Diabetes, Dr Alka

8/11/2019 Diabetes, Dr Alka

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Diabetes Mellitus in

Pregnancy

Dr. Alka Kriplani

Professor, Head - Unit-II

Department of Obst. & Gynae.

All India Institute of edi!al "!ien!es

#e$ Del%i


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Gestational diabetes mellitus

+arbo%ydrate intoleran!e of *ariable se*erity

$it% onset or first re!onition durin

prenan!y

eardless of $%et%er insulin is used for

treatment or t%e !ondition persists after

prenan!y

Does not e)!lude unre!onied lu!oseintoleran!e before prenan!y


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Screening

%om to s!reen/

et%od of s!reenin/

0ime 1POG2 of s!reenin/

Ad*antaes and disad*antaes of

s!reenin and sele!ted met%od


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Whom to screen

A+OG and HO 3

uni*ersal s!reenin at 45-46 $eeks

%i% risk $omen- s!reenin at fist antenatal

*isit

ADA 147762- risk fa!tor analysis

-OG00 if indi!ated


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Risk factors for GDM Obesity 18477 lbs or 89:; of non prenant ideal body $ei%t2

Positi*e family %istory of diabetes 1siblin or parent2

Persistent ly!osuria

H


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Universal vs selectivescreening- Indian scenario

Pre*alen!e of GD- 9?.::; 1"es%ia% @ et al. Asso! P%ysians India 47752

of GD in Indians 99.> times !ompared to $%ite

$omen (Diabet Med 1992)Uni*ersal s!reenin

ore sensiti*e

BOH !omponent not a*ailable in nulliparousissin GD -ad*erse lon term effe!ts

Universal screening is preferred over selective

screening in India


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Glucose challenge test

world wide accepted50g glucose load regardless of meals

140mg/dl 130mg/dl

Sensitivity C; 7;

specificity 6C;

Need for GTT 95-96; 47-4:;

With 140mg/dl as cut-off-ood reprodu!ibility

If 9%r -957m


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Diagnosis of GDM

Glu!oseload0%res%olds 1m%r

AA

977

1+arp& +2

=: = 967 = 9:: = 957

C: = : = 967 = 9::

A!"G

#NG2

977 = 97: = 97 = 9?: = 95:

$%" C: = 94? = 957

COG, 2007


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ne ste! diagnosis of GDM

HO 3 C: OG00

useful in populations $it% %i% pre*alen!e of GD 1 India2

1J Obstet Gynecol India. 2005;55(6) 525!529)

Does not reuires :7 G+0

Glu!ose load Fastin

1m


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ne ste! diagnosis of GDMcontd"""

Ad*antaes o*er 977OG00

"inle step met%od

ore sensiti*e

+%eap n !on*enient for t%e patients

Does not need :7 G+0

Disad*antaes

O*er dianosis


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)MP'I)%$I&S

"(stetric

+onenital anomalies

"pontaneous abortion

Poly%ydroamnios

Preterm deli*ery

a!rosomia

Une)plained fetaldeat%

Pre-e!lampsia

IUG

0raumati! deli*ery

)edical

etinopat%y

#ep%ropat%y

Diabeti! keto-a!idosis

Hypertension

Hypoly!emia

#europat%y

Infe!tions


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Congenital anomalies+ardio*as!ular

0GA, @"D, A"D, +oar!. of aorta, situs in*ersus+#"A!rania, anen!ep%aly, #0Ds, mi!ro!ep%aly

"keletal system

Hemi*ertibra, +AUDA (G(""IO# "#DO(14:4times more !ommon2

enalenal aenesis, ureter dupli!ation, %ydronep%rosis

Gastrointestinal-duodenal atresia, imperforate anus

%(A1c levels vs ris* of anomalies?;- >;

9:;- 857;


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)acrosomiaE Birt% $t E +4'0 *g in dia(etic+4'5 *g in non,dia(etic

!omplications of macrosomia )aternal

in'uries to t%e birt% !anal

in!reased risk of "+" ->7;

(Jensen et al.Diabetes Med 20002 -etal

Intrapartum asp%y)ia birt% trauma 1e.. !la*i!ular fra!tures2

s%oulder dysto!ia

bra!%ial ple)us in'ury

fetal deat% 17.5;2

Macrosomia*'G%


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Pathogenesis -Pederson hy!othesis

J


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M%&%G#M#&$

DI#$#+#R)IS#I&SU'I& $,#R%P

. R%' ,PG')#MI)S


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Medical nutrition thera!y

Primary t%erapy for >737; of $omen dianosed$it% GD

92"tart $it% diet

onitorin E9-4 $eekly till >? $eeks

eekly after >? $eeks

42 .ercise- >-5 times $eekly for 47->7 min per session

>2 Blood sugar profile- FB" - post meals

ostprandial monitoring results in more improvedglycemic control in G)

(eciana ) * +ng , )ed 1"" !%%%#12&1-&%'


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)om!osition of diabetic diet

(uly!emi! diet- old !on!ept

*uch diet causes

excessi!e weight gainse!ere postprandial hyperglycemia

+urrent !on!ept- lo$ !arbo%ydrate diet

8maternal postprandialglucose,impro*ed maternal & fetal out!ome

(,ovanovic .lin stet necol 2000!4%(1'#4-'


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$arget glucose levels during!regnancy

Time enous plasmaglucose levels #mg/dl2

Fastin 1BBF2 ?7-7

Before lun!%, dinner ,bedtime sna!k

?7-97:

After meals14%2 947

4E77 to ?E77am 8?7

CG 2007


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$y!es of insulin0P( O#"(0 P(AK DUA0IO#

U0A-"HO0 A+0I#G

ispro, Aspart, Glulisine7-9:min >7-

7min5-:%rs

"HO0-A+0I#G

(GUA>7-5:min 4-5%rs ?-6%rs

I#0((DIA0( A+0I#G

#PH

ente

1semilenteLultralente2

9-4%rs

9-4.:%rs

5-97%rs

?-94%rs

96-45%r

47-45%r

O#G-A+0I#G Ultra-lente

Glarine

5- 6%rs

9%r

6-94%rs

none

>?%rs

45%rs


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Insulin thera!y

+al!ulate total dose1 4- intermediate a!tin 1isop%ane2 L 9

s%ort a!tin insulin1 a!trapid2

4 of t%e dose in mornin and 9 in e*eninornin-4 isop%aneL 9 a!trapid

(*enin -9


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Insulin thera!y- facts

)orning doseA(domen

#15,30min2

9unc : dinner

Arm

#30,45min2

7edtime doseTig

#45,;0min2

)aimum

rapid

:a(sorption

Slowa(sorption4 $eeks if IUG, PIH,

#ep%ropat%y,insulin re 8977U2Biop%ysi!alprofile

$eekly

52 Doppler in early dete!tion of


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$iming of deliveryPlan for indu!tion at >6.: $eek

If (F 85.:k- ele!ti*e "+" (*OG 200+)

((+0I@( "+"

Plan early mornin

Usual H" dose

#PO

ornin dose $it%%eld

Blood suar monitorin

"tart #"

:; de)trose if blood suar C7m


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'o5 dose insulin infusion for thediabetic 5oman during the

intra!artum !eriodBlood lu!ose

1m


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Post-!artum managementInsulin reuirement de!reases rapidly 1first 45-C4 %rs2aginal delivery

GD

on diet - no monitorin reuired

on insulin - fastin & PP *alues before dis!%are

Preestational D

"tartin reular diet

One %alf of t%e pre-prenan!y dose 1 PPD92

A!"G &005

9


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Post-!artum management

After cesarean deliveryBld suar monitorin 5-? %rly

eular insulin - if blood suar 8957 -9:7 m


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Post !artum glucose testing;,1& wee*s postpartum

=5g glucose testing

ia(etes

mellitus

mpaired

Glucosetolerance

-7G#>110mg/dl2

=C.7 mmol


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l , l i i


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ral ,y!oglycemic agents in!regnancy

)etformin

7iguanide @!ategory 7 drug

In prenan!y

"%ould it be !ontinued in P+O" patients after

prenan!y/

+an it be used for GD patients/

+an patients $it% type II D !an a!%ie*e ly!emi!!ontrol $it% metformin as insulin and lyburide/


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Metformin in P)S

Gilbert et al. systemi! re*ie$ and meta analysis0reatment $it% metfromin in first trimester $as

asso!iated $it% :C; prote!tion effe!t $it% an anomaly

rate of 9.C; in metformin roup and C.4; in !ontrol

roup.)etformin use not associated 6ith ma7or malformations

(*an J ,&a'acol 2005;12(1)125)

de!reases t%e in!iden!e of GD

(Gl-e *J /- e'od 200;19(3)510!2)

edu!es t%e in!iden!e of spontaneous abortions

( J *lin 4ndoc'inol Metabol 2002;8+52)

MiG t d 3M tf i i t ti l


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MiG study 3Metformin in gestationaldiabetes4

etformin p Insulin p

#o. of patients >?>

-4.?; re!*d metformin

-5?.>; re insulinPrimary out!ome-neonatal%ypoly!emia, prematurity,D", p%otot%erapy need, lo$apar s!ore

>4; >4.4;

"e!ondary out!ome-maternally!emi! !ontrol,%ypertensi*e !ompli!ations,postpartum lu!ose

toleran!e, ) a!!eptability

#o sinifi!ant differen!e bet$een 4roups

RCT7!" women with #DM$2%&& w'sP(#) ( 4n J Med 2008;3582003!2015)

C?.?; $omen preferred to take metformin

in ne)t prenan!y

Gl b id


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Glyburide

*econd generation sulphonylurea +,ategory .

/oes not cross placenta +fetal le!els 0)' of maternal le!els.

/ose 1 start with 2mg 3*4 #ax upto 2%mg5day

6,7- perinatal outcome similar to insulin

(Langer L N Eng J Med ;2000:343)(fficacy similar to insulin till F*0)8%mg5dl

,urrently not recommended by F/9

Rea*hing established levels of gly*emi* *ontrol and not themode of therapy is the 'ey to improve perinatal o+t*ome in

#DM

(Am J Obstet Gyne!"200#;$%2:$34&$3%)


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!ontraception Barrier met%ods- %i% failure rates

Intrauterine de*i!es- no in!reased risk of PID in all diabeti!s. +anbe used safely

(7os et al.Obstet Gynecol *lin o't& A 1996;2323!58)

+ombined O+PMs3

Use lo$est dose +O+

A*oid if %ypertension and ot%er !ardio*as!ular risk fa!torspresent

inipill3 impaired ly!emi! !ontrol

1 proesterone indu!ed %yperly!emia2

In'e!tables3 a*oided as t%ey !ause altered lipid profile, Glu!oseintoleran!e

Indi!ation - estroen !ontraindi!ated

- non !omplian!e 1 HO 92
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Diabetes, Dr Alka