Gestational Diabetes Gestational Hypertension

Dr. TAHER KARIRI

FAMILY PHYSICIAN

OutlineGestational diabetes

▫Epidemiology/Types▫Screening and Diagnosis▫Management

Gestational Hypertension oEpidemiology/Types▫Diagnosis▫Management

•Diabetes in Pregnancy: 2 Categories

Pregestational diabetes Gestational diabetes

Pregnancy in pre-existing diabetes

• Type 1 diabetes • Type 2 diabetes

Diabetes diagnosed in pregnancy

Pre-existing diabetes in pregnancy

Elevated glucose levels can have adverse effects on the fetus

▫1st trimester ↑ fetal malformations, spontaneous abortions

▫2nd and 3rd trimester: ↑ risk of macrosomia and metabolic complications

Preconception Counseling for Pregestational Diabetes

1. Attain a preconception A1C of ≤7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 months pre-conception to 12 weeks post-conception

5. Discontinue potential embryopathic meds:Ace-inhibitors/ARBStatin therapy

Screen for Complications: Pre-pregnancy

Screening for: Retinopathy: Need ophthalmological evaluation

Nephropathy: Assess creatinine + urine microalbumin / creatinine ratio (ACR)▫ Women with microalbuminuria or overt nephropathy are at

↑ risk for hypertension and preeclampsia

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

Gestational diabetes

The terminology for describing diabetes first diagnosed during pregnancy varies among national organizations

"gestational diabetes" has been defined as onset or first recognition of abnormal glucose tolerance during pregnancy ACOG

describe diabetes diagnosed during the second half of pregnancy, (IADPSG), (ADA), (WHO)

PathphysiologyInsulin resistance, mediated primarily by

placental secretion of diabetogenic hormones including :

growth hormone, corticotropin-releasing hormone, placental lactogen,Progesterone

pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state

Prevalence• Prevalence of gestational diabetes is about 6 to 7%

in the United States (range 1 to 25 percent )

• prevalence rates are higher in African American, Hispanic American, Native American, Pacific Islander, and South or East Asian women than in white women

• Prevalence has been increasing over time, possibly due to increases in mean maternal age and weight .

GDM: Detection & Diagnosis•Risk assessment at the first prenatal

visit

High risk patientsOr

Low risk patients

Risk factorsPersonal history of IGT or

gestational diabetes in a previous pregnancy

Member of one of the following ethnic groups

Family history of diabetes, especially in first degree relatives

Prepregnancy ,BMI >30 kg/m2,.Glycosuria at the first prenatal visit

Maternal age >25 years of age

Previous delivery of a baby >9 pounds (4.1 kg)

Previous unexplained perinatal loss or birth of a malformed infant

Maternal birthweight 4.1 kg or < 2.7 kg

Medical condition associated with development of diabetes, metabolic syndrome, (PCOS), current use of glucocorticoids, HTN

SCREENING AND DIAGNOSTIC TESTING 

•  The purpose of screening : is to identify asymptomatic pregnant women with a high probability of developing diabetes followed by appropriate therapy

• Can decrease fetal and maternal morbidity, particularly macrosomia, shoulder dystocia, and preeclampsia

• cost-effective for prevention of type 2 diabetes in populations with a high prevalence of gestational diabetes and type 2 diabetes.

GDM: Detection & Diagnosis•Screening for gestational diabetes is usually

done between 24 and 28 weeks of pregnancy.

•However, screening may be done earlier in the pregnancy if you have risk factors for gestational diabetes, such as:

• A history of gestational diabetes in a previous pregnancy• Obesity• Glucose (sugar) in your urine• A strong family history of diabetes

GDM: Detection & Diagnosis

•Women at high risk of GDM should have glucose testing at the first antenatal visit

If not found to have GDM at that initial screening, retested at between 24 and 28 weeks gestation

• ARE there any criteria for selecting high risk pregnant women for early screening/testing ?????

no validated criteria

USPSTF Asystematic review by the (USPSTF) on the accuracy of

screening tests for gestational diabetes,:the benefits and harms of screening before and after 24 weeks of

gestation, and the benefits and harms of treatment, found good evidence to support universal screening after 24 weeks.

A 2014 (USPSTF) guideline concluded available evidence was insufficient to assess the balance of benefits and harms of screening for diabetes in asymptomatic pregnant women before 24 weeks of gestation

• (IADPSG) suggested that the decision to test for diabetes at the first prenatal visit should be based upon the background frequency of abnormal glucose metabolism in the population and on local circumstances .

• In agreement with (ADA) ,(ACOG) suggests early pregnancy screening for undiagnosed type 2 diabetes in women with risk factors (eg, previous gestational diabetes or known impaired glucose metabolism, obesity)

GDM: Detection & Diagnosis• Diagnosis of GDM

with a 100-g oral glucose load

• Fasting ≥95 mg/dl

• 1-h 180• 2-h 155• 3-h 140

• Diagnosis of GDM with a 75-g oral glucose load

• Fasting ≥92 mg/dl

• 1-h 180• 2-h 153

Two-step approach

patients unable to tolerate oral hyperosmolar glucose:

e.g dumping syndrome after a roux-en-Y gastric bypass procedure

*Serial glucose monitoring: *Fasting plasma glucose :USPSTF, FBG less than 85 mg/dL by 24 weeks of gestation performed well for identifying women who did not have gestational diabetes.*Intravenous GTT

American College of Obstetricians and Gynecologists (ACOG, two step approach

●International Association of Diabetes and Pregnancy Study Groups (IADPSG, one step approach●American Diabetes Association (ADA, one step or two step approach) ●World Health Organization (WHO, one step approach

●Canadian Diabetes Association (CDA, two step [preferred] or one step approach)

●The Endocrine Society (one step approach) ●Australasian Diabetes in Pregnancy Society (WHO approach)●National Institute for Health and Care Excellence (NICE, United Kingdom)

In a prospective study in which the two step approach was replaced by the one step

approach,

othe prevalence of gestational diabetes increased 3.5-foldo, pregnancy outcomes improved significantly, ando the change was cost-effective

• The authors perform universal testing for overt diabetes at the initial prenatal visit by checking A1C; a diagnosis of overt diabetes is made when A1C is ≥6.5 percent (≥48 mmol/mol)

• perform a glucose tolerance test (GTT) when A1C is 5.7 to 6.4 percent (39 to 46 mmol/mol) at the first prenatal visit

• Early in pregnancy, we recommend a 75-gram, two-hour oral GTT and American Diabetes Association criteria for diagnosis of overt diabete

Screening at first antenatal visit

Several adverse outcomes have been associated with diabetes during pregnancy

• Preeclampsia• Hydramnios• Macrosomia and large for gestational age infant• Fetal organomegaly (hepatomegaly, cardiomegaly)• Maternal and infant birth trauma• Operative delivery• Perinatal mortality• Neonatal respiratory problems and metabolic

complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, erythremia)

RATIONALE FOR TREATMENT•  Identifying women with GDM is important to

minimize maternal and neonatal morbidity.

• A 2013 systematic review and meta-analysis of randomized trials for the US Preventive Services Task Force found that appropriate management of GDM (nutritional therapy, self blood glucose monitoring, administration of insulin if target blood glucose concentrations are not met with diet alone) resulted in reductions in :

• Preeclampsia • Birth weight >4000 grams • Shoulder dystocia

•ADA and ACOG glucose targets

Glycemic Management During Pregnancy

Target glucose valuesFasting PG ≤95 mg/dL

1h postprandial PG ≤140 mg/dL 2h postprandial PG ≤120 mg/dL

NUTRITIONAL THERAPY•The goals of medical nutritional therapy

are to:

• Achieve normoglycemia• Prevent ketosis• Provide adequate weight gain based on maternal

body mass index (BMI)• Contribute to fetal well-being

IOM Guidelines for Gestational Weight Gain

Pre-Pregnancy BMI Recommended range of total weight gain

(Kg)

Recommended range of total weight gain

(lb)

BMI <18.5 12.5 – 18.0 28 – 40BMI 18.5 - 24.9 11.5 – 16.0 25 – 35BMI 25.0 - 29.9 7.0 – 11.5 15 – 23 BMI > or = 30 5.0 – 9.0 11 – 20

Recommended rate of weight gain and total weight gain for singleton

Pregnancies according to pre-pregnancy BMI

In clinical practice, women often require 1800 to 2500 kcal per day

the caloric requirement body weight

30 kcal/kg/day ideal body weight

22 to 25 kcal/kg/day overweight

12 to 14 kcal/kg/day morbidly obese women

up to 40 kcal/kg/day underweight

Weight loss in pregnancy is not generally recommended, although controversy exists regarding this recommendation for markedly obese women

obese women (BMI >30 kg/m2), a modest energy restriction to reduce weight gain can be achieved by restricting caloric intake by about 30 % below the Dietary Reference Intakes (DRI) for pregnant women

A typical meal:

(3 small-to-moderate sized meals and 2 to 4 snacks).

• Carbohydrate intake: 35 to 40% • Protein: 20% • Fat: 40%, saturated fat <7 percent of total calories.

EXERCISE • increased tissue sensitivity to insulin.• fasting and postprandial blood glucose

concentrations can be reduced.

GLUCOSE MONITORING • After initially diagnosed with GDM,,measure blood glucose

concentration at least four times daily (fasting and one or two hours after the first bite of each meal)

• Decrease the frequency of glucose monitoring when good glycemic control is accomplished with medical nutritional therapy

MONITORING FOR KETONURIA•  We do not routinely monitor urinary ketones

in women with GDM.

• Diabetic ketoacidosis is extremely rare in women with gestational diabetes

Test their urine for ketones if: the blood glucose concentration is above 180 mg/dL during periods of illness or stress, if there are symptoms compatible with ketoacidosis such

as nausea, vomiting, and abdominal pain.

 If normoglycemia cannot be maintained by medical nutritional therapy, then anti-hyperglycemic agents should be initiated

Target glucose values

Fasting PG ≤95 mg/dL

1h postprandial PG ≤140 mg/dL

2h postprandial PG ≤120 mg/dL

Targets not met within 2 weeks start PHARMACOLOGIC THERAPY 

Caution

PHARMACOLOGIC THERAPY • Insulin (and some insulin analogs)• Oral anti-hyperglycemic agents.

•Hospitalization is not necessary to initiate insulin UNLESS,,,,

Insulin• Four to six glucose measurements each day are needed to optimize therapy

(fasting and one or two hours postprandial with the possible addition of pre-lunch and pre-dinner)

TYPE:

-human insulin is the least immunogenic

rapid acting insulin analogs only lispro and aspart have been investigated in pregnancy and shown to have acceptable safety profiles

Long-acting insulin analogs (insulin glargine, insulin detemir) have not been studied extensively in pregnancy.

• Based on available data, we prefer use of human NPH insulin as part of a multiple injection regimen in pregnant women with GDM

InsulinDose:

•  The dose of insulin varies in different individuals• total insulin dose ranging from 0.7 to 2 units per

kg• The dose and type of insulin used is calculated

based upon the specific abnormality of blood glucose noted during monitoring

a patient whose glucose elevations are mostly postprandial regardless of body weight, is prescribed------

a starting dose of 30 units (20 units of intermediate acting insulin and 10 units of rapid acting insulin)

in the morning prior to breakfast

If the post-dinner glucose level remains elevated, then an additional injection of rapid acting insulin is given just prior to dinner.

• If fasting glucose is elevated,: intermediate acting insulin can be given along with the dinner dose of rapid acting insulin, or can be administered separately at bedtime

• Sometimes an additional dose of rapid acting insulin is necessary to maintain euglycemia after lunch, so that a total of four injections per day are needed.

• If low glucose values are encountered more than once at the same time of day, insulin doses are adjusted downward accordingly.

Oral anti-hyperglycemic agents

• ADA ,ACOG have endorsed the use of oral anti-hyperglycemic agents during pregnancy.

• in the United States, such therapy has not been specifically approved for treatment of GDM by the FDA.

• reasonable alternative for women who fail nutritional therapy and refuse to take, or are unable to comply with, insulin therapy.

Glyburidehas become the most common drug

treatment for GDMA major advantage of glyburide over metformin is that it is usually

effective as single agent therapyHigher risk of macrosomia , higher mean birth weight, higher rate of

any neonatal hypoglycemiaNo studies of long-term effects in offspring (eg, developmental

outcomes, metabolic effects) have been publishedStarting doses of 2.5 to 5 mg once daily, the dose is increased as

needed to a maximum of 20 mg/day

Metformin

• Second and third trimester metformin treatment of GDM appears to be safe in the short term.

• a theoretical risk that fetal exposure to an insulin sensitizing agent such as metformin has long-term effects on offspring.

•Use of thiazolidinediones, glitinides (repaglinide and nateglinide), and GLP-1 during pregnancy is considered experimental.

There are no controlled data available in pregnancy.

MATERNAL PROGNOSIS • Most women with GDM are normoglycemic after delivery.

• high risk for recurrent GDM, prediabetes ,and overt diabetes over the subsequent five years

• Recurrence : One-third to two-thirds of women with GDM will have GDM in a subsequent pregnancy,( older, more parous)

• GDM is predictive of an increased risk of developing type 2 diabetes, type 1 diabetes, metabolic syndrome, and cardiovascular disease.

Follow-up and prevention of type 2 diabetes — ACOG , the ADA• An oral glucose tolerance test 6 to 12 weeks after delivery, using

the two-hour 75 gram oral glucose tolerance test .

• A FBG test and (A1C) are an reasonable alternative

• Prediabetes should be counseled about their subsequent risk for developing overt diabetes and referred for discussion of management options.

Gestational hypertension

Definition

sustained BP readings of ≥140/90 mmHg during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without the presence of proteinuria (<300 mg in 24 hours).

All manifestations of gestational hypertension are presumptive until retrospectively confirmed bycomplete resolution of hypertension and any other new abnormalities by 12 weeks postpartum; otherwise, other diagnoses should be considered.

Epidemiology

• In the UK, gestational hypertension and pre-eclampsia 5% to 6• in the US range from 2% to 12%. • Healthy nulliparous women higher rates (6% to

17%) compared with multiparous women (2% to 4%).

• African-American women may be at greater risk than white women.

• more often in twin pregnancies than in singleton pregnancies

Aetiology

•The exact aetiology of gestational hypertension remains unknown.

• It is thought that insulin resistance???

Classification•Report of (ACOG) Task Force on

Hypertension in Pregnancy

1/Chronic hypertension: • BP ≥140/90 mmHg (preferably on 2 occasions less

than 1 week apart):• Before pregnancy or up to 20 weeks' gestation• New hypertension after 20 weeks' gestation that

persists for 12 weeks postpartum.

2/Gestational hypertension (transient hypertension of pregnancy):

• New hypertension in pregnancy without proteinuria. Normotensive by 12 weeks postpartum.

3/Pre-eclampsia/eclampsia:• Pregnancy-specific syndrome that usually occurs after

20 weeks' gestation• BP >140/90 mmHg and proteinuria >300 mg/24 hours• Eclampsia is defined as seizures in a woman with pre-

eclampsia not attributable to other causes.

4/Chronic hypertension with superimposed pre-eclampsia:

patients with chronic hypertension and one or more:

• New onset of proteinuria• Hypertension with proteinuria after 20 weeks' gestation• Sudden increase in proteinuria that was present before

pregnancy• Sudden increase in BP that had otherwise been well

controlled• Thrombocytopenia (<100 x 10^3/microlitre)• Elevated liver enzymes (ALT or AST).

Risk factors • Nulligravidity (6% to 17%)• black or Hispanic ethnicity,• multiple pregnancies, • obesity, • the mother herself being born small for gestational

age.• type 1 diabetes• migraine

diagnosis

A diagnosis of gestational hypertension should be made only after 2 readings ≥140/90 mmHg, spaced at least 6 hours apart but no more than 7 days apart.

Diagnostic tests

•Urinalysis.•FBC•LFTs•electrolytes, urea, creatinine•uric acid•fetal ultrasound•proteinuria (24-hour urine collection):

Protein levels above 0.3 g/dL in 24 hours are diagnostic for pre-eclampsia.

•Severity classification of gestational hypertension:

•Mild: BP measurements between 140/90 mmHg and 160/110 mmHg.

•Severe: sustained BP elevations for a minimum of 6 hours with systolic BP of at least 160 mmHg and/or diastolic BP of at least 110 mmHg.

women ≤37 weeks' gestationmild or moderate hypertension <160 mmHg and

<110 mmHg)1st: lifestyle modification , diet.weight loss is not recommended for obese patients

severe hypertension:1st : antihypertensive treatment

women >37 weeks' gestation

mild or moderate hypertension1st: induction of labour/deliveryIf the patient does not respond to medical

induction, then delivery by caesarean is necessary.

severe hypertension1st: antihypertensive treatment + induction of

labour/delivery

References