Prevention and Management of Diabetes in Pregnancy

Transcription

1 Prevention and Management of Diabetes in Pregnancy Sridhar Chitturi Consultant Endocrinologist Royal Darwin Hospital

2 Outline of the talk Diabetes in Pregnancy Spectrum Diagnostic criteria Why bother about DIP Fetal complications Maternal complications Prevention GDM T2DM in women who had GDM Management

3 Diabetes in Pregnancy 1. Gestational Diabetes 2. Pre-existing IFG/IGT/Type 2 Diabetes 3. Pre-existing Type 1 Diabetes 4. Other rare forms of diabetes

4 The Confusion over diagnostic approach One step vs 2 steps approach (GCT and OGTT if needed) 2h 75gm OGTT vs 3h 100gm OGTT Single abnormal value vs 2 abnormal values Routine screening vs selective screening based on risk factors Different e diagnostic criteria and therapeutic targets are used in different countries

5 NEJM 2008; 358: HAPO Study

6 IADPSG GDM Overt Diabetes Plasma Glucose threshold % above threshold in HAPO Fasting hr hr HbA1c 65% 6.5% Plasma Glucose threshold Random Plasma glucose 11.1 Diabetes Care 2010, 33;

7 Why Bother About DIP

8 Possible fetal adverse outcomes include T1/T2DM Congenital Malformations Increased risk of miscarraige Preterm birth Still birth/iud (death after 20w gestation) IUGR Increased fetal size (macrosomia/lga) GDM Macrosomia Birth injury

9 Possible Neonatal Complications Hypoglycemia Hyperbilirubinemia Polycythemia Hypocalcemia Respiratory distress Birth injury DIP patients should deliver in a setup with good paediatric care

10 Future outlook for infant of DIP Increased incidence of Obesity T2DM in childhood/adolescence Inattention and hyperactivity

11 Possible maternal complications Common to GDM and DM: Increased interventions: LUSCS, forceps Increased risk of pre-eclampsia Polyhydramnios y T1/T2DM: Exacerbation of microvascular complications: Retinopathy Nephropathy Increased risk of metabolic complications DKA Hypoglycemia Exacerbation of underlying heart disease Increased risk of infectionspyelonephritis

12 Prevention of DIP

13 Predisposition for Diabetes Genetic Epigenetic- role of intrauterine environment Environmental factors Sedentary lifestyle Weight gain

14 Prevention of DIP Prevention of GDM Reproductive age women with high risk In women who had GDM in the past (likely to be cost effective) Prevention of T2DM in women who had Prevention of T2DM in women who had GDM

15 Identify Women at High Risk 1. Previous glucose intolerance/gdm 2. Signs of IR: obesity, skin tags, acanthosis nigricans 3. Diabetes in first degree relatives 4. Previous infant with macrosomia 5. Current glycosuria 6. PCOS 7. Race/ethnic group

16 Incorporate the Diabetes Prevention Strategies into existing Adult Checks High risk women in reproductive age group should be targeted for inclusion in programs to reduce calorie intake Increase physical activity Advice on pregnancy planning for women with pre-existing dysglycaemia (IFG/IGT/DM)

17 Future Risk of GDM and T2D Recurrence rates of GDM 1 Non Hispanic White: 30-37% Minority Populations: 52-69% Future risk of T2DM following GDM % risk of developing T2D in 5-10y Highest risk of future T2D after pregnancy in women diagnosed early in pregnancy IFG/IGT post partum, rising BGLs during follow up High BGLs needing insulin during pregnancy 1. Diabetes Care 30: , Diabetes Care 25: , 2002

18 Metformin Vs Intensive Lifestyle in Women with history of GDM in DPP J Clin Endocrinol Metab 93: , 2008

19 Lessons Learnt From Diabetes Prevention Studies Women with previous GDM are more likely to develop future T2DM than women with similar IFG/IGT who had no GDM Lifestyle and metformin are equally effective to prevent T2DM in women with GDM Diabetes prevention correlated more strongly with weight loss > diet change and exercise

20 Management of DIP Pre-conception care Care in pregnancy After delivery care

21 Pre-conception care for Diabetic women Unplanned pregnancies >>planned pregnancies even in pre-existing existing diabetics- major impediment for preconception care Glycemic goals; Aim for HbA1c <7% at the time of conception Commence BGL monitoring Initiate appropriate p therapy (diet, exercise, metformin and insulin) to achieve good glycemic control prior to conception Offer contraception till glycaemic goals are achieved Folate supplementation (5mg vs 1mg) in the first trimester Smoking and alcohol cessation Check B12 if woman is taking metformin

22 Pre-conception care for T2DM Medication review and substitute with drugs safe in pregnancy Stop ACEI, Statins, ARBs, SU Microvascular complications: Assess for retinopathy and nephropathy prior to pregnancy and in each trimester thereafter if they are already present Foot care advise Identify and adequately manage Co-morbidities: Hypertension Obesity Dyslipidemia Macrovascular complications: Optimize IHD and PVD treatment

23 Pre-conception care for T1DM As per T2DM, in addition refer to endocrinologist early Thyroid disease: TPO antibodies, FT4, TSH Coeliac disease

24 Management of Glycaemia Diet Exercise Pharmacological l intervention ti Insulin Oral agents Metformin Glibenclamide

25 Which Insulin Insulin Aspart trialled in pregnancy Lispro- recently approved by TGA for use in pregnancy (some concern about LGA compared to Human Insulin) Glargine not studied in pregnancy Detemir recently studied d in pregnancy 1 Rapid acting analogues much better at addressing the post meal BGL excursions Most common insulins we use are Protaphane and Aspart 1. Diabetes Care 35: , 2012

26 Insulin Regimens Individualise treatment based on need and acceptance by the patient Once daily intermediate/long acting insulin Twice daily pre-mixed insulin Basal bolus regimen with 1,2,3 or more boluses depending on the number of meals with significant CHO content Combination of oral agents and insulin

27 MIG Study Randomised open trial of 751 women with GDM diagnosed between 20 to 33 weeks of gestation Metformin (with supplemental insulin if required) vs insulin The primary outcome was a composite of neonatal hypoglycemia, respiratory distress, need for phototherapy, py, birth trauma, 5-minute Apgar score less than 7, or prematurity 363 women assigned to metformin, 92.6% continued to take it till term and 46.3% received supplemental insulin Metformin was not associated with increased perinatal complications as compared with insulin N Engl J Med 2008;358:

28 Glibenclamide in GDM Randomised trial of 404 women with singleton pregnancy Glibenclamide vs Insulin commenced between weeks gestation Comparable glycaemic control achieved with no significant differences in maternal and neonatal complications Cord serum insulin concentrations were comparable in 2 groups and Glib was not detected in cord serum of any infant in the Glib group N Engl J Med 2000;343:1134-8

29 Glycemic targets in Pregnancy Ideal: FPG <5.5 vs 5.0 (4-5.1) PPG <7 vs 6.7 (4-6.7) 67) BGL monitoring: FBG 2h AB, AL and AD If BGLs are outside target range > 1 occasion per week adjust OHA/insulin dose

30 Intervention Trials in GDM ACHOIS (Australia) 24-34w gestation Fasting <7.8, 2h at 2h Treatment targets Fasting/Pre meal <5.5 Post meal <7 Primary outcomes significantly better 1% vs 4% 1. N Engl J Med 2005;352: N Engl J Med 2009;361: MFMUN (USA) 24-31w gestation Fasting < AV on OGTT Treatment targets Fasting <5.3 Post meal < 6.7 Primary Outcome NS Secondary outcomes Wt, Wt >4kg, LGA and fat mass were less in intervention group

31 Care After The Delivery J Clin Endocrinol Metab, December 2011, 96(12):

32 Thank You