gestational diabetes mellitusmed.mui.ac.ir/sites/default/files/users/zanan/1_41.pdf · a week later...
TRANSCRIPT
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Gestational Diabetes MellitusMellitus
Dr Zarean
Dr valian
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Case 1
• 26yG2Ab1
• PMH: neg
• Pregestational weight:57kg and BMI:23.7 kg.m2
• OGTT with 75g of glucose in 25 weeks was performed:
• FBS:95mg/dl• FBS:95mg/dl
• 1h:117mg/dl
• 2h:95mg/dl
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• In application of IADPSGc, her diagnosis was GDM.
• Instruction:
Self monitoring of blood glucose (SMBG) in our GDM unit
Nutritional and lifestyle recommendationsNutritional and lifestyle recommendations
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A week later
• Fasting and pre-dinner capillary blood glucose levels were found to exceed 95 mg/dl (5.3 mmol/L) in 4 out of 5 times
• Basal insulin (insulin NPH) was initiated in her 26th week of gestation
• Was titrated weekly to 6 IU at 29 gestational weeks
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At 32 weeks
• capillary blood glucose levels were >140 mg/dl (7.8 mmol/L) 1 hour following breakfast and lunch, reaching levels up to 165 mg/dl (9.2 mmol/L),
• Insulin novorapid was initiated before both meals
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At week 34
• Was receiving 6 IU of NPH insulin, 2 IU of novorapid insulin before breakfast and 4 IU before lunch
• Doses were maintained until week 39
• At 38 weeks her BW was 75 Kg and her BMI 32 Kg.m-2
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• At week 40+3 days, following vaginal delivery, a male nenonate was born:
• Apgar score of 9 and 10 at 1/5 minutes• Apgar score of 9 and 10 at 1/5 minutes
• Umbilical artery pH 7.32
• Birth weight of 3,200 g
• No other medical complications were recorded.
• Three months after delivery: The patient’s body weight lowered to 58 kg and presented a normal 75 g OGTT on diet alone.
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Case2
• 26yG1
• PMH: hypothyroidism five years before pregnancy
• DH: levothyroxine
• FBS: 94mg/dl
• OGTT with 75g glucose was not performed• OGTT with 75g glucose was not performed
• HbA1C:6%
• Patient went to another hospital, where CCc were applied, and GDM ruled out
• Received no instructions regarding lifestyle and nutrition for GDM
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• Patient continued her obstetrical follow-up at our hospital
• The 32 week fetal ultrasound showed:
A single cephalic male fetus
BPD : 86 mm
HC: 308 mm
AC: 300 mm
FL: 64 mm
Weight estimation was 2300 g (percentile 98)
Was considered (LGA)
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At week 34
• Ultrasound examination revealed:
A single cephalic fetus
BPD: 90mm
AC: 356 mm
FL: 71 mmFL: 71 mm
Weight estimation was 3498 g. (percentile 100)
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• Pregestational BW was 74 kg and BMI 29.6 Kg.m-2, increasing to 89 Kg at week 34.
• She was instructed with nutritional and lifestyle recommendations.
• Three days later, her capillary blood glucose levels:• Three days later, her capillary blood glucose levels:
• Fasting, was found to exceed 105 mg/dl (5.83 mmol/l), with normal 1 hour postprandial values.
• The patient was started on insulin NPH, 6 IU, and her capillary glucose levels met target levels 2 days later.
• Her capillary glucose levels remained on target
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Week 39+6 days
• Had a vaginal delivery with episiotomy.
• A male son was born
• Weighing 4,040 g
• With apgar scores of 9/10 at 1/5 minutes
• Umbilical artery pH 7.33. • Umbilical artery pH 7.33.
• There were no post-partum complications
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SCREENING AND DIAGNOSTIC TESTING
• Two-step approach –most widely used approach:
• The first step is a 50-gram one-hour glucose challenge test (GCT).
• Screen-positive patients go on to the second step: 100-gram, three-hour oral glucose tolerance test (GTT)> diagnostic test for GDM
• One-step approach –only a 75-gram, two-hour oral GTT.• One-step approach –only a 75-gram, two-hour oral GTT.
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50-gram one-hour glucose screenGCT or GLT
• A 50-gram oral glucose load is given without regard to the time elapsed since the last meal and plasma glucose is measured one hour later
• Positive screen: ≥130 mg/dL, ≥135 mg/dL, or ≥140mg/dL (7.2 mmol/L, 7.5 mmol/L, or 7.8 mmol/L).
• Women with 50-gram one-hour glucose results ≥200 mg/dL (11.1 mmol/L),= diagnosis of gestational diabetes mellitus
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75-gram two-hour glucose screen
• If a 75-gram two-hour GTT is planned and the fasting glucose level is ≥92 mg/dL (5.1 mmol/L), then the diagnosis of gestational diabetes mellitus is made and the GTT is cancelled
• The 75-gram two-hour oral GTT is more convenient, better tolerated, • The 75-gram two-hour oral GTT is more convenient, better tolerated, and more sensitive
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RECOMMENDATIONS OF NATIONAL AND INTERNATIONALORGANIZATIONS FOR SCREENING AND DIAGNOSIS OF DIABETES IN PREGNANCY
• ACOG > two-step approach
• International Association of Diabetes and Pregnancy Study Groups (IADPSG) > one-step approach
• American Diabetes Association (ADA)> one-step or two-step approachapproach
• WHO > one-step approach
• Canadian Diabetes Association (CDA) > two-step [preferred] or one-step approach
• The Endocrine Society (one-step approach)
• Australasian Diabetes in Pregnancy Society (WHO approach)
• International Federation of Gynecology and Obstetrics (FIGO) > (one-step approach)
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Approach
• Performs testing for overt diabetes at the initial prenatal visit in patients with risk factors by checking A1C
• Diagnosis of overt diabetes is made when A1C is ≥6.5 percent
• Early in pregnancy> ADA criteria for diagnosis of overt diabetes
• ACOG criteria & (IADPSG)/ADA criteria for diagnosis of gestational • ACOG criteria & (IADPSG)/ADA criteria for diagnosis of gestational diabetes mellitus at 24 to 28
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Managment
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Hyperglycemia and Adverse Pregnancy Outcome
• Continuous relationship between maternal glucose and adverse outcomes:
• FBS: 100 to 105 mg/dL (5.6 to 5.8 mmol/L) associated with a risk of macrosomia
• Overly tight metabolic control in gestational diabetes (ie,average• Overly tight metabolic control in gestational diabetes (ie,averageblood glucose levels ≤86 mg/dL) can result in an increase in SGA
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EXERCISE
• Both fasting and postprandial blood glucose concentrations can be reduced
• Need for insulin may be obviated
• ADA encourages a program of moderate exercise as part of the treatment plantreatment plan
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Gestational Diabetes Mellitus and Frequency of BloodGlucose Monitoring: A Randomized Controlled Trial• Mendez-Figueroa H, Schuster M, Maggio L, et al.
• Obstet Gynecol 2017; 130:163.
• Testing blood glucose every other day versus four times daily resulted in similar birth weights and frequency of macrosomia
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One hour postprandial monitoring was associated with the following benefits ascompared with preprandial monitoring:
• Better glycemic control
• A lower incidence of LGA• A lower incidence of LGA
• A lower rate of cesarean delivery for CPD
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Glucose target
• ADA and ACOG glucose targets are:
• FBS :
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• Uptodate: oral antihyperglycemic agents are a reasonable alternative
• ACOG and ADA: prefer use of insulin but have endorsed the use of oral antihyperglycemic agents (metformin or glyburide) in certain circumstances
• ACOG: recommends metformin over glyburide as the preferred oral
PHARMACOLOGIC THERAPY
• ACOG: recommends metformin over glyburide as the preferred oral antihyperglycemic agent
• FDA: such therapy has not been specifically approved
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Oral anti-diabetic pharmacological therapies for the treatment ofwomen with gestational diabetes
• Brown J. et al
• Glyburide was compared with metformin in a 2017 Cochrane Database Syst Revsystematic review
• Clinically important pregnancy outcomes are generally similarClinically important pregnancy outcomes are generally similar
• Metformin use resulted in:
Lower mean birth weight
Less gestational weight gain
Less composite neonatal death or serious morbidity.
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Type of insulin
• Only lispro and aspart have been investigated in pregnancy and are comparable in immunogenicity to human regular insulin
• Detemir or glargine appear to be safe for use in pregnancy
• We prefer use of human NPH insulin
• 0.7 to 2 units per kg (present pregnant weight) to achieve glucose • 0.7 to 2 units per kg (present pregnant weight) to achieve glucose control
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Follow-up and prevention of type 2 diabetes
• Oral GTT 4 to 12 weeks after delivery, using the two-hour 75 g
• FBS
• Diabetes is diagnosed if:
FBS≥126 mg/dL (7.0 mmol/L)
Two-hour glucose is ≥200 mg/dL (11.1 mmol/L)Two-hour glucose is ≥200 mg/dL (11.1 mmol/L)
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Prevention of diabetes in women with a history ofgestational diabetes: effects of metforminand lifestyle interventions
• Ratner RE, Christophi CA, Metzger BE, et al.
• J Clin Endocrinol Metab 2008
• Intensive lifestyle and metformin therapy reduced the incidence of future diabetes by approximately 50 percent compared with placebo
• Metformin was much more effective than lifestyle intervention• Metformin was much more effective than lifestyle intervention
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Follow-up laboratory testing
• At a minimum of every three years
• More frequent screening (every one or two years) may also be indicated in:
women with other risk factors for diabetes
women who may become pregnant againwomen who may become pregnant again
• Two-hour 75 g oral GTT is the more sensitive test for diagnosis of diabetes and impaired glucose tolerance in most populations
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Assesment of fetal growth
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Estimators of birth weight in pregnant women requiring insulin: acomparison of seven sonographic models
• McLaren RA, Puckett JL, Chauhan SPAm
• Obstet Gynecol 1995; 85:565
• One review of pregnant women with diabetes treated with insulin found that the sonographically estimated fetal weight had to be ≥4800 grams for there to be at least a 50 percent chance the infant's ≥4800 grams for there to be at least a 50 percent chance the infant's birthweight would be ≥4500 grams
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Timing of deliveryTiming of delivery
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A2 GDM
• GDM whose glucose levels are medically managed with insulin or oral agents
• Induction of labor at 39 weeks of gestation
• Induction of labor prior to 39 weeks of gestation:
If a concomitant medical condition (eg, hypertension) is present If a concomitant medical condition (eg, hypertension) is present
glycemic control is suboptimal
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ACOG suggests:
• Women with GDM well controlled with medication:
• Delivery at 39+0 to 39+6 weeks
• Women with poor glycemic control:
• Delivery at 37+0 to 38+6 weeks of gestation may be reasonable
• Delivery prior to 37+0 weeks should only be done when more aggressive eforts to control blood sugars, such as hospitalization, have failed.
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Labor and delivery
• Women with GDM who were euglycemic without use of insulin or oral antihyperglycemic drugs during pregnancy:
Do not normally require insulin during labor and delivery
Do not need their blood glucose levels checked hourly
• Women with GDM who used insulin or oral antihyperglycemic drugs • Women with GDM who used insulin or oral antihyperglycemic drugs to maintain euglycemia:
Occasionally need insulin during labor and delivery to maintain euglycemia
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Checking blood glucose measurements
• The Endocrine Society:
Suggests target glucose levels of 72 to 126 mg/dL (4.0 to 7.0 mmol/L)
Check blood glucose measurements every two hours during labor
Begin intravenous insulin at glucose levels above 120 mg/dL (6.7 Begin intravenous insulin at glucose levels above 120 mg/dL (6.7 mmol/L)
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POSTPARTUM MANAGEMENT AND FOLLOW-UP
• Check glucose concentrations for 24 to 72 hours after delivery
• If FBS suggest overt diabetes (FBS ≥126 mg/dL [7 mmol/L] or random glu ≥200 mg/dL [11.1 mmol/L]), treatment is warranted
• Women who have FBS< 126 mg/dL (7mmol/L) after delivery should have a two-hour 75-gram OGTT 6 to 12 weeks postpartumhave a two-hour 75-gram OGTT 6 to 12 weeks postpartum
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Lactation and Progression to Type 2 Diabetes Mellitus AfterGestational Diabetes Mellitus: A Prospective Cohort Study
• Gunderson EP, Hurston SR, Ning X, et al.
• Ann Intern Med 2015; 163:889
• Breastfeeding decreased the incidence of diabetes two years after a diagnosis of gestational diabetes mellitus compared with not breastfeedingbreastfeeding
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• Thank you for your attention