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Gestational Diabetes Mellitus

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Gestational Diabetes Mellitus Among women diagnosed with GDM, one of the most commonly reported problems is fetal macrosomia. Excessive fetal growth remains a ... – PowerPoint PPT presentation

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Title: Gestational Diabetes Mellitus


1
Gestational Diabetes Mellitus
2
  • Dr. Hema Divakar

Director, Divakars Hospital for Women,
Bangalore. Secretary General, ICOG Former Vice
president FOGSI Lots of publication on Diabetes
in pregnancy
3
Gestational Diabetes Mellitus
  • Diagnosed first time in pregnancy
  • May not last after

4
incidence
  • West
  • India

5
Diabetes
  • The rate of GDM in Asian women is
  • 510 times higher than in white women 1

1.Reece EA et al.Lancet. 2009 373 17891797. 2.
Sela HY et al.Expert Rev of Obstet
Gynecol. 20094(5)547-554.
6
Screening
  • Universal
  • Selective ----- high risk

7
tests
  • GCT
  • OGTT
  • CC
  • NDDG
  • DIPSI

8
WHEN
  • Booking
  • 24 wks
  • Late ?

9
WHAT NEXT
  • DIET
  • INSULIN
  • SURVIELLENCE
  • Delivery
  • POSTPARTUM CARE

10
Diabetic mothers are at higher risk for caesarean
section
Women with diabetes have a less satisfactory
pregnancy outcome compared with the general
population and they have a 2.5-fold greater risk
of a perinatal mortality.
Dunne F, Brydon P, Smith K, et al. Diabet Med.
2003 Sep20(9)734-8.
de Valk HW, van Nieuwaal NH, Visser GH.Rev Diabet
Stud. 2006 Fall 3(3) 134142
11

Gestational Diabetes
  • The reported incidence of macrosomia (gt4000 g) in
    women with
  • GDM varies between 16 and 29, as against to 10
    rate
  • in women without GDM 1

1. Sela HY et al.Expert Rev of Obstet
Gynecol. 20094(5)547-554.
12
INTERVAL PERIOD
  • Preconceptional
  • HbA1 C
  • Cong malformations

13
High caesarean births Obesity to Blame?
Pre-eclampsia
Gestational diabetes
Thromboembolic disorders
Caesarean sections
Obesity
Low apgar scores
Macrosomia
Galtier-Dereure F, Boegner C, Bringer J. Am J
Clin Nutr. 200071(5 Suppl)1242S-8S.
Stagnation of induced labor
http//www.cdc.gov/reproductivehealth/maternalinfa
nthealth/PregComplications.htm
14
CASE ONE - Previous end trimester loss
  • 3.85 kg RDS neonatal death36 wks IUD - large
    baby

15
This time she reports to you at 8 wks gestation
  • You would (1) Do a clinical examination
    inclusive of PV(2) Ultrasound examination(3)
    First trimester biochemical tests(4) Any other
    investigations(5) Nothing now - will see later

16
  • Would you institute any treatment at this stage ?
  • Would you advice pregnancy termination if
    glycosylated Hb is 9.5 ?

17
Fetal Surveillance
  • Fetal age established by CRL scan
  • 11 14 wks NT scan
  • Anomalies ruled out
  • in Targeted scan

18
  • There is no increase in birth defects in
    offspring of diabetic fathers
  • prediabetic women and women who develop
    gestational diabetes after the first trimester,
  • suggesting that glysemic control during
    embryogenesis is the main factor in the genesis
    of diabetes-associated birth defects.

19
Evidence
  • Major congenital malformations
  • Preconception programme
  • Enhanced control
  • 1.2 Vs 10.9
  • -Kitzmiller/ Gavin - JAMA 1991

20
Preconceptional folic acid
  • RCT
  • Significant reduction in NTD
  • MRC vitamin study research group Lancet 1991

21
Prospective studies
  • NEng J
  • Obst/gynecol
  • Spontaneous abortions
  • Study group 7
  • Control group 24
  • Control of blood glucose/ HbA1C prepregnancy and
    in first trimester

22
Conclusion
  • GDM is an entity mandating universal screening
    meticulous follow-up to yield optimal outcome
  • Early diagnosis of gestational diabetes mellitus
    (GDM) is a prerequisite to reducing fetal and
    neonatal complications of
    GDM

23
Take Home
  • importance preconceptional counselling
  • and care during interval period and advice.

24
Interventions during pregnancyMonitoring/Screenin
g
  • Weighing pregnant women
  • Early OGTT
  • Early screening for vascular disease
  • Anomaly screening
  • High risk model of care with regular screening
    for preeclampsia early urinary protein
    estimation and baseline blood pressure
    measurement

25
  • Peripartum
  • Cesarean delivery
  • Failed vaginal birth after cesarean delivery
  • Operative morbidities
  • 1) Anesthesia complications
  • 2) Postpartum endometritis
  • 3) Wound breakdown
  • 4) Postpartum thrombophlebitis

26
Management at cesarean delivery
27
(2) CASE TWOPrevious mid trimester loss
  • History and documentation
  • very clearly suggestive of cervical incompetance

28
Present pregnancy - she presents at six weeks
  • You would
  • (1) Complete bed rest
  • (2) Progesterone support
  • (3) Cervical length assesment by scan
  • (4) Post her for cerclage
  • (5)Give tocolytics
  • (6) Give longterm antibiotics

29
Short cervix
30
Managing first trimester safely in BOH cases
  • Moderator
  • Dr. Hema Divakar
  • Hon. Sec. ICOG
  • President KSOGA- Karnataka

31
Pleasure to Introduce to you
  • R Dutta Ahmed              
  • Dr Surender kumar
  • Dr Abha Rani Sinha        
  • Dr Ramesh Ganapathy        
  • Dr Manpreet J Tehalia
  • Dr Smiti Nanda                  

32
  • So much new knowledge
  • Technological Advances

33
Abnormal cervical appearance
  • Shortening
  • Funneling
  • Dilatation of cervical canal.

Dynamic event
serial scans required
34
Cervical length normal values
  • 2.5 cms to 4.5cms
  • Ethnic difference seen in length varies with
    gestational age of pregnancy
  • Shortening seen from 30 wks onwards

35
Transvaginal USG of cervix
  • Closer to cervix
  • Higher resolution
  • Bladder should be empty
  • Distended bladder can elongate cx close the
    dilated OS

36
Etiology
  • Congenital disorders (congenital mullerian duct
    abnormalities)
  • DES exposure in utero.
  • Connective tissue disorder (Ehlers-Danlos
    syndrome)
  • Surgical trauma (conization, repeated
    cervical dilatation
    associated with
    termination of pregnancies)
  • Idiopathic (most)

37
ANATOMICAL CAUSES
  • 3 De Cherny 10 Hafer
  • Septum RPL rate reduced
  • Aschermans from 77.4 to 18.2
  • AJOG 2000
  • Hickok.
  • Highlights the role of
    laprohysteroscopic surgery.

38
Many uncertainties wrt uterine anomalies
  • incidence 1.8 - 37.6
  • ? Higher incidence associated with late
    miscarraiges
  • Recent evidence suggests high rates of
    miscarriage PTB in untreated cases
  • But open surgery associated with risk of
    infertility scar rupture during pregnancy
  • - hysteroscopic surgery averts the above
    risks
  • ?Role for HSG
  • Patient discomfort
  • Risk of infection
  • Radiation exposure
  • No more sensitive than 2D ultrasound in skilled
    hands.
  • ? A new role for 3D ultrasound

39
Cervical length Preterm Labor
  • lt 20 mm 100 PPV
  • gt 30 mm 100 NPV

Majority of women with short cervix and funneling
may not have preterm labor
40
  • Cervical weakness
  • Diagnosis based on history of late miscarriage,
    preceded by SROM
  • or painless cervical dilatation.
  • But
  • Over-diagnosed
  • No satisfactory test to identify women in the
    non-pregnant state
  • TVS might be useful but ultrasound-indicated
    cerclage has not been
    shown to improve perinatal
    survival
  • MRC/RCOG trial of elective cervical cerclage
    -
    small benefit

41
  • Transabdominal cerclage (for short and scarred
    cervix in women with previous failed
    transvaginal cerclage.
  • No controlled trials
  • Potential benefits must be weighed against high
    risks of operative complications

42
Take Home
  • Some situations are simple and straightforward
    and need specific action
  • Also the importance of clear documentation of
    previous loss

43
(3) CASE threePrevious four early pregnancy
losses
  • FHeart documented in all cases at around 7 to 8
    weeks By 9-10 weeks - no cardiac activity

44
Recurrent first trimester loss
  • 3 or more
    1 of couples
  • 2 or more
    3 of couples

45
  • Pre -Embryonic loss - (less than 6 weeks)
  • Embryonic loss - (6 8 weeks)
  • FP FH ?
  • gt8 weeks FH - APLA / Anatomic
  • but lost later others

46
APLA syndrome
  • Investigations
  • Aspirin heparin treatment
  • Adjuvant therapies if any
  • Prognosis

47
Lab. Tests to confirm
  • Lupus Anticoagulant aptt
  • aCL medium or high titer IgG
  • normal RPL
  • LA 1 2 16
  • aCL 2 - 4 20
    - Am J obg 1991

48
  • Primary Antiphospholipid Syndrome
  • Diagnosis
  • 2 positive tests at least 6 weeks apart
    for either LA and/or aPL (IgG and/or IgM class
  • NB test results
  • the dilute Russells viper venom time (dRVVT)
    is more sensitive and specific than either
  • aPTT or the KCL.
  • aPL are detected using standardised ELISA, but
    considerable
  • inter-laboratory variation due temporal
    fluctuation of a
  • PL titres in individual patients transient
    positive result due
  • to infections suboptimal sample collection
    lack of
  • standardisation of lab tests.

49
Informative investigations in RPL
  • Karyotype of couple
  • 2. Cytogenetic analysis of POC in all couples
    with a h/o RSM in the next pregnancy if that
    fails
  • 3. Pelvic ultrasound to assess uterine anatomy
    and ovarian morphology
  • 4. Screening for APS
  • 5. Screening for bacterial vaginosis

50
Non-informative investigations in RPL
  • Routine screening for thyroid antibodies
  • 2. Routine HLA typing of couple
  • 3. Routine screening for occult diabetes and
    thyroid
  • disease with OGTT or TFTs
  • 4. TORCH screening
  • 5. Routine thrombophilia screen

51
Early pregnancy support
  • Progesterone
  • Oral Depo
    Pessaries
  • Alleynesterol
  • hCG
  • Bed Rest
  • Low dose aspirin

52
  • 6 trials meta analysis
  • Exogenous Progesterone does not improve
    pregnancy outcome
  • ? Lack of controlled trials
  • ? Lack of Progesterone receptors

53
  • Micronised natural progesterone
  • logical support in LPD
  • Immunomodulation

54
Current concepts about implantation
  • Why did your mother reject you?
  • PIBF

55
Depot progesterone (17 OHC)
  • Improvement in Pregnancy outcome not
    statistically significant
  • -Resendus et al
  • Questionable efficacy
  • - Vytiska Binstorfer

56
  • Allylestrenol
  • Associated with congenital anomalies like
  • - club foot
  • - Hypospadias
  • Teratogenic
  • Contraindicated in Pregnancy
  • (Lewis 2000)

57
Current therapy
  • Empirical
  • Limited controlled prospective data
  • Directed at
  • Coagulation Mechanisms
  • Immunologic mechanisms
  • OR
  • Both

58
Systematic review of therapeutic trialsCochrane
controlled trials registerRCT / quasi RCT
total of 10 trials
  • 3 trials Aspirin alone
  • no significant reduction in pregnancy loss RR
    1.05
  • 5 trials Prednisolone Aspirin No
    significant reduction in pregnancy loss RR 0.
    85
  • BUT significant increase in prematurity RR 4.83
  • 2 trials Heparin Aspirin
  • significant reduction in
  • pregnancy loss RR 0.46

59
Update on management 2001 June
  • Sub cut. Heparin LDA Std. Rx
  • Prednisolone High risk of maternal / fetal
    complications
  • IVIG important additional Rx in those who
    failed with
    Heparin LDA
  • H/O previous thrombosis full therapeutic

  • anti-coagulation

60
Frequency of factors associated with recurrent
Loss
  • Chromosomal 3.5
  • Anatomical 1.6
  • Infection 0.5
  • Endocrine 20
  • Immunological 20
  • Idiopathic 43

61
  • 50 - no reason !
  • Role of TLC psychotherapy
  • Has to be taken more seriously

62
  • Unexplained RPL
  • Excellent prognosis (75) with
  • Supportive care
  • Dedicated early pregnancy assessment unit
  • NB
  • data is from non-randomised studies
  • prognosis worsens with increasing maternal age
  • prognosis worsens with increasing
  • number of previous miscarriages

63
Authors in study No. of Women Success Rate (TLC) Success Rate (controls)
Liddle et all (1991) 51 86 33
S. Pederson and Stray Pederson (1985) 408 85 36




64
What do you mean by TLC ?
  • Care provided in a specialized , dedicated
    clinic
  • Psychological support
  • Ample opportunity to discuss concerns
  • Close monitoring, including USG during the first
    trimester of pregnancy
  • Appropriate reassurance
  • Staff should be caring , helpful and
    never dismissive

    (Li T.C. Hum. Repod.1998)

65
Some cautionary issues in the management of RPL
  • Accepting blame / taking credit
  • 2. Excellent prognosis where no abnormality is
    detected
  • 3. The need to practice evidence-based medicine

66
THANKS
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