Detection and Treatment of Diabetes

in Pregnancy

Ma Luz Vicenta V Guanzon MD FPCP FPSEDMJeremy F Robles MD FPCP FPSEDM

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Gestational Diabetesbull Condition of Carbohydrate Intolerance with onset or

first recognition in pregnancybull Incidence increasing with advancing maternal age

and obesity epidemicbull Adverse outcomes

bull Maternal gestational hypertension and preeclampsia

bull Neonatal hyperinsulinemia macrosomia shoulder dystocia caesarian delivery hypoglycaemia and later life risk for obesity and type 2 diabetes mellitus Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Gestational Diabetesbull Gestational Diabetes gtgtgt (26-70) Type 2

diabetes Mellitus within 10 - 15 years of delivery

bull Universal screening for GDM in most developed nations (including the Philippines) Selective screening in low risk or poor resource poor setting

bull RCTrsquos demonstrated improved maternal and neonatal outcomes with subsequent treatment of GDM

bull Inflammation and biomarkers provide insights amp context to pathophysiology amp risk predictionInt J Mol Sci 2015 Jun 16(6) 13442ndash13473

The vicious cycle of obesity and reproductive complications

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Inflammation and insulin resistance in obesity pregnancy and GDM

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Gestational Diabetesbull Condition of Carbohydrate Intolerance with onset or

first recognition in pregnancybull Incidence increasing with advancing maternal age

and obesity epidemicbull Adverse outcomes

bull Maternal gestational hypertension and preeclampsia

bull Neonatal hyperinsulinemia macrosomia shoulder dystocia caesarian delivery hypoglycaemia and later life risk for obesity and type 2 diabetes mellitus Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Gestational Diabetesbull Gestational Diabetes gtgtgt (26-70) Type 2

diabetes Mellitus within 10 - 15 years of delivery

bull Universal screening for GDM in most developed nations (including the Philippines) Selective screening in low risk or poor resource poor setting

bull RCTrsquos demonstrated improved maternal and neonatal outcomes with subsequent treatment of GDM

bull Inflammation and biomarkers provide insights amp context to pathophysiology amp risk predictionInt J Mol Sci 2015 Jun 16(6) 13442ndash13473

The vicious cycle of obesity and reproductive complications

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Inflammation and insulin resistance in obesity pregnancy and GDM

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Gestational Diabetesbull Gestational Diabetes gtgtgt (26-70) Type 2

diabetes Mellitus within 10 - 15 years of delivery

bull Universal screening for GDM in most developed nations (including the Philippines) Selective screening in low risk or poor resource poor setting

bull RCTrsquos demonstrated improved maternal and neonatal outcomes with subsequent treatment of GDM

bull Inflammation and biomarkers provide insights amp context to pathophysiology amp risk predictionInt J Mol Sci 2015 Jun 16(6) 13442ndash13473

The vicious cycle of obesity and reproductive complications

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Inflammation and insulin resistance in obesity pregnancy and GDM

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

The vicious cycle of obesity and reproductive complications

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Inflammation and insulin resistance in obesity pregnancy and GDM

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Inflammation and insulin resistance in obesity pregnancy and GDM

Int J Mol Sci 2015 Jun 16(6) 13442ndash13473

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Casebull 38 yo patient consulted the clinic for advise

because she recently found out that she was pregnant She has a strong familial history of Diabetes with both with her mom amp dad currently on insulin therapy

bull She is on her 1st pregnancy Subsequent Obstetric Ultrasound showed that her pregnancy was at 24 weeks She weighs 90 kg with a BMI of 30 kgm2

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Risk Factors for Gestational

Diabetes

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Risk Factors for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Screening

2011 UNITE FOR DIABETES (PHILIPPINES)

bull All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Grade C Level 4)

bull High-risk women should be screened at the soonest possible time (Grade B Level 3)

bull Routine testing for gestational diabetes is recommended at 24 to 28 weeks age of gestation for women with no risk factors (Grade B Level 3)

bull Testing for gestational diabetes should still be carried out in women at risk even beyond 24 to 28 weeks age of gestation (Grade C Level 3)

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Diagnosis of Gestational

Diabetes

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Diagnosis of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Diagnosis of GDM

GlucoseLevels

2011 POGS

2011 UNITE

IADPSG

2015 ADA1 step

approach 2 step approach

Step 1 gt=130-140 mgdL (78 mmolL) proceed to a 100-g OGTT

Fasting gt=92 mgdL (51 mmolL) gt=92 mgdL (51 mmolL)

gt=95 mgdL

(51 mmolL)

gt=105 mgdL

(58 mmolL)

1 hour - - - gt=180 mgdL (100 mmolL)gt=180

mgdL (100 mmolL)

gt=190 mgdL (106

mmolL)

2 hours

gt=140 mgdL

(78 mmolL)gt=153 mgdL (85 mmolL)

gt=155 mgdL

(86 mmolL)

gt=165 mgdL

(92 mmolL)

3 hours - - - - - -

gt=140 mgdL

(78 mmolL)

gt=145 mgdL

(80 mmolL)Needs at least 1 Needs at least 1 Needs at least 2

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Diagnosis of Overt Diabetes in Pregnancy

Parameter Consensus threshold

FBS gt or = 111309270 mmoll or 126 mgdl

HbA1c gt or = 111309265 (DCCTUKPDS standardized)

RBS1113092gt or =111 mmoll (200 mgdl)

If a random plasma glucose is the initial measure the tentative diagnosis of overt diabetes in pregnancy should

be confirmed by FPG or A1C using a DCCT UKPDS-standardized assay

Thresholds for DM will be the same as non‐pregnant individuals for FBS or RBS Those with glucosuria elevated CBG or HbA1c should undergo OGTT

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Casebull Patient took a 75 gm OGTT test with the

following results FBS = 120mgdl 2nd hr glucose 180mgdl

bull She was diagnosed to have Gestational Diabetes

bull Counselling for GDM was initiated the discussion included self monitoring of blood glucose and lifestyle modification

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

CaseMonitoring day 1

(mgdl)

pre - breakfast 130

1 hr post BF 180

pre - lunch 135

1 hr post lunch 150

pre - dinner 120

1 hr post dinner 115

bedtime 120

bull 7 point monitoring revealed elevated blood sugars pre and post meals at certain times of the day

bull Patient was referred to the Dietary Department for instructions and counselling

bull Management plans were discussed with the patient

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Casebull Patient was asked to be admitted for

monitoring of blood sugar and initiation of therapy

bull 7 point monitoring for blood sugars was started pre-meals 1 hour post meals and bedtime

bull Patient was referred to the Dietary Department for instructions and counselling

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Treatment Targets of Gestational

Diabetes

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Treatment Targets for GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Medical Nutrition Therapybull All women with GDM should receive

nutritional counselling for Medical Nutrition Therapy (MNT)

bull Individualized MNT

bull adequate calories amp nutrients for pregnancy

bull consistent with maternal blood glucose goals

bull Noncaloric sweeteners may be used in moderation 2015 American Diabetes Association

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Medical Nutrition Therapy

bull MNT is a primary therapy for 30-90 of women with GDM ( decrease A1c by 1)

bull Carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain normoglycemia and absence of ketosis

bull Nutrition therapy + SMBG = positive impact on maternal amp infant outcomes

2007 Diabetes Care (Reader DM)

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Weight Gain During Pregnancy

2013 American College of Obstetricians and Gynecologists

(125-13 kg)

(115-16 kg)

(7-115 kg)

(5- 9 kg)

(05kg)

(04 kg)

(03 kg)

(02 kg)

Recommended Daily Allowance (RDA)

+340 kcalday for 2nd trimester+452 kcalday for 3rd trimester

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Casebull Patient had a BMI of 28 kgm2 prior to getting

pregnant

bull Based on IOM weight recommendation we expect her to gain 7 - 115 kg in this pregnancy Recommended weight gain in the 2nd and 3rd trimester would be 03 kg per week

bull Remember to add +340 kcalday for 2nd trimester and +452 kcalday for 3rd trimester to the total caloric requirement

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Medical Nutrition Therapy

bull Wide range of caloric intakes compatible with successful pregnancy outcomes (1500 - 2800 kcal)

bull lt1500 kcalday increase ketonuria amp ketonemia

bull Caloric requirement per day using pre gravid wtbull 25 - 30 kcalkg for overweight patientsbull 30 - 35 kcalkg for normal weight patientsbull 35 - 40 kcalday for under weight patients 2007 Diabetes Care (Reader DM)

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Medical Nutrition Therapy

bull 175 g carbohydrateday for pregnant

bull Limit carbohydrate intake 35-45 (main nutrient that affects post prandial glucose levels)

bull Low glycemic index (lt55) produce lower post meal glucose elevations ( decrease A1c by 04 )

bull No specific glucose benefit with high fiber diet

2007 Diabetes Care (Reader DM)

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Caloric Distribution of Meals

bull 40-45 of total calories for Carbohydrates

bull 20-25 of total calories for Protein

bull 35-40 of total calories Fat

Medical Management of Pregnancy Complicated by Diabetes 4th Edition 2009

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Dietary Recommendations for Gestational Diabetes

bull Breakfast matters - eat smaller amounts

bull Avoid fruit juice

bull Strictly limit sweets and desserts

bull Use artificial sweeteners ( equal or splenda)

bull Keep food records

httpwwwucsfhealthorg

Dietary Recommendations for Gestational Diabetes

bull Distribute between 3 meals and 2-3 snacks day

bull Eat reasonable portions of starch

bull Drink one cup of milk at a time

bull Limit fruit portions

bull Do not eat fruit that has been canned in syrup

httpwwwucsfhealthorg

Case

bull Caloric Distribution were as followsbull 10 Breakfast 30 Lunch 30 Dinnerbull 10 snacks x 3

bull Meal Distribution were as followsbull Carbohydrates 45 Protein 25 Fat 30

Physical Activity

bull Exercise is an adjunct to MNT

bull Monitor fetal activity amp blood glucose levels

bull Limit physical activity to 15 - 30 mins

bull GDM patients to walk briskly or do arm exercises while seated in a chair for at least 10 min after each meal accomplishes this goal

DIABETES CARE VOLUME 30 SUPPLEMENT 2 JULY 2007

Pharmacologic Treatment of

Gestational Diabetes

Pharmacologic Treatment of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

If targets not achieved with lifestyle modifications within 2 weeks

initiate pharmacotherapy

Medication with limited ampor no data in Gestational Diabetes

Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Agent Summary of Available data

Therapeutic considerations

Alpha glucosidase inhibitors limited to no human data available

Not recommended for use currently

DPP IV inhibitors limited to no human data available

GLP-1 receptor agonists no human data available

Meglitinides no human data availableanimal studies - fetal adverse

SGLT-2 inhibitors no human data availableanimal studies - fetal adverse

Thiazolidinediones no human data availableanimal studies - fetal adverse

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Physical Activity

bull Exercise is an adjunct to MNT

bull Monitor fetal activity amp blood glucose levels

bull Limit physical activity to 15 - 30 mins

bull GDM patients to walk briskly or do arm exercises while seated in a chair for at least 10 min after each meal accomplishes this goal

DIABETES CARE VOLUME 30 SUPPLEMENT 2 JULY 2007

Pharmacologic Treatment of

Gestational Diabetes

Pharmacologic Treatment of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

If targets not achieved with lifestyle modifications within 2 weeks

initiate pharmacotherapy

Medication with limited ampor no data in Gestational Diabetes

Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Agent Summary of Available data

Therapeutic considerations

Alpha glucosidase inhibitors limited to no human data available

Not recommended for use currently

DPP IV inhibitors limited to no human data available

GLP-1 receptor agonists no human data available

Meglitinides no human data availableanimal studies - fetal adverse

SGLT-2 inhibitors no human data availableanimal studies - fetal adverse

Thiazolidinediones no human data availableanimal studies - fetal adverse

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Pharmacologic Treatment of

Gestational Diabetes

Pharmacologic Treatment of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

If targets not achieved with lifestyle modifications within 2 weeks

initiate pharmacotherapy

Medication with limited ampor no data in Gestational Diabetes

Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Agent Summary of Available data

Therapeutic considerations

Alpha glucosidase inhibitors limited to no human data available

Not recommended for use currently

DPP IV inhibitors limited to no human data available

GLP-1 receptor agonists no human data available

Meglitinides no human data availableanimal studies - fetal adverse

SGLT-2 inhibitors no human data availableanimal studies - fetal adverse

Thiazolidinediones no human data availableanimal studies - fetal adverse

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Pharmacologic Treatment of GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

If targets not achieved with lifestyle modifications within 2 weeks

initiate pharmacotherapy

Medication with limited ampor no data in Gestational Diabetes

Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Agent Summary of Available data

Therapeutic considerations

Alpha glucosidase inhibitors limited to no human data available

Not recommended for use currently

DPP IV inhibitors limited to no human data available

GLP-1 receptor agonists no human data available

Meglitinides no human data availableanimal studies - fetal adverse

SGLT-2 inhibitors no human data availableanimal studies - fetal adverse

Thiazolidinediones no human data availableanimal studies - fetal adverse

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Medication with limited ampor no data in Gestational Diabetes

Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

Agent Summary of Available data

Therapeutic considerations

Alpha glucosidase inhibitors limited to no human data available

Not recommended for use currently

DPP IV inhibitors limited to no human data available

GLP-1 receptor agonists no human data available

Meglitinides no human data availableanimal studies - fetal adverse

SGLT-2 inhibitors no human data availableanimal studies - fetal adverse

Thiazolidinediones no human data availableanimal studies - fetal adverse

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Insulin therapy for Gestational

Diabetes

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Glucose Homeostasis in Pregnancy

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Insulin therapy in GDM

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Many guidelines continue to recommend insulin as the first-line therapy

bull Regular insulin is the standard against which rapid analogs are compared

bull Neutral protamine hagedorn (NPH) insulin is the standard against which long-acting analogs are compared

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Question

Due to the concern that her glucose values are increasing what would you recommend as the next step to help manage her blood glucose

A ExenatideB GlyburideC InsulinD Pioglitazone

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Question

Which of the type of insulin would be most appropriate for the initial treatment for the patient A Regular insulinB Rapid acting analog insulinC Neutral protamine hagedornD Long acting analog insulin

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Caseday 1 (mgdl)

Insulin coverage

day 2 (mgdl)

Insulin coverage

day 3 (mgdl)

Insulin coverage

pre - breakfast 130 - - - 120 rapid insulin

4 units sc 95 rapid insulin 4 units sc

1 hr post BF 180 - - - 115 - - - 120

pre - lunch 135 rapid insulin 4 units sc 140 rapid insulin

4 units sc 122 rapid insulin 6 units sc

1 hr post lunch 150 - - - 160 - - - 118

pre - dinner 120 rapid insulin 4 units sc 120 rapid insulin

4 units sc 115 rapid insulin 4 units sc

1 hr post dinner 115 - - - 110 - - - 120

bedtime 120 - - - 1105 units

intermediate insulin sc

1165 units

intermediate insulin sc

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Casebull Patient was discharged with the following

insulin regimen

bull Rapid acting insulin 4 - 6 - 4 units pre meals (breakfast - lunch - dinner doses of insulin sc)

bull Intermediate acting insulin 5 units at bedtime

bull Blood sugar monitoring at home was continued preemies and at bedtime ( 4 point monitoring )

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Casebull Patient was asked to follow up after 2 weeks

bull Her blood sugar level levels remained controlled with her insulin regimen She continued her diet and had light exercises

bull Succeeding follow up was unremarkable Blood sugars remained controlled throughout pregnancy with minor insulin adjustments

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Insulin therapy in GDMbull Insulin requirements progressively increases

throughout pregnancy07 unitkg up to week 1208 unitkg for weeks 13 to 2609 unitkg for weeks 26 to 36

10 unitkg for weeks 36 to term

Obese patients may require 15 to 20 unitskg to overcome the combined insulin resistance amp obesity

Uptodate 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Post Partum Management

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Maternal and infant blood glucose should be monitored very closely

bull Maternal insulin requirements may decrease significantly a few hours after delivery and continue to decline

bull Breastfeeding is encouraged metformin glyburide glipizide and insulin are considered preferred therapies in breastfeeding women

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Question

How will you follow up your Gestational Diabetes patientA Follow- up after 2 weeksB Follow- up after 2 monthsC Follow- up after 2 yearsD No need for follow-up

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Kelly KW Carroll DG Meyer A Drugs in Context 2015 4 212282

bull Post partum follow up should be done between 6 weeks to 6 months

bull Interval periodic screening for high risk patients done yearly amp 2-3 year interval for low risk patients

bull Various screening methods may be utilized for follow up ( OGTT FBS HbA1c )

Post Partum Management

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

bull Randomized trials have shown that medical nutritional therapy self-monitoring of blood glucose levels amp insulin therapy when needed improves perinatal outcome in GDM patients

bull Medical nutritional therapy is the initial approach

bull Moderate exercise should be part of the treatment plan for women with no medical or obstetrical contraindications to this level of physical activity

Key points

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

bull Insulin therapy in women who do not achieve adequate glycemic control with nutritional therapy and exercise alone

bull Glyburide amp metformin oral medications are alternatives to patients who refuse or cannot comply with insulin

bull Postpartum follow up with emphasis of lifestyle change are essential to prevent progression to type 2 diabetes mellitus

Key points

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015

Detection and Treatment of Diabetes

in Pregnancy

The Filipino Endocrinologist teaching the Filipino Doctor

wwwendo-societyorgph

PHILIPPINE SOCIETY OF ENDOCRINOLOGY DIABETES amp METABOLISMCourse in Endocrinology Diabetes amp Metabolism in Bacolod

August 6 2015