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Preconception Care and Management of Gestational Diabetes

Preconception Care and Management of Gestational Diabetes. Mahmud Rajabalee M.B.BCh (Ainshams, Cairo) DIS (France). Learning objectives. To realize the importance of preconception care of women with diabetes to prevent adverse pregnancy outcomes

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Preconception Care and Management of Gestational Diabetes

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  1. Preconception Care and Management of Gestational Diabetes Mahmud Rajabalee M.B.BCh (Ainshams, Cairo) DIS (France)

  2. Learning objectives • To realize the importance of preconception care of women with diabetes to prevent adverse pregnancy outcomes • To describe how to achieve optimal glycemic control in the preconception period and throughout pregnancy • To point out the need for postpartum follow-up of patients with gestational diabetes

  3. Outline • Case study • Prevalence of diabetes & IGT in the child bearing period • Preconception care of women with diabetes • Management of gestational diabetes • Postpartum monitoring • Conclusion

  4. Case Study • 31 year old woman G1P0 presents to the clinic at 6 weeks’ gestation • Known type 2 diabetes on Glibenclamide and Metformin • HbA1C is 8.1% • She expresses concerns about the impact on her health and her future newborn • How should she be managed?

  5. Outline • Case study • Prevalence of diabetes & IGT in the child bearing period • Preconception care of women with diabetes • Management of gestational diabetes • Postpartum monitoring • Conclusion

  6. Diabetes 20-29 years: 2.2 % 30-39 years: 8.9 % 40-49 years: 15.4 % IGT 20-29 years: 5.9% 30-39 years: 11.8% 40-49 years: 15.9% Prevalence of Diabetes & IGT in the child bearing period

  7. Prevalence of Diabetes and IGT in the childbearing period • 20-29 years: 8.1% • 30-39 years: 20.7% • 40-49 years: 31.3%

  8. Outline • Case study • Prevalence of diabetes & IGT in the child bearing period • Preconception care of women with diabetes • Management of gestational diabetes • Postpartum monitoring • Conclusion

  9. Preconception Care • Elevated maternal glucose or HbA1C levels during embryogenesis is associated with high rates of spontaneous abortions and major malformations in newborns • Unfortunately, unplanned pregnancies occur in about two-thirds of women with diabetes Preconception Care of Women With Diabetes Diabetes Care 27: 76S-78S.

  10. Preconception Care • Counselling about the risk of malformations • Use of effective contraception

  11. Preconception Care Program • Multidisciplinary team • Internist • Obstetrician • Diabetes educators • The patient is the most active member

  12. Preconception Care Program • Patient education about the effects of diabetes on pregnancy outcomes • Appropriate use of contraception • Diabetes self-management skills • Follow up

  13. Preconception Care : goals of treatment Optimal HBA1C : • Medical nutrition therapy (MNT) • Self-monitoring of blood glucose (SMBG) • Self-administration of insulin and self-adjustment of insulin doses • Education about hypoglycaemia • Physical activity

  14. Preconception Care : Initial visit Medical & obstetric history • Duration and type of diabetes (1 or 2) • H/O acute complications • H/O chronic complications • Diabetes management : Insulin regimen, oral hypoglycaemic, SMBG, diet, physical activity

  15. Preconception Care: Physical Examination • Blood pressure, including orthostatic • Fundoscopy • Cardiovascular examination • Neurological examination

  16. Preconception Care : Laboratory evaluation • HbA1C measurement • Serum creatinine • Albumin/creatinine ratio or 24 hour albumin excretion rate. • Protein excretion >190 mg/24 hours: at a 3-fold increased risk for hypertensive disorders during pregnancy

  17. Preconception Care : Laboratory evaluation • Those with protein excretion >400 mg/24 hours are at risk for intrauterine growth retardation during later pregnancy • ACE inhibitors should be stopped • TSH and/or FT4 in women with type 1 diabetes

  18. Preconception Care : Management plan Counselling about • The risk and prevention of congenital anomalies • fetal and neonatal complications of maternal diabetes • effects of pregnancy on maternal diabetic complications

  19. Preconception Care : Management plan Counselling about • risks of obstetrical complications that occur with increased frequency in diabetic pregnancies • the need for effective contraception until glycemia is well controlled

  20. Preconception Care : Selection of antihyperglycemic therapy • Insulin is the gold standard: efficacy, does not cross placenta • Oral hypoglycemic currently not recommended

  21. Preconception Care: Goals for SMBG • Pre-meals capillary plasma glucose 4.4 – 6.1 mmol/L • 2 hours postprandial capillary plasma glucose < 8.6 mmol/L • Follow-up: 1 to 2 months’ intervals

  22. Preconception Care: Special considerations • Hypoglycemia • Retinopathy: glycemic control, laser photocoagulation

  23. Preconception Care: Special considerations Hypertension • frequent concomitant or complicating disorder • pregnancy induced hypertension occurs more frequently • Aggressive control • ACE inhibitors, B-blockers and diuretics avoided

  24. Preconception Care: Special considerations Nephropathy • renal function: serum creatinine and urinary protein excretion - potential impact of pregnancy on proteinuria - impact of renal insufficiency on fetal growth and development.

  25. Preconception Care: Special considerations Nephropathy • Incipient renal failure (Creatinine clearance < 50 ml/min) → permanent worsening of renal function in > 40% • Less severe nephropathy → transient worsening of renal function

  26. Preconception Care: Special considerations Neuropathy • autonomic neuropathy: gastroparesis, urinary retention, hypoglycemic unawareness, or orthostatic hypotension • Peripheral neuropathy, especially carpal tunnel syndrome, may be exacerbated by pregnancy.

  27. Preconception Care: Special considerations Cardiovascular disease • Untreated CAD is associated with a high mortality rate during pregnancy • Exercise tolerance should be normal

  28. Preconception Care: Special considerations • At the earliest possible time after conception, pregnancy should be confirmed by laboratory assessment (urinary or serum B-hCG). • The woman should be reevaluated by the health care team

  29. Outline • Case study • Prevalence of diabetes & IGT in the child bearing period • Preconception care of women with diabetes • Management of gestational diabetes • Postpartum monitoring • Conclusion

  30. Management of Gestational Diabetes (GDM) Definition & Prevalence • glucose intolerance that is first detected during pregnancy • prevalence is 7% worldwide. Gestational diabetes mellitus. Diabetes Care 2004; 27 Suppl 1:S88.

  31. GDM: Detection & Diagnosis • Risk assessment at the first prenatal visit • High risk patients: obesity personal history of GDM strong family history of diabetes ethnic group with a high prevalence of diabetes

  32. GDM: Detection & Diagnosis • Women at high risk of GDM should have glucose testing at the first antenatal visit • If not found to have GDM at that initial screening, retested at between 24 and 28 weeks gestation

  33. GDM: Detection & Diagnosis Two-step approach • An initial screening: plasma glucose 1 hour after a 50-g oral glucose load (glucose challenge test – GCT). • A value above 7.8 mmol/L identifies 80% of women with GDM. • Confirmed with an OGTT using 75 or 100 g glucose load.

  34. Diagnosis of GDM with a 100-g oral glucose load Fasting 5.3 mmolL 1-h 10.0 2-h 8.6 3-h 7.8 Diagnosis of GDM with a 75-g oral glucose load Fasting 5.3 mmolL 1-h 10.0 2-h 8.6 GDM: Detection & Diagnosis

  35. GDM: Detection & Diagnosis • One-step approach • Cost-effective in high-risk populations

  36. GDM: Obstetrics and Perinatal considerations Increase in the risk of • intrauterine fetal death during the last 4–8 weeks of gestation • Fetal macrosomia and its associated risk of shoulder dystocia and birth trauma • Neonatal hypoglycemia, jaundice, polycythemia, and hypocalcemia Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477-2486.

  37. GDM: Obstetrics and Perinatal considerations Increased frequency of • Maternal hypertensive disorders • Need for cesarean delivery - Fetal growth disorders - Alterations in obstetric management due to the knowledge that the mother has GDM

  38. GDM: Long term considerations • Women with GDM are at increased risk of developing diabetes, usually type 2, after pregnancy • Offspring of women with GDM are at increased risk of obesity, glucose intolerance, and diabetes in late adolescence and young adulthood

  39. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) Goals: • achieve normoglycemia • prevent ketosis • provide adequate weight gain • contribute to fetal wellbeing

  40. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) Calorie allotment • BMI of 22 to 27: 30 kcal/kg per day • BMI 27 to 29: 24 kcal/kg per day • BMI > 30: 12 to 15 kcal/kg per day • BMI less than 22: 40 kcal/kg per day

  41. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) • Carbohydrate intake: 35 to 40% • Protein: 20% • Fat: 40%

  42. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) Calorie distribution: 3 meals and 3 snacks • Overweight: snacks are eliminated. • Breakfast: 10% of total calories • Lunch: 30% • Dinner: 30% • Snacks: 30%

  43. GDM: Therapeutic strategies Glucose monitoring: • SMBG: Fasting and 2 hours postprandial • Goals: FPG < 5.3 mmol/L 2 hours postprandial < 6.5 mmol/L • HbA1C every 4 weeks American College of Obstetricians and Gynecologists. Gestational Diabetes. ACOG practice bulletin #30, American College of Obstetricians and Gynecologists, Washington, DC 2001.

  44. GDM: Therapeutic strategies Insulin • 15% requires insulin • When diet fails to maintain SMBG at the following levels: - Fasting plasma glucose 5.3 mmol/L - 2 hours postprandial plasma glucose 6.5 mmol/L

  45. GDM: Therapeutic strategies Insulin • Premixed insulin is not appropriate • If FPG is high, an intermediate acting insulin is given at bedtime. • if the postprandial blood glucose high, short acting insulin is given before the meals

  46. GDM: Therapeutic strategies Insulin • if both fasting and postprandial blood glucose high, an intermediate acting insulin is given before breakfast and at bedtime and a short acting insulin is given tid before meals

  47. GDM: Therapeutic strategies Insulin dose • varies in different populations because of varied rates of obesity and ethnic characteristics. • Intermediate acting: 40% of total daily dose • Regular Insulin: 60% of total daily dose

  48. GDM: Therapeutic strategies Insulin dose • No absolute rule • Dose distribution is modified according to - individual requirements - amount she will eat at each meals. • Morning sickness should be taken in consideration.

  49. GDM: Therapeutic strategies Insulin dose • greater in obese women • may need to be increased progressively as pregnancy advances to term • SMBG guides the doses and timing of the insulin regimen

  50. GDM: Therapeutic strategies Insulin dose • The evening dose of intermediate acting insulin is modified according to the fasting capillary blood glucose • The pre-meals short acting insulin dose is modified according to the postprandial capillary blood glucose.

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