Gestational Diabetes Mellitus: A Current Approachnutrition.utk.edu/wp-content/blogs.dir/118/files/... · GDM-carbohydrate intolerance of any degree ... Knoxville September 28, 2012

KendrickJ_Gestational Diabetes: A Current Approach. Promoting Healthy Weight Colloquium, University of Tennessee, Knoxville

September 28, 2012

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Gestational Diabetes Mellitus: A Current Approach

Jo’s Office

[email protected]

  GDM-carbohydrate intolerance of any degree with onset or diagnosis during pregnancy (ADA, 2012)   GDM A1-diet controlled   GDM A2-insulin requiring


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 GDM comprises 90% of all DM in pregnancy  Reported rates of GDM 5-14% of all pregnancies-true

incidence unknown due to lack of uniform diagnostic criteria  Five to 10% of women with GDM have undiagnosed type 2 DM  Women over the age of 20 comprise over half of individuals

with diabetes type 2 diabetes and only 25% know it  New diagnostic criteria for GDM will increase incidence to 18%

of all pregnancies   Increasing prevalence due to delayed childbearing and obesity

  Overweight increases risk factor (RF) by 2.1; obese increases RF

3.6; severely obese increases RF 8.6

NIDDK, NATIONAL DIABETES STATISTICS, 2011

Obesity 26%

Diabetes 9%


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Weekly food expenditure: $341.98

Food expenditure for one week: 387.85 Egyptian Pounds or $68.53


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PORTABLE PHONES

REMOTE CONTROLS


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How Food is Digested

1. Food enters stomach

5. Insulin unlocks receptors

4. Pancreas releases insulin

2. Food is converted into glucose

3. Glucose enters bloodstream

6. Glucose enters cell

  Anabolic Phase   enhanced insulin secretion due to estrogen,

progesterone mediated beta cell hyperplasia-hyperinsulinemia

  increased insulin sensitivity   exogenous insulin needs decreased   lipogenesis and fat deposition


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  Catabolic Phase   diabetogenic state   decreased insulin

sensitivity due to anti-insulin placental hormones

  Accelerated starvation-fat breakdown/lipolysis

  decreased acid buffering capacity

  increased risk for DKA   dramatically increased

insulin needs

  First prenatal visit—all or at risk   Fasting plasma glucose (FPG)->126 mg./

dL.   Hgb Aic-6.5%   Random Plasma Glucose (RPG)->200 mg./

dL.*   If FPG is 92-125, considered early GDM   If all of the above normal—then

administer 75 gram OGTT at 24-28 weeks

International Association of Diabetes and Pregnancy Study Groups (IADPSG, 2010). Diabetes Care, 33,#3, March 2010.

MEASURE OF GLYCEMIA THRESHOLD

Fasting Plasma Glucose (FPG)

> 126 mg./dL

A1c > 6.5%

Random plasma glucose (RPG)

> 200 mg./dL confirmed*

*Random plasma glucose must be confirmed by FPG or A1c

Accepted by ADA, 2010, Rejected by ACOG, 2011


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Timing Criteria mg./dL mmol/l Fasting plasma glucose

92 5.1

1 hr plasma glucose

180 10.0

2 hr plasma glucose

153 8.5

*One abnormal values constitutes GDM Accepted by ADA, 2010, Rejected by ACOG, 2011

  Low risk does not require screening   Age < 25 years   Pre-pregnancy weight normal (BMI of 25 or less)   No known diabetes in first degree relatives   Not a member of high risk racial-ethnic group ▪  Hispanic ▪  African American ▪  Native American ▪  Asian

  No history of abnormal glucose tolerance   No history of poor obstetric outcome

American Diabetes Association; 2008

  Requires testing between 24-28 weeks   Abnormal pre-pregnancy weight   High risk racial ethnic heritage   Family history of type 2 diabetes in first

degree relative   History of abnormal glucose tolerance test   History of poor obstetric outcome   History of fetal macrosomia (>4000 grams)



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  Requires testing as soon as pregnancy confirmed:   Severe obesity   Prior history of GDM or delivery of a

large-for gestational age infant   Presence of glycosuria   Diagnosis of polycystic ovarian syndrome   Strong family history of type 2 diabetes


  50 gram 1 hour oral glucose challenge test (GCT)   Positive at 130 mg./dL ( non fasting)*** ▪  Requires step #2---3 hour OGTT ▪  Requires 25% of women to have OGTT

  Positive at 140 mg./dL (fasting) *** ▪  Requires 15% to have OGTT but will miss 10%

  Diagnostic at 200 mg./dL.

***Berkus, Stern, Mitchell et al. Does fasting interval affect the glucose challenge test? Am J Obstet Gynecol 1990;163: 1282.

  Diagnostic 3 hour oral glucose tolerance test 100 gm(OGTT) for high risk population or 75 gram OGTT

  Plasma fasting prior to ingestion   Diagnostic for GDM at 120 mg./dL.

  Testing should be performed after an overnight

fast with no smoking or activity during test.

  Diet prior to fast should be unrestricted (150 gms. CHO) for 3 days


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Organization Test type Diagnostic threshold

ACOG (2011) 100 gm 3 h. OGTT 75 gm

National Diabetes Data Group (NDDG) F: >105 1 hr >195, 2 hr.>165 3 hr>145 Carpenter & Coustan F.>95, 1 hr> 180, 2 hr.>155, 3 hr.>140 F> 95, 1 hr>180, 2 hr.>155

WHO (2010): ADA 2010

75 gm OGTT F: >92, 1 hr>180, 2hr >153

Mullholland, Njorge, Mersereau & Williams, 2007. Comparison of guidelines available in the US for diagnosis and management of diabetes Before, during and after pregnancy. Journal of Women’s Health, 16,790-801.

DIABETES

DIABETES

DIABETES

DIABETES

  Women with risk factors with normal 3 h OGTT may benefit from repeat testing at 32 weeks1

  Macrosomia associated with one abnormal value2

  consider nutrition intervention and repeat OGTT 4 weeks later

1. Neiger, Coustan.(1991) The role of repeat glucose tolerance tests in the diagnosis of GDM. Am J Obstet Gynecol,165:787-790.

2.  Lindsay, MK., Graves, Klein. (1989). The relationship of one abnormal glucose tolerance test value and pregnancy complications. Obstet Gynecol, 73; 103-6.


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  Total of 25,505 women in 15 centers in nine countries

  Took 9 years and 20 million dollars

  75 gm OGTT between 24-32 weeks

  Blinded to women with FPG < 105 and 1 or 2 hour PG <200 mg./dL.

  Analysis based on assigned glucose category The HAPO Study cooperative Research Group (2008). Hyperglycemia and adversePregnancy outcome. NEJM 358 (19); 1991-2002.

Category Fasting Glucose 1 hr. Glucose 2 hr. Glucose

1 <75 <105 <90

2 75-79 106-132 91-108

3 80-84 133-155 109-125

4 85-89 156-171 126-139

5 90-94 172-193 140-157

6 95-99 194-211 158-177

7 100 or more 212 or more 178 or more

  Directly proportional change in outcomes to maternal glucose

  Adjusted for confounders of maternal BMI, previous macrosomia and previous GDM

  Outcome measures   Birth weight   Umbilical cord c-peptide (chosen due to stability in

frozen sample)   Incidence of cesarean delivery   Incidence of neonatal hypoglycemia


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  Secondary outcome measures with positive associations(related to 1 and 2 hr. glucose but not fasting)   Preeclampsia   Shoulder dystocia or birth injury   Premature delivery   Intensive neonatal care   hyperbilirubinemia

The HAPO Study Cooperative Research Group. N Engl J Med 2008;358:1991-2002

  Evaluated the HAPO results and published their recommendations for screening and diagnosis of hyperglycemia in pregnancy in Diabetes Care 2010;33: 676-682


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  International consensus recommendation for the screening and diagnosis of gestational diabetes   75 gram OGTT, one abnormal value   Thresholds: FBS: 92 (8.3%) OR 1 hr.: 180

(5.7%) OR 2 hr: 153 (2.1%) Total: 17.8%   Odds ratio of 1.75 FOR PRIMARY

OUTCOMES

  Prevalence of GDM will be increased to 17.8 % which more closely reflects the incidence of T2dm/pre dm

  Cost/benefit analysis not obtained

  Requires the availability of dietitians, diabetes educators and staff for increased surveillance of these pregnancies

  Additional costs associated with therapy   Number of inductions will be increased and

risk for CS

  Requires fasting and morning appt.

  Overt DM can be detected and treated and vascular disease assessment obtained during pregnancy, allows postpartum referral, negating need for further testing

  Will allow a global data base and true epidemiology and prevalence determined

  Treating lower glycemic thresholds may reduce risks for metabolic syndrome/T2DM later

  Treating lower thresholds should reduce the risk of adverse outcomes


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  Japan   Parts of India   Germany (with modifications)   China (with modifications)   Italy   Brazil (with modifications)

  The American Diabetes Association   WHO has reviewed HAPO data and other data and will

publish revised guidelines soon.   NIH will hold a consensus conference October 29-31,

2012 and will make independent recommendations that may or may not be the same as IADPSG.

(Boyd Metzger, 2012)

  Pre eclampsia/eclampsia   HTN and worsening of HTN   Urinary tract infections   Polyhydramnios   Preterm labor/birth   Spontaneous abortion   Cesarean section   Operative delivery

Managing Preexisting Diabetes and Pregnancy, 2008

complication incidence cause Hypoglycemia Hypocalcemia Hypomagnesemia Polycythemia Cardiomyopathy Hyperbilirubinemia Respiratory Distress Syndrome (RDS) Stillbirth

10-25% 50% 33% 5-6% <1% 20-40% 2-6% 2.5-4%

Excessive neonatal insulin secretion Transient hypoparathyroidism Often secondary to hypocalcemia Intrauterine hypoxia Anabolic effect of hyperinsulinemia Increased hemolysis, ineffective erythropoiesis Decreased surfactant production with hyperinsulinemia Polyhydramnios, chronic fetal hypoxia or acidemia

Fraser RA, 2010; Ogata ES, 2008;Hawson JM, 2010;Girling J, 2010


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  Cesarean birth   Excessive blood loss   Infection   Wound breakdown

  Macrosomia   HTN   GDM   Fetal death   Birth defects-NTD   Longer hospital

stays   Miscarriage

  Inability to monitor fetus

  Difficult epidural or spinal anesthesia

  Higher NICU admissions

  Increased deep veinthrombosis

  n=323, 1 hr. <130 PP, predicted 28% macrosomia (Institute control prior to 32 weeks) (DIEP, J Obstet Gynecol,164:1991)

  1 hr. PP decreases risk of macrosomia from 42% preprandial to 12% (DeVenciana et al. N Engl J Med. 333:1995)

  1 hr PP BG< 120 mg./dL eliminates macrosomia (Combs et al. Diabetes Care, 15; 1992)

  1 hr. PP BG < 120 decreases risk of neonatal hypocalcemia (Demarini et al. Obstet Gynecol. 823; 1994)

  Mean PP BG of <105 significantly correlated to abd. circumference (Paretti et al. Diabetes Care 24;2001)

  Significant reduction in LGA and emergent CS in 1 hr. PP testing and pt. preference (Moses et al. Aust NZ J Obstet. Gynecol, 39; 1999)


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Organization Capillary Blood Glucose (mg./dL)

ADA, 2010 Fasting 60-99 Peak Postprandial 1 h 100-129 Mean Daily BG <110 A1c <6.0%

AACE (2007) Fasting 60-90 Peak Postprandial 1 hr <120 Initiate Insulin >90 >120 post meals A1c <6.0%

ACOG, 2005 Fasting <95 Premeal <100 Postprandial 1 hr. <140 Postprandial 2 hr. <120 Mean Daily BG 100 A1c <6.0%


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  Individualized meal plan based on BMI, height , weight and gestational age

  Consider cultural, ethnic, religious influences, schedule and finances

  Carbohydrate content divided between meals and snacks   175 grams CHO, 28 gms fiber, 1.1 gm/kg/day

protein (Reader, DM, 2008)   Non-nutritive sweeteners approved by FDA in

pregnancy   Saccharin, aspartame (except in PKU), acesulfame K,

sucralose neotame-not always recommended   Monitor weight gain and loss and tolerance of therapy

  Prenatal vitamin with DHA

  Calcium 1500 mg/day, folic acid 600mcg/day (dietary or supplements)

  Avoid alcohol/smoking

  Limit caffeine to 300mg/d, artificial sweeteners 1-2 portions/day

  Avoid fish potentially high in mercury

  Increase calories after 1st trimester by300kcal/day

Reader, Managing Preexisting Diabetes and Pregnancy, 2008

BMI IOM, 2009 Kiel et al, 2007

Cedergren, 2007

<18.6 28-40 lbs 9-22 lbs

18.6-24.9 25-35 lbs 5 to 22 lbs

>25-29 15-25 lbs <20 lbs

>30 11-20 lbs No more than 13 lbs

30-35 10-15 lbs

>35 0-9 lbs

>40 0-9 lbs wt. loss


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  May decrease maternal glucose levels decreasing need for insulin or amount of insulin required

  Planned physical activity of 30 minutes daily unless contraindicated, well hydrated with HR less than 150 bpm

  Arm exercise in GDM while seated for 10 minutes postmeal reduces BG

  May decrease stress and anxiety Summary and Recommendations of Fifth International Workshop

Conference on GDM (2008)

  Pregnancy Considerations   Risks of moderate-intensity activity done by healthy

pregnant women very low   Risks for low birth weight, preterm birth or early pregnancy

loss not increased   May reduce risk of pregnancy complications; preeclampsia

and gestational diabetes

  Key Guidelines   150 minutes (2 hrs./30 minutes) of moderate intensity

aerobic activity per week for women who are NOT already highly active

  Pregnant women who habitually engage in vigorous-intensity aerobic activity may continue

www.health.gov/paguidelines

  Avoid doing exercise lying on back after the first trimester

  Avoid activities that increase the risk of falling or abdominal trauma   Contact or collision sports   Horseback riding, downhill

skiing, soccer, basketball


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CONTRAINDICATIONS WARNINGS TO DISCONTINUE

  Significant heart or lung dz.

  Incompetent cervix   Persistent bleeding   Preterm labor (PTL)   Multiple gestation-PTL   Ruptured membranes   Pregnancy induced

hypertension

  Vaginal bleeding   Dyspnea   Headache   Chest pain   Decreased fetal

movement   Amniotic fluid leaking   Muscle weakness   Preterm labor   Calf pain or swelling

Day Events Monday (1) Ini3al visit, inser3on of the Con3nuous Glucose Monitoring

System (CGMS), and pedometer placement.

Tuesday (2) Fixed carbohydrate meal for lunch, 30 minutes res3ng, and either 30 minutes of walking on the treadmill or 30 minutes of TV.

Wednesday (3) No visit.

Thursday (4) Fixed carbohydrate meal for lunch, 30 minutes res3ng, and either 30 minutes of walking on the treadmill or 30 minutes of TV.

Friday (5) Final visit and removal of the CGMS

Dawn P. Coe1, Jo M. Kendrick2, Bobby Howard2, David R. Bassett Jr.1, FACSM, Dixie L. Thompson1, FACSM, Scott A. Conger1, and Jennifer D. White1

80 85 90 95

100 105 110 115 120 125 130

Pre-Tr

eatm

ent

Post-

Treatm

ent

2 Hou

rs

3 Hou

rs

4 Hou

rs

5 Hou

rs

6 Hou

rs

Glu

cose

Lev

els

(mg/

dL)

Postprandial Glucose Levels

Walk

Sedentary

Results

Figure 1. Postprandial glucose levels following walking and sedentary condi9ons

*

**

*p<0.001 **p<0.05


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Pharmacologic Intervention

  Insulin only FDA approved treatment for diabetes in pregnancy

  Glyburide-second generation sulfonylurea   Insulin secretagogue   Onset of action 4 hrs lasting 10 hrs.   Low placental transfer

  Metformin-biguanide

  Decreases hepatic conversion of glycogen to glucose   Improves peripheral insulin sensitivity   Crosses placenta freely


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  Lispro/Aspart, Humulin/Novolin N, Detemir category B

  Glargine category C

  Algorithm based on weight

  Preconception 0.6U/kg/day   First Trimester (6w) 0.7U/kg/day   Second Trimester(16w) 0.8U/kg/day   Third Trimester(26w) 0.9U/kg/day   >150%ideal 1.5 to 2U/kg

  Basal (50%) and bolus insulin (50%), evaluate BG

Adapted from Jovanovic and Peterson,1982.

  Evaluate blood glucose every 1 to 2 weeks based on glycemic control

  Serial ultrasound to assess growth after 26-28 weeks

  Fetal kick counts at 28 weeks

  Begin weekly to twice weekly fetal testing by electronic fetal monitor or ultrasound based on any co-morbidities and level of glycemic control

  Deliver at 39 to 40 weeks


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  Macrosomia (>90percentile)   > 4000 gms. (8# 13 oz)   incidence-1.4--9% with good

control, 25-42% without normoglycemia (Langer,2004)

  Organomegaly-heart, liver   Fetal echo r/o hypertrophy with

impaired cardiac function which is associated with fetal death (Leslie 82: Sardesai 01)

  excessive fat deposition (shoulders & trunk)

  birth trauma-shoulder dystocia, fractured clavicles, brachial plexus injury, asphyxia, and other injuries

  intrauterine growth restriction (IUGR)   < 10th percentile carries

significant risk for neonatal death (Boulet 06)

  incidence 20 %

  associated with vasculopathy, HTN, placental insufficiency, decreased renal function, smoking

LONG TERM RISKS RISK REDUCTION

  Obesity   Insulin resistance   Glucose intolerance   T2dm   GDM (females)   HTN   Other types of

cardiovascular disease

  Parents should be educated regarding long term risks

  Encourage breast feeding   Encourage healthy diets

and active lifestyle   Providers should monitor

growth and development of children


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  Consider 39-40 week delivery-well controlled, no comorbidities—earlier with amnio for FLM with worsening vascular disease, poor glycemic control, macrosomia

  Continuous fetal heart rate monitoring

  Maintain normoglycemia (70-100 mg./dL) to minimize risk of neonatal hypoglycemia   Maternal bedside BG monitoring every 1-2 hrs   Continuous infusion of insulin/and/or glucose as

indicated   May use basal rate on insulin pump and bolus as

indicated

Conway & Catalano, 2008

  Insulin resistance dramatically improves immediately after birth   GDM resolves   Insulin/oral medications require dosage decrease of 50% in

women with prepregnancy diabetes

  Breast feeding   Requires 500 additional calories   Not all oral medications are safe   Decreases insulin requirements in type 1 and 2 diabetes   Decreases risk of development of type 2 diabetes and obesity in

offspring (Dabelea, 2007; Schaefer-Graf et al, 2006)   Decreases risk of transmission of type 1 diabetes (Virtanen &

Knip, 2003)


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  EDUCATION   Risk of GDM subsequent pregnancy-30-84% (Kim, Berger &

Chamany, 2007)   Lifetime risk of overt diabetes 50-60% (AACE, 2007; Kjos, 2007)   Lifestyle modifications and metformin decreases the risk of

development of type 2 diabetes (Ratner et al, Diabetes Prevention Research Group, 2008)

  Test every 1 to 3 years and prior to subsequent pregnancy (ADA, 2012)

  Preconceptual counseling

  75 gram 2 hr. glucose tolerance test   36% obtain f/u testing   32% of physicians order 75 gm   Providing written requisition increases testing frequency (Kim,

2007)

Normoglycemia IFG and IGT Diabetes Mellitus FPG <100 FPG between 100-125

mg./dL FPG> 126 mg./dL

2 hr plasma glucose <140

2 hr. plasma glucose 140-199 mg./dL

2 hr. plasma glucose > 200 mg./dL Symptoms of diabetes mellitus and casual plasma glucose >200 mg./dL

Diagnosis must be confirmed on a subsequent day of any of the three methods in the absence of unequivocal hyperglycemia.

Documents

Gestational Diabetes Mellitus: A Current Approachnutrition.utk.edu/wp-content/blogs.dir/118/files/... · GDM-carbohydrate intolerance of any degree ... Knoxville September 28, 2012