Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
4/11/2018
1
{
DIABETES CARE OF MOTHER
BYHemant K Satpathy, MD, FACOGMFMMethodist Women HospitalOmaha, NE, USA
GDM
Pregestational
DM-1
DM-II
CLASSIFICATION
GDM
Gestational diabetes mellitus is a condition in which carbohydrate intolerance first recognized or diagnosed during pregnancy.
DEFINITION
Diabetes in pregnancy 6-9%
GDM 90%
INCIDENCE
{ {MATERNAL
PIH Polyhydramnios CD Shoulder dystocia PTD Operative delivery Diabetes Metabolic syndrome Cardiovascular disease
FETAL
IUFD
Macrosomia
Birth trauma
Hypoglycemia
Insulin resistance
Obesity
COMPLICATIONS
4/11/2018
2
In 2014, the U.S. Preventive Services Task Force made a recommendation to screen all preg-nant women for GDM at or beyond 24 weeks of gestation
DIAGNOSIS
Early pregnancy screening for undiagnosed type 2 diabetes, preferably at the initiation of prenatal care, is suggested in over- weight and obese women with additional diabetic risk factors, including those with a prior history of GDM
DIAGNOSIS
In women who have positive 50-g screening test results, but negative follow- up test results early in pregnancy, it is common to use the follow-up test at 24–28 weeks of gestation without repeating the 50-g screening test.
DIAGNOSIS
DIAGNOSIS
GDM diagnosed <20 weeks, counseling and management should be as for pregestational diabetes.
DIAGNOSIS
Two step GCT
100 g OGTT
One step 75 g OGTT
**No trial has evaluated the efficacy of any therapy based on these new values, and so the one step screening cannot be used yet for clinical care.
4/11/2018
3
in 2010, the International Association of Diabetes and Pregnancy Study Group (IADPSG) recommended that a universal 75-g, 2-hour OGTT be performed during pregnancy
In 2011, the ADA endorsed these criteria while acknowledging that adopting these cutoffs would significantly increase the prevalence of GDM
DIAGNOSIS
In 2013, a NICHD Consensus Development Conference on Diagnosing Gestational Diabetes recommended that obstetricians and obstetric care providers continue to use a two-step approach to screen for and diagnose GDM.
As of 2017, the ADA continues to recognize that there is an absence of clear evidence that supports the IADPSG-recommended approach versus the more traditional two-step screening approach
ACOG supports the two-step process
DIAGNOSIS
STEP ONE:
ACOG recommends choosing 135 mg/dL or 140 mg/dL as the cutoff.
More than 80% of women with values ≥200 mg/dL will fail the three-hour glucose tolerance test (GTT), so many use this cutoff as meeting the diagnosis of GDM
DIAGNOSIS
In the absence of clear comparative trials, one set of diagnostic criteria for the 3-hour OGTT cannot be clearly recommended over the other.
The Carpenter–Coustan stricter criteria increase by about 50% the number of women with a diagnosis of GDM compared to the NDDG criteria, and these pregnancies have elevated incidences of macrosomia and neonatal insulinemia
DIAGNOSIS
4/11/2018
4
Women who have even one abnormal value on the 100-g 3-hour OGTT have a significantly increased risk of adverse perinatal outcomes compared with women with no GDM.
DIAGNOSIS
ANTEPARTUM TREATMENT
4/11/2018
5
INSULIN
30% end up needing medications
Oral antidiabetic medications (e.g., metformin and glyburide) increasingly are being used among women with GDM, despite the fact that they have not been approved by the U.S. Food and Drug Administration for this indication and even though insulin continues to be the ADA-recommended first-line therapy.
ANTEPARTUM TREATMENT
4/11/2018
6
METFORMIN may be a reasonable second-line approach to
treat gestational diabetes after Insulin
Limitations of Metformin
-increased preterm birth
-placental transfer of the drug
-lack of long-term data in exposed offspring.
-between 26% and 46% of women who took metformin alone eventually required insulin
ANTEPARTUM TREATMENT
METFORMIN
Check baseline renal function
Starting dose 500 mg with meal
Maximum dose 3000 mg
Common side effects involve GI tract
In women whose total insulin dose is ≥1.12 IU/kg, the addition of metformin has been shown to improve glycemic control, decrease maternal hypoglycemia, reduce neonatal hypoglycemia and decrease NICU admission
ANTEPARTUM TREATMENT
METFORMIN
In women with polycystic ovary syndrome, metformin is often continued until the end of the first trimester, despite only limited evidence to suggest that such use decreases the risks of adverse pregnancy outcomes, including first-trimester loss
ANTEPARTUM TREATMENT
GLYBURIDE
This drug should NOT be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin or metformin
ANTEPARTUM TREATMENTGlibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis.
GLYBURIDE
Avoid in patients with sulfa allergy
Dose 2.5-20 mg/day
4-16% treatment failure
ANTEPARTUM TREATMENT
4/11/2018
7
ANTEPARTUM TESTING
Initiate at 32 weeks
Indicated for GDMA2 and pregestational DM
FETAL GROWTH US in late third trimester
ANTEPARTUM TREATMENT
Timing of delivery
GDMA1 39-41 weeks
GDMA2 39-39 6/7 weeks
Uncontrolled GDM/DM 34-39 weeks
ANTEPARTUM TREATMENT
CESAREAN FOR MACROSOMIA
it appears reasonable to recommend that women with GDM should be counseled regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 gm or more
INDUCTION FOR MACROSOMIA
ACOG does not recommend induction prior to 39 weeks for suspected fetal macrosomia.
ANTEPARTUM TREATMENT
PTL
Avoid beta-mimetic as tocolytic
Steroids for FLM up to 37 weeks
Wait 7 days prior to offering GCT
ANTEPARTUM TREATMENT
4/11/2018
8
Glucose monitoring in GDMA2 Q 4-6 hrs
Unlike in DM-I, Insulin gtt not necessary in most patients with GDM
Target intrapartum glucose 70-120 mg/dl
INTRAPARTUM CARE
SCHEDULED CESAREAN SECTIONS
Schedule in the morning
Only reduce the nighttime long acting Insulin dose by 50%
Hold Insulin or oral hypoglycemic in the morning
Avoid D5 bolus prior to regional block
1/3 dose of long/intermediate acting insulin given in the morning with D5 gtt if surgery scheduled in the afternoon
INTRAPARTUM CARE
Induction of labor
Schedule in morning
Use 50% of nighttime dose of long acting insulin
Light breakfast
Reduce morning insulin dose by 50%
INTRAPARTUM CARE
Encourage early breast feeding
Check FBS for 24-72 hours
Avoid BS >180 mg/dl
Don’t need insulin or oral hypoglycemic
75 g OGTT/FBS/A1C at 4-12 weeks postpartum visit
POSTPARTUM CARE
4/11/2018
9
Thanks