gestational diabetes mellitus (gdm) nabeel s. bondagji md, frcsc, facog associate professor...

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GESTATIONAL DIABETES GESTATIONAL DIABETES MELLITUS (GDM) MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

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Page 1: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

GESTATIONAL DIABETES GESTATIONAL DIABETES MELLITUS (GDM)MELLITUS (GDM)

NABEEL S. BONDAGJIMD, FRCSC, FACOGAssociate professor

Consultant PerinatologistDepartment of OB/GYN

Page 2: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Incidence of GDM

Approximate prevalence 3-5%IncreasingIn SA 15-20% diabeticGDM 3-7% Varies with ethnic,race,social habits

Page 3: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

DIABETES AND PREGNANCY

0.2-0.3% of women of reproductive

age have diabetes prior to

conception.

30% of patients with gestational

diabetes

develop non-Insulin

dependent

diabetes later in life

Page 4: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

D. M IN PREGNANCY

Type I Type IIGDM

Page 5: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

What is Gestational Diabetes?

Carbohydrate intolerance of varying severity first manifest or diagnosed in pregnancy.

The definition applies irrespective of the need for insulin treatment and the result of any postnatal glucose tolerance test.

Page 6: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Effect of Pregnancy on Diabetes

Pregnancy is diabetogenicHPL, progesterone antagonize insulinPregnancy causes insulin resistance

Page 7: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Maternal Effects of Diabetes

Miscarriage

Polyhydramnios

Preeclampsia (more if diabetic nephropathy)

Infection (UTI, candidiasis, chorioamnionitis)

Operative delivery (CS rate 50%)

Page 8: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Long-term Effects

NephropathyNone if mild-moderateIf severe (creatinine > 0.25

mmol/L), may exacerbate renal failure

RetinopathySeems to make it worse

Page 9: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Fetal Effects of DiabetesMiscarriage

Congenital Malformations 2 - 3 times background rate minimized by good control pre

and post-conception. commonest are cardiac defects Caudal regression (sacral

agenesis)

Perinatal Death Late “unexplained” IUFD perinatal mortality rate doubled

Page 10: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Neonatal Effects of Maternal Diabetes

(IDM)Macrosomia (40%)Birth trauma shoulder dystociaHypoglycemiaHypocalcaemia/magnesaemiaRespiratory distress syndromeHyperbilirubinaemiaHyperviscosity/ polycythaemiaThe risk of type 1 diabetes mellitus in the child of a woman with the condition is 2%.

Page 11: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN
Page 12: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN
Page 13: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Risk Factors

Body mass index 25 kg/m2

Family history of type 2 diabetes Age older than 25 yearsMultiparityPrevious gestational diabetes: Macrosomic or large-for-gestational age infant

Page 14: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Cont. - Risk Factors

Previous impaired glucose tolerance with oral glucose tolerance test American Indian or Alaska Native; African American; Asian; Hispanic; Pacific Islander

Page 15: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Screening50 gram glucose challenge test

at 24-28 weeks7.8mmol or more GTT80% sensitivity 7.2, 90% sensitivity

Random blood sugarnot adequate

Fasting blood sugarinadequate data

Page 16: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Diagnosis

75g GTTFasting glucose, 75 g

load, 2-hour glucoseGDM = fasting 5.5

mmol/L OR 2-hour 8.0 mmol/L

Page 17: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

O. Sullivan and Mahan

mg/dl mmol/L mg/dl mmol/L

Fasting 95 5.3 105 5.8

One hour 180 10.0 190 10.6

Two hours 155 8.6 165 9.2

Three hours 140 7.8 145 8.0

Two (2) Abnormal Reading = GDM

Page 18: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Treatment of Diabetes

Type 1 : diet, exercise & insulinType 2 : diet, exercise

: metformin or sulphonylurea alone

: metformin and sulphynylurea : metformin, sulphonylurea & thiazolidinedione

: insulin

GDM : diet: insulin

Page 19: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Drugs to treat hyperglycemia

Insulin and insulin analogues

Insulin secretagogues sulphonylurea gliclazide,

glibenclamide

glyburide. non-sulphonylurea repaglinide, nateglinide

lispro insulinaspart insulininsulin glargine

Page 20: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Drugs to treat hyperglycemia

Insulin sensitizers biguanide metformin

thiazolidinedione rosiglitazone, pioglitazone

Intestinal absorption inhibitorsacarboseorlistat

Page 21: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

TEXT BOOKS TEACHINGOral hypoglycemia are contraindicated in pregnancy

Risk of fetal anomalies

Risk of neonatal hypoglycemiaIncreasing risk of PET

Page 22: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

ACOG/ADA

Insulin and its analogues are the only agents to be used in pregnancy

SOGS !!!!!!!!!

Page 23: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

BUILLDING EVIDANCE

No evident that it causes fetal hypoglycemia 3 cases studies.

No strong evidence it cause congenital anomalies.

Page 24: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Evidence

Early reports

Oral hypoglycemic Fetal congenital anomalies

Critical review of old data suggested that the

described reports associated with fetal anomalies

are most likely related to hyperglycemia

Poor control prior to pregnancy diabetic

emberyopathy

Page 25: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Elliot et al – (American Journal of Obstetrics & Gynecology 1991).

Elliot et al –(American Journal of Obstetrics & Gynecology 1994) proved in Lab. that Glyburide does not cross the placenta in significant amounts (in human placental modules).

Page 26: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Perfusion studies of glyburide transfer across thehuman placenta: Implications for fetal safety

Jennifer Kraemer, MSc, Julia Klein, MSc, Angelica Lubetsky,

Am j Ob& Gyne 2006The objective of study was to document, using

a human placenta perfusion model, whether glyburide is actively effluxed from the fetal to the maternal circulation.

Conclusion: these experiments suggest that glyburide is actively efflux by a transporter from the maternal to fetal site

Page 27: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Coetzee etall (South African MJ 1984)

Oral hypoglycemic in the first trimester and fetal

outcome

171 Patients retrospective review

78 used OHA

93 not

No significant difference in the outcome

Comparable results in blood sugar control

Page 28: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

The safety of oral hypoglycemic agents in the first trimester of pregnancy :a meta-analysis

Gutzin ea alCan J Clinical Pharm 2003

OBJECTIVE: To examine the relationship between first trimester exposure to oral hypoglycemic agents and ,fetal congenital anomalies and neonatal morbidity.

METHODS: a systematic review and meta-analysis of all studies that was reported on women exposed to OHGA in the first trimester

Page 29: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Gulzin etalCan J. Clin. Pharmacology (2003)

Meta-analysis on the safety of OHA in

the first trimester/University of Toronto

10 studies fulfilled the criteria

Results

In all studies

No difference in major anomalies among

Exposed Vs non exposed fetuses

Page 30: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

RESULTS: Ten studies met the inclusion criteria -There was no significant difference in the rate of congenital anomalies betweenexposed and non exposed-No difference in the neonatal deathConclusions:

First trimester exposure to OHA did not increase the rate of congenital anomalies nor the neonatal deathFurther studies needed do document the safety and the glycemic control

Page 31: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Safety of glyburide for gestational diabetes:a meta-analysis of pregnancy outcomes

Moretti ME, Rezvani M, Koren G.

Ann Pharmacotherapy. 2008 Apr

OBJECTIVE: To determine the safety of glyburide use in pregnancy in the treatment of gestational diabetes compared with insulin therapy by analyzing all available human studies.

METHODS: a systematic review and meta-analysis of all randomized and cohort studies that reported on the perinatal complications among women with gestational diabetes who received glyburide versus insulin

Page 32: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

RESULTS: Nine studies met the inclusion criteria, including a total of 745 glyburide

exposed pregnancies and 637 insulin-

exposed pregnancies

CONCLUSIONS: The data do not suggest increased perinatal risks with glyburide. The effectiveness and safety of glyburide require further evaluation, as most studies to date were not randomized

Page 33: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Comparison of Glyburide and insulin for the management of gestational diabetes in a large managed care

organization(American j Obstet Gynecol 2005)

Jacobson GF

A retrospective study

268 insulin 1999-2000

236 glyburide 2001-2002

Page 34: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusions:

No difference in glycemic control birth

weight NN outcome

Slight increase in PET + phototherapy

Need for glyburide group

Page 35: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

A comparison of glyburide and insulin in women with gestational diabetes mellitus.

Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Hospital Center, New York 10019,

USA. [email protected]

Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O.

N Engl J Med. 2000 Oct. 19;343(16):1178-9

Page 36: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

404 women randomized11 – 33 weeks

Group I Glyburide201

Group II insulin 203

Page 37: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Results

No difference in the glucose blood level.

No difference in congenital anomalies.

No difference in the birth weight.

Glyburide was not detected in the cord blood of any of the fetuses of the glyburide group.

Page 38: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

There were no significant differences between the glyburide and insulin groups in lung complications (8 percent and 6 percenthypoglycemia (9 percent and 6 percentwho were admitted to a neonatal intensive care unit (6 percent and 7 percent

Page 39: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusion

In women with GDM, Glyburide is clinically effective alternative to insulin.

Page 40: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Langer O. Am. J. Obst. & Gynecol ,2005 J

Insulin and glyburide therapy: dosage, severity

level of gestational diabetes , and pregnancy

outcome

Secondary analysis of the trial

Conclusion:

Glyburide and insulin are equally efficient for

Treatment of GDM at all level of severity

Page 41: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

In PCO patients

Metformin use in the first trimester does not increase M C A

Glueck et all ( pilot study)

continues metformin through out pregnancy in women with PCO

Safe and decrease first trimester abortion(Fertility & sterility 2001)

Page 42: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Glueck etall (human reproduction 2004)

Follow up of 126 infants born for PCO

women on continuous metformin through

out pregnancy

Conclusion:Decrease GDM does not cause any adverse

effects on babies up to 4 year follow up

Page 43: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Jakubaurez et all

Effect of Metformin in early pregnancy loss in PCO

(J. Of Clinical endocrinology & Metabolism 2002)

safe

Page 44: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Metformin Therapy Throughout Pregnancy Reduces GDMetformin Helps Prevent Gestational DiabetesMetformin Shows Promise in Preventing Miscarriage

Wait for the MIG TRIAL 2007 ?

Page 45: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

First Visit

Routine management PLUS Counseling Urinary protein Ophthalmoscopy each trimester Glycaemic control Organize fetal surveillance

Page 46: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Blood sugar control and the prevention of the complication of D.M.

Blood sugar control 100mg ml the incidence of neonatal metabolic complications and improve lung maturation.

Page 47: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Blood sugar 87- 100 Will the incidence of macrosomia

Blood sugar 60 – 106 Will incidence of abortion

Blood sugar 90 - 120 Will prevent still birth

Blood sugar 120 – 140Prevent congenital anomalies

Page 48: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Treatment

GOALS1. Achieve normoglycaemia2. Monitor fetal well-being3. Appropriate timing of delivery

Page 49: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Glycaemic Control

Home blood glucose monitoring qidGoals are 5.5 mmol/L fasting and 7

mmol/L 2 hours postprandial

HbA1c monthlyDietary managementAppropriate energy intake50-60% CHO, 25% fat, 15% proteinEven distribution

Exercise - 30 minutes walk a dayInsulin

Page 50: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

DIET Blood Sugar Control

Fasting 105 5.8 mmol 1 hour 140 7.8 2 hours 120 6.7 How long on diet2 weeks

Page 51: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Testing <6.7mmlP.P. <7.8mml Diet

<6.7 – 7.8 <7.8 – 10

Insulin

Page 52: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Fetal SurveillanceUltrasound12 weeks

gross morphology, dates, plurality, nuchal translucency

18-20 weeksdetailed morphology

30 and 34 weeksgrowth

Other scans, Doppler's umbilical and UTERINE ARTERY

CTG or BPS weekly from 32 weeks

Page 53: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Timing and Route of Delivery

RCT suggests advantage in delivery at 38 - 39 weeksDecreased macrosomia, shoulder dystocia

40 weeks if perfect control, no complications

Page 54: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Cont. - Timing and Route of Delivery

?Role of elective CS for macrosomiaDiabetes is independent risk factor for shoulder dystocia

Recommend if estimated fetal weight > 4.5 kg

Consider if EFW 4 - 4.5 kg

Page 55: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Management in Labour1. Glycaemic control

Notify endocrinologist Omit morning insulin the day of induction.Measure blood glucose on admission and every 2 hours.

Page 56: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Cont. - Management in Labour

1. Glycaemic control50 U insulin in 50 mL 0.9% NaCl (1U/mL) via syringe pumpStart at 1mL/hourAdjust to keep glucose 4-7 mmol/LSimultaneous 5% dextrose at 100 mL/hour

Page 57: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Management at Delivery

Prepare for shoulder dystociaCease insulin if used at deliveryMonitor infant’s blood glucose after deliveryMeasure mother’s blood glucose BD for 2 days

Page 58: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Puerperium

Cease insulin infusion at delivery (unless Caesarean section)Often reduced needs for 24 hoursThen back to prepregnancy doseType 2 may need no treatment in puerperiumOHAs discouraged in lactation

Page 59: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

?

Long-term management

Recall at 6 weeks postpartum for GTT2% will have diabetes10% will have IGTLong-term risk of diabetes mellitus 50% over 10 yearsLong-term follow-upLifestyle modification50% recurrence in future pregnancy

Page 60: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusion - I

New generation of oral hypoglycemic agents glyburide does not cross the placenta and may be used to replace insulin between 11 – 33 weeks of gestation. Further studies to be done to document its safety in early pregnancy.

Page 61: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusion - II

METFORMIN can be used in P.C.O. patients during the whole pregnancy it showed that it reduces miscarriages in the incidence of G.D.M. Nevertheless does not show good control of blood sugar.

Page 62: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusion - III

Maintaining blood sugar at certain thresholds may reduce certain complications of GDM.

Page 63: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

THANKYOU

Page 64: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN
Page 65: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Glyburide for the management of gestational diabetes: Risk factors predictive of failure and associated pregnancy outcomes. Am J ob&gyn 2006Meredith Rochon, MD,a,* Larry Rand, MD,a Lisa Roth, MD,a Sreedhar Gaddipati, M

Objective: to identify characteristics that may predict failure of glyburide therapy

101 patient 79% successfully treated

Conclusion: Predicting glyburide failure is difficult, but failure does not appear to be associated with increased adverse pregnancy outcomes.

Page 66: GESTATIONAL DIABETES MELLITUS (GDM) NABEEL S. BONDAGJI MD, FRCSC, FACOG Associate professor Consultant Perinatologist Department of OB/GYN

Conclusion: Glyburide and insulin are equally efficient for treatment of GDM in all levels ofdisease severity. Achieving the established level of glycemic control, not the mode ofpharmacologic therapy, is the key to improving the outcome in GDM.