Gestational Diabetes: Diagnosis, Treatment Long Term Management, and Followup

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(No Transcript)
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Gestational DiabetesDiagnosis, TreatmentLong
Term Management, and Followup

• Eric Lind Johnson, M.D.
• Assistant Professor
• Department of Family and Community Medicine
• University of North Dakota School of Medicine
• And Health Sciences
• Assistant Medical Director
• Altru Diabetes Center
• Grand Forks, ND

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Objectives

• Discuss Gestational Diabetes Mellitus (GDM) and
  Treatment
• Recognize common problems of GDM in Pregnancy
• Discuss long term followup of Gestational
  Diabetes Mellitus (GDM)

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Gestational Diabetes Mellitus
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Gestational Diabetes

• Reduced sensitivity to insulin in 2nd and 3rd
  trimesters
• Diabetogenic State when insulin production
  doesnt meet with increased insulin resistance

Hod and Yogev Diabetes Care 30S180-S187,
2007 Crowther, et al NEJM 35224772486, 2005
Langer, et al Am J Obstet Gynecol 192989997,
2005
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Gestational Diabetes

• Human placental lactogen, leptin, prolactin, and
  cortisol result in insulin resistance
• Lack of diagnosis and treatment-increased risk of
  perinatal morbidities

Hod and Yogev Diabetes Care 30S180-S187,
2007 Crowther, et al NEJM 35224772486, 2005
Langer, et al Am J Obstet Gynecol 192989997,
2005
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Gestational Diabetes

• Occurs in 2-9 of pregnancies
• 135,000 cases in U.S. annually
• Management can include insulin (usually
  preferred, better efficacy) or sulfonylureas (in
  very select cases)

Am J Obstet Gynecol 19217681776, 2005 Diabetes
Care 31(S1) 2008 Diabetes Care 251862-1868,
2002
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Gestational Diabetes and Type 2 Diabetes Risk

• Gestational Diabetes should be considered a
  pre-diabetes condition
• Women with gestational diabetes have a 7-fold
  future risk of type 2 diabetes vs.women with
  normoglycemic pregnancy

Lancet, 2009, 373(9677) 1773-9
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Gestational Diabetes-Screening

• Screen all very high risk and high risk
• Very high risk Previous GDM, strong FH,
  previous infant gt9lbs
• High risk Those not in very high risk or low
  risk category

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Gestational Diabetes-Screening

• Low Risk (all of following)
• Age lt25 years
• Weight normal before pregnancy
• Member of an ethnic group with a low prevalence
  of diabetes

Diabetes Care 31(S1) 2008
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Gestational Diabetes-Screening

• Low Risk (all of following)(contd)
• No known diabetes in first-degree relatives
• No history of abnormal glucose tolerance
• No history of poor obstetrical outcome

Diabetes Care 31(S1) 2008
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Gestational Diabetes Screening

• 2 step approach
• oral glucose tolerance test (OGTT)
• 1) 50gm 1 hour OGTT
• 2) 100gm 2 hour OGTT

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Gestational Diabetes-Screening

• GDM screening at 2428 weeks
• Two-step approach
• 1) Initial screening plasma or serum glucose
• 1 h after a 50-g oral glucose load
• Glucose threshold
• 140 mg/dl identifies 80 of GDM
• 130 mg/dl identifies 90 of GDM

Diabetes Care 31(S1) 2008
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Gestational Diabetes-Screening

• GDM screening at 2428 weeks
• Two-step approach (contd)
• 2) 3 hour OGTT
• (100g glucose load)
• Fasting gt95 mg/dl (5.3 mmol/l)1 h gt180
  mg/dl (10.0 mmol/l)2 h gt155 mg/dl (8.6
  mmol/l)3 h gt140 mg/dl (7.8 mmol/l)

2 of 4 Diabetes
Care 31(S1) 2008
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Gestational Diabetes Management

• Dietician
• Diabetes Educator
• Consider referral to Diabetologist or
  Endocrinologist
• Moderate Physical Activity 30 minutes daily when
  appropriate

Summary and Recommendations of the Fifth
International Workshop-Conference on Gestational
Diabetes Mellitus Diabetes Care 30S251-S260,
2007
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Glucose Control in GDM

• Preprandial lt95 mg/dl, and either
• 1-h postmeal lt140 mg/dl
• or
• 2-h postmeal lt120 mg/dl and Urine ketones
  negative

Summary and recommendations of the Fourth
International Workshop-Conference on Gestational
Diabetes Mellitus. The Organizing Committee.
Diabetes Care 21(2)B161B167, 1998
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Gestational Diabetes-Medications

• Patients who do not meet metabolic goals within
  one week or show signs of excessive fetal growth
• Insulin has been the usual first choice
• Sulfonylureas (glyburide) may be used in select
  patients
• Other diabetes medications not recommended in GDM

Summary and Recommendations of the Fifth
International Workshop-Conference on Gestational
Diabetes Mellitus Diabetes Care 30S251-S260,
2007 Langer et al N Engl J Med 34311341138,
2000
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Diabetes MedicationsInsulins-Safety

• Aspart, Lispro, NPH, R, Lispro protamine all
  Category B and used in pregnancy
• All other insulins Category C
• Human Insulins-Least Immunogenic
• Breastfeed-All insulins considered safe

Data from Package Inserts
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Gestational Diabetes-Management

• Fasting, pre-meal, 2-hour post-prandial blood
  glucose probably all important
• Mean blood glucose gt105-115, greater perinatal
  mortality
• A1C in GDM probably not important

Am J Obstet Gynecol 19217681776, 2005 ADA
Position Statement Pettit, et al Diabetes Care
3458464, 1980 Karlsson, Kjellmer Am J Obstet
Gynecol 112213220, 1972 Langer, et al Am J
Obstet Gynecol 15914781483, 1988
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Insulin Dosing-GDM

• Insulin dosing
• Can use usual weight based dosing (i.e., 0.5
  u/kg)
• Practical dosing can be to start 10 units
  NPH with evening meal
• Most will titrate to BID, with eventual addition
  of
• Regular or Rapid Acting BID

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Alternate Insulin Dosing in GDM

• Regular or rapid acting (lispro or aspart) with
  meals, NPH at bedtime
• NPH Regular or rapid acting in AM, regular or
  rapid acting at supper, NPH at bedtime
• Titrate insulin based on SBGM values, tested
  fasting, pre-meal, 2 hour post-meal, bedtime,
  occasional 3 AM.

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Gestational Diabetes Complications
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GDM Complications

• Macrosomia
• Fractures
• Shoulder dystocia
• Nerve palsies (Erbs C5-6)
• Neonatal hypoglycemia
• Pregnancy outcomes can be very poor with
  HTN/nephropathy

Gabbe, Obstetrics Normal and Problem
Pregnancies 2002
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Gestational DiabetesOutcomes

• Hyperglycemia and Adverse Pregnancy Outcomes
  (HAPO) Study 28,000 women
• Four primary outcomes
• 1) weight above the 90th percentile for
  gestational age
• 2) primary cesarean delivery
• 3) clinical neonatal hypoglycemia
• 4) cord-blood serum C-peptide level above the
  90th percentile (fetal hyperinsulinemia)

NEJM (358) 2008
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Gestational DiabetesOutcomes

• Hyperglycemia and Adverse Pregnancy Outcomes
  (HAPO)
• Five secondary outcomes
• 1)premature delivery (before 37 weeks)
• 2)shoulder dystocia or birth injury
• 3)need for intensive neonatal care
• 4)hyperbilirubinemia
• 5)preeclampsia

NEJM (358) 2008
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HAPO Primary and Secondary Outcomes
NEJM (358) 2008
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Gestational Diabetes Post-natal

• GDM is a prediabetes syndrome
• Some women will have frank type 2 diabetes
  presenting in pregnancy
• Blood glucose testing first few days after
  delivery

Kitzmiller, et al Diabetes Care 30S225-S235,
2007
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GDM Post-natal and Long Term
Followup
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Gestational Diabetes Post-natal

• Fasting glucose rechecked 6-12 weeks following
  delivery
• Every 6 months thereafter to be screened for type
  2 diabetes
• Higher risk of developing Type 2 Diabetes

Kitzmiller, et al Diabetes Care 30S225-S235,
2007
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Case Study

• 28 y/o caucasian female
• 2nd pregnancy
• 1st pregnancy at age 22, term male infant, 10 lbs
  2oz, normal delivery
• Thinks had high blood sugar
• Very high risk (gt9 lb infant, possible GDM)

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Case Study

• No other significant medical history No
  tobacco
• Physical Exam VS normal
• 5 2
• 210 lbs
• BMI 38.4
• Remainder consistent with 12 weeks
  gestation

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Case Study

• 26 weeks, no problems, maybe slightly large for
  dates
• 12 lb weight gain
• Went directly to 3 hour GTT (100g)

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Case Study

• FBG 94 ( gt 95)
• 1 hour 192 (gt180)
• 2 hour 160 (gt155)
• 3 hour 149 (gt140)
• 3 of 4 values abnormal GDM

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Case Study

• Referred to Diabetes Educator and Dietician
• SMBG FBG, pre-meal, 2 hour post-prandial, HS, 3
  am prn
• Meal Plan
• No contraindications to exercise, encouraged to
  walk 15 min/daily

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Glucose Control in GDM

• Preprandial lt95 mg/dl, and either
• 1-h postmeal lt140 mg/dl
• or
• 2-h postmeal lt120 mg/dl and Urine ketones
  negative

Summary and recommendations of the Fourth
International Workshop-Conference on Gestational
Diabetes Mellitus. The Organizing Committee.
Diabetes Care 21(2)B161B167, 1998
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Case Study

• Returns one week later
• Has been following meal plan 90
  of time
• Has walked 15 minutes 2 times
• Has 4 FBG gt 100
• 6 other values above target

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Case Study

• Referred to Diabetes Educator for insulin
  start
• NPH 10 units, 3 units Insulin aspart BID
• Phone followup q 3 days
• Continues appropriate clinic appointments

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Case Study

• 1-2 SMBG values out of target 1st week
• 3 weeks later, FBG, 2 hour post lunch and 2 hour
  post supper elevated about 50 of time
• NPH increased in PM (or could move to HS),
  insulin aspart added at lunch (2 or 3 units) and
  increased at supper

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Case Study

• Normal vaginal delivery at 38 weeks
• 8lb 10oz healthy female infant
• Patients FBS day after delivery 90
• Enrolled in Diabetes Prevention Program
• Converted to type 2 diabetes 2 years later
• Had lap-band 4 years later

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Gestational Diabetes MellitusRisk of Type 2
Diabetes

• Meta analysis 20 studies 675,455 women
• 7-fold increase in risk of type 2 diabetes
  following gestational diabetes vs. normoglycemic
  pregnancy
• Post pregnancy surveillance important

Bellamy, L. et al. Lancet, 2009, 373(9677) 1773-9
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5 Reasons to perform glucose tolerance testing
after pregnancies complicated by GDM

• 1) The substantial prevalence of glucose
  abnormalities detected by 3 months postpartum.
• 2) Abnormal test results identify women at high
  risk of developing diabetes over the next 510
  years (15-50 risk)
• 3)Ample clinical trial evidence in women with
  glucose intolerance that type 2 diabetes can be
  delayed or prevented by lifestyle interventions
  or modest and perhaps intermittent drug therapy.

Kitzmiller, et al Diabetes Care 30S225-S235,
2007 Kim et al Diabetes Care 251862-1868,
2002 Lauenborg, et al Diabetes Care 271194-1199,
2004
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5 Reasons to perform glucose tolerance testing
after pregnancies complicated by GDM contd

• 4) Women with prior GDM and IGT or IFG have CVD
  risk factors. Interventions may also reduce
  subsequent CVD, which is the leading cause of
  death in both types of diabetes. GDM 71 higher
  risk of future CVD-other risk factors (HTN,
  lipids, smoking) assessed and managed
• 5) Identification, treatment, and planning
  pregnancy in women developing diabetes after GDM
  should reduce subsequent early fetal loss and
  major congenital malformations.

Kitzmiller, et al Diabetes Care 30S225-S235,
2007 Shah, et al Diabetes Care 311668-1669, 2008
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Type 2 Diabetes Prevention

• Lifestyle- over 50 reduction of future type 2
  diabetes
• Bariatric (Lap-Band-future preg?)- strong
  consideration in BMI gt40 or gt35 with co-morbid
  conditions
• Future treatments/prevention- no current
  medication role, possible in future

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Diagnosis Guidelines

• Category FPG (mg/dL)
• Normal lt100
• Impaired Fasting Glucose (IFG) 100 125
• Diabetes gt126
• OR A1C gt6.5
• On 2 separate occasions

American Diabetes Association
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Initial Type 2 Diabetes Treatment

• Current guidelines (ADA/EASD, AACE) recommend
  metformin at diagnosis in additional to lifestyle
  management
• Diabetes Educator/Dietician
• Eye Exam
• Evaluation of cholesterol and blood pressure

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Key References

• Summary and Recommendations of the Fifth
  International Workshop-Conference on Gestational
  Diabetes Mellitus
• Diabetes Care July 2007
  30S251-S260
• American Diabetes Association Consensus Statement
  Pre-existing DM in Pregnancy
• Diabetes Care May 2008 vol.
  31 no. 5 1060-1079
• American Diabetes Association
  Clinical Practice
  Recommendations
• http//care.diabetesjournals.org/content/33/Supple
  ment_1 2010
• International Diabetes Federation
• http//www.idf.org/global-guideline-pregnancy-and-
  diabetes 2009

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Summary

• GDM Meet targets, avoid hypoglycemia, reduce
  risk of complications
• GDM is a pre-diabetes syndrome
• Many women with GDM will go on to have repeat GDM
  or type 2 DM and have CVD risk

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Acknowledgements

• William Zaks, M.D., Ph.D.,
• Assistant Medical Director
• Altru Diabetes Center
• Grand Forks, ND
• Slide and Content Review

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Contact Info/Slide Decks/Media

• e-mail
• eric.l.johnson_at_med.und.edu
• ejohnson_at_altru.org
• Phone
• 701-795-2861 or 701-777-3811
• Slide Decks (Diabetes, Tobacco,
  other)http//www.med.und.edu/familymedicine/slide
  decks.html
• iTunes Podcasts (Diabetes)http//www.med.und.edu/
  podcasts/ or iTunesgtgtsearch UND Medcast (1/21/10
  release)
• WebMD Pagehttp//www.webmd.com/eric-l-johnson
• Diabetes e-columns (archived)
• http//www.ndhealth.gov/diabetescoalition/DrJohnso
  n/DrJohnson.htm