DR. TARIK Y. ZAMZAMIDR. TARIK Y. ZAMZAMI

MD, CABOG, FICSMD, CABOG, FICS

ASSOCIATE PROFESSORASSOCIATE PROFESSOR

CONSULTANT OB/GYNCONSULTANT OB/GYN

KAUHKAUH

Email.tzamzami@kaau.edu.saEmail.tzamzami@kaau.edu.sa

Gestational DiabetesGestational Diabetes(GDM)(GDM)

DefinitionDefinition

Prevalence Prevalence

1-14 %1-14 %

Carbohydrate MetabolismCarbohydrate Metabolism

Pregnancy is potentially Pregnancy is potentially diabetogenicdiabetogenic stat: stat:

First half: tendency to hypoglycemiaFirst half: tendency to hypoglycemia

Second half: tendency to hyperglycemiaSecond half: tendency to hyperglycemia

Progressive insulin resistance as pregnancy Progressive insulin resistance as pregnancy progressesprogresses::

HPLHPL

EstrogenEstrogen

ProgesteroneProgesterone

CortisolCortisol

PathophysiologyPathophysiology

Deficiency of insulin receptors Deficiency of insulin receptors prior to pregnancyprior to pregnancy

Deficient insulin productionDeficient insulin production HPL block insulin receptorsHPL block insulin receptors

Detection and Detection and diagnosisdiagnosis

Risk assessment for GDM Risk assessment for GDM should be undertaken at the should be undertaken at the

first prenatal visitfirst prenatal visit

RisksRisks

Maternal Maternal FetalFetal

Maternal RisksMaternal Risks

Hypertensive disordersHypertensive disorders Increase cesarean delivery Increase cesarean delivery Developing type II DM after Developing type II DM after

deliverydelivery

Fetal risksFetal risks

MacrosomiaMacrosomia N.hypoglycemia N.hypoglycemia hypocalcemiahypocalcemia polycythemia polycythemia JaundiceJaundice PMR 4.3 foldsPMR 4.3 folds

ScreeningScreening

When to screenWhen to screen

High risk patients: High risk patients:

.test as soon as possible.test as soon as possible

. If test was –ve repeat . If test was –ve repeat at at

24-28 wks24-28 wks Low risk patients: at 24-28 wksLow risk patients: at 24-28 wks

High RiskHigh Risk

AgeAge ObesityObesity Family history of DMFamily history of DM Previous large babyPrevious large baby Previous perinatal lossPrevious perinatal loss

Low riskLow risk

Age < 25 yearsAge < 25 years Weight normal before pregnancyWeight normal before pregnancy Member of an ethnic group with a low Member of an ethnic group with a low

prevalence of GDMprevalence of GDM No known diabetes in first-degree No known diabetes in first-degree

relativesrelatives No history of abnormal glucose No history of abnormal glucose

tolerancetolerance No history of poor obstetric outcomeNo history of poor obstetric outcome

How to screenHow to screen

One step approach: One step approach:

. using OGTT. using OGTT

Two step approach:Two step approach:

. Using 50 gm GCT. Using 50 gm GCT

. If > 140 mg/dl (7.8 . If > 140 mg/dl (7.8 mmol/l) mmol/l)

perform OGTT perform OGTT

Diagnosis of GDM with Diagnosis of GDM with 100 gm GTT (ADA)100 gm GTT (ADA)

O’sullivan O’sullivan criteria:criteria:

. . F >105 mg/dl (5.8F >105 mg/dl (5.8

MMOL/LMMOL/L))

. 1 hr > 190 mg/dl . 1 hr > 190 mg/dl (10.6)(10.6)

. 2 hr > 165 mg/dl (9.2). 2 hr > 165 mg/dl (9.2)

. 3 hr >145 mg/dl (8.1). 3 hr >145 mg/dl (8.1)

Carpenter criteria Carpenter criteria (new):(new):

. . F > 95 mg/dl (5.3 F > 95 mg/dl (5.3 MMOL/LMMOL/L))

. 1 hr > 180 mg/dl . 1 hr > 180 mg/dl (10)(10)

. 2 hr > 155 mg/dl . 2 hr > 155 mg/dl (8.6)(8.6)

. 3 hr >140 mg/dl . 3 hr >140 mg/dl (7.8)(7.8)

Diagnosis of GDM with 75 Diagnosis of GDM with 75 gm GTT (WHO)gm GTT (WHO)

Fasting > 95 mg/dl (5.3 Fasting > 95 mg/dl (5.3 mmol/L)mmol/L)

2 hr > 155 mg/dl (8.6 mmol/L)2 hr > 155 mg/dl (8.6 mmol/L)

Diagnosis of Frank DMDiagnosis of Frank DM

Fasting > 126 mg/dl (7 mmol/L)Fasting > 126 mg/dl (7 mmol/L) Random >200 mg/dl (11.1 Random >200 mg/dl (11.1

mmol/L)mmol/L)

Obstetric managementObstetric management

U/S to assess growth pattern U/S to assess growth pattern Surveillance fetal well being at Surveillance fetal well being at

term:term:

. Fetal kick counts. Fetal kick counts

. CTG. CTG

. BPP . BPP

. Amniotic fluid. Amniotic fluid

Monitoring degree of Monitoring degree of glycemic controlglycemic control Daily self monitoring (home) Daily self monitoring (home) Post-prandial is superior to Post-prandial is superior to

pre-prandialpre-prandial (glucose profile)(glucose profile) Urine glucose is not reliableUrine glucose is not reliable HB A1c is reliable substitute for HB A1c is reliable substitute for

self monitoringself monitoring Urine ketonesUrine ketones

ManagementManagement

Nutritional counselingNutritional counseling An intake of ~1,800 kcal/dayAn intake of ~1,800 kcal/day Insulin therapy indicated when medical Insulin therapy indicated when medical

nutrition therapy (MNT), fails to nutrition therapy (MNT), fails to maintain fasting whole blood glucose maintain fasting whole blood glucose levels levels << 95 mg/dl (5.3 mmol/l) or 2-h 95 mg/dl (5.3 mmol/l) or 2-h postprandial whole blood glucose postprandial whole blood glucose levels levels << 120 mg/dl (6.7 mmol/l). 120 mg/dl (6.7 mmol/l).

Cont.Cont.

Oral glucose-lowering agents are Oral glucose-lowering agents are not recommended during pregnancynot recommended during pregnancy

Program of moderate exerciseProgram of moderate exercise GDM is not of itself an indication for GDM is not of itself an indication for

cesarean delivery or for delivery cesarean delivery or for delivery before 38 weeks completed before 38 weeks completed gestation. gestation.

Breast-feeding, as always, should be Breast-feeding, as always, should be encouraged in women with GDM encouraged in women with GDM

LONG-TERM THERAPEUTIC LONG-TERM THERAPEUTIC

CONSIDERATIONSCONSIDERATIONS

Glycemic status should be performed at least Glycemic status should be performed at least 6 weeks6 weeks after delivery after delivery

If glucose levels are normal postpartum, reassessment If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of of glycemia should be undertaken at a minimum of 3-3-year intervals.year intervals.

Women with Women with IFG or IGTIFG or IGT in the postpartum period should in the postpartum period should be be tested at more frequent intervalstested at more frequent intervals. Patients should be . Patients should be educatededucated regarding lifestyle modifications that lessen regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal insulin resistance, including maintenance of normal body weight through MNT and physical activity.body weight through MNT and physical activity.