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8/13/2019 GDM presetation
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Current Recommendations
Regarding Gestational
Diabetes
By Brandon Ernst
UNMC PharmD Candidate 2007Friday, January 26
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Objectives for Today
Define gestational diabetes mellitus (GDM)
Indicate possible adverse effects of GDM
Discuss diagnosing GDM
Evaluate monitoring and treatment possibilities
Reassess mother and offspring postpartum
Briefly discuss the results of the Australian
Carbohydrate Intolerance Study in PregnantWomen (ACHOIS)
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What is Gestational Diabetes?1
Gestational Diabetes Mellitus (GDM) is
glucose intolerance usually recognized
during pregnancy
GDM is thought to occur in about 7% of all
pregnancies
- Hispanic, Native, African, Asian-Americans,
and Pacific Islanders are at highest risk
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Why may GDM occur? The
Thought is that:2
1. The placenta supports the fetus as it grows byproviding hormones for development
2. These hormones block the action of themothers insulin, causing insulin resistance (3x
more insulin)3. Mothers body is unable to lower BGL, causing
hyperglycemia
4. The high BGLs remain in the blood stream,
cross the placenta, and cause the fetusspancreas to produce more insulin to regulateits own hyperglycemic environment
5. Therefore, leading to possible adverse effects
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Possible Problems in GDM2
As the baby continues in this high glycemicenvironment:- Higher glucose gives more energy than needed for
growth, causing fat storage
- Macrosomia (large body size) increases the risk ofdamage to shoulders and limbs during delivery
- Increased pancreas/insulin use in baby may causelow BGL and breathing problems at birth
- Cesarean delivery
- Risk of children developing obesity and adults withtype 2 diabetes
- Jaundice, polycythemia, and hypocalcemia at birth
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Possible Problems in GDM2
The mothers possible complications
include:
- Increased chance of cesarean delivery
- Increased frequency of maternal hypertensive
disorders
- Increase risk of developing diabetes after
pregnancy, typically type 2
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Diagnosing GDM3
Risk assessment should always be done
at first prenatal visit, especially with:
- Obese patients
- Personal history of GDM
- Glycosuria
- Strong family history
- High risk ethnic groups
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Diagnosing GDM3
All women, unless low risk, should be
tested for GDM at 24-28 weeks.
- Low risk must meet all criteria:
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Diagnosing GDM3,4
Two Different Approaches
One step approach
1. Perform a diagnostic 75 g or 100 gOGTT without any prior plasma test
This may be best for patients that cant
afford more tests or in patients that are
already at high risk
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Diagnosing GDM3,4
Two Different Approaches
Two step approach
1. Perform screen using 50 g oral glucose load
(OGL) and check BGL at 1 hour
2. If >130 mg/dL at 1 hour, retest for diagnoses
using 75 g or 100 g OGTT
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Diagnosing GDM3
The OGTT diagnosis criteria
Patient must be above the BGL at the time
interval measured
Positive result must be confirmed on a
following occasion
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Monitoring of GDM3,4
Daily self monitoring of blood glucose (SMBG)is best- Either Pre or Post -prandial testing is best for
obtaining levels (according to ACOG and ADA)
Screen urine for glucose, ketones, and proteins
Monitor blood pressure
Monitor for fetal demise when pregnancy goes
past term Check for asymmetric fetal growth using
ultrasound
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Treatment Options in GDM3
All women should receive diet andnutrition counseling regarding pregnancy
- If BMI > 30 kg/m2:
Lower caloric intake to 25 kcal/kg/day Lower carbohydrate intake to only 25-30% of total
calories
Moderate exercise should be done with
physicians consent Delivery during or before the 38thweek is
encouraged, as is breast-feeding
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When to Add Insulin3,4
If medical nutritional therapy (MNT) fails then
add insulin when BGL are:
ADA ACOG
Fasting 105 mg/dL 95 mg/dL
1-H postprandial 155 mg/dL 130-140 mg/dL
2-H postprandial 130 mg/dL 120 mg/dL
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Treatment Options in GDM3,5,6
Insulin treatment is best for blood glucose
control
- Human insulin should be used when
prescribed, due to lack of analogs studies
NPH or Regular
Humalog is catagory B, and is being used under
Dr. supervision
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Treatment Options in GDM3,5,6
Oral agents are still questionable
- Glyburide (category B), and insulin were compared in
a trial and found to be similar in outcomes- Metformin (category B), shows some good evidence
toward its use in PCOS. Its currently being studied in
GDM and following up with offspring
- Glyburide and Metformin are still not FDA approvedfor GDM
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Treatment Options in GDM
Do not use in pregnancy:
- Aspirin (D)
- Statins (X)
- ACE Inhbitors (D)
- ARBs (D)
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Delivery Time2
During Labor:- Active labor lowers insulin needs for about 24-72
hours after delivery
After Delivery:- May have better BGL control for a few weeks
- Still could have unpredictable BGL swings
- Check BGLs more often during this time
- Breastfeeding is encouraged Have snack before or during nursing, and keep something
close to treat low BGLs
Drink fluids
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Reassessing Offspring2
Following delivery:
- Monitor newborn for any of the possible
abnormalities discussed earlier
- Monitor for development of obesity
- Evaluate for any irregularity in glucose
tolerance
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Reassessing Mother3,4
A mother having GDM:- Has a 50% chance of developing type 2 diabetes
- Should be have BGL evaluated at least 6 weeks
postpartum
If normoglycemic, then testing should be done every 3 years
If IFG or IGT, then testing should be repeated annually
If FPG 126mg/dL or 2-hr 200, then testing should be
repeated on a separate occasion for DM diagnosis
C
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The Australian Carbohydrate Intolerance
Study in Pregnant Women (ACHOIS)7
Randomized clinical trial
Wanted to determine whether treatingwomen with GDM reduced perinatal
complications One thousand women randomized
- Intervention group490 women, received
dietary advice, BGM, and insulin therapy- Routine group510 women
Weeks gestation - 24-34
Th A t li C b h d t I t l
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The Australian Carbohydrate Intolerance
Study in Pregnant Women (ACHOIS)7
Primary endpoint
- Serious perinatal complications
death, shoulder dystocia, bone fracture, nerve
palsy, admit. neonatal nursery, jaundice, induct. oflabor, cesarean birth, anxiety, depression, health
Secondary endpoint
- Birth weights, large for gestational age,macrosomia, small for gestational age
Th A t li C b h d t I t l
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The Australian Carbohydrate Intolerance
Study in Pregnant Women (ACHOIS)7
Primary outcome results (only clinicallysignificant):
- Any serious perinatal complication was
significantly lower in the treatment group Number needed to treat for benefit was 34
- Admission to the neonatal nursery was higherin the treatment group, but length of stay was
equal- Induction of labor was higher in the treatment
group
Th A t li C b h d t I t l
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The Australian Carbohydrate Intolerance
Study in Pregnant Women (ACHOIS)7
Secondary outcome results (only clinicallysignificant)
- Birth weight was lower in the treatment
group
- There were higher rates of macrosomia
and large for gestational age in the
routine group
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Questions?
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References
1. Isley WL, Oki JC. Diabetes Mellitus. In: DiPiro JT, Talbert RL, Yee GC,Matzke GR, Well BG, Posey LM, eds. Pharmacotherapy: A Pathologicapproach. 5th ed. New York, NY: McGraw-Hill; 2002: 1335.
2. American Diabetes Association web site. Available at:http://www.diabetes.org/home.jsp/. Accessed January 23, 2007.
3. American Diabetes Association. Gestational Diabetes Mellitus. Diabetes
Care 2004;27:suppl 1: S88-S90.4. Clinical management guidelines for obstetrician-gynecologists. ACOG
practice bulletin no. 30. Washington, D.C.: American College ofObstetricians and Gynecologists, 2001.
5. American Diabetes Association. Gestational Diabetes Mellitus. DiabetesCare 2006;29:suppl 2: 485.
6. Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A
comparison of glyburide and insulin in women with gestational diabetesmellitus. New Engl J Med 2000;343:1134-1138 (Level 1)
7. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS.Effect of treatment of gestational diabetes mellitus on pregnancyoutcomes. N Engl J Med. 2005;352:2477-86.
http://www.diabetes.org/home.jsp/http://www.diabetes.org/home.jsp/http://www.diabetes.org/home.jsp/