1. Gestational Diabetes Gestational Diabetes

2. Definition Any degree of glucose intolerance with onset or 1 st recognition during pregnancy. Any degree of glucose intolerance with onset or 1 st recognition during pregnancy. Diabetes Care, 2003 Jan:26(1):s103 Diabetes Care, 2003 Jan:26(1):s103 prevalence 1.4 – 14% prevalence 1.4 – 14% UTD 11.2 UTD 11.2

3. Etiology Early pregnancy Early pregnancy estrogen-progesteron counterbalance estrogen-progesteron counterbalance 2 nd trimester 2 nd trimester  hPL,  Cortisol,  Prolactin  hPL,  Cortisol,  Prolactin Underlying  cell defect Underlying  cell defect Evidence-Based Diabetes Care 2001 Evidence-Based Diabetes Care 2001

4. Risk Factors  Age  Age +ve F Hx. of DM +ve F Hx. of DM Increasing obesity, Wt. gain in early adulthood Increasing obesity, Wt. gain in early adulthood Ethnicity Ethnicity Asians  5, Hispanics  2.5, African Americans  2 Asians  5, Hispanics  2.5, African Americans  2 Cigarette smoking Cigarette smoking Evidence-Based Diabetes Care 2001 Evidence-Based Diabetes Care 2001

5. Short Term Risk for The Fetus Macrosomia & possible birth trauma Macrosomia & possible birth trauma Neonatal hypoglycemia Neonatal hypoglycemia Jaundice Jaundice Hypocalcemia Hypocalcemia Polycythemia Polycythemia RDS RDS Myocardial hypertrophy Myocardial hypertrophy

6. Long Term Risks for The Offsprings  Susceptibility for glucose intolerance  Susceptibility for glucose intolerance  Insulin resistance during puberty  Insulin resistance during puberty Obesity Obesity

7. Mother’s Risks Long term risk for DM Long term risk for DM 50% diabetes, 75% any IGT 50% diabetes, 75% any IGT Rarely DKA, Retinopathy Rarely DKA, Retinopathy Preeclampsia Preeclampsia Polyhydramnios Polyhydramnios Fetal macrosomia Fetal macrosomia Birth trauma Birth trauma Operative delivery Operative delivery Perinatal mortality Perinatal mortality

8. Risk Factors for Progression to Diabetes  Prepregnancy BMI  Prepregnancy BMI Severity of glucose intolerance during pregnancy Severity of glucose intolerance during pregnancy Earlier gestational age of onset Earlier gestational age of onset  FPG  FPG Need for insulin Need for insulin Presence of higher glucose values on postpartum OGTT Presence of higher glucose values on postpartum OGTT

9. Screening Selective ( ADA & ACOG ) Selective ( ADA & ACOG ) Universal Universal * If screening had been selective, 10% of women with GDM have been missed * If screening had been selective, 10% of women with GDM have been missed

10. Screening (continued) Screening GCT threshold Sensitivity Cost per case diagnosed Universal 130 mg/dl 100% $ 249 Universal 140 mg/dl 90% $ 222 Selective 140 mg/dl 85% $ 192

11. Screening (continued) Low risk Low risk Age<25 yr Age<25 yr Nl weight before pregnancy Nl weight before pregnancy Member of an ethnic group with low prevalence of GDM Member of an ethnic group with low prevalence of GDM No known diabetes in 1 st degree relatives No known diabetes in 1 st degree relatives No Hx. of abn. Glucose tolerance No Hx. of abn. Glucose tolerance No Hx. of adverse pregnancy outcomes often associated with GDM No Hx. of adverse pregnancy outcomes often associated with GDM Diabetes Care, 2003 Jan:26(1):S34 Diabetes Care, 2003 Jan:26(1):S34

12. Screening(continued) High Risk High Risk Marked obesity (prepregnancy Wt. of 110% of IBW) Marked obesity (prepregnancy Wt. of 110% of IBW) Personal Hx. of GDM Personal Hx. of GDM Strong F Hx. of diabetes Strong F Hx. of diabetes Glycosuria Glycosuria Diabetes Care, 2003 Jan:26(1):S34 Diabetes Care, 2003 Jan:26(1):S34 Age>25 yr Age>25 yr Hx. of abn. glucose tolerance Hx. of abn. glucose tolerance Previous large baby Previous large baby PCO PCO Maternal low birth Wt. Maternal low birth Wt. The mother was large at birth The mother was large at birth Member of an ethnic group with a higher than Nl rate of type2 DM Member of an ethnic group with a higher than Nl rate of type2 DM Previous unexplained prenatal loss or birth malformed child Previous unexplained prenatal loss or birth malformed child UTD 11.2 UTD 11.2

13. Screening(continued) Timing Timing High risk : 1 st prenatal visit High risk : 1 st prenatal visit If -ve If -ve Mod. risk : between 24-28 wks Mod. risk : between 24-28 wks Low risk : need no glucose testing Low risk : need no glucose testing Diabetes Care, 2003 Jan:26(1):S34 Diabetes Care, 2003 Jan:26(1):S34

14. UTD 11.2

16. Management Diet : in women who do not meet criteria for gestational diabetes (abnormal GTT) if they have FPG >90 mg/dL or an abnormal GCT. Diet : in women who do not meet criteria for gestational diabetes (abnormal GTT) if they have FPG >90 mg/dL or an abnormal GCT. Exercise Exercise Insulin : ٭ when FPG >90 mg/dl & Insulin : ٭ when FPG >90 mg/dl & 1hr PP blood sugar >120 mg/dl 1hr PP blood sugar >120 mg/dl ٭ 15% of women with GDM require ٭ 15% of women with GDM require insulin Rx. insulin Rx.

17. Management (continued) Caloric Allotment Caloric Allotment 30 kcal per present weight in kg per day in pregnant women who are 80 to 120 % of IBW at the start of pregnancy. 30 kcal per present weight in kg per day in pregnant women who are 80 to 120 % of IBW at the start of pregnancy. 24 kcal per present weight in kg per day in overweight pregnant women (120 to 150 % of IBW). 24 kcal per present weight in kg per day in overweight pregnant women (120 to 150 % of IBW). 12 to 15 kcal per present weight in kg per day for morbidly obese pregnant women (>150 % of IBW). 12 to 15 kcal per present weight in kg per day for morbidly obese pregnant women (>150 % of IBW). 40 kcal per present weight in kg per day in pregnant women who are < 80 % of IBW. 40 kcal per present weight in kg per day in pregnant women who are < 80 % of IBW.

18. Management (continued) Insulin Regimen Insulin Regimen  if ↑FPG : NPH 0.15 IU/kg before bedtime  if ↑FPG : NPH 0.15 IU/kg before bedtime  if ↑PP blood glucose : Insulin regular or lispro  if ↑PP blood glucose : Insulin regular or lispro 1.5 IU/10gr CHO before breakfast & 1.5 IU/10gr CHO before breakfast & 1 IU/10gr CHO before lunch and dinner meals. 1 IU/10gr CHO before lunch and dinner meals.

19. Management (continued)  if both ↑FPG & ↑PP blood glucose : four- injection per day regimen should be initiated :  if both ↑FPG & ↑PP blood glucose : four- injection per day regimen should be initiated : NPH 45% Regular 55% NPH 45% Regular 55% 30% breakfast 22% breakfast 30% breakfast 22% breakfast 15% bedtime 16.5% lunch 15% bedtime 16.5% lunch 16.5% dinner 16.5% dinner Insulin requirement Week of gestation 0.7 IU/kg 6-18 0.8 IU/kg 19-26 0.9 IU/kg 27-36 1 IU/kg 37 to term

21. Management (continued) Goal of glucose concentration Goal of glucose concentration FPG <90 mg/dl FPG <90 mg/dl BS 1hr PP <140 mg/dl BS 1hr PP <140 mg/dl Plasma Plasma BS 2hr PP <120 mg/dl BS 2hr PP <120 mg/dl

22. Management (continued) Postpartum F/U Postpartum F/U ٭ 1/3 to 2/3 of women will have gestational diabetes in a subsequent pregnancy. ٭ 1/3 to 2/3 of women will have gestational diabetes in a subsequent pregnancy. ٭ As many as 20 % of women with GDM have IGT during the early postpartum period. ٭ As many as 20 % of women with GDM have IGT during the early postpartum period. ٭ The risk of type 2 diabetes is also importantly affected by body weight, being 50 to 75 % in obese women versus < 25 % in women who achieve IBW after delivery. ٭ The risk of type 2 diabetes is also importantly affected by body weight, being 50 to 75 % in obese women versus < 25 % in women who achieve IBW after delivery. ٭ GDM is also a risk factor for the development of type 1 diabetes. Specific HLA alleles (DR3 or DR4) may predispose to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies. ٭ GDM is also a risk factor for the development of type 1 diabetes. Specific HLA alleles (DR3 or DR4) may predispose to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies.

23. Postpartum F/U Immediately after delivery, FPG should be < 115 mg/dL & one-hour PP should be <140 mg/dL. Immediately after delivery, FPG should be < 115 mg/dL & one-hour PP should be <140 mg/dL. ~ 6-8 wks after delivery, or shortly after cessation of breast feeding, a two-hour 75 gr OGTT is recommended by the ADA and the 4 th International Workshop-Conference on GDM. ~ 6-8 wks after delivery, or shortly after cessation of breast feeding, a two-hour 75 gr OGTT is recommended by the ADA and the 4 th International Workshop-Conference on GDM.