clinical practice guideline: gestational diabetes
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Lecture at the 2010 Philippine Society of Endocrinology & Metabolism Annual ConventionTRANSCRIPT
Clinical Practice GuidelineGestational Diabetes
Iris Thiele Isip Tan MD, FPCP, FPSEMMS Health Informatics (cand.)
Clinical Associate Professor, UP College of MedicineSection of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital
18 March 2010
DisclosureNone ...
ADA
IDFAS
GO
DIP
CDA
NICEHAPO
IADPSG
Where guidelines disagreed, I picked the one I agreed with ☺
AACE
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Referred for rapid weight gain of 5 kg in the last 4 weeks
Her mother has type 2 diabetes
Screen for GDM?
There is not sufficient high-level evidence to make a recommendation for, or against, screening for GDM.
US Preventive Services Task Force 2008 UK National Health Service 2002
Canadian Task Force on Periodic Health Examination 1994
“Screening, diagnosis and treatment of gestational diabetes is cost-effective.”
UK National Institute for Health and Clinical Excellence 2008
No consensus on GDM screening
Who? When? How?
1998
Umbrella organization to facilitate
collaboration
International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care Mar 2010; 33(3):676-82.
“This report represents the opinions of individual members of the IADPSG Consensus Panel and does not necessarily reflect the position of the organizations they represent.”
First prenatal visit Measure FPG, A1c or random plasma glucose in all or only on high-risk women
IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682.
FPG >7 mmol/L A1c >6.5%
RPG >11.1 mmol/L
Overt Diabetes in Pregnancy
If results not diagnostic of overt diabetes and
FPG 5.1-6.9 mmol/L (92-125 mg/dL) → GDMFPG <5.1 mmol/L → 75-g OGTT at 24-28 wks AOG
75-g OGTT at 24-28 wksOvert diabetes if FPG >7.0 mmol/L (126 mg/dL)GDM if one or more values equals or exceeds thresholdsNormal if all values on OGTT less than thresholds
Benefit of early testing?IASDPG Consensus Panel
Diabetes Care Mar 2010; 33(3):676–682.
75-g OGTT thresholdsFPG 5.1 mmol/L (92 mg/dL)1-h PG 10.0 mmol/L (180 mg/dL)2-h PG 8.5 mmol/L (153 mg/dL)
First prenatal visit Screen women at very high risk using standard* diagnostic testing.
ADA Standards of Medical Care 2010
* FPG, HbA1c, 75-g OGTT or random plasma glucose
Very high riskSevere obesityPrior history of GDM or delivery of LGA infantPresence of glycosuriaDiagnosis of PCOSStrong family history of Type 2 diabetes
Greater than low risk womenTest for GDM at 24-28 weeks AOG
Low risk (must fulfill all)
Age < 25 yearsWeight normal before pregnancyEthnic group with low DM prevalenceNo known diabetes in first-degree relativesNo history of abnormal glucose toleranceNo history of poor obstetrical outcome
Low risk womenNo testing required
ADA Standards of Medical Care 2010
IADPSG
FPG, HbA1c or random plasma glucose
First prenatal visit
ADA ASGODIP
FPG, HbA1c, 75-g OGTT or random plasma glucose
50-g GCT (low risk) or 75-g OGTT (high risk)
Thresholds FPG >7.0 mmol/L Overt diabetes
75-g OGTT FPG 5.1 mmol/L (92 mg/dL) 1-h 10 mmol/L (180 mg/dL) 2-h 8.5 mmol/L (153 mg/dL)
Further testing 24-28 wks
75-g OGTT if FPG <5.1 mmol/L
GCT ➝ 100-g OGTT100-g OGTT (1-step)
If GCT <130 If 2-h OGTT <140
100-g OGTT FPG 95 mg/dL 1-h 180 mg/dL 2-h 155 mg/dL 3-h 140 mg/dL
75-g OGTT 2h 140 mg/dL
1996
at least 2
any value
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Referred for rapid weight gain of 5 kg in the last 4 weeks
Her mother has type 2 diabetes
FBS or 75-g OGTT?
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
75-g OGTT:Fasting 1021 h PG 1922 h PG 155
⤳ GDM by FBS criterion
Diet prescription in GDM?
“Initiate MNT immediately
once diagnosed.”AACE 2007
“All women with GDM should receive nutritional counseling by a registered dietitian when possible.”
ADA GDM Position Statement 2004
Choose where possible CHO from low GI sources
Lean proteins including oily fishBalance of poly- and monounsaturated fats
NICE 2008
If pre-pregnancy BMI >27, restrict caloric intake to <25 kcal/kg/day ...
... and take moderate exercise (>30 min daily).
NICE 2008
Obese women (BMI >30):
30-33% calorie restriction (to ~25 kcal/kg
actual weight/day)
Restrict CHO to 35-40%
of calories.ADA GDM Position Statement 2004
3 meals and 3 snacks
50-60% complex high fiber carbohydrates
18-20% protein or at least 75 g<30% fats
Monitor urine ketones before breakfast to detect starvation ketonuria
ASGODIP 1996
“Non-caloric sweeteners
may be used in moderation.”
ADA GDM Position Statement 2004
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Ht 165 cm Wt 90 kgTCR = 90 x 25 kcal/kg = 2250 kcal/day
3 meals and 3 snacksCHO (50%) 281 gCHON (20%) 112 gfats (30%) rest
Urine ketones at ff-up
Blood glucose monitoring?
“SMBG is essential during pregnancy.”
Canadian Diabetes Association 2008
“Daily SMBG appears to be superior to intermittent office monitoring of plasma glucose.”
ADA GDM Position Statement 2004
“For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.”
ADA GDM Position Statement 2004
Both preprandial and postprandial testing are recommended.
If on insulin, test at night because of increased risk of nocturnal hypoglycemia.
Canadian Diabetes Association 2008
Patients should intensively monitor BG
AACE 2007
Diet onlyMonitor BG 4x a day (prebreakfast and 1 h after the first bite of food at each meal)
Insulin therapyMonitor BG 6x a day (before each meal* and 1 h after the first bite of food at each meal)
* to determine insulin dosage correction
“Urine glucose monitoring is not useful in GDM.”
ADA GDM Position Statement 2004
“Urine ketone monitoring may be useful in detecting insufficient or caloric or CHO intake in women treated with caloric restriction.”
ADA GDM Position Statement 2004
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Diagnosed GDM
MNT startedMonitor CBG 3x a day, alternate between- prebreakfast and 1 h after breakfast & lunch- 1 h after meals
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Diagnosed GDM
After 2 weeksPreprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dL
How long can we wait before declaring diet therapy a failure?
Consider insulin when ...
Diet and exercise fail to maintain glucose targets during a period of 1-2 weeks
Ultrasound suggests incipient fetal macrosomia (AC >70th percentile)
NICE 2008
Glucose targets
Between 60 to 90 mg/dL (fasting) and less than 120 mg/dL (1 hour after the first
bite of food at each meal)
AACE 2007
“HbA1c should not be used routinely for assessing glycemic control in the second and third trimesters of pregnancy.”
NICE 2008
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Diagnosed GDM
Preprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dLStart insulin to bring down postprandial CBGs
Can we give Metformin in GDM?
How about Glibenclamide?
Canadian Diabetes Association 2008
Use of metformin or glibenclamide during pregnancy not an approved indication
Discuss with patients
Off-label use
Option of giving metformin or glibenclamide
NICE 2008
“... tailored to glycemic profile of, and acceptability to, the individual woman.”
Obtain and document informed consent.
Metformin in Gestational Diabetes (MiG) Study
Combination therapy
MiG study
Women taking metformin (who had insulin added) required lower insulin dose
? metformin + glibenclamide
IDF 2009
Insulin remains the agent of choice
“In poorly resourced areas of the world, the theoretical disadvantages of using oral glucose-lowering agents ... far less than the risks of non-treatment.”
IDF 2009
Recommended insulin regimens?
Prandial, basal bolus, split-mixed? Analogues?
Initiate a basal-bolus regimen if a patient cannot maintain glucose targets with diet alone.
NPH insulin (basal) and rapid-acting insulin at meals
Subcutaneous insulin infusion with an insulin pump
AACE 2007
Insulin regimens in GDM
Intermediate-acting insulin
30 min prebreakfast and presupper + rapid-acting insulin3 injections of rapid-acting
insulin given 30 min before
each meal + intermediate-
acting OR long-acting insulin at bedtime
ASGODIP 1996
Insulin therapy in GDM
ASGODIP 1996
Initiating dose depends on the blood glucose
May start daily insulin dose 0.1-0.3 u/kg BW
“ ... rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy ...”
NICE 2008
Which type of insulin and which regimen? Discuss with patient.
31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG
Diagnosed GDM
Preprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dLStart prandial (regular) insulin i.e. 4-6 units premeals tid
Ht 165 cm Wt 90 kg
How often to follow-up?
ASGODIP 1996
Subsequent Visits
Every 2 weeks for
Glycemic control: check 2-h PPBGObstetric complications:
macrosomia, IUGR, preeclampsia, and hydramnios
Ultrasound
At first visit to determine age of pregnancy
At 20-22 wks to detect malformations
At 32-34 wks to monitor growth
ASGODIP 1996
Management during labor and delivery
Protocol for Spontaneous Delivery
Infusion of 500 ml 5% dextrose/saline x 4 h
CBG q 4hGive short-acting insulin for
CBG >140 mg/dL
- Dose equal to mmol of CBG
i.e. 12 u for 12 mmol/L
- Dose equal to 1/20th of mg/dL of
CBG i.e. 12 u for 240 mg/dL
Omit insulin for CBG <140
mg/dL ASGODIP 1996
Maternal hyperglycemia is the main cause of neonatal hypoglycemia
Insulin is still required before
active labor; SC or IV to maintain BG 70-90 mg/dL
Infuse glucose 2.5 mg/kg/
minMeasure CBG q hourly
Double the glucose infusion
for the next hour if BG <60
mg/dLGive regular insulin SC or IV
for BG >120 mg/dL AACE 2007
ASGODIP 1996
After delivery
Resume diet
GDMs with high insulin requirements during pregnancy should have glucose profiles
Give insulin if BG persistently
high (>200 mg/dL)
Postpartum follow-up
Reclassify at least 6 weeks after delivery
Reassess q 3 years if normal BG postpartum
Test for diabetes annually if with IFG or IGT postpartum
ADA GDM Position Statement 2004
All patients with prior GDM should be educated re: lifestyle modifications
Maintain normal body weight: MNT and physical activity
ADA GDM Position Statement 2004
Women with IFG or IGT postpartum: intensive MNT and individualized exercise program
Planning subsequent pregnancies
Plan future pregnancies in consultation with health care provider
Assess glucose tolerance prior to conception to assure normoglycemia at time of conception
Canadian Diabetes Association 2008
“As always, solutions of an immediate problem raise questions
for the future.”
Robert G. Moses, MD
Thank You
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