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GDMA Doctors PrayerDear Lord, You are the greatest Healer,

All life and health comes from YouWithout 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.

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GDMA Doctors PrayerGive 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.

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GDMA Doctors PrayerProtect 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.

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GDMA Doctors PrayerAll 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.

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GDM

Diabetes Mellitus

in Pregnancy

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GDMDiabetes Mellitus 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 NutritionResearch Institute survey, DOH)

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

Diabetes on the Rise among Filipinos, www.bio-medicine.org/medicine-news/Diabetes-on-the-Rise-among-Filipinos-15022-1/6

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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.htm7

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Gestational diabetes in North America

USA 145,748 293,655,4051

Canada 16,134 32,507,8742

Gestational diabetes in EuropeAustria 4,057 8,174,7622

Belgium 5,136 10,348,2762

Britain (United Kingdom) 29,913 60,270,708 for UK2

Czech Republic 618 1,0246,1782

Denmark 2,686 5,413,3922

Finland 2,588 5,214,5122

France 29,989 60,424,2132

Greece 5,284 10,647,5292

Germany 40,909 82,424,6092

Iceland 145 293,9662

Hungary 4,979 10,032,3752

Liechtenstein 16 33,43628

http://www.cureresearch.com/risk/geography.htmhttp://www.cureresearch.com/risk/geography.htm

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Ireland 1,970 3,969,5582

Italy 28,815 58,057,4772

Luxembourg 229 462,6902

Monaco 16 32,2702

Netherlands (Holland) 8,099 16,318,1992

Poland 19,171 38,626,3492

Portugal 5,223 10,524,1452

Spain 19,992 40,280,7802

Sweden 4,460 8,986,4002

Switzerland 3,698 7,450,8672

United Kingdom 29,913 60,270,7082

Wales 1,448 2,918,0002

Gestational diabetes in the Balkans

Albania 1,759 3,544,8082

Bosnia and Herzegovina 202 407,6082

Croatia 2,231 4,496,86929

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Macedonia 1,012 2,040,0852

Serbia and Montenegro 5,373 10,825,9002

Gestational diabetes in AsiaBangladesh 70,150 141,340,4762

Bhutan 1,084 2,185,5692

China 644,648 1,298,847,6242

East Timor 505 1,019,2522

Hong Kong s.a.r. 3,402 6,855,1252

India 528,619 1,065,070,6072

Indonesia 118,349 238,452,9522

Japan 63,198 127,333,0022

Laos 3,011 6,068,1172

Macau s.a.r. 221 445,2862

Malaysia 11,674 23,522,4822

Mongolia 1,365 2,751,3142

Philippines 42,803 86,241,697210

http://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htmhttp://www.cureresearch.com/risk/asia.htm

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Papua New Guinea 2,690 5,420,2802

Vietnam 41,027 82,662,8002

Singapore 2,160 4,353,8932

Pakistan 79,012 159,196,3362

North Korea 11,265 22,697,5532

South Korea 23,939 48,233,7602

Sri Lanka 9,879 19,905,1652

Taiwan 11,291 22,749,8382

Thailand 32,194 64,865,5232

Gestational diabetes in Eastern Europe

Azerbaijan 3,905 7,868,3852

Belarus 5,117 10,310,5202

Bulgaria 3,731 7,517,9732

Estonia 665 1,341,6642

Georgia 2,329 4,693,8922

Kazakhstan 7,516 15,143,704211

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Latvia 1,144 2,306,3062

Lithuania 1,790 3,607,8992

Romania 11,095 22,355,5512

Russia 71,457 143,974,0592

Slovakia 2,691 5,423,5672

Slovenia 998 2,011,473 2

Tajikistan 3,480 7,011,556 2

Ukraine 23,690 47,732,0792

Uzbekistan 13,108 26,410,4162

Gestational diabetes in Australasia and Southern Pacific

Australia 9,883 19,913,1442

New Zealand 1,982 3,993,8172

Gestational diabetes in the Middle East

Afghanistan 14,152 28,513,6772

Egypt 37,778 76,117,4212

Gaza strip 657 1,324,991212

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Iran 33,503 67,503,2052

Iraq 12,594 25,374,6912

Israel 3,076 6,199,0082

Jordan 2,784 5,611,2022

Kuwait 1,120 2,257,5492

Lebanon 1,874 3,777,2182

Libya 2,795 5,631,5852

Saudi Arabia 12,803 25,795,9382

Syria 8,942 18,016,8742

Turkey 34,193 68,893,9182

United Arab Emirates 1,252 2,523,9152

West Bank 1,147 2,311,2042

Yemen 9,938 20,024,8672

Gestational diabetes in South America

Belize 135 272,9452

Brazil 91,373 184,101,109213

http://www.cureresearch.com/risk/south_america.htmhttp://www.cureresearch.com/risk/south_america.htm

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GDMCountry/Region Extrapolated Incidence Population Estimated Used

Chile 7,853 15,823,9572

Colombia 20,999 42,310,7752

Guatemala 7,087 14,280,5962

Mexico 52,093 104,959,5942

Nicaragua 2,660 5,359,7592

Paraguay 3,072 6,191,3682

Peru 13,670 27,544,3052

Puerto Rico 1,934 3,897,9602

Venezuela 12,416 25,017,3872

Gestational diabetes in Africa

Angola 5,448 10,978,5522

Botswana 813 1,639,2312

Central African Republic 1,857 3,742,4822

Chad 4,734 9,538,5442

Congo Brazzaville 1,487 2,998,0402

Congo kinshasa 28,944 58,317,030214

http://www.cureresearch.com/risk/africa.htmhttp://www.cureresearch.com/risk/africa.htm

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GDM MOST COMMON endocrine disorder in

pregnancy

90 to 95%: GDM

MOST COMMON medical complicationof 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

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GDMGlucose Intolerance in Pregnancy

16

Prevalenceof GDM 3 to 18 %

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GDMNormal Regulation of PlasmaGlucose

Hepaticinsulin response Muscle/fatinsulin response

Controlled

glucose production

Controlled

glucose clearance

Insulinsecretion

Normalplasma glucose

12

Glucose enters

peripheral tissues

Glucose enters

the blood

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GDMHyperglycemiaThe Defining Feature of Diabetes

Hyperglycemia

Excessive

glucose productionImpaired

glucose clearance

Tissue injury

1

g

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GDM

Hyperglycemia

a ogenes s o ypeDiabetesOne Defect

Unrestrained

glucose production

Impaired glucose

clearance

No hepatic

insulin effect

No muscle/fat

insulin effect

Absentinsulinsecretion

Glycosuria 13

More glucose enters

the blood

Less glucose enters

peripheral tissues

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GDMPathogenesis of GDM Pregnancy is a state of INSULIN

RESISTANCE Insulin Resistance (IR), cell stimulation

50 to 70% lower (INSULIN ACTION) vs. healthynon-pregnant women

Butte, 2000: Williams Obstetrics

Normal pregnancy

Mild fasting hypoglycemia Postprandial hyperglycemia

Hyperinsulinemia

20

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GDMPathogenesis of GDM Increased basal level of insulin with

unique responses to glucose ingestion:

Prolonged hyperglycemia andhyperinsulinemia

Suppression of glucagonperipheral resistance to insulin

Sustained postprandial glucose supplyto the fetus

Phelps and associates, 1981: Williams Obstetrics.

21

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GDMPathogenesis of GDM & Sustained glucose levels

fasting

plasma glucose & amino acids (alanine)

Free FA, TG, Chol

ACCELERATED STARVATION

Pregnancy-induced switch of fuels fromglucose to lipids

Risk for Ketonemia

Freinkel and colleagues, 1985: Williams Obstetrics22

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GDMPathogenesis of 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 insulinresistance

Prolactin Freinkel, 1980: Williams Obstetrics 23

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GDMPathogenesis of 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

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GDMFundamental Defect in 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

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GDMNormal Glucose Tolerance

www.drsarma.in 26

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GDMAbnormal GT in GDM

www.drsarma.in 27

N t l Hi t Of P T 1

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GDMPutativetrigger

Circulating autoantibodies (ICA, GAD65)

Cellular autoimmunity

Loss of first-phaseinsulin response (IVGTT)

Glucose intolerance(OGTT)

Clinicalonsetonly10% of

-cellsremain

Time

-Cellmass 100%

Pre-diabetes

Geneticpredisposition

Insulitis-Cell injury

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

Diabetes

Natural History Of PreType 1Diabetes

14

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GDMGDM - Definition CARBOHYDRATE INTOLERANCE of

variable severity with onset of firstrecognition during pregnancy.

Regardless of:

insulin use or

persistence after pregnancy.

Does not exclude unrecognized glucoseintolerance antecedent to pregnancy

Williams ObstetricsTextbook of Obstetrics 3rd edition, Sumpaico et al. 29

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GDMGDM - Definition 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

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GDMClassification of Diabetes(Powers, 2001)

ABSOLUTE INSULIN DEFICIENCY

Type 1 Diabetes

DEFECTIVE INSULIN SECRETION

OR

DEFECTIVE INSULIN RESISTANCE Type II Diabetes

31

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GDMEtiological Classification of Diabetes Mellitus

Type 1 A Immune-mediated -cell destruction

Type 1 B Idiopathic -cell destruction

Type 2 May range from predominantly insulin resistance topredominantly 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, -adrenergicagonists, others

Infectionse.g., congenital rubella, cytomegalovirus, coxsackievirus

Adapted from Powers 2001 32

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GDMClassification of Diabetes(Powers, 2001)

Insulin Dependent Diabetes Mellitus(IDDM)

Noninsulin-dependent Diabetes Mellitus(NIDDM)

AGE

33

-cell destruction: ANY AGEMost common onset: < 30 years old

5 to 10%- >30 years oldType 2 diabetes- most typical with increasing age but

also occurs in OBESE ADOLESCENTS

Cl ifi ti D i P

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GDMClassification During Pregnancy(ACOG, 1986)

Class Onset Fasting PlasmaGlucose

2-hourPostprandial

Glucose

Therapy

A1 Gestational < 105 mg/dL < 120 mg/dL Diet

A2 Gestational > 105 mg/dL > 120 mg/dL Insulin

Class Age of Onset (yr) Duration(yr)

Vascular Disease Therapy

B Over 20 < 10 None Insulin

C 10 to 19 10 to 19 None Insulin

D Before 10 > 20 Benign

retinopathy

Insulin

F Any Any Nephropathy* Insulin

R Any Any Proliferativeretinopathy

Insulin

H Any Any Heart Insulin

* When diagnosed during pregnancy: 500 mg or more proteinuria per 24 hoursmeasured before 20 weeks gestation. 34

REPLACED1994, ACOGA single classification based on the presence or absence of good

maternal metabolic control and the presence or absence of maternaldiabetic vasculopathy is more helpful

15 % of women with GDM exhibit FASTING HYPERGLYCEMIA.Sheffield & co-workers, 1999

Classes B to H: WHITE CLASSIFICATION (1978)-OVERT DIABETES antecedent to pregnancy

-END-ORGAN DERANGEMENT

Di i

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GDMDiagnosis:OVERT DIABETES

CRITERIA FOR DIAGNOSIS (AmericanDiabetes Association, 2004):

1. Fasting plasma glucose of >125 mg/dL

2. Glucosuria

3. Ketoacidosis

4. Random plasma glucose level >200 mg/dL

5. Presence of Classic signs & symptoms: Polydypsia, Polyphagia, polyuria, unexplained weight loss

6. High index of suspicion Strong family history, previous delivery of large infants,

unexplained fetal losses, persistent glucosuria

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GDMScreening: 30 years of research

NO CONSENSUS regarding the OPTIMALAPPROACH to SCREENING

Issues:

UNIVERSAL SCREENING

SELECTIVE SCREENING

Plasma glucose level after 50-gm glucosetesting

36Bonomo and colleagues, 1998; Danilenko-Dizon and colleagues, 1999:

Williams Obstetrics

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GDMScreening Since 1980

4 international work-shop conferences

Consensus statements on screening Metzger and Coustan, 1998

37

R d d S i S B d Ri k

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GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

Low Risk Blood glucose testing NOT ROUTINELY required if

all of the following characteristics are present:

Member of ethnic group with a low prevalence forgestational 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

38Adopted from ADA guidelinesMetzger and Coustan, 1998

R d d S i St t B d Ri k

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GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

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 oftype 2 diabetes, prior gestational diabetes, or glucosuria

Metzger and Coustan, 1998 39Adopted from ADA guidelines

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GDMRecommended Screening Strategy Based on RiskAssessment for Detecting Gestational Diabetes(4th International Workshop- Conference on Gestational Diabetes)

HIGH Risk

Perform blood glucose testing as soon asfeasible.

If gestational diabetes is not diagnosed, bloodglucose testing should be repeated at 2428weeks or at any time a patient has symptoms

or signs suggestive of hyperglycemia

Metzger and Coustan, 1998 40Adopted from ADA guidelines

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GDMRisk Stratification for 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 classes41Adopted from ADA guidelines

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GDMScreening 1997 Workshop

SELECTIVE SCREENING

1. 24 to 28 weeks AOG

2. Women with no known glucose intoleranceearlier in pregnancy

3. Do a 1-step or a 2-step procedure

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GDMScreening ACOG, 2001

Selective screening in some clinical settingsand universal screening in others

Brody and colleagues, 2003

Insufficient to recommend for or against

screening.

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GDMScreening 1-step procedure

FBS

75-gm glucose

Extract another blood sample 2 hours afterglucose 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

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GDMScreening 2-step procedure

50-g OGTT followed by diagnostic 100g- OGTT ifresults exceed a predetermined plasma glucose level.

Plasma glucose level is measured 1-hour after a 50-gOGTT without regard to TIME OF DAY or TIME OFLAST 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

45

Textbook of Obstetrics 3rd edition, Sumpaico et al.

Martin and colleagues, 2003, Williams Obstetrics.

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GDMGDM Two Step Screening Two Step Screening

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

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GDMg y g

Criteria for Diagnosis of Gestational Diabetes Using the 100-g OralGlucose Tolerance Test

Plasma/SerumCarpenter and Coustan

National DiabetesPlasma Data Group

Status mg/dL mmol/L mg/dL mmol/L

Fasting 95 5.3 105 5.8

1- hour 180 10.00 190 10.6

2-hour 155 8.6 165 9.2

3-hour 140 7.8 145 8.0

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GDMGlucose Challenge Test (GCT)

< 140

No GDMrepeat 24 wk

140 to 180

Need to doOGTT 3 hr

180+

GDM

confirmed

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GDMOGTT100g3 hour Test

Test sample timing Plasma Glucose value

Fasting (mg%) 95

1 hour (mg%) 180

2 hour (mg%) 155

3 hour (mg%) 140

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GDMPlease be specific 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

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GDMDiagnosis: NO international agreement: optimal

OGTT for definitive diagnosis of GDM

WHO, Europe

75-g 2-hour OGTTWeiss and collegues, 1998

US, ACOG, 2001 100g- 3 hour OGTT after an overnight fast

remains the standard

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GDMMaternal & Fetal Effects Adverse maternal effects:

Increased frequency of hypertension and cesareansection

Maternal deaths are uncommon but the risk isincreased 10x. (Cousins, 1987)

Due to ketoacidosis, hypertension, preeclampsia andpyelonephritis.

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GDMMaternal Effects: Diabetic Nephropathy

Leading cause of end-stage renal failure inthe US

30% for type 1 diabetes and 4 to 20 %- type 2diabetes

25% decrease in nephropathy for each 10%

decrease in hemoglobin A1Clevels. (DiabetesControl and Complications Trial, 2002)

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GDMMaternal Effects: Diabetic Nephropathy

Clinically detectable nephropathy begins withMICROALBUMINURIA

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

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GDMMaternal Effects: Diabetic Nephropathy

5 % with diabetes are class FHanson 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 ofpreeclampsia.

Gordon and associates (1996)55

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GDMMaternal Effects: Diabetic Retinopathy

Diabetic Neuropathy

Pre-eclampsia Ketoacidosis

Infections

56

GDM

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GDMNeonatal Effects Macrosomia of the baby

CPD Shoulder Dystocia

Intrapartum Trauma Feto-maternal Congenital Anomalies, HCM

Neonatal Hypoglycemia

Neonatal Hypocalcemia Neonatal Hyperbilirubinemia

Respiratory Distress Syndrome (RDS)

Pol c themia secondar in the new bornwww.drsarma.in 57

GDM

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GDMMacrosomia 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, Multiparity58

GDM

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GDMMacrosomic Newborn

59

GDM

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GDMShoulder Dystocia

60

Erbs palsy

GDMM i

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GDMMacrosomia

GDM Non DM P value

Birth Weight 3512 g 3333 g < 0.05

LGA 40.4% 13.7% < 0.001

Macrosomia 32.0% 11.0% < 0.01

GDM

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GDMNeonatal Hypoglycemia 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

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GDMMinor Adverse Health Effects

Birth Wt (g) 330364 364951 384972

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GDMCNS 6.4% 18.4%

Congenital heart disease 7.5% 21.0%

Respiratory disease 2.9% 7.9%

Intestinal atresia 0.6% 2.6%

Anal atresia 1.0% 2.6%

Renal & Urinary defect 3.1% 11.8%

Upper limb deficiencies 2.3% 3.9%Lower limb deficiencies 1.2% 6.6%

Upper + Lower spine 0.1% 6.6%

Caudal digenesis 0.1% 5.3%

Normal DM

Major Adverse Health Effects

GDMC

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GDMNeonatal Complications

T. hypoglycemia(%) 52 28 3

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GDMCongenital Anomalies - DM Control

Maternal HbA1c levels

< 7.2 Nil

7.2-9.1 14%9.2-11.1 23%

> 11.2 25%

Critical periods - 3-6 weeks post conception

Need pre-conceptional metabolic care

GDML t ff t th ff i

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GDMLate effects on the offspring Increased risk of IGT

Future risk of T2DM

Risk of Obesity

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GDMM t

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GDMManagement: Insulin therapy

Diet

Exercise Oral anti-diabetic drugs

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GDMGDM Gl i T t

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GDMGDM Glycemic Targets

Recommended values for Glycemic Targets

Pre-pregnancy Hb A1c 7.00 (if possible 6.00)

Pregnancy values Range

FPG 70 - 95

1 hr PPG 100 140

2 hr PPG 90 120

Hb A1c 6.00

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GDM

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GDM American Diabetes Association (2000)

nutritional counseling with individualization basedon height and weight

average of 30 kcal/kg/d based on prepregnant bodyweight for nonobese women.

obese women with a body mass index greater than 30kg/m2

may benefit from a 30- to 33-percent caloricrestriction.

Monitored weekly tests- ketonuria maternal ketonemia has been linked with impaired

psychomotor development in the offspring

(Rizzo and colleagues, 1995).70

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GDM

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Body Mass Index andRecommended Weigh Gain

Pre-pregnant weight

statusRecommended

range of weight gain

A. Twin Pregnancy 35-45 lbs

B.Underweight(BMI 30.0) 15 lbs

GDMGDM d MNT

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GDMGDM and MNT 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

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GDMDiet therapy in GDM

Small, frequent meals

Avoid eating for two Avoid fasts and feasts

Avoid health drinks

Eat a bedtime snack

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GDMTips for diet management

Small breakfast

Mid morning snack

High protein lunch

Mid afternoon snack

Usual dinner Bed time snack

GDMGDM and E ercise

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GDMGDM and Exercise 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

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GDMInsulin Therapy

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GDMInsulin Therapy Usually recommended when standard

dietary management does not consistentlymaintain:

FBS at

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GDMGDM and Insulins 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?)

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GDMInsulin Regimen

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GDMInsulin Regimen 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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GDMGDM and Delivery

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GDMGDM and Delivery Delivery until 40 weeks is not recommended

Delivery before 39th week assess thepulmonary 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

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GDMThank You!

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GDMThank You!