAVAO MEDICAL CENTER
DIABETES IN PREGNANCY
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OBJECTIVES
Discuss and define Diabetes in pregnancy
Discuss clinical considerations and recommendations
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References
William’s Obstetrics
Greasy & Resnik’s Maternal-Fetal Medicine 6th edition
ACOG Compendium 2008
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DIABETES
IMPAIRED GLUCOSE TOLERANCE
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HOW IS DIABETES IN PREGNANCY CLASSIFIED?
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CLASSIFICATION
PREGESTATIONAL OR OVERT
GESTATIONAL
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ETIOLOGICAL CLASSIFICATION
TYPE 1A IMMUNE-MEDIATED B CELL DESTRUCTIONTYPE 1B IDIOPATHIC B CELL DESTRUCTIONTYPE 2 MAY RANGE FROM PREDOMINANTLY INSULIN RESISTANCE TO PREDOMINANTLY AN INSULIN SECRETORY DEFECT WITH INSULIN RESISTANCE
GENETIC MUTATIONS IN B CELL FUNCTIONGENETIC DEFECTS IN INSULIN ACTIONGENETIC SYNDROMES-DOWN, TURNERDISEASE OF THE EXOCRINE PANCREAS– PANCREATITISENDOCRINOPATHIES– CUSHING SYNDROME, OTHERSDRUG OR CHEMICAL INDUCED– GLUCOCORTICOSTERIDS, THIAZIDESINFECTIONS– CONGENITAL RUBELLA, CYTOMEGALOVIRUS
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CLASS ONSET FASTING PLAS MA GLUCOSE
2 HOUR POSTPRANDIAL GLUCOSE
THERAPY
A1
A2
GESTATIONAL
GESTATIONAL
< 105 MG/DL>105 MG/DL
< 120 MG/DL
<120 MG/DL
DIETINSULIN
CLASS AGE OF ONSET (YR)
DURATION (YR)
VASCULAR DISEASE
THERAPY
B
C
D
F
R
H
OVER 20
10 TO 19
BEFORE 10
ANY
ANY
ANY
<10
10 TO 19
>20
ANY
ANY
ANY
NONE
NONE
BENIGN RETINOPATHY
NEPHROPATHY
PROLIF. RETINOPATHY
HEART
INSULIN
INSULIN
INSULIN
INSULIN
INSULIN
INSULIN
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OVERT DIABETES IN PREGNANCY HIGH PLASMA GLUCOSE LEVELS GLUCOSURIA KETOACIDOSIS
RANDOM PLASMA GLUCOSE >200 MG/DL PLUS POLYDIPSIA, POLYURIA AND UNEXPLAINED WEIGHT LOSS OR A FASTING GLUCOSE EXCEEDING 125 MG/DL
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HOW SHOULD SCREENING FOR GDM BE ACCOMPLISHED?
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ALL PREGNANT PATIENTS
CLINICAL RISK FACTORS ASSOCIATED WITH INCREASED LIKELIHOOD OF GDMAGEETHNICITYOBESITYFAMILY HISTORYPAST OBSTETRIC HISTORY
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LOW RISK MEETS ALL THE CRITERIA:
AGE YOUNGER THAN 25 YEARS NOT A MEMBER OF AN ETHNIC GROUP
(HISPANIC, AFRICAN, NATIVE AMERICAN, SOUTH OR EAST ASIAN, PACIFIC ISLANDS ANCESTRY)
BODY MASS INDEX OF 25 OR LESS NO PREVIOUS HX OF ABNORMAL GLUCOSE
TOLERANCE NO PREVIOUS HX OF ADVERSE OBSTETRIC
OUTCOME ASSO. W/ GDM NO KNOWN DIABETES IN FIRST DEGREE
RELATIVE
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SCREENING TEST: 50 GM ORAL GLUCOSE CHALLENGE TEST
USE HISTORIC RISK FACTORS TO IDENTIFY THE INDIVIDUALS WHO MAY HAVE SUCH A LOW RISK FOR GDM THAT GLUCOSE CHALLENGE TESTING MAY NOT BE WORTHWHILE
THERE MAY BE GROUPS AT SUCH HIGH RISK FOR GDM THAT IT MAY BE MORE CONVENIENT AND COST EFFECTIVE TO PROCEED DIRECTLY TO THE DIAGNOSTIC GTT WITHOUT OBTAINING THE SCREENING TEST
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AT WHAT GESTATIONAL AGE SHOULD LABORATORY SCREENING BE PERFORMED?
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PREVALENCE OF GDM INCREASES W/ ADVANCING GESTATION
50 GM, 1 HOUR ORAL GLUCOSE CHALLENGE TEST AT 24-28 WEEKS AGE OF GESTATION
INSULIN RESISTANCE INCREASES AS PREGNANCY PROGRESSES- TESTING LATER IN PREGNANCY WILL YIELD HIGHER ABNORMAL TESTS
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PX WITH HX OF GDM PREVIOUS PREGNANCY 30 TO 35% LIKELIHOOD OF RECURRENCE IN SUBSEQUENT PREGNANCY
PXS WITH HX OF GDM SHOULD BE TESTED IN BETWEEN PREGNANCIES TO DETECT PREEXISTING DIABETES
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HOW IS LABORATORY SCREENING ACCOMPLISHED?
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50 GM, 1 HOUR GLUCOSE CHALLENGE TEST
PURE GLUCOSE LOAD OF 50 GM IN 150 ML OF FLUID
GLUCOSE POLYMER SOLUTIONS
( FEWER GI SYMPTOMS) SENSITIVITY: 80-90% THE SCREENING TEST MAY BE
ADMINISTERED WITHOUT REGARD TO THE TIME ELAPSED SINCE THE LAST MEAL
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IS THERE AN APPROPRIATE THRESHOLD VALUE FOR THE LABORATORY SCREENING TEST?
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AMERICAN DIABETES ASSOCIATION:
PAST: 140 MG/CL
CURRENT: 130 MG/DL
SENSITIVITY: 79%
SPECIFICITY: 97%
** EITHER THRESHOLD IS STILL ACCEPTABLE***
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HOW IS GDM DIAGNOSED?
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DIAGNOSTIC TEST SPECIFIC: 100 GM, 3 HOUR ORAL GTT
POSTIVE DIAGNOSIS REQUIRES 2 OR MORE THRESHOLDS BE MET OR EXCEEDED
PXS W/ ONLY ONE ABNORMAL VALUE HAVE INCREASED RISK FOR MACROSOMIC INFANT AND OTHER MORBIDITIES
PXS SHOULD REMAIN SEATED DURING THE TEST
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INSTRUCTED TO FOLLOW AN UNRESTRICTED DIET CONSUMING AT LEAST 150 GM OF CHO PER DAY FOR AT LEAST 3 DAYS PRIOR THE TEST TO AVOID CHO DEPLETION WHICH COULD CAUSE SPURIOUSLY HIGH VALUES ON THE GTT
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DIAGNOSTIC CRITERIA FOR GDM
STATUS PLASMA OR SERUM GLUCOSE LEVEL CARPENTER/COUSTAN CONVERSION
PLASMA LEVELNATIONAL DIABETES DATA GROUP CONVERSION
MG/DL MMOL/L MG/DL MMOL/L
FASTING 95 5.3 105 5.8
ONE HOUR 180 10 190 10.6
TWO HOURS 155 8.6 165 9.2
THREE HOURS
140 7.8 145 8
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HOW SHOULD BLOOD GLUCOSE BE MONITORED IN A WOMAN W/ GDM?
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CAPILLARY GLUCOSE MONITORING
Frequency & timing should be individualized
Postprandial have the strongest correlation w/ fetal growth
Typical glucose monitoring:Rising in the morning1 or 2 hrs after breakfastBefore & after lunchBefore dinnerBedtime
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Target Capillary Glucose Levels
Fasting plasma glucose level of 90 to 99 mg/dL (5.0 to 5.5 mmol/L)
and 1 hour postprandial plasma glucose
level <140 mg/dL (<7.8 mmol/L)
or 2 hour postprandial plasma glucose
level < 120 to 127 mg/dL (<6.7 to 7,1 mmol/L)
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Target Plasma Glucose Values:
Preprandially: 65 to 95 mg/dL
Postprandially: 130 to 140 mg/dL
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POSTPRANDIAL GLUCOSE VALUES APPEAR TO BE MOST EFFECTIVE AT DETERMINING THE LIKELIHOOD OF MACROSOMIA AND OTHER ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH GDM
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Recommended Glucose GoalFASTING/PREMEAL <95 MG/DL
1 HOUR POST PRANDIAL 140MG/DL
2 HOURS POST PRANDIAL <120 MG/DL
MEAN PLASMA GLUCOSE 90-100 MG/DL
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IS THERE A ROLE FOR DIET THERAPY IN THE TREATMENT OF GDM?
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YES NUTRITIONAL INTERVENTION
SHOULD BE STARTED PXS DELIVER FEWER MACROSOMIC
INFANTS AMERICAN DIABETES ASSOCIATION:
OVESE WOMEN (BMI > 30): MODERATE CALORIC RESTRICTION (30-33%)
SUPPLEMENTARY DIETARY FIBER MAY IMPROVE GLYCEMIC CONTROL
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IS THERE A ROLE FOR ORAL ANTIDIABETIC AGENTS IN THE TREATMENT OF GDM?
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ORAL ANTIDIABETIC AGENTS CONTRAINDICATED
EARLY GENERATION SULFONYLUREAS CROSSES THE PLACENTA STIMULATE FETAL PANCREASE FETAL HYPERINSULINEMIA AND TERATOGENIC
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PRINCIPLES OF INSULIN THERAPY
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Goal of exogenous insulin therapy during pregnancy: postprandial blood glucose excursions maintained w/in a relatively narrow range (70 to 120 mg/dL)
As pregnancy progresses increasing fetal demand for glucose results in lower fasting & between meal blood glucose levels increasing risk of symptomatic hypoglycemia
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Insulin Preparation
Time to Peak Action (Hr)
Total Duration of Action (Hr)
Comment
Insulin Lispro 1 2 Onset w/in 10 mins of injection; no need to delay meal onset after injection
Insulin Aspart 1 2 Onset w/in 10 mins of injection; no need to delay meal onset of injection
Regular Insulin 2 4 Good coverage of individual meals if injected 20 min before eating; increased risk of postprandial hypoglycemia w/ unopposed action 2-3 hr after eating
NPH Insulin 4 8 Provides intermediate acting control; give on rising & at bedtime; risk of 3 am hypoglycemia
Insulin Glargine 5 <24 Prolonged flat action profile; limited pregnancy experience; increased ris of nocturnal hypoglycemia or undertreatment during the day
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Period of maximal fetal growth velocity & fat accretion occurs at 33.5 wks gestation
Delay in therapy by 33-34 wks AOG would miss maximal glycemic intervention effective in modulation fetal growth
Allow a 1 to 2 week trial of dietary management
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Insulin regiment used should be individualized accordin to the patient’s profile
Short acting insulin (4 to 8 units to start) before meals
If > 10 units of short acting insulin is needed before the noon meal add 6 to 8 doses of NPH before breakfast
Doses are scaled up as necessary
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INTRAPARTUM GLYCEMIC MGT Maternal hyperglycemia perinatal
asphyxia & neonatal hypoglycemia Strict maternal euglycemia does not
guarantee newborn metabolic stability in infants w/ macrosomia
Use of combined insulin & glucose infusion durinng labor maintains maternal plasma glucose level in narrow range (80 – 110 mg/dL)
-- reduces incidence of neonatal hypoglycemia
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Typical infusion rates5% Dextrose in Ringer’s lactate at 100
ml/hour ANDLispro or aspart insulin at 0.5 to 1 units per
hour CBG monitored q hourly For patients with diet controlled GDM
avoiding dextrose in all IV fluids during labor maintains excellent glucose control
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For CS
Procedure should be performed early in the day to avoid prolonged fasting
Night before surgery: instructed to take full dose of NPH or
glyburideNo morning insulin or glyburide should be
taken
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Postpartum Metabolic Mgt In the Recovery Room & after delivery
Insulin subcutaneously
Insulin dose required after delivery typically 30 to 50% of the preprandial doses required during pregnancy just before delivery
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IS FETAL ASSESSMENT INDICATED IN PREGNANCIES COMPLICATED BY GDM?
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Antepartum fetal testing recommended
3rd trimester Goal mgt: prevent stillbirth adn asphyxia while optimizing the opportunity for safe vaginal delivery
Monitoring fetal growth to determine proper timing & route of delivery and testing for fetal well being at frequent intervals
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PRECONCEPTION Maternal glycemic control
8-10 WKS Sonographic crown rump measurement
16 WKS Maternal serum AFP
20-22 WKS High resolution sonography, fetal cardiac echocardiography in women in suboptimal diabetic control at first prenatal visit
24 WKS Baseline sonographic growth assessment of the fetus
28 WKS Daily fetal movement counting by the mother
32 WKS Repeat sonography for fetal growth
34 WKS Biophysical testing: 2x weekly NST or weekly CST or weekly BPS
36 WKS Estimation of fetal weight by sonography
37-38.5 WKS Amniocentesis & delivery for pxs in poor control
38.5-40 WKS Delivery w/o amniocentesis for pxs in good control who have excellent dating criteria
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Fetal movement counting
1. Count the baby’s movement EVERY NIGHT2. A movement may be a kick, swish or roll. Do not count hiccups or
small flutters3. You can start counting any time in the evening when the baby is
active. BUT: COUNT EVERY NIGHT4. Count the baby’s movement while lying down, preferable on the left
side5. Mark down the time the baby’s movement felt for the first time6. Mark down down the time the baby’s movement felt for the tenth
time7. Should feel at least 10 fetal movements within one hour. Be
alarmed if
a. No 10 fetal movements with 1 hourb. It takes longer and longers for the baby to move ten timesc. Have not felt the baby move all day
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When and how should deliveries be accomplished in patients with GDM?
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Timing of delivery should minimize neonatal morbidity & mortality while maximizing the likelihood of vaginal delivery
Optimal time for delivery: 38.5 to 40 weeks
Labor or Cesarean?ACOG recommended primary cesarean for diabetic
gravidas with EFW greater than 4500 gm to reduce risk of shoulder dystocia
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Indications for delivery in diabetic pregnancy
TYPE INDICATION
FETAL Nonreactive, + CSTReactive, + CST, mature fetusSonographic evidence of fetal growth arrestDecline in fetal growth ratge w/ decreased AFI40-41 wks AOG
MATERNAL Severe preeclampsiaMild preeclampsia, mature fetusMarkedly failing renal function
OBSTETRIC Preterm labor with failure of tocolysisMature fetus, inducible cervix
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Confirmation of fetal maturity before termination of pregnancy
Phosphatidylglycerol >3% in amniotic fluid colleted from the
vaginal pool or by amniocentesis
Completion of 38.5 weeks gestation
Normal last menstural period
First pelvic exam before 12 wk confirms dates
Sonogram before 24 wk confirms dates
Documentation of more than 18 wk of unamplified (fetoscope) fetal heart tones
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Should women with a history of GDM be screened postpartum?
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Women w/ a history of GDM are at increased risk developing diabetes (generally type 2) later in life
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What are the fetal effects of GDM?
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Fetal Effects
Abortion Preterm Delivery Malformations Unexplained Fetal Demise Hydramnios
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Fetal Death In pregnancies not receiving optimal
care After 36 wks gestation in pxs w/
Vascular diseasePoor glycemic controlHydramniosFetal macrosomiaPreeclampsia
Chronic hypoxia as likely cause of fetal death
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Anomaly Incidence
Caudal regression
Situs inversus
Spina bifida, hydrocephaly, or other CNS defect
Anencephaly
Heart Anomalies
Anal/rectal atresia
Renal Anomalies Agenesis Cystic Kidney Duplex ureter
252
84
2
3
4
3
5
44
2.3
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Neonatal Effects
Respiratory distress Hypoglycemia Hypocalcemia Hyperbilirubienmia Cardiac Hypertrophy Long Term Cognitive Development Inheritance of Diabetes Altered Fetal Growth
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What are the Maternal Effects
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Diabetic Nephropathy Diabetic Retinopathy Diabetic Neuropathy Preeclampsia Ketoacidosis Infections