GESTATIONAL DIABETES : SCREENING AND MANAGEMENT Kyla O’Keefe RD CDE Diabetes Matters May 12, 2017

DISCLOSURES I have no disclosures

OUTLINE Screening

Process as recommended by CPGs Situations where early screening is recommended

Management of GDM Process for referrals on PEI

Postpartum screening

SCREENING Method of screening is controversial

Universal vs selective screening 1 step vs 2 step

Why screen? Generally an asymptomatic condition Studies have shown that treating hyperglycemia in

pregnancy reduces the risk of complications for both mother and baby (1)

SCREENING CDA recommends a 2 step approach

Universal screening done between 24-28 weeks gestation

1st step = 50 g oral glucose challenge test (OGCT) Blood glucose is checked at one hour post only Not a fasting test

2nd step = 75 g oral glucose tolerance test (OGTT) (1) Alternative 1 step approach can be used, however

CDA recommends the 2 step process as the preferred approach

(2)

If an early screen returns a normal result, screen should be repeated at

24-28 weeks gestation (75 g OGTT only) (2)

HYPERTENSION AS A RISK FACTOR One study has shown that women who have

hypertension within 5 years pre-pregnancy or diagnosed during the 1st trimester and at 2x the risk of developing GDM (3)

Not included as a risk factor in the 2013 CPGs

REFERRAL PROCESS If diagnosed with GDM, the patient should be an

early referral to the Obstetricians and referred to the Diabetes Program simultaneously to reduce delays in interventions

All women from Kings, Queens East and Queens West are seen at the Queens East office

All women from East and West Prince are seen at the East Prince office

MONITORING Both pre and post prandial monitoring are

recommended No consensus on whether to check 1 or 2 hour

post meal (1) Elevated post meal readings are related to an

increased incidence of high blood pressure in pregnancy (4)

SBGM is recommended at least 4 x/day (2) Fasting and 1 or 2 hours after each meal (1)

BLOOD GLUCOSE TARGETS IN PREGNANCY (1)

Fasting < 5.3 mmol/L 1 hour post meal < 7.8 mmol/L 2 hours post meal <6.7 mmol/L

MANAGEMENT

Healthy Eating Moderate carbohydrate restriction: 3 meals + 3

snacks (1) Most require reduced carbs at breakfast (5)

Avoid hypocaloric diet weight loss + ketosis (1) Physical Activity

Unless contraindicated (1) Targets not met within 2 weeks start insulin

(1)

ORAL AGENTS (1) Canadian Diabetes Association does not

recommend the routine use of oral antihyperglycemic agents in pregnancy

Metformin and glyburide can be considered for women who refuse insulin

The patient should be advised the use of oral agents is off label, if that is the method they choose

ORAL AGENTS – GLYBURIDE (1) Safe and effective in management of blood

glucose levels in > 80 % of patients with GDM

Does not cross the placenta Not as effective in:

Older women Women who were diagnosed early in pregnancy Women with higher blood sugars

ORAL AGENTS – METFORMIN (1) Crosses the placenta Less hypoglycemia in babies after delivery Increased risk of early delivery (< 37 weeks

gestation) Less weight gain and hypoglycemia compared to

glyburide Appears to be safe, however more research is

required

INSULIN (1) If blood glucose targets cannot be met within 2

weeks of initiating diet and exercise modifications, insulin should be started Approximately 20% of women with GDM will require

insulin (5) Use of insulin to meet glucose target decreases

fetal and maternal morbidity

INSULIN (1) The choice and timing of insulin would depend on

which blood glucose level were elevated Basal insulin would be used to target pre-meal

hyperglycemia (ie. NPH, determir, glargine) Bolus insulin would be used to target postprandial

hyperglycemia (ie. Aspart, lispro) Rapid is recommended over regular, although outcomes are

similar

Regular adjustment of doses is usually required to meet targets

POST PARTUM SCREENING 75 g OGTT recommended between 6 weeks to 6

months post partum to ensure BGs have returned to normal (1)

How are we doing? Chart audit completed over a 24 month period (Jan

2014- Dec 2015) Only 36.7 % of women had follow up OGTT (54 of

147) 63.3% had no evidence of postpartum OGTT

OF THOSE WHO HAD A POSTPARTUM SCREEN

11%

9%

13%

67%

Total # of OGTT results ordered = 54

% who had evidence of type 2

% who had evidence of prediabetes

% cancelled by the lab

% with normal glycemia

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THANK YOU FOR YOUR TIME!

REFERENCES 1. Canadian Diabetes Association Clinical Practice

Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada: Diabetes and pregnancy. Can J Diabetes. 2013;37:S168-183

2. Pregnancy and Diabetes Working Group. Pregnancy and diabetes guidelines: approaches to practice. 2014. Halifax, NS.

3. Hedderson MM, Ferrara A. High blood pressure before and during early pregnancy is associated with an increased risk of gestational diabetes mellitus. Diabetes care. 2008; 31 (12): 2362-2367.

4. WHO diagnostic criteria and Classification of Hyperglycemia First Detected in Pregnancy. 2013.

5. Jones H, Cleave B, Fredericks C, Gorecki K, Hamilton C, Opsteen C, et al. Building competency in diabetes education: the essentials. 3rd ed. 2013. Toronto, ON.