Академический Документы
Профессиональный Документы
Культура Документы
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.
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)
GDM
Incidence (annual) of Gestational diabetes:
135,000 pregnant women every year 3-5% of pregnant women.
Country/Region
Extrapolated Incidence
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
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
GDM
2,040,0852 10,825,9002 141,340,4762 2,185,5692 1,298,847,6242
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
GDM
5,420,2802 82,662,8002 4,353,8932 159,196,3362 22,697,5532 48,233,7602
Sri Lanka
Taiwan Thailand
9,879
11,291 32,194
19,905,1652
22,749,8382 64,865,5232
Estonia
Georgia Kazakhstan
665
2,329 7,516
1,341,6642
4,693,8922 15,143,7042
11
GDM
2,306,3062 3,607,8992 22,355,5512 143,974,0592 5,423,5672 2,011,473 2
Tajikistan
Ukraine Uzbekistan
3,480
23,690 13,108
7,011,556 2
47,732,0792 26,410,4162
14,152
37,778 657
28,513,6772
76,117,4212 1,324,9912
12
GDM
67,503,2052 25,374,6912 6,199,0082 5,611,2022 2,257,5492 3,777,2182
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
GDM
15,823,9572 42,310,7752 14,280,5962 104,959,5942 5,359,7592 6,191,3682
Peru
Puerto Rico Venezuela
13,670
1,934 12,416
27,544,3052
3,897,9602 25,017,3872
Chad
Congo Brazzaville Congo kinshasa
4,734
1,487 28,944
9,538,5442
2,998,0402 58,317,0302
14
GDM
GDM
Prevalence of GDM 3 to 18 %
16
GDM
Muscle/fat insulin response
Controlled glucose clearance
Hyperglycemia
The Defining Feature of Diabetes
GDM
Impaired glucose clearance
Tissue injury
1
GDM
No muscle/fat insulin effect
Impaired glucose clearance
Hyperglycemia
Glycosuria
13
Pathogenesis of GDM
GDM
Insulin Resistance (IR), cell stimulation 50 to 70% lower (INSULIN ACTION) vs. healthy non-pregnant women
Butte, 2000: Williams Obstetrics
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
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
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
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
GDM
www.drsarma.in
26
Abnormal GT in GDM
GDM
www.drsarma.in
27
GDM
Clinical onset only 10% of -cells remain
Genetic predisposition
Prediabetes
Diabetes
GDM - Definition
GDM
CARBOHYDRATE INTOLERANCE of variable severity with onset of first recognition during pregnancy. Regardless of:
insulin use or persistence after pregnancy.
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
GDM
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
GDM
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
< 10 10 to 19 > 20
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.
Nephropathy*
maternal metabolic control andAny presence or absence of maternal the H Any Heart Insulin diabetic vasculopathy is more helpful
34
GDM
Screening:
30 years of research
GDM
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
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
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
40
GDM
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
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
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
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
GDM
180+
GDM confirmed
< 140
No GDM repeat 24 wk
140 to 180
Need to do OGTT 3 hr
48
GDM
www.drsarma.in
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
WHO, Europe
75-g 2-hour OGTT
GDM
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
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
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
www.drsarma.in
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
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
GDM
DM
18.4%
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%
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
Polycythemia(%)
RDS(%) IUGR(%)
11
5 2
7
2 1
0
0 0
<0.01
<0.01 <0.05
GDM
9.2-11.1
> 11.2
23%
25%
GDM
67
Management:
Insulin therapy Diet Exercise Oral anti-diabetic drugs
GDM
68
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
GDM
28-40 lbs
25-35 lbs 15-25 lbs
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
GDM
GDM
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
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
www.drsarma.in
78
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