gdm satellite congress
TRANSCRIPT
Gestational Diabetes Mellitus
Screening
Diagnosis
Challenges in managementDr Hema Divakar
GDM
GDM refers to women who are shown to be diabetic for the first time during pregnancy
regardless of whether diabetes persists after pregnancy
Screening for GDM
Story of failure to screen
Society of obstetricians – Canada Recommend universal screening
Doctor failed to implement this policy Missed the diagnosis Did not request ultrasound
Baby – macrosomic / erbs / 4.4 kg/shoulder dystocia
Court found that his care was negligent He failed to follow guideline recommendations
Universal screening for GDM is essential
The prevalence of GDM in India varied from 15 to 21% in different parts of the country compared to 3.8 % in the west
It is generally accepted that women of Asian origin and especially ethnic Indians, are at a higher risk of developing GDM
(and subsequent type 2 diabetes)
Screening for GDM
Indians fall into the high-risk category for developing GDM
therefore universal screening is recommended in pregnancy
When ??
offer universal screening – to ALL antenatal women at 24 – 28 wks of gestation
and an early screening at booking if there are additional risk factors identified by
historyo Previous unexplained loss at termo Previous baby weight > 4 kgo Previous Pregnancy with GDMo Strong F/H
Patients who had GDM in a previous pregnancy have a 33–50% likelihood of recurrence in a subsequent pregnancy.
Therefore women who have had GDM in a previous pregnancy must be screened at first booking and then at regular intervals.
Screening- HOW ???
50 gm GCT for screening Ref : Sacks DA. et al. How reliable is the fifty-gram, one-hour glucose
screening test? AM J OBSTET GYNECOL 1989; 161(3):642-645 Glucose screening and testing-American Pregnancy Association (Aug 2007) ADA/NDDG and Medical Journal of Australia 2005, 183(6):288-289
No short cuts Venous sample more reliable in correctly diagnosing
GDM
Glucometer vs Venous Sample Reference : Journal of Obs & Gynae of India. Glucometer screening of
Gestational Diabetes, Vinita Das. et al. KGMC, Lucknow (INDIA) November/December 2006, 499-501
Screen Positive
GCT >140 mg/dlsubjected to OGTT with 100 gms Glucose.
100 gm OGTT according to Carpenter & Coustan criteria
Fasting <95 mg/dl 1 hours <180 mg/dl 2 hours <155 mg/dl 3 hours <140mg/dl
Gestational Diabetes Mellitus (GDM) is diagnosed if 2 or more of the values are met or exceeded
Diagnosis
One step test – screening and diagnosis
75g oral glucose load*, without regard to the time of the last meal.
2 hours later A venous blood sample
GDM is diagnosed if 2 hr plasma glucose is ≥ 140 mg/dl.
Avoids – multiple visits/multiple samples Validated by dr Seshiah and team – Chennai Published in ACTA – 2009
Once diagnosed as Gestational diabetes the patients are under the care of a team for monitoring of maternal sugar and fetal well being. The team -
EndocrinologistDieticianObstetricianPediatricianSonologist
Management ApproachMulti-Disciplinary
Maternal Risks
Hypoglycaemia Diabetic Ketoacidosis Retinopathy Nephropathy Hypertension Atherosclerosis Neuropathy Infection Operative Delivery
Fetal Risks
Congenital Anomalies Early pregnancy losses Preterm labor Fetal Growth - macrosomia Shoulder Dystocia & birth
trauma
Neonatal Complications
Hypoglycaemia Hyperbilirubinemia Hypocalcaemia Polycythemia Cardiomyopathy RDS
Diet Dietician charts a diet plan according
to patients
Body Weight Obese women : 25-30 kcal / kg Non-obese : 35 –40 kcal /kg
Dietary compliance is evaluated and reinforced during weekly hospital visits
Targeted values are Fasting < 95 mg/dl 1 hour post meal < 140 mg/dl
Glucose Monitoring For further quality control, blood glucose is
measured in the laboratory at weekly visit
Patients on insulin therapy are instructed to use Glucometer and self monitor blood glucose at home
Patient Education
The compliance with the treatment plan depends on the patient’s understanding of:
The implications of GDM for her baby and herself The dietary and exercise recommendations Self monitoring of blood glucose
Self administration of insulin and adjustment of insulin doses
The role of oral antidiabetic agents in the treatment of GDM
Oral antidiabetic agents have, till now, been contraindicated in pregnancy.
Glyburide, a secondgeneration sulfonylurea, was compared with insulin in a randomized trial among patients with GDM who failed to achieve adequate glycemic control with diet alone Glucose control was similar, and the glyburide group had pregnancy outcomes similar to those of the insulin group,including rates of cesarean delivery, preeclampsia, macrosomia (>4 kg), and neonatal hypoglycemia.
Further study is recommended before the use of newer oral
hypoglycemic agents can be supported for use in pregnancy
At 28 weeks – Inj Betnesol 12 mg 2 doses
All patients on diet therapy before 32 weeks are followed by fortnight visit and weekly visits thereafter
Patients on insulin therapy are always monitored by weekly visit
Antepartum Management
Antepartum Management(contd)… As per ACOG recommendations for
GDM patients weekly fetal surveillance was started from 32nd week of gestation for
Clinical ExaminationGrowth profileBiophysical profileNon stress test
The decision for intervention depends on the maternal outcome variables such as
Poor glycemic control on diet / insulin or
Macrosomia Surveillance test showing
non-assuring / omnious NST – flat NST
Decision for Intervention
Liq
Timing of delivery
Good glucose control with diet and exercise
and no complications: expectant management till 40 weeks of gestation
GDM on insulin: induction of labour at 38 weeks because the incidence of shoulder dystocia
GDM with HTN or previous stillbirth: induction of labour at 37-38 weeks depending on the condition of the fetus
Post Partum Management Maternal sugars are monitored
Every 6-8 hours for the first post operative day
Every 12 hours in the 2nd POD
4th POD Fasting / 1 hour post meal
Patients were reviewed after 6 weeks with Fasting / 2 hour post OGTT with 75 gms glucose
Advise on contraception and weight reduction and long term risk of Diabetes and risk of GDM in subsequent pregnancy is given
With good obstetric care, the With good obstetric care, the perinatal mortality rate for a perinatal mortality rate for a GDM pregnancy is similar to that GDM pregnancy is similar to that in the non-diabetic populationin the non-diabetic population
The future …..The future …..
women who exhibit glucose intolerance during pregnancy have an increased risk of developing type 2 diabetes within 15 years .
Children born out of these – childhood obesity / adult onset
diabetes
Timely action taken now in screening all pregnant women for glucose intolerance
achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability
the vicious cycle of transmitting glucose intolerance from one generation to another
More to understandMore to understand
More to do More to do
Thank YouThank You
Dr Hema DivakarDr Hema Divakar