DR GAYATHRI MARIAPPA

OVERVIEW

❖ INTRODUCTION

❖ WHAT IS NEW?

❖ WHAT IS CONTROVERSIAL IN MALAYSIA?

❖ MANAGEMENT ALGORITHM

❖ DO’S

❖ DON’T

❖ TAKE HOME MESSAGE

❖ REFERENCES

2

❖ WORLDWIDE PREVALENCE – 16% IN PREGNANCY

❖ SIGNIFICANT MATERNAL & FETAL IMPLICATIONS

INTRODUCTION

❖ < 20 weeks of POG • Anabolic phase • Increase in Insulin sensitivity

❖ > 20 weeks of POG• Catabolic phase • Increase in Insulin resistance

PATHOPHYSIOLOGY

• The pancreas releases 1.5–2.5 times more insulin in order to respond to the resultant increase in insulin resistance.Normal patient meets the demand

In GDM :• Post receptor defect. Inadequate insulin release

MECHANISM OF INSULIN RESISTANCE

MALAYSIA

❖ PREVALENCE OF GDM- 5%

❖ LACK OF STANDARDIZED OF DIAGNOSTIC CRITERIA

❖ SELECTIVE SCREENING RATHER THEN UNIVERSAL SCREENING

WHAT IS NEW?

❖ DEFINITION

❖ DIAGNOSTIC CRITERIA

❖ EXERCISE IN PREGNANCY

❖ APPROACH TO MANAGEMENT

❖ SAFETY OF OHA?

❖ NEW INSULINS?

WHAT IS NEW?DEFINITION

❖HYPERGLYCAEMIA FOR THE 1ST TIME IN PREGNANCY – IS NOT ALWAYS GDM

❖DM VS GDM?

Pregestational DM Cut off values

Fasting >7mmol/L

2 hours post prandial

>11.1mmol/L

Random>11.1mmol/L and symptomatic

WHAT IS NEW?DEFINITION

HYPERGLYCAEMIA IN PREGNANCY : ❖1) TYPE II DM/PREGESTATIONAL

ACHOIS (NEW ENGLAND JOURNAL MED 2005

❖ DIET AND LIFESTYLE MODIFICATIONS – EXTREMELY BENEFICIAL

❖ START INSULIN – REDUCE MACROSOMIA, STILLBIRTH AND DYSTOCIA

IMPORTANCE OF SCREENING

BENEFITS:❖ALLOWS ACTIVE INTERVENTION❖REDUCED MACROSOMIA/SHOULDER DYSTOCIA/BIRTH TRAUMA

RISKS:❖INCREASED INTERVENTION (EG.IOL)

❖INCREASED MONITORING

CONCLUSION SO FAR

❖ GDM IS SIGNIFICANT IN SOUTH EAST ASIA!

❖ THE LOWER THE GLYCAEMIC CONTROL – THE BETTER

❖ ACTIVE INTERVENTION – IMPROVES OUTCOMES

❖ SCREENING BASED ON RISK FACTORS – 50% OF PATIENTS WILL BE MISSED

WHAT IS CONTROVERSIAL IN MALAYSIAN CONTEXT?

❖ UNIVERSAL VS SELECTIVE SCREENING

❖ COST EFFECTIVENESS

❖ RESOURCES

MALAYSIAN CPG 2009

CUT OFF VALUES IN MALAYSIA?

❖ TILL NEWER GUIDELINES IN THE NEAR FUTURE,MOGTT VALUES :

❖ FASTING - 5.6 MMOL/L

❖ 2 HOURS POST PRANDIAL - 7.8MMOL/L

Almost everyone except age<25, weight < 27kg/m2

Almost everyone except age<25, weight < 27kg/m2

Extremely high riskEg Obesity, advanced

age, bad obstetric outcomes

Screen as early as possible (16-18weeks)

Routine screening

Screen at 24-28weeks

If normal repeat at 28 weeks

Advice on lifestyle modification

Refer dietician as soon possible/ provide leaflets

Exercise

Blood sugar profile within 2 weeks of diagnosis & intervention

Active intervention

Active intervention

WHAT’S NEW?APPROACH TO MANAGEMENT

Start insulin if failure to achieve desired levels within 2 weeks of lifestyle modification

VENOUS OR CAPILLARY?

❖ FASTING – CAPILLARY OR VENOUS – SIMILAR

❖ POST PRANDIAL – CAPILLARY > VENOUS

• No evidence that one is superior then another• Best outcomes are combination of pre and post

prandial sugars• Post prandial sugars which are deranged will

reflect on the babes growth

4 POINT OR 7 POINT BSP ??

Is there any place to monitor glycosylated hemoglobin (HbA1c) in pregnant women with gestational diabetes? Especially in relation to predicting fetal morbidity such as macrosomia/ shoulder dystocia?

The NICE guideline on diabetes in pregnancy (National Collaborating Centre) recommends that HbA1c should not be used routinely for assessing glycaemic control in the second and third trimesters of pregnancy.

“Do not use routine measurement of HbA1c for management”

TREATMENT

1) LIFESTYLE MODIFICATIONS

❖- MILD TO MODERATE EXERCISE

❖- DIETARY MODIFICATIONS

❖2) 7–20% WILL REQUIRE TREATMENT

❖- INSULIN

❖- OHA

WHAT’S NEW?EXERCISE

❖ MILD TO MODERATE NOT WEIGHT BEARING EXERCISE – PROVEN TO BE SAFE IN PREGNANCY- CYCLING, SWIMMING, AEROBICS

❖ REDUCE INSULIN REQUIREMENTS

❖ SHORTENS LABOUR

❖ MORE PRONE FOR VAGINAL DELIVERY

THERAPEUTIC DIET

❖ AVERAGE WEIGHT - 30–35 KCAL/KG/DAY

❖ OBESE - 24KCAL/KG/DAY

CALORIC COMPOSITION

❖ 40–50% FROM COMPLEX, HIGH-FIBER CARBOHYDRATES

❖ 20% FROM PROTEIN

❖ AND 30–40% FROM PRIMARILY UNSATURATED FATS

DIET

❖ DISTRIBUTION :

❖ 10–20% AT BREAKFAST;

❖ 20–30% AT LUNCH;

❖ 30–40% AT DINNER;

❖ AND UP TO 30% FOR SNACKS, ESPECIALLY A BEDTIME SNACK

Time Plasma glucose

Fasting < 5.3

1 hr < 8.0

2 hr < (6.7)

If targetsIf targetsnot reached within 2 weeks, not reached within 2 weeks,

Initiate insulinInitiate insulin

International Assoc of Diabetes & Pregnancy Study Groups (IADPSG), D Care 2010;33(3):676-82

TARGETS OF GLYCAEMIC CONTROL

OTHER INDICATIONS TO START INSULIN

❖FETAL GROWTH ABOVE 70TH PERCENTILE OF POPULATION

❖(IMPORTANCE OF GROWTH CHART)

❖POLYHYDRAMNIOS

❖LIMITED ROLE OF HBA1C

NEW KID IN THE BLOCK?

❖ RAPID ACTING INSULIN ANALOGS – LISPRO, ASPART

❖ S/C INSULIN PUMPS

❖ GLARGINE HUMAN INSULIN ANALOG PRODUCED WITH RECOMBINANT DNA

INSULIN ACTION PROFILE

GLIBENCLAMIDE

- LANGER ET ALL (N ENGL J MED 2000) 402 PATIENTS

- CONVERSION RATE TO INSULIN ONLY 4%

- NOT DETECTED IN CORD BLOOD

- BUT BETTER FASTING GLUCOSE PROFILE

- RECOMMENDED FOR WOMEN WITH PRE EXISTING DM

MULTIPLE STUDIES SINCE THEN – HIGH CONVERSION RATE TO INSULIN (20-30%)

OHA? IS IT SAFE?

OHA?

METFORMIN

❖ ROWAN ET AL. (MIG STUDY)

❖ SIMILAR OUTCOME TO INSULIN

❖ CONVERSION RATE – 46% HAD INADEQUATE CONTROL AND REQUIRED INSULIN

❖ LOWER MATERNAL WEIGHT GAIN, LOWER GLYCEMIC RANGE AND COMPLICATIONS

IS OHA SAFE?

❖ METFORMIN AND GLIBENCLAMIDE CROSS THE PLACENTA

❖ NO IMMEDIATE SAFETY CONCERNS FOR THE FETUS HAVE BEEN DEMONSTRATED

❖ POTENTIAL LONG-TERM EFFECTS REMAIN UNDER INVESTIGATION

❖ FDA CLASS B

❖ MAY BE USED IN CERTAIN GROUP OF PATIENTS

MONITORING• 2 weekly BSP till 36 weeks (if within

normal range)• Weekly BSP if abnormal or escalation

of treatment (till normal)• Weekly BSP after 36 weeks

Each visitReview BP

Screen for PE

TIMING OF DELIVERY

• Offer induction of labour at 38 weeks if on treatment• Offer induction of labour at 40 weeks if not on treatment

• Earlier if evidence of macrosomia/polyhydramnios or poor control at term

GROWTH SCAN•Scan at 28 and 34 weeks for growth

•Scan at 36 weeks for EBW and serial growth scans

PLOT GROWTH CHART

ANTENATAL MANAGEMENT OF GDM

ANTENATAL

GOOD CONTROL – CAN BE MANAGED IN HEALTH CLINIC

DIETICIAN REVIEW

WHEN TO REFER TO SPECIALIST CLINIC

-FOR INSULIN COMMENCEMENT

-EVIDENCE OF MACROSOMIA/POLYHYDRAMNIOS

❖ EXCLUDE MACROSOMIA AT TERM (DOCUMENT IN NOTES)

❖ NO ROLE FOR DOPPLER UNLESS EVIDENCE OF IUGR

❖ POLYHYDRAMNIOS OR MACROSOMIA IS AN INDICATION FOR INSULIN/EARLY DELIVERY

FETAL ASSESSMENT

INTRA-PARTUM CARE

❖ DELIVER AT 40 WEEKS (OFFER IOL)

❖ EARLIER IF POORLY CONTROLLED, DEVELOPED PIH/PE

❖ IF EVIDENCE OF MACROSOMIA – DELIVER BY LSCS

❖ 2 HOURLY CAPILLARY BLOOD GLUCOSE, MAINTAIN BETWEEN 4-7MMOL/L (GIK REGIME)

POSTPARTUM

❖ IF GDM, NO NEED FOR POST DELIVERY MONITORING

❖ STOP INSULIN POST DELIVERY (ENSURE SHE HAS GDM & NOT DM)

❖ UNLESS ITS HIGH REQUIREMENT OF INSULIN ANTENATALLY

PREVENTION OF NEONATAL HYPOGLYCAEMIA

❖FEED SOON AFTER BIRTH (WITHIN 30 MINUTES)

❖FREQUENT INTERVALS (EVERY 2–3 HOURS)

❖ROUTINE MONITORING OF BABY

– 2-4 HOURS AFTER BIRTH (PAEDIATRIC REFERRAL

IF <2MMOL/L)

POST NATAL CARE

❖ 6 WEEKS – FBS (NICE) (LOW RISK)

HIGH RISK PATIENTS – DO MOGTT

❖ YEARLY FBS

❖ OGTT NEXT PREGNANCY AT 16-18WEEKS

DO’S❖ SCREEN ALMOST EVERYONE

❖ THE LOWER THE GLYCAEMIC CONTROL – THE BETTER

❖ PATIENT EDUCATION

❖ ACTIVE INTERVENTION – EXERCISE, DIET, INSULIN

❖ MONITORING – CONSIDER LOGISTICS/FEASIBILITY

❖ HAND HELD RECORDS

DON’T

❖ LABEL EVERYONE AS GDM

❖ USE FBS/RBS/GLYCOSURIA FOR DIAGNOSIS

❖ 1 HOUR POST PRANDIAL SUGAR

❖ REPEAT 3X OR UNNECESSARILY

❖ DELAY IN DIETARY REFERRAL & LIFESTYLE MODIFICATIONS

❖ DELAY IN INITIATING INSULIN

❖ EARLIER IOL TO PREVENT MACROSOMIA

TAKE HOME MESSAGE

❖ GDM – EXTREMELY IMPORTANT IN MALAYSIA

❖ SCREENING ALLOWS INTERVENTION – SHORT TERM AND LONG TERM

❖ ACTIVE INTERVENTION IMPROVES OUTCOMES

❖ STANDARDISED EVIDENCE BASED APPROACH

❖ INDIVIDUALISED CARE

❖ KEEP ABREAST WITH CHANGES – NEW DEVELOPMENTS ARE COMING OUR WAY

THANK YOU

❖ NICE

❖ WHO 2013 ATLAS

❖ ACOG GDM GUIDELINES