Gestational Diabetes Could Be Prevented ?

Prof.Lobna Farag Eltoony

Head Of internal medicine department

Head of Diabetes and Endocrine Unit

Assiut University

Gestational Diabetes

One of the most challenging aspects of diabetes practice

Seemingly easy: Practically difficult

Needs a lot of commitment on part of doctor, patient and family

Success can be achieved if we try together

Introduction

Diabetes mellitus, whether gestational or pregestational, represents one of the most challenging medical complications encountered in pregnancy.

A comprehensive and multidisciplinary approach is required to improve maternal and neonatal outcomes.

Diabetes in pregnancy

Pre-existing diabetes Gestational diabetes

Pre-existing diabetesIDDM

(Type1)

NIDDM

(Type2)True GDM

Growth Abnormalities(1)Two Extremes Of Growth Abn:

Diabetes in Pregnancy: Avoiding Complications

• Advances in diagnosis and treatment have dramatically reduced morbidity and mortality in both mothers and infants1,2

Preconception care

• Renal impairment, cardiac disease, neuropathy3Careful evaluations

at each visit

• 1st trimester through 1st year postpartum

• Examine active lesions more frequently1

Regular ophthalmologic exams

• Target: systolic BP 110-129 mmHg; diastolic BP 65-79 mmHg

• Lifestyle changes, behavior therapy, and pregnancy-safe medications (ACE inhibitors and ARBs contraindicated in pregnancy)3

Hypertension management

1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Jovanovic L, et al. Diabetes Care.

2011;34(1):53-54.

3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. ADA. Diabetes Care.

2013;36(suppl 1):S11-S66.

Insulin Use During PregnancyPatient Education

• Insulin administration, dietary modifications in response to self-monitoring of blood glucose (SMBG), hypoglycemia awareness and management1

Basal Insulin

• Intermediate- or long-acting insulin administered by injection, or

• Rapid-acting insulin administered by insulin pump2,3

Postprandial Hyperglycemia

• Recommended approach: rapid-acting insulin analogues2

• Alternative approach: regular insulin to control postprandial glucose spikes; must be administered 60-90 minutes prior to meals (considered less effective than rapid-acting insulin and may increase hypoglycemia risk)3

Insulin Options

• Insulin NPH: safe intermediate alternative (category B)2

• Insulin detemir: safe long-acting alternative (category B)2,3

• Lispro and aspart: safe rapid-acting insulin analogues (category B)2,3

• Insulin glargine: frequently prescribed in pregnancy; however, safety in pregnancy has not been definitively established (category C)2,3

1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53.

3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

Insulin Delivery Throughout PregnancyCalculating Daily Insulin Dose for Pregnancy With Preexisting Diabetes

Gestational

week

4–12

12–24

24–38

38–42

0.7 U

0.8 U

0.9 U

1.0 U

Insulin dose

Multiplied by

current

pregnant

weight in kg

Jovanovic L. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY:

Marcel Dekker Inc; 2002:139-151

Diabetes and embryogenesis

Early fetal loss due to apoptosis ofblastocyst, modulated by regulatory gene Bax, which is stimulated by high BG

Malformation rate 3X higher [4-10%]

High BG reduces total cell mass and number of blastocysts, esp in inner cell layer

Cardiac 4x

Anencephaly 5x

Spina bifida 3x

Caudal regression syn 212x

Arthrogryposis 28x

Cleft lip/palate 1.5x

Ureteric duplication 23x

Renal agenesis 5x

Pseudohermaphroditism 11x

Anorectal atresia 4x

Gestational diabetesDefinition

• Glucose intolerance with onset or first recognition during pregnancy

• Characterized by β-cell function that is unable to meet the body’s insulin needs

ADA 2015

Maternal hyperglycemia

Fetal hyperglycemia

Fetal hyperinsulinemia

Pederson

Hypothesis

(1952)

Macrosomia,organomegaly, polycythaemia,

hypoglycemia, RDS

Pathogenesis of Gestational diabetes

Problems with the Current Diagnostic Criteria for GDM

NO CONSENSUS ON GDM SCREENING

Who ? Why? When? How?

SELECTIVE VS UNIVERSAL SCREENING

American Diabetes Association (ADA) 2015 recommends screening for selective (high risk)population. But compared to selective screening, universal screening for GDM detects more cases and improves maternal and neonatal prognosis [Cosson EASD 2004] , hence universal screening for GDM is essential.

Risk factors for GDM

High risk

• Obesity

• Diabetes in 1st degree relative

• Previous history of GDM or glucose intolerance

• Previous infant with macrosomia > 3.5 kg

• High risk ethnic group; South Asian, East Asian, Indigenous American or Australian, Hispanic

• PCOS

Low risk

• Age less than 25 years

• No previous poor pregnancy outcomes

• No diabetes in 1st degree relatives

• Normal prepregnancy weight and weight gain during pregnancy

• No history of abnormal glucose tolerance

Perkins, Dunn, Jagastia, 2007

Why diagnose and treat GDM?

• Short term risks for the mother– Development of gestational hypertension, and preeclampsia – Operative delivery - related to macrosomia– Polyhydramnios– Premature labour

• Long term risks for the mother– Development of type 2 diabetes (30-60% depending on

population)– Development of cardiovascular disease

CDA, 2013

Metzger, Buchanan, et al. 2007

Why diagnose and treat GDM?

• no increase in congenital anomalies

• Short term risks for the baby– Macrosomia– Neonatal hypoglycemia– Jaundice– Preterm birth– Birth injury– Hypocalcemia/ hypomagnesimia– Respiratory distress syndrome

• Long term risks for the baby– Obesity– Type 2 diabetes

Shoulder dystocia and Erb’s palsy

The evolution of a diagnosticcontroversy

How?1 hr 50 g OGTT.

2 hr 75 g oral OGTT

3 hr 100 g OGTT

Gestational Diabetes Care In Upper Egypt

ObjectivesEstablish 5 GDM care and control centers in University hospitals .

The existing government healthcare centers will be involved and strengthened to perform GDM screening and care.

Reduction of the incidence of future diabetes of women that diagnosed with GDM and her baby .

Training of health care providers.

NGO's women self help groups will be involved for their effective participation.

Raising the public awareness.

Screening and care

Assiut

GDM care and control center

Al-Fayoum

GDM care center

Beni-Suif

GDM care center

El-Menia

GDM care center

Sohag-NaghHammady

GDM care center

PROJECT ACTIVITIES

The project combines hospital based care with community based primary care in order to detect gestational diabetes early and ensure proper management of the disease.

Capacity building

Screening & care

Increase awarenes

s

When to screenScreening for GDM

• Screening should be done at 24-28 weeks

• Diagnosis based on a 75 gm glucose load• 2 hr >140 mg/dl

• If woman tests negative, screening at 32 weeks also may be necessary in presence of high risks

The IDF WINGS expert committee advises using WHO

criteria for the project in view of the logistic simplicity

and lower cost

World Health Organization, 2013

Diet

Exercise

Glucose monitoring

Insulin other medications

Management

Primary prevention of gestational diabetes for women who are overweight and obese: a randomised controlled trial.

CONCLUSIONS: The results indicate that there may be some benefits of dietary counseling,, or an exercise program. However, better-designed studies are required to generate higher quality evidence.

Oostdam,N., Van Poppel,M.N.M., Wouters,M.G.A.J., & van,Mechelen W. (2011). Interventions for preventing gestational diabetes mellitus: A systematic review and meta-analysis. Journal of Women's Health, 20(10), 1551-1563. BMC Pregnancy Childbirth. 2013 Mar 13;13:65. doi: 10.1186/1471-2393-13-65.

Dietary Modifications

Decrease carbohydrate content 40%

Frequent small feedings

Small breakfast meals

Bedtime snacks

No > 10 hours overnight fast

NO JUICE

Adequate calorie intake

Exercise improved cardiorespiratory fitness

Physical activity reduced risk of GDM

Resistance exercise diminished the need for insulin therapy in overweight women with GDM

Exercise

Target Blood Glucose Values for GDM

Glucose level

Fasting - 90-99 mg/dL (5.0–5.5 mmol/L)

1- hr PP - < 140 mg/dL (7.8 mmol/L)

2- hr PP - < 120-127 mg/dL (6.7–7.1 mmol/L)

Fifth International Workshop Conference on Gestational Diabetes

Pharmacologic Therapy ( When MNT alone fails , insulin has traditionally been instituted )

1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.

3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.

5. Micronase PI. Pifizer. Division of Pifizer, NY, NY, 2010. 6. Diabeta PI. Sanofi-Aventis U.S. Bridgewater, NJ, 2009.

7. Lamis Latif, ,The British Journal of Diabetes & Vascular Disease 13(4) 178–182 © The Author(s) 2013.

Medication Crosses Placenta

Classification 2 most commonly prescribed oral antihyperglycemicagents during pregnancy1,2

Metformin Yes Category B1 Metformin and glyburide should not be used in the first trimester, because its effects, if any, on the embryo are unknown , may be insufficient to maintain normoglycemia at all times, particularly during postprandial periods2

Metformin improved insulin sensitivity , Wt. , risk of pre-eclampsia , operative deliver & treatment satisfaction or QoL7

Glyburide Minimal transfer

Some formulations category B, others category C1,5,6

AACE guidelines recommend insulin as the optimal approach1

Due to efficacy and safety concerns, the ADA does not recommend

oral antihyperglycemic agents for (GDM) or preexisting T2DM3,4

Screening and care

GDM is not of itself an indication for cesarean delivery.

Breast-feeding, as always, should be encouraged in women with GDM.

Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the OGTT and non pregnancy diagnostic criteria.

- impaired fasting………….(repeat annually )

- Normal……………………(repeat every 3 years

Normal glucose tolerance 5

Impaired glucose tolerance 3

Diabetes mellitus 1

1/9

5/93/9

Normal glucose tolerance Impaired glucose tolerance Diabetes mellitus

Post partum follow up at 6 weeks

TARGET GROUP

all pregnant women.

General population.

Health professional providing the service in different centers from both public and private sectors in Upper Egypt cities

Gestational Diabetes Education and Diabetes Prevention Strategies

•February 2015, 28 (1)

ADA

. .

. It is important for health care providers to take a

proactive approach to create awareness in women with

GDM that their own and their child's lifelong risk for

developing type 2 diabetes is increased.

1- Future risk of developing type 2 diabetes after diagnosis of

GDM for themselves and their children

2-Recommended follow-up care with their health care

provider after birth of the child

3-Prevention of type 2 diabetes

Diabetes Prevention Program (DPP) results

Role of breastfeeding

4-Nutrition recommendations for lactation

5-Effect of contraceptive medications on blood glucose

Conclusion

Women with a history of GDM as well as their offspring exposed to maternal diabetes in utero should be a major area of focus for preventive medicine . Preventive measures against Type 2 DM should start during intrauterine period and continue throughout life from early childhood .

ConclusionSo, a short term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the offspring.

The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists.

So , Don’t hesitate and join us in our GDM project in upper Egpt Extending it to all Egypt .

LOBNA