1. DR. TARIK Y. ZAMZAMI MD, CABOG, FICS ASSOCIATE PROFESSOR CONSULTANT OB/GYN KAUHEmail.tzamzami@kaau.edu.sa

2. Gestational Diabetes (GDM) Definition Definition

3. Prevalence 1-14 % 1-14 %

4. Carbohydrate Metabolism Pregnancy is potentially diabetogenic stat: First half: tendency to hypoglycemia Second half: tendency to hyperglycemia Progressive insulin resistance as pregnancy progresses : HPLEstrogenProgesteroneCortisol

5. Pathophysiology Deficiency of insulin receptors prior to pregnancy Deficiency of insulin receptors prior to pregnancy Deficient insulin production Deficient insulin production HPL block insulin receptors HPL block insulin receptors

6. Detection and diagnosis Risk assessment for GDM should be undertaken at the first prenatal visit

7. Risks Maternal Maternal Fetal Fetal

8. Maternal Risks Hypertensive disorders Hypertensive disorders Increase cesarean delivery Increase cesarean delivery Developing type II DM after delivery Developing type II DM after delivery

9. Fetal risks Macrosomia Macrosomia N.hypoglycemia N.hypoglycemia hypocalcemia hypocalcemia polycythemia polycythemia Jaundice Jaundice PMR 4.3 folds PMR 4.3 folds

10. Screening

11. When to screen High risk patients: High risk patients:.test as soon as possible.test as soon as possible. If test was –ve repeat at. If test was –ve repeat at 24-28 wks 24-28 wks Low risk patients: at 24-28 wks Low risk patients: at 24-28 wks

12. High Risk Age Age Obesity Obesity Family history of DM Family history of DM Previous large baby Previous large baby Previous perinatal loss Previous perinatal loss

13. Low risk Age < 25 years Age < 25 years Weight normal before pregnancy Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDM Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of abnormal glucose tolerance No history of poor obstetric outcome No history of poor obstetric outcome

14. How to screen One step approach: One step approach:. using OGTT. using OGTT Two step approach: Two step approach:. Using 50 gm GCT. Using 50 gm GCT. If > 140 mg/dl (7.8 mmol/l). If > 140 mg/dl (7.8 mmol/l) perform OGTT perform OGTT

15. Diagnosis of GDM with 100 gm GTT (ADA) O’sullivan criteria: O’sullivan criteria:. F >105 mg/dl (5.8 MMOL/L ). 1 hr > 190 mg/dl (10.6). 2 hr > 165 mg/dl (9.2). 3 hr >145 mg/dl (8.1) Carpenter criteria (new): Carpenter criteria (new):. F > 95 mg/dl (5.3 MMOL/L ). 1 hr > 180 mg/dl (10). 2 hr > 155 mg/dl (8.6). 3 hr >140 mg/dl (7.8)

16. Diagnosis of GDM with 75 gm GTT (WHO) Fasting > 95 mg/dl (5.3 mmol/L) Fasting > 95 mg/dl (5.3 mmol/L) 2 hr > 155 mg/dl (8.6 mmol/L) 2 hr > 155 mg/dl (8.6 mmol/L)

17. Diagnosis of Frank DM Fasting > 126 mg/dl (7 mmol/L) Fasting > 126 mg/dl (7 mmol/L) Random >200 mg/dl (11.1 mmol/L) Random >200 mg/dl (11.1 mmol/L)

18. Obstetric management U/S to assess growth pattern U/S to assess growth pattern Surveillance fetal well being at term: Surveillance fetal well being at term:. Fetal kick counts. Fetal kick counts. CTG. CTG. BPP. BPP. Amniotic fluid. Amniotic fluid

19. Monitoring degree of glycemic control Daily self monitoring (home) Daily self monitoring (home) Post-prandial is superior to pre- prandial (glucose profile) Post-prandial is superior to pre- prandial (glucose profile) Urine glucose is not reliable Urine glucose is not reliable HB A1c is reliable substitute for self monitoring HB A1c is reliable substitute for self monitoring Urine ketones Urine ketones

20. Management Nutritional counseling Nutritional counseling An intake of ~1,800 kcal/day An intake of ~1,800 kcal/day Insulin therapy indicated when medical nutrition therapy (MNT), fails to maintain fasting whole blood glucose levels < 95 mg/dl (5.3 mmol/l) or 2-h postprandial whole blood glucose levels < 120 mg/dl (6.7 mmol/l). Insulin therapy indicated when medical nutrition therapy (MNT), fails to maintain fasting whole blood glucose levels < 95 mg/dl (5.3 mmol/l) or 2-h postprandial whole blood glucose levels < 120 mg/dl (6.7 mmol/l).

21. Cont. Oral glucose-lowering agents are not recommended during pregnancy Oral glucose-lowering agents are not recommended during pregnancy Program of moderate exercise Program of moderate exercise GDM is not of itself an indication for cesarean delivery or for delivery before 38 weeks completed gestation. GDM is not of itself an indication for cesarean delivery or for delivery before 38 weeks completed gestation. Breast-feeding, as always, should be encouraged in women with GDM Breast-feeding, as always, should be encouraged in women with GDM

22. LONG-TERM THERAPEUTIC CONSIDERATIONS Glycemic status should be performed at least 6 weeks after delivery Glycemic status should be performed at least 6 weeks after delivery If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. Women with IFG or IGT in the postpartum period should be tested at more frequent intervals. Patients should be educated regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal body weight through MNT and physical activity. Women with IFG or IGT in the postpartum period should be tested at more frequent intervals. Patients should be educated regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal body weight through MNT and physical activity.