Diabete gestazionale a termine di gravidanza: gestione clinicaoria.pdf · Standards of medical care in diabetes – 2013. Diabetes Care 2013;36 (Suppl 1):S11–66. American Diabetes

Diabete gestazionale a termine di gravidanza:

gestione clinicaPatrizia D’OriaAlzano Lombardo

giovedì 30 novembre 17

• aumento della prevalenza

• conseguente aumento dei costi

• aumento dei carichi di lavoro

• aumento della “medicalizzazione”

• rischio di aumento di TC

Nuovi criteri nuovi problemi


Nuovi criteri nuovi problemi

• Percorsi per la gravidanza a rischio in tutti i casi

• Valutazione crescita fetale (quando e quante volte)

• epoca del parto

• tipo di parto

?giovedì 30 novembre 17

Gestational diabetes mellitus (GDM), is defined as “any degree of glucose intolerance with onset or first recognition during pregnancy, excluding women diagnosed with overt diabetes by standard criteria at their initial prenatal visits.

Diabete gestazionale GDM

International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, et al. International association of diabetes and pregnancy study group recommendations on

the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–82. American Diabetes Association. Standards of medical care in diabetes – 2013. Diabetes Care 2013;36 (Suppl 1):S11–66.

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 (Suppl 1):S81–90.


Screening GDM

Prima visita in gravidanzaFPG o RPG

valutazione fattori di rischio

FPG > 126 g/dlRPG > 200 g/dlHbA1 > 6,5%

diabete manifesto

FPG > 126 g/dl RPG > 200 g/dlHbA1 > 6,5%

FPG 100-125 g/dlBMI > 30 Kg/m2pregresso GDM

OGTT 16-18 sgDa ripetere a 24-28 sg se negativa

FPG <100g/dl BMI > 25 ,> 35 anni,etnia, familiarità, pregressa macrosomiaOGTT negativa a 16-18

OGTT 24-28 sg


Diagnosi

< 95g/dl “mild diabetes”


•A1 compensato dalla dieta e esercizio

•A2 compensato da terapia medica

>>>>dd>>><Testo

mg/dl

< 95

< 140

< 120

(Livello della prova VI, Forza della raccomandazione B)

Diabete compensato


• La più frequente complicanza non ostetrica (8-25% delle gravidanze)

• in aumento per incremento obesità, età materna

• prevalenza in Italia dal 7,8 a circa 11% (+ 3% )

Dimensioni del problema

Corrado F, Pintaudi B, Di Vieste G, Interdonato ML, Magliarditi M, Santamaria A, et al. Italian risk factor-based screening for gestational diabetes. J Matern Fetal Neonatal Med 2014; 27: 1445-1448.

Lacaria E, Lencioni C, Russo L, Romano M, Lemmi P, Battini L, et al. Selective screening for GDM in Italy: application and e ectiveness of National Guidelines. J Matern Fetal Neonatal Med 2015; 28(15): 1842-1844.

Lapolla A, Dalfrà MG, Ragazzi E, De Cata AP, Fedele D. New International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosing gestational diabetes compared with former criteria: a retrospective study on pregnancy outcome. Diabet Med 2011 Sep; 28(9): 1074-1077.


Primary outcomes

Cesarean section

Birth weight >90th p

Clinical neonatal hypoglycemia

Cord-blood serum C peptide >90th p

Secondary outcomePremature delivery (before 37 wk)

Shoulder dystocia or birth injury

Intensive neonatal care

Hyperbilirubinemia

GMD ed esiti della gravidanza


MEF GDM

Because the absolute risks of stillbirth and infant death are so low, an increase in short-term neonatal morbidities such as neonatal intensive care unit admissions associated with a policy of early delivery may have a public health ramification that overshadows any small mortality benefit.


questione controversa

politica di induzione vs attesa

Tempi e modalità del parto


questione controversa

politica di induzione vs attesa

Macer JA, Macer CL, Chan LS. Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol

1992;166:1690–7.

Remsberg KE, McKeown RE, McFarland KF, Irwin LS. Diabetes in pregnancy and cesarean delivery. Diabetes Care 1999;22:1561–7.

, Berka RJ, Socol ML, Dooley SL. Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstet Gynecol 1999;94:600-7.

riduzione complicanze legate

alla macrosomiaTC, distocia di spalla,

lesioni alla nascita

aumento TC nullipare, morbosità

neonatale legata alla prematurità

Rosenstein MG, Cheng YV, Snowden JM, Nicholson JA, Doss AE, Caughey AB. The risk of stillbirth and infant death stratified by gestational age in women with

gestational diabetes. Am J Obstet Gynecol 2012;206:309.e1–e7.

Bond DM, Gordon A, Hyett J, de Vries B, Carberry AE, Morris J. Planned early delivery versus expectant management of the term suspected compromised baby

for improving outcomes. Cochrane Database Syst Rev 2015;

Melamed N, Ray JG, Geary M, Bedard D, Yang C, Sprague A, et al. Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in

women with gestational diabetes mellitus. Am J Obstet Gynecol 2016;214:364.e1–8.

Tempi e modalità del parto


Induzione GDM

1 RCT (n = 200) neonati con peso alla nascita superiore al 90 ° percentile era significativamente maggiore nel gruppo di gestione in attesa (23% rispetto al 10% con induzione attiva, P = .02) non esistevano differenze significative nei tassi di TC, nella distocia delle spalle, nell'ipoglicemia neonatale o nella morte perinatale.4 studi osservazionali. una potenziale riduzione della macrosomia e della distocia delle spalle con induzione del lavoro e TC per indicatori di peso fetale stimato, ma non vi erano prove sufficienti per valutare altri risultati clinici. CONCLUSION: Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.

VOL. 113, NO. 1, JANUARY 2009 OBSTETRICS & GYNECOLOGY


VOL. 122, NO. 4, OCTOBER 2013 OBSTETRICS & GYNECOLOGY

20152013

2012

Diabete gestazionale GDM


induzione DGM

CONCLUSION: Induction of labor in women with mild gestational diabetes mellitus does not increase the rate of cesarean delivery at <40 weeks’ gestation...However, IOL was associated with a 3-fold increase in cesarean delivery rate at 41 weeks’ gestation and beyond, as compared with IOL at 39 weeks’ gestation. Similarly, there was a 3-fold increase in the cesarean delivery rate in women who were induced when compared with those who were treated expectantly at 40 completed weeks’ gestation. ...


ConclusionIn women with gestational diabetes mellitus, the routine induction of labor at 38 or 39 weeks is associated with a lower risk of cesarean delivery compared with expectant management but may increase the risk of neonatal intensive care unit admission when done at <39 weeks of gestation.

Induzione GDM


GINEXMAL

Obiettivo: valutare gli esiti materno-perinatali dopo induzione del travaglio vs attesa in gravidanze a termine con GDM

Studio clinico randomizzato multicentrico

425 donne circa 210 per braccio senza nessun altro fattore di rischio. Induzione a 38-39 sett vs attesa (ev induzione a 41 sg)


Obiettivo: valutare gli esiti materno-perinatali dopo induzione del travaglio vs attesa in gravidanze a termine con GDM Studio clinico randomizzato multicentrico 425 donne circa 210 per braccio senza nessun altro fattore di rischio. Induzione a 38-39 sett vs attesa (ev induzione a 41 sg)

GINEXMAL


GINEXMAL


GINEXMAL


GINEXMAL


GINEXMAL

ConclusionIn conclusion, our results are transferable only to a comparable low-risk population, except for GDM diagnosis. In similar conditions, our results suggest no clinical difference in birth outcomes can be expected, regardless of the approach used (i.e. active versus expectant management). Although the study is underpowered, the magnitude of the between-group difference is small and without clinical relevance.


• la macrosomia è notevolmente più comune nelle donne con GDM e la distocia delle spalle è più probabile a qualsiasi dato peso fetale in GDM

• Monitoraggio ecografico longitudinale della crescita (rapporto CC/CA) dalla diagnosi ogni 4 sett e del liquido amniotico ogni 2 sett.

• parametri ecografici di crescita fetale considerati come indici indiretti di insulinizzazione

Monitoraggio ostetrico GDM

G Visser Management of diabetes in pregnancy:Antenatal follow-up and decisions concerning timing and mode of delivery Best Practice & Research Clinical Obstetrics and Gynaecology 2014

ACOG Gestational Diabetes mellitus 2013 NICE Diabetes in Pregnancy up date 2015


Monitoraggio ostetrico GDM

G Visser Management of diabetes in pregnancy:Antenatal follow-up and decisions concerning timing and mode of delivery Best Practice & Research Clinical Obstetrics and Gynaecology 2014

ACOG Gestational Diabetes mellitus 2013 NICE Diabetes in Pregnancy up date 2015


• Ultrasonography significantly overestimates the prevalence of LGA in women with gestational diabetes mellitus,

• The sensitivity and specificity 75.7% and 76.8%, respectively; the positive predictive value was 22.6%, and the negative predictive value was 97.3%.

LGA e DGM


LGA e DGM

• ultrasound diagnosis of LGA is associated with an increased risk for cesarean delivery independent of birth weight.

• the likelihood of over- diagnosis of LGA in women with GDM and subsequent increased risk for cesarean delivery are an important component of patient counseling.


Timing and mode of birth

1.4.4 Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015]1.4.5 Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015]1.4.6 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. [2008]1.4.7 Explain to pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus about the risks and benets of vaginal birth, induction of labour and caesarean section. [2008]

Linee guida NICE 2015


t

Linee guida ACOG 2017


tIn contrast, expert opinion has supported earlier delivery for women with poorly controlled GDM ...In such a setting, delivery between 37 0/7 weeks and 38 6/7 weeks of gestation may be justified..., but delivery in the late preterm period from 34 0/7 weeks to 36 6/7 weeks of gestation should be reserved for those women who fail in-hospital attempts to improve glycemic control or who have abnormal antepartum fetal testing.

Linee guida ACOG 2017


MEF GDM

2016


• A1GDM con crescita fetale regolare, in assenza di altra patologia MF attesa fino a 40.6 sg

• A2GDM con crescita fetale regolare attesa fino a 39.6 sg (ACOG diverso RCOG fino a 40.6 sg)

• Nel GDM non compensato ( profilo glicemico e/o crescita fetale accellerata con CA ≥ 75°percentile, e/o AFI ≥ 90°percentile) valutare induzione tra 37 e 38.6 sg

• In caso di peso previsto ≥ 4500 g TC elettivo

• Nel sospetto di macrosomia spiegare alla donna i rischi e benefici dell’induzione vs attesa spiegando la possibilità di una sovradiagnosi ecografica e per questo il rischio aumentato di TC

CONCLUSIONI


grazie!




Documents

Diabete gestazionale a termine di gravidanza: gestione clinicaoria.pdf · Standards of medical care in diabetes – 2013. Diabetes Care 2013;36 (Suppl 1):S11–66. American Diabetes