Diabetes in pregnancy

Transcription

1 Diabetes in pregnancy Bipin Sethi Department of Endocrinology Care Hospitals Hyderabad, India Declared no potential conflict of interest

2 Diabetes in pregnancy Bipin Kumar Sethi Department of Endocrinology, CARE Hospitals, Hyderabad, India

3 Conflict of interest Bipin Sethi has declared no potential conflicts of interest.

4 Learning objectives To appreciate the difficulties of managing a situation that has incompetent (maternal) and competent (fetal) beta cells To learn about recent guidelines for gestational diabetes and the differences between them To understand the many different elements of managing gestational diabetes To recognise the importance of long-term care of the mother postpartum

5 Definition of diabetes in pregnancy Any degree of glucose intolerance with onset or first recognition during pregnancy Encompasses hyperglycaemia that occurs before, during and due to pregnancy 92,180,153

6 Issues High background and increasing prevalence of T2DM Pregnancy-induced insulin resistance The role of incompetent (maternal) and competent (fetal) beta cells Fuel-mediated problems that may include teratogenesis 92,180,153

7 Fetal, neonatal and adult consequences of uncontrolled maternal hyperglycaemia during pregnancy Short term (fetal and neonatal) LGA Organomegaly Neonatal hypoglycaemia Transient tachypnoea, respiratory distress Birth trauma (Erb s palsy, asphyxia, fractured bones) Feeding abnormalities Long term (adult) Obesity Visceral adiposity Hyperinsulinaemia Insulin resistance T2DM Metabolic syndrome

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9 Is she diabetic? YSL 35 years old 28 weeks gestation, both parents diabetic Conceived after IVF for PCOD Plasma glucose values after 75 g GTT: Fasting, 90 mg/dl 1h, 193 mg/dl 2h, 130 mg/dl

10 Criteria for diagnosis of gestational diabetes (GDM) O Sullivan and Mahan Carpenter and Coustan WHO IADPSG, Revised ADA* *Post HAPO 92,180,153

11 Carpenter and Coustan criteria 100 g glucose load, 2 of the values to exceed the following: Fasting blood glucose level 95 (105) mg/dl 1 hour blood glucose level 180 (190) mg/dl 2 hour blood glucose level 155 (165) mg/dl 3 hour blood glucose level 140 (145) mg/dl ADA also conceded that 75g glucose load can be used and the sample can be at 0, 1 and 2 hours O Sullivan and Mahan 92,180,153

12 HAPO study primary neonatal outcomes Birth weight above the 90th percentile for gestational age Primary Caesarean delivery Clinically diagnosed neonatal hypoglycaemia Cord-blood serum C-peptide level above the 90th percentile

13 What are the differences? Different numbers Only one abnormal value sufficient One-step procedure avoids GCT No stratification by risk category Based on fetal outcomes rather than prediction of future maternal diabetes from a more representative sample

14 Endocrine Society Guideline (2013): screening for GDM Recommends universal screening for those not known to have DM FPG, HbA1c or RPG at first prenatal visit (before 13 weeks gestation or as soon as possible thereafter) Diagnosis FPG (mg/dl) RPG (mg/dl) HbA1c (%) Overt DM GDM NA NA NA, not applicable. In case of overt DM and not GDM, a second test (FPG, untimed RPG, HbA1c or OGTT) should be performed on another day for confirmation of diagnosis Blumer I et al. J Clin Endocrinol Metab 2013;98:

15 DIPSI Guidelines for Diagnosis of GDM One-step procedure: 75 g oral glucose load given in fasting state At 2 h, plasma glucose estimation performed 2 h plasma glucose Plasma glucose concentration in mg/dl 140 mg/dl 120 mg/dl Diagnosis GDM Decreased Gestational Glucose Tolerance (DGGT) Diabetes In Pregnancy Study Group. J Assoc Physicians India 2006;54:622-8.

16 Comparison of different guidelines Reference study Population studied IADPSG 1 HAPO study Nine different countries from North America, Europe, Middle-East, Asia and Australia ADA 2 HAPO study + NIH consensus DIPSI 3 Indians Same as above 1. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Diabetes Care 2010;33:676-82; 2. American Diabetes Association. Diabetes Care 2012;35(Suppl 1):S11-63; 3. Diabetes In Pregnancy Study Group. J Assoc Physicians India 2006;54:622-8.

17 Is she diabetic? According to criteria currently in use, she has gestational diabetes Plasma glucose values after 75 g GTT: Fasting, 90 mg/dl 1h, 193 mg/dl 2h, 130 mg/dl

18 Now, is this woman diabetic? 34 years old, slim, G2P1, 28 weeks gestation Since she had a family history of diabetes, only fetal blood sampling was carried out prior to her scheduled antenatal visits Fasting plasma glucose 101 mg/dl Does she need a GTT?

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21 Management Assess and discuss risk (do not scare) Non-pharmacological: Diet Exercise Pharmacological: Insulin (?), analogues, oral agents (?), metformin, glibenclamide

22 Diet Both past and present diets Multiple meals Retain the patient s native dietary pattern Avoid powders, health foods

23 Objectives of medical nutrition therapy in diabetes and pregnancy Determine energy needs Set appropriate weight goals Develop an individualised, nutritionally balanced plan Provide education concerning nutrition-related lifestyle issues Counsel on the importance of normoglycaemia before, during and after pregnancy Evaluate adherence to the meal plan

24 Exercise Walking Cycling About 10 minutes after each meal

25 Contraindications to exercise in pregnancy Risk of premature labour Cardiac disease Vaginal bleeding Placenta previa Hypertension Anaemia Intrauterine growth retardation Malpresentation Extreme obesity Extreme underweight

26 Exercise Benefits known to all, practised by none Rediscovering methods to prevent pregnancy loss and preterm labour Bed rest has other tangible benefits

27 Self-monitoring blood glucose: suggested frequencies Fasting 1 hour post-prandial Bedtime Preprandial, when indicated 3 am, when indicated

28 Targets Fasting: mg/dl Post-meal: <120 mg/dl (2 hour); <140 mg/dl (1 hour)

29 Glucose monitoring SMBG: Once diet therapy is started for efficacy (no evidence/guideline for monitoring in a diet-controlled patient) Fasting 1 hour or 2 hour post-meal (1 hour preferred as complications of macrosomia, neonatal hypoglycaemia and Caesarean delivery are directly related) De Veciana M et al. N Engl J Med 1995;333:

30 When to start drugs? When a fair trial of the diet and exercise has been conducted but failed to get the patient to the assigned target Glycaemic pattern is a guide to treatment: Post-prandial hyperglycaemia Fasting hyperglycaemia Both Glucometer, training on whom to contact and what to say!

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32 Which insulin, which regimen? Native/Analogue? Prandial Basal Basal bolus Premixed

33 Rapid-acting analogues More accurately target post-prandial blood sugars Provide more flexibility in meal timings Fewer hypoglycaemic episodes? Macrosomia No increased risk of worsening retinopathy Recommended by US and UK guidelines More useful when started before preconception?

34 Basal analogues Only one of the available basal analogues (detemir) is formally approved for use No unexpected or adverse maternal or fetal outcomes proven Women taking them preconception may continue to use them

35 Medical management The American Congress of Obstetricians and Gynaecologists Guidelines on Exercise During Pregnancy and Postpartum Period. Available at Accessed Insulin (human, lispro, aspart, detemir) Multiple dose: plain + intermediate acting CSII/insulin pump May require hospital management for rapid control Education and self-monitoring are a must Initiation and monitoring of insulin therapy in GDM is the same as standard care but glycaemic goals are stringent CSII, continuous subcutaneous insulin injection.

36 Which OAD? Metformin Acarbose Glibenclamide

37 OADs in diabetes Issues of control vs agent/means (placental transfer, maternal weight gain, hypoglycaemia) Metformin is often added for those with poor control despite high doses of insulin No acknowledgement of OADs by major guidelines May one day be approved given that they are more accepted and pose no major risks The saga of metformin the dilemma of a 4 months pregnant woman well controlled on OADs

38 Endocrine Society Guideline (2013): metformin in GDM Use only for the following: Non-satisfactory control with medical nutrition therapy (MNT) + exercise Those who refuse or cannot use insulin or glyburide and who are not in the first trimester Metformin freely crosses the placenta Increased rates of preterm low birth weight have been reported Blumer I et al. J Clin Endocrinol Metab 2013;98:

39 Glibenclamide in GDM Glyburide (glibenclamide) is a suitable alternative to insulin when insufficient glycaemic control has been achieved after adequate MNT + exercise It is not to be given if GDM is diagnosed before 25 weeks gestation and if FPG 110 mg/dl Evidence for use: Umbilical cord glibenclamide not detectable/very low Effective in controlling GDM, with favourable neonatal outcomes Meta-analysis of six RCTs supports use of glibenclamide in GDM Discuss with patients (lack of FDA approval) Not to be used in T2DM with pregnancy (no studies in T2DM with pregnancy) Neonatal hypoglycaemia, respiratory distress and greater need for NICU stay have been issues with glibenclamide Blumer I et al. J Clin Endocrinol Metab 2013;98: ; Castillo WC. JAMA 2015.

40 High-risk situations for hyperglycemia Stress Sympathomimetics (terbutaline, ephedrine) Steroids (e.g., betamethasone) Sepsis (infection) Stout (obesity) Advanced gestation (>24 weeks)

41 Recommendation for increased insulin needs with betamethasone Day 1 Day 2 Day 3 Day 4 Double insulin dose (if basic dose is 10 units, then give 20 units) Continue with increased dose; modify as needed for blood glucose (+) double dose of 20 units Decrease the previous increased dose by 50% and add to the basic dose (i.e., 15 units) Revert to betamethasone insulin dose and regimen (i.e., 20 units)

42 Management during labour Prevention of neonatal hypoglycaemia Blood glucose targets mg/dl Most GDM patients do not need insulin on the day of the procedure Requirements of pre-existing diabetics vary, as do those of T1DM patients (who must receive insulin at all times) Insulin must be given by infusion

43 It is difficult to make predictions

44 27-year-old female Comes to you with a sweet box for having managed her GDM well; she comes with her 14-day-old baby She is euglycaemic and off insulin She has not brought her records with her but you recall that her parents are under your care for diabetes She is obese Slide no 46

45 Her GDM preceded her T2DM Scheduled to have a GTT 4 weeks later, and the necessary action thereafter The following points discussed: Benefits of weight loss, even if GTT is normal Dietary plan (with her mother in attendance) Breastfeeding, child s diet and obesity prevention Slide no 47

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47 Postpartum follow-up Schedule visit after 6 12 weeks, perform GTT Normal annual follow-up with HbA1c and FPG Impaired 3 6-monthly HbA1c and FPG Diabetic treat appropriately

48 Contraception Low-dose oestrogen pills preferred Avoid progesterone-only pills Can use progesterone-containing IUCDs

49 Conclusions T2DM has assumed epidemic proportions and it is natural therefore that GDM is prevalent and needs universal screening The new criteria for diagnosis are simple and based on more relevant (fetal) outcomes Managing GDM poses challenges but also provides opportunities for better health, fostering interdisciplinary co-operation and understanding We are all involved up to delivery but the woman needs long-term care Cost containment should be seriously looked into

50 Many thanks For not snoring while asleep and letting others do the same!!

51 4-5 July 2015, Mumbai, India 2015 Asia Pacific Conference on Cardiometabolic Diseases Management IMPROVING THE PATIENT S LIFE THROUGH MEDICAL EDUCATION