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