Current Recommendations Regarding Gestational Diabetes

By Brandon Ernst
UNMC PharmD Candidate 2007 Friday, January 26

Objectives for Today

Define gestational diabetes mellitus (GDM) Indicate possible adverse effects of GDM Discuss diagnosing GDM Evaluate monitoring and treatment possibilities Reassess mother and offspring postpartum Briefly discuss the results of the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS)

What is Gestational Diabetes?

Gestational Diabetes Mellitus (GDM) is glucose intolerance usually recognized during pregnancy GDM is thought to occur in about 7% of all pregnancies
-

Hispanic, Native, African, Asian-Americans, and Pacific Islanders are at highest risk

Why may GDM occur? The 2 Thought is that:

1. 2.

3.
4.

5.

The placenta supports the fetus as it grows by providing hormones for development These hormones block the action of the mothers insulin, causing insulin resistance (3x more insulin) Mothers body is unable to lower BGL, causing hyperglycemia The high BGLs remain in the blood stream, cross the placenta, and cause the fetuss pancreas to produce more insulin to regulate its own hyperglycemic environment Therefore, leading to possible adverse effects

Possible Problems in GDM

As the baby continues in this high glycemic environment:

-

Higher glucose gives more energy than needed for growth, causing fat storage Macrosomia (large body size) increases the risk of damage to shoulders and limbs during delivery Increased pancreas/insulin use in baby may cause low BGL and breathing problems at birth Cesarean delivery Risk of children developing obesity and adults with type 2 diabetes Jaundice, polycythemia, and hypocalcemia at birth

Possible Problems in GDM

The mothers possible complications include:

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Increased chance of cesarean delivery Increased frequency of maternal hypertensive disorders Increase risk of developing diabetes after pregnancy, typically type 2

Diagnosing GDM

Risk assessment should always be done at first prenatal visit, especially with:
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Obese patients Personal history of GDM Glycosuria Strong family history High risk ethnic groups

Diagnosing GDM

All women, unless low risk, should be tested for GDM at 24-28 weeks.
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Low risk must meet all criteria:

<25

y.o. Normal weight before pregnancy Member of low ethnic prevalence No diabetes in first degree relative No history of abnormal glucose tolerance, and poor birth outcome

Diagnosing GDM

3,4

Two Different Approaches One step approach 1. Perform a diagnostic 75 g or 100 g OGTT without any prior plasma test

This may be best for patients that cant afford more tests or in patients that are already at high risk

Diagnosing GDM

3,4

Two Different Approaches Two step approach

1.

2.

Perform screen using 50 g oral glucose load (OGL) and check BGL at 1 hour If >130 mg/dL at 1 hour, retest for diagnoses using 75 g or 100 g OGTT

Diagnosing GDM

The OGTT diagnosis criteria

Patient must be above the BGL at the time

interval measured Positive result must be confirmed on a following occasion

Monitoring of GDM

3,4

Daily self monitoring of blood glucose (SMBG) is best

-

Either Pre or Post -prandial testing is best for obtaining levels (according to ACOG and ADA)

Screen urine for glucose, ketones, and proteins Monitor blood pressure Monitor for fetal demise when pregnancy goes past term Check for asymmetric fetal growth using ultrasound

Treatment Options in GDM

All women should receive diet and nutrition counseling regarding pregnancy
-

If BMI > 30 kg/m2:

Lower caloric intake to 25 kcal/kg/day Lower carbohydrate intake to only 25-30% of total calories

Moderate exercise should be done with physicians consent Delivery during or before the 38th week is encouraged, as is breast-feeding

When to Add Insulin

3,4

If medical nutritional therapy (MNT) fails then add insulin when BGL are:

ADA

ACOG

Fasting 1-H postprandial

2-H postprandial

105 mg/dL 155 mg/dL

130 mg/dL

95 mg/dL 130-140 mg/dL

120 mg/dL

Treatment Options in GDM

3,5,6

Insulin treatment is best for blood glucose control

-

Human insulin should be used when prescribed, due to lack of analogs studies
NPH or Regular Humalog is catagory B, and is being used under Dr. supervision

Treatment Options in GDM

3,5,6

Oral agents are still questionable

-

Glyburide (category B), and insulin were compared in a trial and found to be similar in outcomes Metformin (category B), shows some good evidence toward its use in PCOS. Its currently being studied in GDM and following up with offspring Glyburide and Metformin are still not FDA approved for GDM

Treatment Options in GDM

Do not use in pregnancy:
-

Aspirin (D) Statins (X) ACE Inhbitors (D) ARBs (D)

Delivery Time

During Labor:
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Active labor lowers insulin needs for about 24-72 hours after delivery
May have better BGL control for a few weeks Still could have unpredictable BGL swings Check BGLs more often during this time Breastfeeding is encouraged

After Delivery:
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Have snack before or during nursing, and keep something close to treat low BGLs Drink fluids

Reassessing Offspring

Following delivery:
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Monitor newborn for any of the possible abnormalities discussed earlier Monitor for development of obesity Evaluate for any irregularity in glucose tolerance

Reassessing Mother
A mother having GDM:
-

3,4

Has a 50% chance of developing type 2 diabetes Should be have BGL evaluated at least 6 weeks postpartum

If normoglycemic, then testing should be done every 3 years If IFG or IGT, then testing should be repeated annually If FPG 126mg/dL or 2-hr 200, then testing should be repeated on a separate occasion for DM diagnosis

The Australian Carbohydrate Intolerance 7 Study in Pregnant Women (ACHOIS)

Randomized clinical trial Wanted to determine whether treating women with GDM reduced perinatal complications One thousand women randomized

Intervention group 490 women, received dietary advice, BGM, and insulin therapy Routine group 510 women

Weeks gestation - 24-34

The Australian Carbohydrate Intolerance 7 Study in Pregnant Women (ACHOIS)

Primary endpoint
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Serious perinatal complications

death, shoulder dystocia, bone fracture, nerve palsy, admit. neonatal nursery, jaundice, induct. of labor, cesarean birth, anxiety, depression, health

Secondary endpoint
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Birth weights, large for gestational age, macrosomia, small for gestational age

The Australian Carbohydrate Intolerance 7 Study in Pregnant Women (ACHOIS)

Primary outcome results (only clinically significant):

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Any serious perinatal complication was significantly lower in the treatment group

Number needed to treat for benefit was 34

Admission to the neonatal nursery was higher in the treatment group, but length of stay was equal Induction of labor was higher in the treatment group

The Australian Carbohydrate Intolerance 7 Study in Pregnant Women (ACHOIS)

Secondary outcome results (only clinically

significant)
-

Birth weight was lower in the treatment group There were higher rates of macrosomia and large for gestational age in the routine group

Questions?

References
1. 2. 3. 4.

5. 6.

7.

Isley WL, Oki JC. Diabetes Mellitus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Well BG, Posey LM, eds. Pharmacotherapy: A Pathologic approach. 5th ed. New York, NY: McGraw-Hill; 2002: 1335. American Diabetes Association web site. Available at: http://www.diabetes.org/home.jsp/. Accessed January 23, 2007. American Diabetes Association. Gestational Diabetes Mellitus. Diabetes Care 2004;27:suppl 1: S88-S90. Clinical management guidelines for obstetrician-gynecologists. ACOG practice bulletin no. 30. Washington, D.C.: American College of Obstetricians and Gynecologists, 2001. American Diabetes Association. Gestational Diabetes Mellitus. Diabetes Care 2006;29:suppl 2: 485. Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A comparison of glyburide and insulin in women with gestational diabetes mellitus. New Engl J Med 2000;343:1134-1138 (Level 1) Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352:2477-86.