GDM Training Madhya Pradesh 12 April 2016 Presentation title Date 1 Dr Sachin Chittawar DM Endocrinology Diabetes a public health crisis Diabetes and maternal health and pregnancy ID: 525824
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Slide1
Gestational Diabetes Mellitus(GDM)
Training, Madhya Pradesh 1-2 April, 2016
Presentation title
Date
1
Dr
Sachin
Chittawar
DM (Endocrinology)Slide2
Diabetes – a public health crisis
Diabetes and maternal health and pregnancy
Gestational diabetes and pregnancy outcomes
National guidelines for diagnosis and management of GDM
Testing for GDM
Management of GDM
Agenda
Presentation title
Date
2Slide3
Presentation title
Date
3
Diabetes
a public health crisisSlide4
Globally diabetes has reached pandemic status
Presentation titleDate
4
415 million
people have diabetes
1
As of 2015
318 million
people have
prediabetes
*,
1* Prediabetes is the number of people estimated to have impaired glucose tolerance, a precursor to developing type 2 diabetesSource: IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015 Slide5
Numbers are also rapidly increasing in India
Presentation title
Date
5
Number of adults (20–79) with diabetes in India
2009
1
2015
2
2040
2
124 millionpeople
69 million
people
51
million
people
IDF Diabetes Atlas, 4th
edn
.
Brussels, Belgium: International Diabetes Federation, 2009
IDF
Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015
36 million
people are undiagnosed
(52%)
2Slide6
Diabetes is associated with serious complications
Presentation titleDate
6
Consistently high blood glucose levels can lead to serious disease affecting the heart and blood vessels, eyes, kidneys and nerves
STROKE
Strokes are up to
four times as likely
BLINDNESS
Diabetes
is a
leading cause
of blindness HEART ATTACK Heart attack is three times as likely KIDNEY FAILURE
Total
kidney
failure is three times as likely
AMPUTATION
Diabetes
is a
leading cause
of non-traumatic lower-limb amputations
Source:
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015 Slide7
The costs to society are high
Presentation titleDate
7
Healthcare costs for people with diabetes are two-
to three-fold higher than for people without diabetes and the costs are increasing
IDF
Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015
IDF
Diabetes Atlas, 4th edn. Brussels, Belgium: International Diabetes Federation, 2009 IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013 * Estimated global diabetes-related healthcare expenditure1
12% of global healthcare expenditure was for diabetes in 2015
Global diabetes healthcare expenditure has increased 79%
since 2009
79%
increase
*
$6.5 billion
in India
2Slide8
Presentation title
Date
8
What does diabetes
have to do with maternal health and pregnancy?Slide9
Hyperglycaemia in pregnancy canbe classified as:
Presentation title
Date
9
Diabetes in Pregnancy (DIP)
Gestational Diabetes (GDM)
Diabetes detected prior to pregnancy
(Type 1 and Type 2)
Diabetes first detected in pregnancy
(Type 1 and Type 2)
Diabetes continues post delivery
Pregnant women who have never had diabetes but who have high blood glucose levels during pregnancy
Transient and disappears after birth
Source:
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation,
2015
Hod
M,
Kapur
A, Sacks DA, et al. The International Federation of
Gynecology
and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care.
International Journal of
Gynecology
and Obstetrics: the official organ of the International Federation of
Gynecology
and Obstetrics.
2015;131:S173.
Slide10
Gestational diabetes is the most common cause of
hyperglycaemia in pregnancy1
Gestational Diabetes
March 2016
10
International Diabetes Federation. IDF Diabetes Atlas, 7th edn
.
Brussels, Belgium: International Diabetes Federation, 2015.
Feig
DS,
Corcoy R, Jensen DM, et al. Diabetes in pregnancy outcomes: A systematic review and proposed codification of definitions. Diabetes/metabolism research and reviews. 2015;31(7):680–690.15% of casesDiabetes in pregnancy2DIP maybe either pre-existing diabetes (type 1 or type 2) antedating pregnancy, or diabetes first detected during pregnancy
85% of cases
Gestational diabetes2
Glucose intolerance with first onset during pregnancy Slide11
Hyperglycaemia
is one of the most common medical conditions associated with pregnancy1
Gestational Diabetes
March 2016
11
International
Diabetes Federation.
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015.HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study associations with neonatal anthropometrics. Diabetes. 2009;58(2):453-459.
20.9
million live births
are affected by hyperglycaemia in pregnancy1
Globally
30%
(6.2 million)
are in India
1Slide12
Hyperglycaemia in pregnancy in India
Gestational DiabetesMarch 2016
12
International
Diabetes Federation. IDF Diabetes Atlas, 7th
edn. Brussels, Belgium: International Diabetes Federation, 2015.Nielsen, K. K., Damm, P., Kapur, A., Balaji
, V.,
Balaji
, M. S., Seshiah, V., &
Bygbjerg
, I. C. (2016). Risk Factors for
Hyperglycaemia in Pregnancy in Tamil Nadu, India. PloS one, 11(3), e0151311. 6.2 million live births are affected by hyperglycaemia in pregnancy1
5.9 million
are due to GDM
1
Difference in GDM urban/rural distribution
(
Tamil Nadu field
study
2
)
Urban areas
Semi-urban areas
Rural areas
17.8%
13.8
%
9.9%
Of which,
GDM prevalence
27.6%
1Slide13
Presentation title
Date
13
How does GDM impact pregnancy outcomes?Slide14
Food for thought!!!
All are diabetogenic in GDM except1) hPL
2) Progesterone3) GH4) increase in insulin5) Beta cell failure.Slide15
Pre-eclampsiaPolyhydramnios
Prolonged labourObstructed labourCaesarean SectionUterine atony
Postpartum haermorrhageInfection
Gestational diabetes is associated with a number of maternal complications
Presentation title
Date
15
1.
Crowther
CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
New England Journal of Medicine
. 2005;352(24):2477–2486. 2. The HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. 3. Hod
M, Kapur A, Sacks DA, et al. The International Federation of
Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care
. International Journal of Gynecology
and
Obstetrics
: the official organ of the International Federation of
Gynecology
and Obstetrics.
2015;131:S173
.
4.
International Diabetes Federation.
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015.
5.
Ehrenberg HM,
Durnwald
CP, Catalano P, Mercer BM. The influence of obesity and diabetes on the risk of
cesarean
delivery.
Am J
Obstet
Gynecol.
2004;191(3):969-974.
7.
Rudge
MV, Calderon IM, Ramos MD,
Peracoli
JC,
Pim A. Hypertensive disorders in pregnant women with diabetes mellitus. Gynecol Obstet Invest. 1997;44(1):11-15. 8
.
Yogev
Y,
Xenakis
EM, Langer O. The association between preeclampsia and the severity of gestational diabetes: the impact of
glycemic
control.
American journal of obstetrics and
gynecology
.
2004;191(5):1655-1660
.Slide16
Congenital anomaliesIntra Uterine Growth Restriction (IUGR)
Increase in still-birthsMacrosomiaIncreased respiratory problemsJaundiceShoulder dystocia
Birth injuriesNeonatal hypoglycaemiaInfant respiratory distress syndrome
Gestational diabetes is associated with a number of consequences for the foetus
Presentation title
Date
16
1.
Crowther
CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
New England Journal of Medicine
. 2005;352(24):2477–2486. 2. The HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. 3. Hod M,
Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and
care. International Journal
of Gynecology and
Obstetrics
: the official organ of the International Federation of
Gynecology
and Obstetrics.
2015;131:S173
.
4.
International Diabetes Federation.
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015.
5. Slide17
Children born to mothers with GDM are up to
8-times
more likely to develop type 2 diabetes and obesity
in their teens or early adulthood.
Gestational diabetes also increases the risk for type 2 diabetes in both mother
and childPresentation title
Date
17
Approximately
50% of women
with GDM go on to develop type 2 diabetes
within five year of pregnancy.SOURCES: 1. Kim C, Newton KM, Knopp RH. Gestational Diabetes and the Incidence of Type 2 Diabetes: A Systematic Review, Diabetes Care 25, 2002. 2.
Clausen TD, Mathiesen ER, Hansen T, et al. High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes the role of intrauterine hyperglycemia.
Diabetes care.
2008;31(2): 340-346 3. Hod
M,
Kapur
A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO)
l of Gynecology and Obstetrics.
2015;131:S137
4.
International Diabetes Federation.
IDF Diabetes Atlas, 7th
edn
.
Brussels, Belgium: International Diabetes Federation, 2015
.
Slide18
All of this goes hand in hand with a general rise of
the diabetes pandemicPresentation title
Date
18Slide19
Globally recognised risk factors
Gestational diabetes risk factors
Presentation titleDate
19
Personal history of IGT or GDM in a previous pregnancy
Ethnicity
Family history of diabetes, especially in first degree relatives
BMI >30 kg/m
2
Maternal age >25 years of age
Previous delivery of a baby >9 pounds (4.1 kg)Previous unexplained perinatal loss Glycosuria at the first prenatal visitMedical condition/setting associated with development of diabetes, such as metabolic syndrome, polycystic ovary syndrome (PCOS), current use of glucocorticoids, hypertensionSOURCES: 1. Solomon, et al. (1997). A prospective study of pregravid determinants of gestational diabetes mellitus.
Jama, 278(13), 1078-1083.
2. Kim, C, et al. (2009). Does frank diabetes in first-degree relatives of a pregnant woman affect the likelihood of her developing gestational diabetes mellitus or
nongestational diabetes?. American journal of obstetrics and gynecology
,
201
(6), 576-e1.
2.
Hedderson
, et al. (2008). Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus.
American journal of obstetrics and
gynecology
,
198
(4), 409-e1.
R
isk
increases when multiple risk factors are presentSlide20
Food for thought!!!
Exercise increases all exceptInsulin secretion.Insulin independent glucose consumption.
AmP kinase activity.
Insulin resistance.Insulin sensitivity.Slide21
In a recent study (2015) from Tamil
Nadu, globally recognised risk factors were not significant:1
Although risk factors, to some extent,
point to additional risk among certain women, testing according to risk factors would imply missing out on 20-30% of hypoglycaemia in pregnancy cases1
GDM risk factors
Presentation title
Date
21
Source:
Nielsen
, K. K.,
Damm, P., Kapur, A., Balaji, V., Balaji, M. S., Seshiah, V., & Bygbjerg, I. C. (2016). Risk Factors for Hyperglycaemia in Pregnancy in Tamil Nadu, India. PloS one, 11
(3), e0151311.Slide22
“In India… studies indicate that GDM may be associated with increasing socio-economic status, and similar trends have been found for type 2 diabetes.”
GDM risk factors
Presentation title
Date
22
Source: Nielsen
, K. K.,
Damm
, P.,
Kapur
, A.,
Balaji, V., Balaji, M. S., Seshiah, V., & Bygbjerg, I. C. (2016). Risk Factors for Hyperglycaemia in Pregnancy in Tamil Nadu, India. PloS one, 11(3), e0151311.
“…
among women attending the rural health centre a doubling in income caused an 80% increased risk of HIP [hyperglycaemia in pregnancy].” Slide23
Screening and diagnostic testing for diabetes are performed because
identifying pregnant women with diabetes followed by appropriate therapy can decrease feotal and maternal morbidity
, particularly macrosomia, shoulder dystocia,
and pre-eclampsia.
Universal testing for GDM is recommended
1Screening and diagnostic testing
Presentation title
Date
23
Sources: 1
.
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide24
Food for thought!!!
What is optimal blood sugars in pregnancy?Fasting >100,PP >150.Fasting >95,PP >140.Fasting <95,PP <140.Fasting ≤92,PP ≤ 120.
None of the above.Slide25
Presentation title
Date
25
Are there national guidelines for diagnosis and management
of GDM?Slide26
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus
Presentation title
Date
26
Available at:
www.nrhmorissa.gov.in
/
writereaddata
/Upload/Documents/National%20Guidelines%20for%20Diagnosis%20
&%20Management%20of%20Gestational%20Diabetes%20Mellitus.pdfSlide27
Testing for GDM
Presentation title
Date
27Slide28
Considering the high prevalence of GDM in India and the maternal & foetal morbidity associated with untreated GDM
all pregnant women should be tested for GDMTesting for GDM
Presentation title
Date
28
Testing for GDM is recommended twice
during
antenatal care (ANC)
First testing done during first ANC contact
Second testing done during 24-28 weeks of pregnancy if first test is negative
There should be at least 4 weeks gap between the two tests
If a woman presents beyond 28 weeks of pregnancy only one test is doneIf the test is positive at any point, protocol management should be followedSource: National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide29
Testing for GDM – protocol of investigations
Presentation title
Date
29
Source: National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus
All pregnant women in the community
Testing for GDM at 1st Antenatal visit
(75 g oral
glucose -
2
hr
Plasma Glucose value)Manage as GDM
as per guidelines
Negative (2
hr
PG <140mg/dl)
Repeat
Testing at
24-28
weeks
Positive (2
hr
PG ≥ 140 mg/dl
)
Negative (2
hr
PG < 140mg/dl
)
Manage as normal ANC
Manage as GDM
as per guidelines
Positive (2
hr
PG ≥ 140 mg/dl
)Slide30
Single step testing using 75 g Oral Glucose Tolerance Test (OGTT) and measuring plasma glucose 2 hours after ingestion
75 g glucose to be given orally after dissolving in approximately 300 ml water whether woman comes in fasting or non-fasting stateIntake of solution has to be completed within 5 min.A plasma standardised glucometer should be used to evaluate blood glucose 2 hours after the oral glucose load
If vomiting occurs within 30 min of oral glucose intake the test has to be repeated the next day. If vomiting occurs after 30 minutes the test continuesThe threshold plasma glucose level of ≥140 mg/
dL is taken as cut off for diagnosis of GDM
Methodology: Test for diagnosis
Presentation titleDate
30
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide31
Food for thought!!!
True about insulin resistance (IR) ? 1) Increases by 50-60 % in 2-3 rd trimester.
2) Insulin sensitivity increases by 50-60 % in 2-3 rd trimester.
3) IR increases in late first trimester.4) IR decreases in third trimesterSlide32
Management of GDM
Presentation titleDate
32Slide33
GDM is managed initially with Medical Nutrition Therapy (MNT)
and if not controlled with MNT, insulin therapy is added to the MNTManagement of GDM
Presentation title
Date
33
Pregnant woman with GDM
Medical Nutrition Therapy
2
hr
Post Prandial Plasma Glucose (PPPG)
2 weeks
≥ 120
mg/dl
Start Insulin Therapy
< 120 mg/dl
Continue MNT
Monitor FBG & 2
hr
PPPG every
3rd
day
or more frequently
till
Insulin dose adjusted to
maintain
normal plasma glucose
levels
Monitor 2
hr
PPPG
once weekly
Monitor 2
hr
PPPG
Up to 28
wks
: Once in 2
weeks
After 28
wks
: Once a week
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide34
In most cases GDM can be managed by Medical Nutrition Therapy (MNT)Principles of MNT
MNT for GDM primarily involves a carbohydrate controlled balanced meal plan Nutrition assessment should be individualisedMaternal weight gain is the important measure in follow up visits to determine whether energy intake is adequate to support
fetal growth
Medical Nutrition Therapy (MNT)Overall Principles
Presentation title
Date
34
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus, page 11.Slide35
Carbohydrate foods are essential for a healthy diet for mother and baby. Once digested, carbohydrate foods are broken down to glucose, which goes into the blood stream. The type, amount and frequency of carbohydrate intake has a major influence on blood glucose readings.
Large amounts of carbohydrate foods eaten at one time will lead to high blood glucose level and should be avoided. It is better to spread carbohydrate foods over 3 small meals and 2-3 snacks each day than taking 3 large meals.
Complex carbohydrates (e.g. whole grain cereals) should be preferred over simple carbohydrates like foods with lots of added sugar or honey or foods that are made from refined white flour.Counting the number of carbohydrates serves that a mother eats during the days will help her to eat the right amount.
Medical Nutrition Therapy (MNT)
Careful Selection of Carbohydrates
Presentation titleDate
35
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus, page 11.Slide36
Saturated fat intake (ghee, butter, coconut oil, palm oil, red meat, organ meat, full cream milk etc.) should be less than 10% of total calories and dietary cholesterol should be less than 300 mg/day. In obese and overweight patients, a lower fat diet overall can help slow down the rate of weight gain.
RecommendationsUse less fat in cooking and avoid frying of foodsUsing low-fat dairy products in place of whole milk or full cream products
Choose low-fat snack (e.g. fresh fruit) instead of high-fat snacks (cakes, biscuits etc.)Use lean mean instead of read meat
Medical Nutrition Therapy (MNT)Understanding Fat Intake During Pregnancy
Presentation title
Date
36
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus
For more details, see:
Sample Diet Chart and
Food Exchange Chart for MNT in
the National GDM Guidelines.Slide37
When and WhatInsulin therapy is the accepted medical management of pregnant women with GDM not controlled on MNT in 2 weeks
The National Guidelines recommend the use of Human Premix insulin 30/70. Oral tablets for diabetes treatment in pregnancy are not
to be given as they are not considered safe.All pregnant women in whom MNT fails to achieve a 2 hr PPPG <120 mg/
dL are started on insulin, along with MNTIn case of very high 2 hr PPPG:
If 2 hr PPPG is >200 mg/dL at diagnosis, starting dose of insulin should be 8 units pre-mixed insulinThe dose to be adjusted on follow-up and at the same time MNT has been followed. Frequency of monitoring to be decided by the treating Physician/Gynaecologist/Medical Officer.
If the pregnant women requires more than 20 units insulin/day, she should be referred to a higher healthcare centre.Insulin Therapy
Presentation title
Date
37
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide38
Food for thought!!!
Insulin approved in Pregnancy are all except ?Lispro(
Humalog, Humalog
mix25, Humalog
mix 50)Aspart
Detemir , NPH. Glargine , Gluilisin
(
Apidra
),
Degludec
,
Rizodeg.Slide39
Human insulin
pmol
/min
00:00
02:00
04:00
06:00
08:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
00:00
200
400
Time
22:00
Meals
Adapted from
Polonsky
et al. N
Engl
J Med
1988;318:1231
–
9
Healthy
insulin
response
Soluble
human
insulin
NPH
insulin
SC
Insulin
repl.
NPH, neutral protamine
Hagedorn
; SC, subcutaneous
Traditional insulin products do not mimic the healthy insulin responseSlide40
Insulin Aspart
: A step ahead…
Periello.
Diabet Med 2005;22:606–11
PPG
Insulin
*p<
0.05
vs.
human insulin
Mean serum glucose (
mmol
/l)
6
8
10
12
14
0
0
30
60
90
120
150
180
210
240
*
Time (min)
100
200
300
400
0
500
600
Insulin (
pmol
/l)
0
30
60
90
120
150
180
210
240
*
Time (min)
Insulin Aspart
Human insulin
Insulin
Aspart
has a more physiological profile compared to Human Insulins with improved PPG controlSlide41
Insulin
aspart
+ NPH (n=157)
HI + NPH
(n=165)
n
E
Rate
n
E
Rate
Major
38
113
1.4
35
174
2.1
Minor
148
7197
86.4
148
7944
94.5
Symptoms only
85
1055
12.7
85
742
8.8
Insulin
aspart
use
in
pregnancy
Better PPG control compared to human insulin
Safe for the mother: fewer Hypoglycaemic episodes during pregnancy
Safe for foetus: Significantly lower risk of preterm deliveries
Overall Better foetal outcomes
Mathiesen
et al. Diabetes Care
2007;30:771–6,
Hod
et al. Am J
Obstet
Gynecol
2008;198:e1–7Slide42
Another Question
Which is correct as per color coding of insulin syringe?1.Red color is 40 IU syringe.2.Orange for 100 IU syringe.3.Blue for 500 IU syringe.
4.None of the above 5.All of the aboveSlide43
Any pregnant woman on insulin can develop hypoglycaemia at any time
Hypoglycaemia is diagnosed when blood glucose level is < 70 mg/dlImportant to recognise symptoms of hypoglycaemia & treat
immediatelyEarly symptoms - Tremors of hands, sweating, palpitations, hunger, easy
fatigability, headache, mood changes, irritability, low attentiveness, tingling sensation
around the mouth/lips or any other abnormal feelingSevere
- Confusion, abnormal behaviour or both, visual disturbances, nervousness or anxiety, abnormal behaviour.
Uncommon
- Seizures and loss of consciousness
Hypoglycaemia
How to Recognise Hypoglycaemia
Presentation titleDate43Source: National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide44
Ask the pregnant women to take 3 TSF of glucose powder (15-20 grams) dissolved in a glass of water
After taking oral glucose, she must take rest & avoid any physical activity15 minutes after taking glucose, she must eat one chapati with vegetable/rice/one
glass of milk/idli/fruits/anything eatable which is availableIf hypoglycaemia continues, repeat same amount of glucose and wait
If glucose is not available, take one of the following: Sugar - 6 TSF in a glass of water/fruit
juice/honey/anything which is sweet/any foodTake rest, eat regularly and check blood glucose if possibleIf the pregnant woman develops >1 episode of
hypoglycaemia in a day, she should consult any doctorimmediatelyHypoglycaemia
How to Manage Hypoglycaemia
Presentation title
Date
44
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide45
Lowering episodes of hypoglycaemia with the use of right insulin therapy
Heller et al.
J Diabetes 2013; 5:482-491
Per-trial and overall analysis of all nocturnal hypoglycaemic episodes
IAsp, insulin
aspart
NPH
, neutral
protamine
Hagedorn
RHI, regular human insulin
0.1
10
Favours
IAsp
+ NPH
Favours RHI + NPH
Trial
Treatment difference
(%) [95% CI]
P
1
Type 1
Type 1 and Type 2
All
Test of heterogeneity:
P
=0.092
Type 2
035
036
064
065
066
1634
037
1198
Fixed effects
Random effects
0.75 [0.60; 0.93]
0.01
0.69 [0.56; 0.86]
<0.001
0.79 [0.59; 1.06]
0.11
0.79 [0.59; 1.06]
0.83 [0.50; 1.38]
0.12
0.97 [0.59; 1.58]
0.89
0.54 [0.24; 1.22]
0.14
0.68 [0.16; 2.85]
0.59
0.76 [0.67; 0.85]
<0.001
0.76 [0.67; 0.85]
<0.001
0.48
Lower rate of nocturnal
hypoglycaemic
episodes with insulin
aspart
vs human insulin Slide46
Antenatal care of a pregnant woman with GDM should be provided by
a gynaecologist, if available.If GDM is diagnosed before 20 weeks of pregnancy, a foetal anatomical survey by USG should be performed at 18-20 weeks.
For all pregnancies with GDM, a foetal growth scan should be performed at 28-30 weeks gestation & repeated at 34-36 weeks gestation.
There should be at least 3 weeks gap between the two ultrasounds and it should include
fetal biometry & amniotic fluid estimation.Pregnant women with GDM in whom blood glucose level is well controlled and there are
no complications, should go for routine antenatal care as per GoI guidelines.In pregnant women with GDM having uncontrolled blood glucose level or any
other complication
of pregnancy, the frequency of antenatal visits should
be increased
to every 2 weeks in second trimester
and
every week in third trimester.Monitor for abnormal foetal growth (macrosomia/growth restriction) and polyhydramnios at each ANC visit PW with GDM to be diligently monitored for hypertension in pregnancy, proteinuria and other obstetric complicationsIn pregnant women with GDM between 24-34 weeks of gestation and requiring early delivery, antenatal steroids should be given as per GoI guidelines i.e. Inj. Dexamethasone 6 mg IM 12 hourly for 2 days. More vigilant monitoring of blood glucose levels should be done for next 72 hours following injection. In case of raised blood glucose levels during this period, adjustment of insulin dose should be made accordingly.
Special Obstetric Care for Women with GDM
Antenatal Care
Presentation title
Date
46
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide47
Pregnant women with GDM are at an increased risk for foetal
death in utero and this risk is increased in PW requiring medical management. Hence vigilant foetal surveillance is required.Foetal
heart should be monitored by auscultation on each antenatal visit.The pregnant woman should be explained about Daily Fetal Activity
AssessmentWoman to lie down on her side after a meal and note
how long it takes for the foetus to kick 10 times. If the foetus does not kick 10 times within 2 hrs, she should immediately consult a
healthcare worker and if required should be referred to a higher centre for further evaluation.
Foetal surveillance in pregnant
w
oman with GDM
Presentation title
Date
47Source: National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide48
Pregnant women with GDM with good control of
blood glucose (2 hr PPPG < 120 mg/dl) levels may be delivered at their respective health facility.Pregnant women with GDM on insulin therapy with uncontrolled blood glucose
levels (2 hr PPPG ≥120 mg/dl) or insulin requirement >20 U/day should be referred for delivery at
CEmOC centres under care of gynaecologist
at least a week before the planned delivery.Such referred cases must get assured indoor admission or can be kept in a birth waiting home with round the clock availability of
medical staff for monitoring.Timing of delivery
GDM pregnancies are associated with delay in lung maturity of the foetus; so routine delivery prior to 39 weeks is not recommended.
If
a
woman with
GDM with well controlled plasma glucose has not
already delivered spontaneously, induction of labour should be scheduled at or after 39 weeks of pregnancy.In woman with GDM with poor plasma glucose control, those with risk factors like hypertensive disorder of pregnancy, previous still birth and other complications should be delivered earlier. The timing of delivery should be individualised by the obstetrician accordingly.Vaginal delivery should be preferred and LSCS should be done for obstetric indications only.In case of foetal macrosomia (estimated foetal weight > 4 Kg) consideration should be given for a primary
caesarean section at 39 weeks
to avoid shoulder dystocia.Labour and Delivery
Presentation title
Date
48
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide49
Pregnant women with GDM on insulin
require plasma glucose monitoring during labour by a glucometer.The morning dose of insulin is withheld on the day of
induction/labour and the PW should be started on 2 hourly monitoring of plasma glucose.
IV infusion with normal saline (NS) to be started and regular insulin to be
added according to blood glucose levels as per the table to t to the right
Special precaution during labour
Presentation title
Date
49
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide50
All babies born to mothers with GDM are at risk for development of hypoglycaemia
irrespective of treatment whether they are on insulin or not and should be observed closely. All babies
are, hence, to be checked for hypoglycaemia at or within one hour of delivery by glucometer.
All neonates should receive immediately essential newborn care
with emphasis with early breastfeeding to prevent hypoglycaemia.If required, the sick neonates should be immediately resuscitated
as per GoI guidelines.Newborn should be monitored for hypoglycaemia (capillary
blood glucose
<44 mg/dl). Monitoring should be started at 1 hour of
delivery and
continued every 4 hours (prior to next feed) till four stable
glucose values
are obtained.Neonate should be also be evaluated for other neonatal complications like respiratory distress, convulsions, hyperbilirubinaemia.Further details are found in the National GuidelinesImmediate neonatal care for baby of mother with GDMPresentation titleDate
50
Source:
National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide51
Immediate postpartum care women with GDM is not different from women without GDM but these women are at high risk to develop
Type 2 Diabetes mellitus in future.Maternal glucose levels usually return to normal after delivery.Nevertheless, a FPG & 2 hr PPPG is performed on the 3rd day
of delivery at the place of delivery. For this reason, GDM cases are not discharged after 48 hours unlike other normal PNC cases.
6 weeks post partum: 75 g GTT at 6 weeks to evaluate glycaemic status of woman.
Cut offs for normal blood glucose values are:
Fasting plasma glucose: ≥ 126 mg/dl75 g OGTT 2 hour plasma glucoseNormal: < 140 mg/dl
IGT
: 140-199mg/dl
Diabetes
: ≥ 200 mg/dl
Post-delivery follow-up of women with GDM
Presentation titleDate51Source: National Guidelines for Diagnosis & Management of Gestational Diabetes MellitusSlide52
Food for thought!!!
DM after pregnancy(post delivery) ? upto 50 %10%5%
1%Slide53
Bringing blood glucose in good control is almost entirely in the hands of the pregnant woman with GDM
It is important that:The pregnant woman understands both the short- and the long-term potential consequences of her
condition (for her and her unborn child) Her family (husband and in-laws) understand what GDM is and why a change in the woman’s/family’s dietary habits may be necessary
The pregnant woman understands the importance of attending the clinic for observation and follow-upThe pregnant woman understands that, while GDM is transitional, both her and her child at at increased risk of type 2 diabetes in the future
Patient Education - Key to good outcomes
Presentation title
Date
53Slide54
Additional and detailed information and guidance is available
Presentation titleDate
54
Available at:
www.nrhmorissa.gov.in
/
writereaddata
/Upload/Documents/National%20Guidelines%20for%20Diagnosis%20
&%20Management%20of%20Gestational%20Diabetes%20Mellitus.pdf
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus
Includes detailed information on:
EvidenceTechnical guidelines on testing & management of GDMOperational aspects of GDM Programme
Records & Registers
Monitoring and Quality Assurance
Outcome measures to be assessed
Tools and resources related to:
MNT, reporting, Migration
form, Referral slip, Glucometer specifications and calibrationSlide55
Together we can ensure better maternal health and pregnancy outcomes
…
...
and curb the increasing type 2 diabetes epidemic
Presentation title
Date
55