Gestational Diabetes. Benjamin Byers, D.O., FACOG Center for Maternal and Fetal Care Bryan Physician Network

Transcription

1 Gestational Diabetes Benjamin Byers, D.O., FACOG Center for Maternal and Fetal Care Bryan Physician Network

2 Outline Definition Prevalence Risk factors complications Diagnosis Management Nonpharmacologic Pharmacologic Antepartum surveillance Delivery

3 Introduction Pregnancy is accompanied by insulin resistance Growth hormone Corticotropin-releasing hormone Placental lactogen Progesterone Assure that the fetus has an adequate supply of nutrients

4 Diabetes develops during pregnancy in women whose pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state.

5 Definition and prevalence Gestational diabetes mellitus (GDM) Carbohydrate intolerance Diagnosed during pregnancy Prevalence Varies in direct proportion to the prevalence of type 2 DM in the population 90% of DM in pregnancy is GDM Ethnicity variance: Hispanic, African American, Asian, Native American Obesity Increasing prevalence: Obesity, sedentary lifestyle, delayed childbearing

6 5-6% of pregnancies in the USA Correlates with the prevalence of type 2 DM.

7 NE Diabetes Belt

8 Maternal complications Gestational hypertension and preeclampsia Polyhydramnios (high amniotic fluid) Cesarean delivery 50% risk of developing overt DM later in life

9 Fetal complications Miscarriage Congenital anomalies Macrosomia: birth weight > 4500 grams Neonatal hypoglycemia Hyperbilirubinemia Operative delivery Shoulder dystocia Birth trauma Neonatal respiratory problems Perinatal mortality

10 Polyhydramnios: excessive amniotic fluid

11 Congenital Anomalies Caudal Regression Syndrome from untreated diabetes in pregnancy Also known as sacral agenesis

12 Macrosomia

13 Macrosomia

14 Operative delivery Forceps, Vacuum, Cesarean Facial palsy from forceps delivery

15 Subgaleal hemorrhage from vacuum delivery. This baby died at 2 weeks of life.

16 Necrotizing fasciitis from infected cesarean incision % mortality This patient died.

17 Shoulder dystocia Erb s palsy from brachial plexus injury secondary to shoulder dystocia

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19 Risk factors for GDM Previously diagnosed with GDM: 33-50% recurrence risk Impaired glucose metabolism Obesity: BMI 30 kg/m2 Ethnicity: Hispanic-American, African-American, Native American, Asian, Pacific Islander Maternal age >25 Previous infant birth weight >9 lbs. Previous stillbirth or malformed infant The above patients may be candidates for early screening for GDM (1 st or early 2 nd trimester) If gestational diabetes mellitus is not diagnosed, blood glucose testing should be repeated at week of gestation.

20 How is GDM diagnosed? ALL pregnant women should be screened* Historical Patient s family history, personal medical history and OB history 1973: O Sullivan proposed the 50g, one hour glucose tolerance test 95% of OB providers use for ALL their patients

21 Two different approaches to diagnosis of GDM Two-step approach Traditional method in USA Step 1 50 grams Screening test If passes then no GDM If fails then might be GDM Step grams Diagnostic test GDM diagnosed if 2 of 4 values are elevated. One-step approach Proposed in gram test Significant increase in GDM diagnosis Not currently recommended by ACOG or SMFM

22 Two-step approach

23 Either one is okay! Select one for your practice/group 14-23% of patients will fail and need to perform Step 2

24 Either one is okay! Select one for your practice/group

25 One-step approach 2010, International Association of Diabetes and Pregnancy Study Group (IADPSG)* Based on data from the Hyperglycemia and Adverse Pregnancy Outcome study Endorsed by the American Diabetes Association (ADA) 18% of the US population would test positive for GDM

26 *

27 National organizations American College of Obstetricians and Gynecologists (ACOG) Two step International Association of Diabetes and Pregnancy Study Groups (IADPSG) One step American Diabetes Association (ADA) One or two step World Health Organization (WHO) One step Canadian Diabetes Association (CDA) Two step preferred; one step okay The Endocrine Society One step Australian Diabetes in Pregnancy Society (ADIPS) One step

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29 So which one to use?

30 2013: Eunice Kennedy Shriver National Institute of Child Health and Human Development Consensus Development Conference Continue the two-step approach No evidence that the one-step approach would lead to clinically significant improvements in maternal or newborn outcomes Significant increase in healthcare costs 15-20% prevalence ACOG supports the above More studies needed to confirm superiority (of the one step) National Institutes of Health Consensus Development Conference Statement. Diagnosing Gestational Diabetes Mellitus, March 4-6, Obstet Gynecol, Aug 2013

31 Dr. Byers s method

32 I can t drink that stuff Nausea and vomiting Dumping syndrome* Periodic fasting and postprandial finger sticks Fasting plasma glucose >85 Other methods of high glucose sources Jelly beans Soft drinks Not endorsed by the ADA or ACOG

33 So your patient has GDM now what? Are there benefits to treating GDM? Are there risks to treating GDM? 2005: Australian Carbohydrate Intolerance Study in Pregnant Women trial Randomized trial for GDM Treatment of GDM resulted in significant reduction in the composite primary outcome Perinatal death Shoulder dystocia Birth trauma (fracture and nerve palsy) Large-for-gestational-age (LGA) fetuses Maternal preeclampsia

34 2009: Eunice Kennedy Shriver NICHHD/Maternal-Fetal Medicine Network Randomized trial of 958 women with GDM Decreased frequency in the treatment-arm LGA infants Neonatal fat mass Cesarean delivery Shoulder dystocia Hypertensive disorders

35 2013: Systematic review and meta-analysis Treatment of GDM with nutrition therapy, self blood glucose monitoring, and insulin (if needed) Reductions in Preeclampsia (RR 0.62) Birth weight >4000 grams (RR 0.50) Shoulder dystocia (RR 0.42) Only potential harm Increased number of prenatal visits Hartling L et al. Benefits and harms of treating gestational diabetes mellitus. Ann Intern Med 2013; 159:123.

36 Optimal glycemic control = Better maternal and fetal outcomes Suboptimal glycemic control = Worse maternal and fetal outcomes

37 Risks for treating GDM Insulin and oral hypoglycemic medications Hypoglycemia Increased pregnancy surveillance false positive fetal testing increased labor induction failed labor induction cesarean delivery Postpartum hemorrhage, infection, hysterectomy, thromboembolism, placenta previa, uterine rupture Increased NICU admission rate Separates mom and baby, interrupts bonding

38 2013: ACOG practice bulletin #137 women in whom GDM is diagnosed should be treated with nutrition therapy and, when necessary, medication for both fetal and maternal benefit.

39 How should blood glucose be monitored? No consensus General recommendations based on expert opinion Finger stick blood glucose four times daily Fasting, postprandial each meal* Goal blood glucose values: Fasting: 95 mg/dl 1 hour: 140 mg/dl 2 hour: 120 mg/dl De Veciana et al. Postprandial versus pre-prandial blood glucose monitoring in women with gestational diabetes requiring insulin therapy. N Engl J Med 1995; 333:1237

40 Optimal glycemic control on diet alone? Consider decreasing the frequency of self blood glucose checks Increase patient convenience Decreased health care costs Every third day is reasonable Mendez-Figueroa H, et al. Comparing daily versus less frequent blood glucose monitoring in patients with mild gestational diabetes. J Matern Fetal Neonatal Med 2013; 26: 1268.

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42 What Nonpharmacologic treatments are effective? Nutrition therapy goals Achieve normoglycemia Prevent ketosis Provide adequate weight gain Contribute to fetal well-being Nutritional counseling by registered dietician Individualized treatment plan based on BMI

43 Three basic components Caloric allotment kcal/day* Carbohydrate intake Caloric distribution Carbohydrates: 33-40% Protein: 20% Fat: 40%

44 Complex carbohydrates preferred over simple carbohydrates* Less likely to cause postprandial hyperglycemia Three meals per day Two to three snacks per day Moderate exercise also recommended

45 Pay attention to subsequent changes in weight Retrospective cohort study of 31,000 women with GDM Appropriate weight gain: optimal outcomes Excessive weight gain: increase in LGA Preterm birth Cesarean delivery Institute of Medicine, Food and Nutrition Board, Committee on Nutritional Status During Pregnancy, part I; National Academy Press, Washington, DC 2000

46 What pharmacologic treatments are effective? Medications utilized when nutrition therapy fails to achieve normoglycemia No consistent threshold value at which clinicians should initiate medical therapy* Insulin therapy Historical treatment Oral agents May now be used as first-line therapy

47 Insulin Does not cross the placenta units/kg daily in divided doses Combination of intermediate-acting (NPH) and short (regular) or rapid (lispro, aspart) acting insulin*

48 {

49 Oral antidiabetic agents Increased usage in the USA Not FDA approved for GDM Glyburide and metformin most common No significant difference in glucose levels when compared in insulin No evidence for short term adverse outcomes Both can be considered for glycemic control in women with GDM Gestational Diabetes Mellitus. ACOG PB 137, 2013

50 Glyburide Sulfonylurea Increases insulin secretion from the pancreatic beta cells and increases insulin sensitivity in peripheral tissues Do not use if sulfa allergy! 20-40% will fail and need insulin* mg daily, typically BID

51 Metformin Biguanide Inhibits hepatic gluconeogenesis and glucose absorption Stimulates glucose uptake in peripheral tissues Typically used in two scenarios*: Pregestational DM Continue metformin Add insulin if needed Polycystic ovarian syndrome (PCOS) Continue metformin, but DC after 1 st trimester

52 Glyburide vs. metformin RCT Glyburide: 16% eventually needed insulin Metformin: 35% eventually needed insulin Glyburide may be superior to metformin in achieving satisfactory glycemic control. Moore et al. Metformin compared with glyburide in gestational diabetes: a randomized controlled trial. Obstet Gynecol 2010; 115:55.

53 However Glyburide does cross the placenta Umbilical cord analysis: no detectable glyburide So No short term adverse effects Unknown long-term effects*

54 Do I need to watch the GDM pregnancies closer? Antepartum fetal testing (APFT) recommended for pregestational DM GDM with good control APFT not needed GDM with suboptimal or poor control APFT indicated

55 My practice Diet controlled GDM (A1 GDM) Evaluate glucose logs each visit Fundal height measurements for fetal growth Await spontaneous labor APFT if undelivered by their due date Medication-controlled GDM (A2 GDM) Evaluate glucose logs each visit Serial US for fetal growth (4-6 weeks) APFT 32 weeks until delivery Delivery 39 weeks Rosenstein et al. The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. Am J Obstet Gynecol 2012; 206:309e1

56 APFT 32 weeks 1. Nonstress test 2x/week 2. Amniotic Fluid Index (AFI) ultrasound 1x/week

57 What about delivery? Macrosomia Birth trauma Shoulder dystocia Assess fetal growth in late 3 rd trimester Vaginal delivery in most cases ACOG PB 137 reasonable to recommend that women with GDM be counseled regarding the option of a scheduled cesarean delivery when the estimated fetal weight is 4,500 or more.

58 Glycemic monitoring during delivery Finger stick blood glucose every 2 hours while in labor Goal glucose level: If >120: insulin infusion Regular insulin: start at 1 unit/hour Check blood glucose every hour if insulin infusion

59 After delivery and beyond Most women with GDM are normoglycemic after delivery High risk of GDM in future pregnancies High risk of overt DM later in life (50%) All women with GDM should undergo a glucose tolerance test 6-12 weeks postpartum

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61 The future Develop an international diagnostic approach Patient benefit Would the increase in diagnosis of GDM by the IADPSG criteria lead to improved maternal-fetal outcomes? Cost benefit, cost effectiveness, cost utility Psychological and emotional outcomes Long-term maternal-fetal health concerns

62 Summary points Level A evidence (best) If GDM diagnosed, should treat with nutrition and medical therapy if needed Insulin or oral agents may be used, if needed Level B evidence (better) All pregnancies should be screened for GDM If fetal weight >4500 grams, consider cesarean Level C evidence (good) 1 hour test: 135 or 140 can be used as cut-off 3 hour test: Carpenter Coustan or NDDG values Glucose surveillance recommended Good glycemic control: no need to deliver early 6-12 weeks postpartum: screening for DM recommended

63 Thank You