1. GDM Gestational Diabetes Mellitus Dr. Mouna Dakar

2. GDM 2 parts: Preexisting DM and pregnancy Gestational diabetes

3. GDM Glucose Intolerance in Pregnancy www.drsarma.in 3 Prevalence of GDM 3 to 18 %

4. GDM Diabetes in pregnancy Pre-existing diabetesGestational diabetes Pre-existing diabetes IDDM (Type1) NIDDM (Type2) True GDM

5. GDM GDM - Definition Distinguish GDM from Pre-gestational DM Abnormal Glucose Tolerance Onset (begins) with pregnancy or Detected first time during pregnancy No h/o of pre pregnancy DM or IGT Hb A 1 c is usually < 7.5 in GDM In DM + Pregnancy it is > 7.5 GDM is a forerunner of T2DM www.drsarma.in 5

6. GDM Risk Stratification for GDM High Risk Group (Indians mostly) –BMI  30; PCOD; Age > 35 years –F h/o DM; Ethnic predisposition; Acanthosis –Previous h/o GDM, IGT, Macrosomic baby Low Risk Group –Age < 25, BMI < 23, No F h/o DM or IGT –No bad obstetric history; No ↑ risk ethnicity Intermediate Risk Group –Not falling in the above two classes www.drsarma.in 6 Adopted from ADA guidelines

7. GDM Whom to Screen for GDM ? Low Risk Group –No screening required for GDM Intermediate Risk Group –Screen around 24–28 weeks of gestation High Risk Group –As soon as possible after conception –Must - before 24–28 weeks of gestation –Better do a full 3 hr OGTT for GDM –If negative – screening in 2 nd & 3 rd trimester www.drsarma.in 7 Adopted from ADA guidelines

8. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. ENDOCRINE PRACTICE Vol 21 No. 4 April 2015 American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan Writing Committee Cochairpersons Yehuda Handelsman MD, FACP, FACE, FNLA Zachary T. Bloomgarden, MD, MACE George Grunberger, MD, FACP, FACE Guillermo Umpierrez, MD, FACP, FACE Robert S. Zimmerman, MD, FACE 8

9. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Diagnostic Criteria for Gestational Diabetes TestScreen at 24-28 weeks gestation FPG, mg/dL>92 1-h PG*, mg/dL≥180 2-h PG*, mg/dL≥153 *Measured with an OGTT performed 2 hours after 75-g oral glucose load. FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose. Q1. How is diabetes screened and diagnosed? 9

10. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. AACE. Endocrine Pract. 2010;16:155-156. AACE Recommendations for A1C Testing A1C should be considered an additional optional diagnostic criterion, not the primary criterion for diagnosis of diabetes When feasible, AACE/ACE suggest using traditional glucose criteria for diagnosis of diabetes A1C is not recommended for diagnosing type 1 diabetes A1C is not recommended for diagnosing gestational diabetes 10 Q1. How is diabetes screened and diagnosed?

11. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Outpatient Glucose Targets for Pregnant Women ConditionTreatment Goal Gestational diabetes mellitus (GDM) Preprandial glucose, mg/dL≤95* 1-Hour PPG, mg/dL≤140* 2-Hour PPG, mg/dL≤120* Preexisting T1D or T2D Premeal, bedtime, and overnight glucose, mg/dL60-99* Peak PPG, mg/dL100-129* A1C≤6.0%* 11 FPG = fasting plasma glucose; PPG = postprandial glucose. *Provided target can be safely achieved. Q17. How should diabetes in pregnancy be managed?

12. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Glycemic Targets During Pregnancy: AACE & ADA Guidelines 1,2 Glucose Increment Patients with GDM Patients with Preexisting T1DM or T2DM Preprandial, premeal ≤95 mg/dL (5.3 mmol/L)Premeal, bedtime, and overnight glucose: 60-99 mg/dL (3.4-5.5 mmol/L) Postprandial, post-meal 1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or 2-hour post-meal: ≤120 mg/dL (6.7 mmol/L) Peak postprandial glucose 100-129 mg/dL (5.5-7.1 mmol/L) A1CA1C ≤6.0% 1.AACE. Endocr Pract. 2011;17(2):1-53. 2.ADA. Diabetes Care. 2013;36(suppl 1):S11-66.

13. GDM Diagnosis GDM Diagnostic Criteria for OGTT Testing 75-g 2-hour*100-g 3-hour † Fasting plasma glucose (FPG)≥92 mg/dL (5.1 mmol/L)≥95 mg/dL (5.3 mmol/L) 1-hour post-challenge glucose≥180 mg/dL (10.0 mmol/L) 2-hour post-challenge glucose≥153 mg/dL (8.5 mmol/L≥155 mg/dL (8.6 mmol/L) 3-hour post-challenge glucose≥140 mg/dL (7.8 mmol/L) *A positive diagnosis requires that test results satisfy any one of these criteria. † A positive diagnosis requires that ≥2 thresholds are met or exceeded. AACE, American Association of Clinical Endocrinologists; ACOG, American College of Obstetrics and Gynecology; ADA, American Diabetes Association; GCT, glucose challenge test; GDM, gestational diabetes mellitus; OGTT, oral glucose tolerance test. Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87. ADA. Diabetes Care. 2015;38(suppl 1):S77-S79. Committee on Obstetric Practice. ACOG. 2011;504:1-3. 2 Approaches for Diagnosing GDM AACE- and ADA- recommended 1-step 75-g 2-hour OGTT ACOG- recommended 2 steps: a 50-g 1-hour GCT, followed by a 100-g 3-hour OGTT (if necessary) 13

14. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Treatment of DM During Pregnancy All women with T1D, T2D, or previous GDM should receive preconception care to ensure adequate nutrition and glucose control before conception, during pregnancy, and in the postpartum period Use insulin to treat hyperglycemia in T1D and T2D and when lifestyle measures do not control glycemia in GDM Basal insulin: NPH or insulin detemir Prandial insulin: insulin analogs preferred, but regular insulin acceptable if analogs not available 14 Q17. How should diabetes in pregnancy be managed?

15. Gestational Diabetes Mellitus Screening GDM, gestational diabetes mellitus. Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87. ADA. Diabetes Care. 2015;38(suppl 1):S77-S79. Diabetes risk assessment High risk Screen at confirmation of pregnancy Positive for GDM Negative for GDM Average to low risk Screen at 24 to 28 weeks gestation Positive for GDM Treat Negative for GDM Postpartum Screen for diabetes at 6-12 weeks Lifelong screening for diabetes every 3 years Prediabetes Diabetes Normoglycemia Treat 15

16. Canadian Diabetes Association Clinical Practice Guidelines Pharmacologic Management of Type 2 Diabetes Chapter 13 (Updated July 2015) William Harper, Maureen Clement, Ronald Goldenberg, Amir Hanna, Andrea Main, Ravi Retnakaran, Diana Sherifali,Vincent Woo, Jean-François Yale 2015

17. Canadian Diabetes Association Clinical Practice Guidelines Pregnancy Chapter 36 David Thompson, Howard Berger, Denice Feig, Robert Gagnon, Tina Kader, Erin Keely, Sharon Kozak, Edmond Ryan, Mathew Sermer, Christina Vinokuroff

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association In collaboration with …

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: 2 Categories Pregestational diabetesGestational diabetes Pregnancy in pre-existing diabetes Type 1 diabetes Type 2 diabetes Diabetes diagnosed in pregnancy

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: Consider Phases Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations Diabetes in Pregnancy: Consider Phases

22. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Dysglycemia in Pregnancy can Result in Adverse Pregnancy Outcome Elevated glucose levels can have adverse effects on the fetus – 1 st trimester  ↑ fetal malformations – 2 nd and 3 rd trimester: ↑ risk of macrosomia and metabolic complications

23. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 1-2: Preconception Care 1.All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of glycemic control prior to pregnancy, impact of BMI on pregnancy outcomes, need for folic acid and the need to stop potentially embyropathic drugs prior to pregnancy [Grade D, Level 4]. 2.Women with type 2 diabetes and irregular menses/PCOS who are started on metformin or a thiazolidinedione should be advised that fertility may improve and be warned about possible pregnancy [Grade D, Consensus].

24. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 3: Preconception Care 3. Before attempting to become pregnant, women with type 1 or type 2 diabetes should: a)Receive preconception counseling that includes optimal diabetes management and nutrition, preferably in consultation with an interdisciplinary pregnancy team to optimize maternal and neonatal outcomes [Grade C, Level 3]

25. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 3: Preconception Care (continued) b)Strive to attain a preconception A1C of ≤7.0% (or A1C as close to normal as can safely be achieved) to decrease the risk of: – Spontaneous abortion [Grade C, Level 3] – Congenital anomalies [Grade C, Level 3] – Pre-eclampsia [Grade C, Level 3] – Progression of retinopathy in pregnancy [Grade A, level 1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association c) Supplement their diet with multivitamins containing 5 mg of folic acid at least 3 months pre- conception and continuing until at least 12 weeks post-conception [Grade D, Level 4]. Supplementation should continue with a multivitamin containing 0.4- 1.0 mg of folic acid from 12 weeks postconception through to 6 weeks postpartum or as long as breastfeeding continues [Grade D, Consensus]. Recommendation 3: Preconception Care (continued)

27. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association d) Discontinue medications that are potentially embryopathic, including any from the following classes: ACE inhibitors and ARBs prior to conception or upon detection of pregnancy [Grade C, Level 3] Statins [Grade D, Level 4] Recommendation 3: Preconception Care (continued)

28. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 4.Women with type 2 diabetes who are planning a pregnancy should switch from non-insulin antihyperglycemic agents to insulin for glycemic control [Grade D, Consensus]. Women with pregestational diabetes who also have PCOS may continue metformin for ovulation induction [Grade D, Consensus]. Recommendation 4: Preconception Care

29. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 5 and 6: Preconception and Complications 5.Women should undergo an ophthalmological evaluation by an eye care specialist [Grade A, Level 1, for type 1; Grade D, Level 4 for type 2]. 6.Women should be screened for chronic kidney disease prior to pregnancy [Grade D level 4 for type 1 diabetes Grade D, consensus for type 2 diabetes]. Women with microalbuminuria or overt nephropathy are at increased risk for the development of HTN and preeclampsia [Grade A level 1]; and should be followed closely for these conditions [Grade D, Consensus]

30. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Screen for Complications: Pre-pregnancy and Intrapartum Screening for: 1.Retinopathy: Need ophthalmological evaluation 2.Nephropathy: Assess creatinine + urine microalbumin / creatinine ratio (ACR) – Women with microalbuminuria or overt nephropathy are at ↑ risk for hypertension and preeclampsia

31. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: Consider Phases Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations

32. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: Consider Phases Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations

33. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 7: Management in Pregnancy for Pregestational Diabetes 7.Pregnant women with type 1 or type 2 diabetes should: a)Receive an individualized insulin regimen and glycemic targets typically using intensive insulin therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2] b) Strive for target glucose values [Grade D consensus]: Fasting PG below 5.3 mmol/L 1h postprandial below 7.8 mmol/L 2h postprandial below 6.7 mmol/L

34. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes Individualized insulin therapy with close monitoring – Bolus insulin: May use aspart or lispro instead of regular insulin – Basal insulin: May use detemir or glargine as alternative to NPH Encourage patients to SMBG pre- and postprandially Target glucose values Fasting PG <5.3 mmol/L- 95 1h postprandial PG <7.8 mmol/L - 140 2h postprandial PG <6.7 mmol/L- 120

35. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 7: Management in Pregnancy for Pre-gestational Diabetes (continued) c) Be prepared to raise these targets if need be because of the increased risk of severe hypoglycemia during pregnancy [Grade D, Consensus] d) Perform SMBG, both pre- and postprandially to achieve glycemic targets and improve pregnancy outcomes [Grade C, Level 3]

36. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 8.Women with pregestational diabetes may use aspart or lispro in pregnancy instead of regular insulin to improve glycemic control and reduce hypoglycemia [Grade B aspart, Grade B, for lispro]. 9.Detemir [Grade B, Level 2] or glargine [Grade C, Level 3 ] may be used in women with pregestational diabetes as an alternative to NPH. Recommendations 8-9: Management in Pregnancy for Pre-gestational Diabetes

37. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 10.Women should be closely monitored during labour and delivery and maternal blood glucose levels should be kept between 4.0(70) and 7.0(126) mmol/L in order to minimize the risk of neonatal hypoglycemia [Grade D, Consensus] 11.Women should receive adequate glucose during labour in order to meet the high energy requirements [Grade D, Consensus] Recommendation 10 and 11: Intrapartum Glucose Management

38. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 12 and 13: Postpartum Glucose Management 12.Women with pregestational diabetes should be carefully monitored postpartum as they have a high risk of hypoglycemia [Grade D, Consensus]. 13.Metformin and glyburide may be used during breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for glyburide].

39. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Postpartum care for pre-existing diabetes 1. Adjust insulin  at risk of hypoglycemia 2. Encourage women to breastfeed 3.Metformin and glyburide may be used during breast- feeding  no long term data but appears safe 4.Screen for postpartum thyroiditis in T1DM  check TSH at 6-8 weeks postpartum

40. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 14 and 15: Postpartum Glucose Management 14.Women with type 1 diabetes in pregnancy should be screened for postpartum thyroiditis with a TSH test at 6-8 weeks postpartum [Grade D, Consensus]. 15.All women should be encouraged to breast-feed, since this may reduce offspring obesity, especially in the setting of maternal obesity [Grade C level 3-]

41. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: Consider Phases Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening & diagnosis 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations

42. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Why Diagnose and Treat GDM? Macrosomia Shoulder dystocia and nerve injury Neonatal hypoglycemia Preterm delivery Hyperbilirubinemia Caesarian section Offspring obesity (?) Offspring diabetes (?)

43. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association HAPO: Incidence of Adverse Outcomes Increases Along Continuum Metzger BE, et al. Hyperglycemia and Adverse Pregnancy Outcomes. NEJM 2008;358(19):1991-2002.

44. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Are there clear threshold glucose levels above which the risk of adverse neonatal or maternal outcomes increases? Diagnosis of GDM

45. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes Care 2010;22:676-682 IADPSG

46. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association HAPO: Incidence of Adverse Outcomes Increases Along Continuum – No Threshold Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.

47. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Are there clear threshold glucose levels above which the risk of adverse neonatal or maternal outcomes increases?

48. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 CDA Diagnostic Criteria for GDM PREFERRED APPROACH (2 steps) 1.50 gram glucose challenge test 2.75 gram oral glucose tolerance test –Using thresholds of OR 2.0 ALTERNATIVE APPROACH (1 step) 1.75 gram oral glucose tolerance test –Using thresholds of OR 1.75

49. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Two Approaches

50. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

51. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

52. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

53. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

54. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

55. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM Diagnosis: Preferred Approach

56. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM diagnosis: Alternative Approach

57. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM diagnosis: Alternative Approach

58. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 16-17: Diagnosis of GDM 16.All pregnant women should be screened for GDM at 24-28 weeks of gestation [Grade C, Level 3]. 17.If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy [Grade D, Consensus]. If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between 24-28 weeks of gestation. (see next slide)

59. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 17: Risk Factors for GDM (continued) Age ≥35 years Previous GDM Prediabetes High risk population – Aboriginal, Hispanic, South Asian, Asian, African BMI ≥30 kg/m 2 Polycystic ovarian syndrome Acanthosis nigricans Corticosteroid use History of macrosomic infant Current fetal macrosomia or polyhydramnios [Grade D, Consensus]

60. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 18: Diagnosis of GDM 18.The preferred approach for the screening and diagnosis of GDM is the following [Grade D, Consensus]: a)Screening for GDM should be conducted using the 50 g glucose challenge test (GCT) administered in the non- fasting state with plasma glucose measured one hour later [Grade D, Level 4]. A plasma glucose value ≥7.8 mmol/L at one hour will be considered a positive screen and will be an indication to proceed to the 75 gram OGTT [Grade C, Level 2]. A plasma glucose value >11.1 mmol/L can be considered to be diagnostic of gestational diabetes and does not require a 75 gram OGTT for confirmation [Grade C, Level 3].

61. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 18: Diagnosis of GDM (continued) b)If the GCT screen is positive, a 75 gram OGTT should be performed as the diagnostic test for GDM using the following criteria: >1 of the following values: – Fasting >5.3 mmol/L, – 1h >10.6 mmol/L, – 2h >9.0 mmol/L [Grade B, Level 1]

62. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 19: Diagnosis of GDM 19.An alternative approach that may be used to screen and diagnose GDM is the one-step approach [Grade D, Consensus]: a)A 75 gram OGTT should be performed (with no prior screening 50g GCT) as the diagnostic test for GDM using the following criteria [Grade D, Consensus]: ≥1 of the following values: –Fasting > 5.1 mmol/L, –1h > 10.0 mmol/L, –2h > 8.5 mmol/L [Grade B, Level 1 (4)]

63. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association World Health Organization (WHO) Australasian Diabetes in pregnancy society Diabetes in pregnancy study group of India International Association of Diabetes and Pregnancy study group (IADPSG) American Diabetes Association (ADA) ALL SUPPORT 75G ONE STEP TESTING AND THE USE OF THE A1C AT THE FIRST VISIT

64. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Americal Congress of Obstetricians and Gynecologists (ACOG) Supports 2 step testing It is estimated that if 75g single step testing is implemented the prevalence of GDM is expected to increase to 20% or higher.

65. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Pregnancy: Consider Phases Pregestational diabetesGestational diabetes 1. Preconception counseling1. Screening & diagnosis 2. Glycemic control during pregnancy 3. Management in labour 4. Postpartum considerations

66. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pre-Pregnancy BMIRecommended range of total weight gain (Kg) Recommended range of total weight gain (lb) BMI <18.512.5 – 18.028 – 40 BMI 18.5 - 24.911.5 – 16.025 – 35 BMI 25.0 - 29.97.0 – 11.515 – 23 BMI > or = 305.0 – 9.011 – 20 Recommended rate of weight gain and total weight gain for singleton Pregnancies according to pre-pregnancy BMI IOM Guidelines for Gestational Weight Gain Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus Report. May 2009. The National Academies Press. Washington, DC.

67. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 20: Management During Pregnancy (GDM) 20.Women with GDM should: a.Strive for target glucose values: – Fasting PG below 5.3 mmol/L [Grade B, Level 2] – 1h postprandial below 7.8 mmol/L [Grade B, Level 2] – 2h postprandial below 6.7 mmol/L [Grade B, Level 2] b.Perform SMBG, both fasting and postprandially to achieve glycemic targets and improve pregnancy outcomes [Grade B, Level 2] c. Avoid ketosis during pregnancy [Grade C, Level 3]

68. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 21: Management During Pregnancy (GDM) 21.Receive nutrition counseling from a registered dietitian during pregnancy [Grade C, Level 3] and postpartum [Grade D, Consensus]. Recommendations for weight gain during pregnancy should be based on pregravid BMI [Grade D, Consensus].

69. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 22 and 24: Management During Pregnancy (GDM) 22.If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated [Grade D, Consensus]. 23.Insulin therapy in the form of multiple injections should be used [Grade A, Level 1]. 24.Rapid-acting bolus analog insulin may be used over regular insulin for postprandial glucose control although perinatal outcomes are similar [Grade B, Level 2].

70. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 25: Management During Pregnancy (GDM) 25.For women who are non-adherent to or who refuse insulin, glyburide [Grade B, Level 2] or metformin [Grade B, Level 2] may be used as alternative agents for glycemic control. Use of oral agents in pregnancy is off-label and this should be discussed with the patient [Grade D, Consensus].

71. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 26: Intrapartum Management (GDM) 26.Women should be closely monitored during labour and delivery and maternal blood glucose levels should be kept between 4.0 and 7.0 mmol/L in order to minimize the risk of neonatal hypoglycemia. [Grade D, Consensus] 26.Women should receive adequate glucose during labour in order to meet the high energy requirements [Grade D, Consensus].

72. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Postpartum GDM Management Checklist 1.Encourage Breastfeeding 2.75g OGTT between 6 weeks - 6 months postpartum to detect prediabetes or diabetes 3.Discuss increased long-term risk of diabetes – Importance of returning to pre-pregnancy weight

73. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 28: Postpartum (GDM) 28.Women with GDM should be encouraged to breastfeed immediately after delivery in order to avoid neonatal hypoglycemia [Grade D, Level 4] and to continue for at least three months postpartum in order to prevent childhood obesity [Grade C, Level 3] and reduce risk of maternal hyperglycemia [Grade C, Level 3]. 29.Women should be screened with a 75g OGTT between 6 weeks and 6 months postpartum to detect prediabetes and diabetes [Grade D, Consensus].