Gestational Diabetes The Therapeutical Education “ in Team“ Obstetric Management in Women affected by Gestational Diabetes Dr. Lorella Battini, MD, Prof. of OGASH General Coordinator of OGASH Institutions Europe Chairman of OGASH Winner of Prof Joseph Jordania International Prize 2008 Nominated “OGASH Professor ” for the E.T. Rippmann Medal de Onoare Saluti e Ringraziamenti … Master for Sanitary Operators February 21, 2009 Pisa, Italy, Accademia Palace Hotel

Obstetric Management in Gestational Diabetes Bibliographical Sources Diabetes Care 30:S175-S179, 2007 DOI: 10.2337/dc07-s212 © 2007 by the American Diabetes Association Obstetric Management in Gestational Diabetes Deborah L. Conway, MD From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center–San Antonio, San Antonio, Texas DIABETES CARE, Ed. Italiana, All. a, ADA, maggio 2003 ACOG Practice Bulletin 2001 AOGOI, Rivista di Ostetricia Ginecologia Pratica e Medicina Perinatale, vol XXII, n° 3/4, 2007 NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period

“ Multidisciplinary Team Play Strategies” Optimizing outcomes for women with gestational diabetes mellitus (GDM) and their fetuses “ Multidisciplinary Team Play Strategies” careful metabolic management (Diabetologists) appropriately applied fetal surveillance techniques (Obstetrics ) thoughtful selection of the most advantageous timing and route of delivery In areas where high-level evidence is lacking, resources should be channeled to designing and implementing clinical studies to get at good answers. In this review, we examine what new information exists in the area of obstetric care of women with GDM since the time of the Fourth International Workshop-Conference in 1997 and highlight areas where there remains a need for sound evidence on which to base practice guidelines. Warning ! Whenever possible, these clinical decisions should be based on the highest level of evidence available and should weigh the likelihood and seriousness of both maternal and fetal/neonatal morbidity

1997- Workshop-Conference on GDM “ The summary statement ” “ the lack of data from controlled clinical studies on which management recommendations can be based was a prominent theme of discussion regarding antepartum management of GDM" (1). In this review, we examine what new information exists in the area of obstetric care of women with GDM since the time of the Fourth International Workshop-Conference in 1997 and highlight areas where there remains a need for sound evidence on which to base practice guidelines. In the end, consensus was reached in the following areas of obstetric management:

Major Risk Factors for GD OMS Age >35 years Istgrade family History : Diabetes Previous GDM Glycosuria Obesity: BMI>28 Macrosomia (>4 Kg) Significant weight increase in Pregnancy Acceleratad or dismorfic fetal growth History of unexplained stillbirth Preconceptional Planning EARLY GCT (50 gr) Negative GCT: Basal Value < 95 1 h post-load < 140 L’ottimizzazione dell’outcome materno-fetale nelle gravidanze con GD presuppone una diagnosi precoce dei maggiori fattori di rischio…per pianificare la gravidanza e intraprendere precocemente le procedure di screening

Screening GDM precoce UO Ost-Gin 2 AOUP Early Flow Chart GDM Screening Direttore: Dr. MG Salerno Screening GDM precoce Joint Diab/Obstet.Ambulatory AOUP Early GDM Screening FLOW CHART Flow Chart

ACOG Practice Bulletin 2001 Fetal surveillance All women with GDM should monitor fetal movements during the last 8–10 weeks of pregnancy and report immediately any reduction in the perception of fetal movements. Non-stress testing and / and/or CST and/or biophysical profile testing should be "considered" since 32 weeks’ gestation in women with poor glycaemic control, or on insulin, or who have concomitant perinatal risk factors Non-stress testing should be "considered" and "at or near" term in women requiring only dietary management and without concomitant perinatal risk factors ACOG Practice Bulletin 2001

Fetal surveillance Biophysical profile testing and/or Doppler velocimetry to assess umbilical blood flow "may be considered" in cases of “ excessive or poor fetal growth “, or when there are comorbid conditions, such as GESTOSIS SYNDROME ( “RIPPMANN ’s SYNDROME “ ) or obstetric history positive for further pathology

Fetal surveillance an optimal monitoring strategy, For uncomplicated, well controlled GDM, treated with only diet, and without further perinatal risk factors No sufficient evidence to propose an optimal monitoring strategy, thus the following chances are allowed: The same tests of complicated GDM since 32nd week of gestation Routine monitoring protocol of normal pregnancies ACOG Practice Bulletin 2001

Mode of Delivery in GD The presence of GDM is not by itself an indication for cesarean delivery. There are no data to support a policy of caesarean delivery purely on the basis of GDM However: MACROSOMIA SHOULDER DYSTOCIA CLAVICULAR FRACTURE BRACHIAL PALSY UNEXPLAINED INTRAUTERINE FETAL DEATH PERINATAL MORBIDITY are more common in women with GDM, therefore Elective Cesarean Delivery is reasonable when macrosomia has been detected (EFW>4500g), on the basis of obstetric history, pelvimetry and careful assessment of risk- benefits balance

Timing of Delivery in GD ADA, Official Position, 2003 GD is not an indication for caesarean or spontaneous delivery before 38 weeks’ gestation, in the absence of evidence of fetal compromise or other maternal risk factors. However Gestational prolonging beyond 38th weeks may lead to Increased risk of fetal macrosomia Without Reducing caesarean section risk Thus Delivery in the course of 38° week of gestation is recommended, unless obstetrical factors don’t indicate different management ACOG Pract. Bulletin, 2001: Not recommended delivery before 40 ws. in uncomplicated GD, without further maternal and/or fetal indications

Preexisting Diabetes Mellitus Summary of Management in Pregnancy Preconceptional Planning after optimizing HbA1C < 6.5g/dl (OMS) Multidisciplinary team approach and follow-up Strict and intensive SMBG Maintenance of blood glucose fasting value < 95-90 Maintenance of blood glucose 1h postprandial value < 130 Avoidance of hypoglycaemia 5 mg folic acid until 12 weeks gestation Physical activity planning Increased frequency of screening for retinopathy Intensive follow up for prevention and/or early detections of complications Delivery in III Level Obstetric Department with NICU Breast feeding recommended

Preexisting Diabetes: Monitoring fetal growth and well-being Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks Women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being.

Preexisting Diabetes: Timing and mode of birth pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks diabetes should not in itself be considered a contraindication to attempting vaginal birth pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section (1) NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period (2) NICE (July 2008 re-issued guidance). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period

The diagnostical-therapeutical route, Conclusion The diagnostical-therapeutical route, shared and managed by a multidisciplinar and multiprofessional team is the fundamental instrument to make safe pregnancy in diabetic women.

Conclusion A. The activation of a structured screening for GDM diagnosis is an essential instrument to avoid unappropriate and late OGTT check To early detect Patients affected by GDM and manage them to safe delivery B. Women affected by pregestational Diabetes Mellitus can live safe pregnancy and delivery, giving birth in a 3rd level Obstetric Unit linked to a Neonatal Intensive Care Unit

Saint Vincent Declaration, 1989 (OMS) Diabetic Woman in Pregnancy is a Patient “at risk” By Saint Vincent Declaration, in 1989, WHO addressed the following Mission to the International Scientifical Diabetology community: To dramatically reduce risk in diabetic women as that in non diabetics To early detect GDM For preventing adverse outcome in Mother and Babies by an adequate screening in “ women at risk “

THE JOINT INTERDEPARTMENT DIABETOLOGIC-OBSTETRIC SERVICE for DIABETES and PREGNANCY- AOUP-PISA G. Di Cianni, L. Volpe, A. Bertolotto, C.Lencioni, A. Ghio, V. Resi L. Battini Dietologist: M. Corfini Nurses: M. Carnevale, A. Civitelli, A. Favati, S. Nuvola, L. Tesi E in questa ottica, la nascita dell’Ambulatorio Diabetologico Ostetrico

Saint Vincent Declaration, 1989 (OMS) Yes, Together, We Can Thank You for Your Attention !