Title: Gestational Diabetes Mellitus
1Gestational Diabetes Mellitus
2Director, Divakars Hospital for Women,
Bangalore. Secretary General, ICOG Former Vice
president FOGSI Lots of publication on Diabetes
in pregnancy
3Gestational Diabetes Mellitus
- Diagnosed first time in pregnancy
- May not last after
4incidence
5Diabetes
- 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.
6Screening
- Universal
- Selective ----- high risk
7tests
8WHEN
9WHAT NEXT
- DIET
- INSULIN
- SURVIELLENCE
- Delivery
- POSTPARTUM CARE
10Diabetic 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.
12INTERVAL PERIOD
- Preconceptional
- HbA1 C
- Cong malformations
13High 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
15This 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 ? -
17Fetal 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.
19Evidence
- Major congenital malformations
- Preconception programme
- Enhanced control
- 1.2 Vs 10.9
- -Kitzmiller/ Gavin - JAMA 1991
20Preconceptional folic acid
- RCT
- Significant reduction in NTD
- MRC vitamin study research group Lancet 1991
21Prospective studies
- NEng J
- Obst/gynecol
- Spontaneous abortions
- Study group 7
- Control group 24
- Control of blood glucose/ HbA1C prepregnancy and
in first trimester
22Conclusion
- 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
23Take Home
- importance preconceptional counselling
- and care during interval period and advice.
24Interventions 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
26Management at cesarean delivery
27(2) CASE TWOPrevious mid trimester loss
- History and documentation
- very clearly suggestive of cervical incompetance
28Present 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
29Short cervix
30Managing first trimester safely in BOH cases
- Moderator
- Dr. Hema Divakar
- Hon. Sec. ICOG
- President KSOGA- Karnataka
31Pleasure 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
34Cervical 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
35Transvaginal USG of cervix
- Closer to cervix
- Higher resolution
- Bladder should be empty
- Distended bladder can elongate cx close the
dilated OS
36Etiology
- 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)
37ANATOMICAL 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. -
38Many 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
39Cervical 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
42Take 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
44Recurrent 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
46APLA syndrome
- Investigations
- Aspirin heparin treatment
- Adjuvant therapies if any
- Prognosis
47Lab. 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.
49Informative 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
50Non-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
51Early 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
54Current concepts about implantation
- Why did your mother reject you?
- PIBF
55Depot 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)
57Current therapy
- Empirical
- Limited controlled prospective data
- Directed at
- Coagulation Mechanisms
- Immunologic mechanisms
- OR
- Both
58Systematic 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
59Update 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
60Frequency 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
63Authors 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
64What 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)
65Some 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
66THANKS