Gestational Diabetes

Mellitus

Agenda

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Gestational Diabetes Mellitus

(GDM)
Defined as any degree of glucose intolerance
with onset or first recognition during
pregnancy
Women with GDM:
May have only a minimal insulin deficiency
Control blood glucose adequately with a meal plan

May have a more severe insulin deficiency

Require insulin along with nutritional therapy

American Diabetes Association. Diabetes care 2004;27 Suppl1:S88-S90

Joslin diabetes center Available at:

Gestational Diabetes Mellitus

(contd)
GDM may revert to impaired glucose
tolerance (IGT) or even normal glucose
tolerance after delivery
GDM usually lasts only through the
pregnancy
Women with diabetes may be at greater risk
of developing T2DM later stages of life (30
60%)
4

Joslin diabetes center Available at: http://www.joslin.org/info/diabetes-

Gestational Diabetes Mellitus

(contd)
Long-term considerations in GDM:
Obesity and other factors promote insulin
resistance
Enhance the risk of T2DM after GDM

Markers of islet celldirected autoimmunity are

associated with an increase in T1DM risk
Offspring of women with GDM are at increased
risk:
Obesity
Glucose intolerance
Diabetes in late adolescence and young adulthood

American Diabetes Association. Diabetes care 2004;27

Agenda

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Potential Complications
Conclusion

Epidemiology of GDM
Affects nearly 7% of all pregnancies
More than 200,000 cases annually

Nearly 50% of women with a history of GDM

develop T2DM within 5 10 years after
delivery
GDM in India:
More common in women living in urban areas
than in the rural areas

American Diabetes Association. Diabetes care 2004;27

Suppl1:S88-S90
IDF Available at : http://www.idf.org/types-diabetes Accessed

Agenda

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Risk Factors for GDM

Maternal demographic and physical factors:

Ethnicity (non - European)

Increasing age
Family history of diabetes
Short stature
Low birth weight
Parity

McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-

Risk Factors for GDM (contd)

Maternal clinical factors:

10

Overweight/obesity
Diet high in red and processed meat
Pregnancy weight gain
Physical inactivity
Polycystic ovarian syndrome
- thalassemia trait
High blood pressure
Multiple pregnancy

McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-

Risk Factors for GDM (contd)

Past obstetric history
Macrosomia
Stillbirth
Past GDM

11

McCance DR, et al. Practical manual of Diabetes in Pregnancy. 1st Edition. Willey-

Risk Category and Clinical

Characteristics
High risk

Marked obesity
Diabetes in first-degree relative
Current glycosuria
Previous history of GDM or
Glucose intolerance
Previous infant with macrosomia

Average risk
Neither high or low risk

12

Perkins JM, et al. Clinical diabetes.

Risk Category and Clinical

Characteristics (contd)
Low risk

13

Age < 25 years

No previous poor obstetrical outcomes
Belongs to a low-risk ethnic group*
No diabetes in first-degree relatives
Normal prepregnancy weight and
Weight gain during pregnancy
No history of abnormal glucose tolerance

Perkins JM, et al. Clinical diabetes.

Agenda

14

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Clinical Features of GDM

Unusual thirst
Frequent urination
Fatigue
Nausea
Frequent infections of bladder, vagina and
skin
Blurred vision
Sugar in urine

15

Available at : http://
www.americanpregnancy.org/pregnancycomplications/gestationaldiabetes.html. Accessed on

Agenda

16

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Diagnosis of GDM
Risk assessment for GDM should be
undertaken at the first prenatal visit
High risk of GDM:

Marked obesity
Personal history of GDM
Glycosuria
Strong family history of diabetes

Essential for Indian pregnant women:

Eleven-fold increased risk of developing glucose

intolerance during pregnancy as compared to
Caucasian women

Essential to undergo glucose testing as soon

as feasible
17

American Diabetes Association. Diabetes care 2004;27

Suppl1:S88-S90

Diagnosis of GDM (contd)

Women with low-risk do not require testing:
Age<25 years
Normal weight before pregnancy
Member of an ethnic group with a low prevalence
of GDM
No known diabetes in first-degree relatives
No history of abnormal glucose tolerance
No history of poor obstetric outcome

18

American Diabetes Association. Diabetes care 2004;27

Diagnosis of GDM (contd)

Use standard diagnostic criteria to screen for
T2DM at the first prenatal visit in those with
risk factors:

19

HbA1c 6.5% OR
Fasting plasma glucose is 126 mg/dL OR
2-h plasma glucose during OGTT 200 mg/dL OR
Random plasma glucose 200 mg/dL in a patient
with classic symptoms of hyperglycemia or
hyperglycemic crisis

American Diabetes Association. Diabetes Care 2012; 35

Diagnosis of GDM (contd)

In pregnant women not previously known to
have diabetes, screen for GDM at 2428
weeks gestation, using a 75-g 2-h OGTT
GDM is diagnosed if any of the following plasma
glucose values are exceeded:
Fasting 92 mg/dL
1 h 180 mg/dL
2 h 153 mg/dL

20

American Diabetes Association. Diabetes Care 2012; 35

Glycaemic Goals in GDM

SMBG:
Preprandial 95mg/dL and either:
1-h postmeal 140mg/dL or
2-h postmeal 120mg/dL

HbA1c < 6%

21

American Diabetes Association. Diabetes Care 2012; 35

Agenda

23

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Treatment of GDM
Medical nutrition therapy (MNT)
For all women with GDM
Individualized
Provision of adequate calories and nutrients to
meet the needs of pregnancy
Consistent with the maternal blood glucose
goals

24

American Diabetes Association. Diabetes care 2004;27

Treatment of GDM (contd)

Insulin is the drug of choice when medical
nutrition therapy alone does not provide
adequate control
Oral hypoglycaemic agents are generally not
recommended during pregnancy
SMBG guides the insulin doses and regimen
timings
Insulin analogues not been adequately
tested in GDM
25

American Diabetes Association. Diabetes care 2004;27

Treatment of GDM (contd)

Calculation of Insulin Dose
Weight in kilograms k = total insulin
requirement,
k = 0.7, 0.8, and 0.9 for first, second, and third
trimesters, respectively

50% of total insulin requirement = Daily

basal insulin dosage
Administered before breakfast (8:00 A.M.),
before supper (4:00 P.M.), and at midnight

26

Angelina L. Diabetes Spectrum.2007;

Treatment of GDM (contd)

NPH insulin have been used extensively to
treat GDM
If the FPG > 90 mg/dl, then NPH at a dose of
0.2 units/kg/day should be initiated at
bedtime
Next, if both FPG and PPG levels are
elevated, a rapid- acting analog should be
added with meals
27

Perkins JM, et al. Clinical diabetes.

Treatment of GDM (contd)

Administer insulin based on FPG, premeal, and 1-hour postprandial glucose
readings
Treat high FPG with bedtime NPH
Treat pre-dinner hyperglycemia with prebreakfast NPH
Treat bedtime hyperglycemia with predinner NPH
Treat abnormal postprandial glucose with
rapid-acting insulin (lispro or aspart)
immediately before the offending meal
28

Jovanovic L,. Medical Management of Pregnancy

Complicated by Diabetes. 3rd ed. Alexandria, Va: American

Treatment of GDM (contd)

May need up to 6 injections/day (3 NPH, 3
lispro or aspart), same as protocol for
preexisting diabetes
Evaluate regimen for 1 week
Adjust as needed to maintain blood glucose levels
<90 mg/dL before meals
<120 mg/dL 1 hour post-meal

29

Jovanovic L,. Medical Management of Pregnancy Complicated

by Diabetes. 3rd ed. Alexandria, Va: American Diabetes

Treatment of GDM (contd)

Role of Insulin Analogues
Human insulin:
Least immunogenic commercial preparation

Rapid-acting insulin analogues: lispro and

aspart:

30

Develop antibodies at rates and titers are

comparable to human regular insulin1
Short duration of action
Better control postprandial glycaemia
Less postprandial hypoglycaemia than regular
insulin
More effective than regular human insulin in
achieving goal glucose levels and reducing the
risk of fetal macrosomia
1. Metzger BE, et al. Diabetes
2 Care. 2007 ;30
Not been found to cross
the
placenta
Suppl 2:S251-60.

Treatment of GDM (contd)

Role of Insulin Analogues
Lispro and aspart have been investigated in
pregnancy and demonstrated:

Clinical effectiveness
Minimal transfer across the placenta
No evidence on teratogenesis
Improves postprandial glucose excursions
compared with human regular insulin
Lower risk of delayed postprandial hypoglycaemia

31

Metzger BE, et al. Diabetes Care. 2007 ;30

Treatment of GDM (contd)

Role of Insulin Analogues
Glulisine use in pregnancy: No reports are
available
Insulin preparations of low antigenicity:
Minimizes the trans placental transport of
insulin antibodies

32

Metzger BE, et al. Diabetes Care. 2007 ;30 Suppl

Treatment of GDM (contd)

Role of Insulin Glargine
Studies

Type of n
diabete
s

Treatment with
glargine

Outcome

Woolderink
et al.

Type 1

5 Treated throughout
pregnancy; 2 began
glargine in second
trimester

HbA1C 6.4%
No congenital
malformations

Dolci et al.

Type 1
1
and
Addisons
disease

Second trimester

Compared to NPH in
first trimester,
better control with
glargine

Di Cianni et
al.

Type 1

First trimester

No congenital
malformations

Devlin et al.

Type 1

Second and third

trimester

Better glycemic
control with glargine
than NPH

Holstein et
al.
33

Type 1

First, second, and third Better glycemic

Trujillo. Diabetes
Spectrum.
trimester
control
with glargine

Treatment of GDM (contd)

Role of Insulin Analogues
Insulin glargine does not cross the human
placenta to a measurable extent
Rapid-acting analogues have the advantage
of dosing 510 minutes before meals, vs. 30
45 minutes before meals with regular insulin

34

1. Erika K.. Diabetes Care. 2010;33(1):29-33.

2. Perkins JM, et al. Clinical diabetes.

Agenda

35

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Follow-up
Monitoring blood glucose at home is
important:
Tailoring specific treatment
Making adjustments as needed
Several studies have shown that monitoring four
times daily leads to more favorable glycaemic
control
Check premeal and 2-hour postmeal glucose
levels
Keep a track on carbohydrate consumption
Monitoring for fasting ketonuria in the morning
Helps in guiding the level of carbohydrate restriction
36

Perkins JM, et al. Clinical diabetes.

Postpartum follow-up
Maternal insulin requirements drop markedly
in the postpartum period
Because patients with GDM have a high risk of
developing T2DM

Important to continue screening these

patients
Poor insulin secretion during pregnancy is
predictive of diabetes after delivery

37

Perkins JM, et al. Clinical diabetes.

Postpartum follow-up (contd)

Patients need to minimize insulin resistance:
Exercise
Maintenance of normal weight
Avoidance of drugs that induce insulin resistance

38

Perkins JM, et al. Clinical diabetes.

Postpartum follow-up (contd)

ADA recommendations:
An annual fasting blood glucose test
A 6-week postpartum 75-g 2-hour OGTT
Contraception to ensure that patients will not
conceive in the face of marked hyperglycaemia
Lead to increased congenital malformations and
dysorganogenesis

39

Perkins JM, et al. Clinical diabetes.

Conservative Recommendations to
Women
Let health care practitioners know of any
history of GDM
Get tested 612 weeks postpartum, then
every 12 years
Reach prepregnancy weight 612 months
postpartum
If still overweight, lose at least 57% of
weight slowly, over time, and keep it off
40

Ratner RE. Diabetes Care. 2007;30 Suppl

Agenda

41

Gestational Diabetes Mellitus

Epidemiology
Risk Factors
Clinical features
Diagnosis
Treatment
Postpartum follow-up
Potential Complications
Conclusion

Potential Complications of
GDM
Obstetric and Perinatal Considerations
in GDM:
Fasting hyperglycaemia >105 mg/dL

Increased risk of intrauterine fetal death (last 48

gestation weeks)

GDM of any severity increases the risk of

fetal
macrosomia
Following may complicate the GDM:
Neonatal hypoglycemia
Jaundice
Polycythemia
Hypocalcaemia
42

American Diabetes Association. Diabetes care 2004;27

Potential Complications of GDM

(contd)
GDM is Associated with:
Increased frequency of maternal hypertensive
disorders
Need for cesarean delivery

Findings suggest:
GDM risk increases substantially with increasing
maternal BMI

43

1. American Diabetes Association. Diabetes care. 2004;27

Suppl1:S88-S90

Potential Complications of GDM

Potential complications in infants of
mothers with diabetes:
Intrauterine demise

Spontaneous abortion
Stillbirth

Macrosomia
Visceromegaly

Cardiomegaly
Hepatic enlargement

44

Jovanovic L, 3rd ed. Alexandria. American Diabetes Association;

Potential Complications of GDM

(contd)
Birth injury

45

Shoulder dystocia
Erbs palsy
Diaphragmatic paralysis
Facial paralysis
Cerebral ischemia
Hemorrhage in brain, eyes, liver and genitalia

Jovanovic L, 3rd ed. Alexandria. American Diabetes Association;

Potential Complications of GDM

(contd)
Asphyxia
Respiratory distress syndrome
Congenital malformations
Cardiac defects
Musculoskeletal deformities

Metabolic abnormalities

46

Hypoglycaemia
Hypokalemia
Hypocalcemia
Hyperbilirubinemia
Erythrocytosis
Jovanovic L, 3rd ed. Alexandria. American Diabetes

Diabetes Prevention for offspring:

National Diabetes Education
Program

Modest weight loss and physical activity can

delay or prevent T2DM
Offspring can lower risk by:
Eating healthy foods
Being active
Avoiding overweight

47

Ratner RE. Diabetes Care. 2007;30 Suppl

Conclusion
Women with GDM are at greater risk of developing
T2DM in later stages of life (3060%)
Tight glycaemic control is essential to prevent
maternal and neonatal complications
Insulin is the drug of choice if MNT alone cannot
achieve adequate glycaemic control
Increasing evidence in favour of insulin glargine use
in pregnancy
Women with GDM need regular follow up
postpartum
48