Gestational DiabetesThe Therapeutical Education “ in Team“

Master for Sanitary OperatorsFebruary 21, 2009

Pisa, Italy, Accademia Palace Hotel

Obstetric Management in Women affected by Gestational Diabetes

Dr. Lorella Battini, MD, Prof. of OGASH General Coordinator of OGASH Institutions

Europe Chairman of OGASHWinner of Prof Joseph Jordania International Prize 2008

Nominated “OGASH Professor ” for the E.T. Rippmann Medal de Onoare

Diabetes Care 30:S175-S179, 2007DOI: 10.2337/dc07-s212

© 2007 by the American Diabetes Association

Obstetric Management in Gestational Diabetes

Deborah L. Conway, MD From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center–San Antonio, San Antonio, Texas

ACOG Practice Bulletin 2001

AOGOI, Rivista di Ostetricia Ginecologia Pratica e Medicina Perinatale, vol XXII, n° 3/4, 2007

DIABETES CARE, Ed. Italiana, All. a, ADA, maggio 2003

NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period

Bibliographical Sources

Optimizing outcomes for women with gestational diabetes mellitus (GDM)

and their fetuses

“ Multidisciplinary Team Play Strategies”

• careful metabolic management (Diabetologists)

• appropriately applied fetal surveillance techniques (Obstetrics )

• thoughtful selection of the most advantageous timing and route of delivery

Warning !Whenever possible, these clinical decisions should be based on the highest level of evidence available and should weigh the likelihood and seriousness of both

maternal and fetal/neonatal morbidity

1997- Workshop-Conference on GDM

“ The summary statement ”

“ the lack of data from controlled clinical studies on which management

recommendations can be based was a prominent theme of discussion regarding antepartum management of GDM" (1).

Major Risk Factors for GD

• Age >35 years• Istgrade family History : Diabetes• Previous GDM• Glycosuria• Obesity: BMI>28• Macrosomia (>4 Kg)• Significant weight increase in Pregnancy• Acceleratad or dismorfic fetal growth • History of unexplained stillbirth

OMS

EARLY GCT (50 gr)

Negative GCT:

Basal Value < 95

1 h post-load < 140

Preconceptional Planning

FLOW CHART

Screening GDM precoce

UO Ost-Gin 2 AOUP

Direttore: Dr. MG Salerno

Flow Chart

Joint Diab/Obstet.Ambulatory AOUP

Early

GDM Screening

Fetal surveillance

• All women with GDM should monitor fetal movements during the last 8–10 weeks of pregnancy and report immediately any reduction in the perception of fetal movements.

• Non-stress testing and / and/or CST and/or biophysical profile testing should be "considered" since 32 weeks’ gestation in women with poor glycaemic control, or on insulin, or who have concomitant perinatal risk factors

• Non-stress testing should be "considered" and "at or near" term in women requiring only dietary management and without concomitant perinatal risk factors

ACOG Practice Bulletin 2001

Fetal surveillance

• Biophysical profile testing and/or Doppler velocimetry to assess umbilical blood flow "may be considered" in cases of “ excessive or poor fetal growth “, or when there are comorbid conditions, such as GESTOSIS SYNDROME ( “RIPPMANN ’s SYNDROME “ ) or obstetric history positive for further pathology

Fetal surveillance• For uncomplicated, well controlled GDM, treated with only diet, and without further

perinatal risk factors

No sufficient evidence to propose an optimal monitoring strategy,

thus the following chances are allowed:

• The same tests of complicated GDM since 32nd week of gestation

• Routine monitoring protocol of normal pregnancies

ACOG Practice Bulletin 2001

• The presence of GDM is not by itself an indication for cesarean delivery.

• There are no data to support a policy of caesarean delivery purely on the basis of GDM

However:

• MACROSOMIA • SHOULDER DYSTOCIA

• CLAVICULAR FRACTURE• BRACHIAL PALSY

• UNEXPLAINED INTRAUTERINE FETAL DEATH• PERINATAL MORBIDITY

are more common in women with GDM, thereforeElective Cesarean Delivery

is reasonable when macrosomia has been detected (EFW>4500g), on the basis of obstetric history,

pelvimetry and careful assessment of risk- benefits balance

Mode of Delivery in GD

Timing of Delivery in GD

• GD is not an indication for caesarean or spontaneous delivery before 38 weeks’ gestation, in the absence of evidence of fetal compromise or other maternal risk factors.

HoweverGestational prolonging beyond 38th weeks may lead to

• Increased risk of fetal macrosomia

Without • Reducing caesarean section risk

Thus • Delivery in the course of 38° week of gestation is

recommended, unless obstetrical factors don’t indicate different management

ADA, Official Position, 2003

ACOG Pract. Bulletin, 2001: Not recommended delivery before 40 ws. in uncomplicated GD, without further maternal and/or fetal

indications

Preexisting Diabetes MellitusSummary of Management in Pregnancy

• Preconceptional Planning after optimizing HbA1C < 6.5g/dl (OMS)

• Multidisciplinary team approach and follow-up• Strict and intensive SMBG • Maintenance of blood glucose fasting value < 95-90• Maintenance of blood glucose 1h postprandial value < 130• Avoidance of hypoglycaemia • 5 mg folic acid until 12 weeks gestation• Physical activity planning• Increased frequency of screening for retinopathy• Intensive follow up for prevention and/or early detections of

complications • Delivery in III Level Obstetric Department with NICU• Breast feeding recommended

Preexisting Diabetes: Monitoring fetal growth and

well-being

• Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks

• Women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being.

Preexisting Diabetes: Timing and mode of birth

• pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks

• diabetes should not in itself be considered a contraindication to attempting vaginal birth

• pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section

(1) NICE (March 2008). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period (2) NICE (July 2008 re-issued guidance). Diabetes in pregnancy Management of diabetes and its complications from pre-conception to the postnatal period

Conclusion

The diagnostical-therapeutical route,shared and managed by a

multidisciplinar and multiprofessional team is the

fundamental instrument to make safe pregnancy in diabetic women.

Conclusion

• A. The activation of a structured screening for GDM diagnosis is an essential instrument to avoid unappropriate and late OGTT check

• To early detect Patients affected by GDM and manage them to safe delivery

• B. Women affected by pregestational Diabetes Mellitus can live safe pregnancy and delivery, giving birth in a 3rd level Obstetric Unit linked to a Neonatal Intensive Care Unit

Saint Vincent Declaration, 1989 (OMS)

Diabetic Woman in Pregnancy is a Patient “at

risk”

By Saint Vincent Declaration, in 1989, WHO addressed the following Mission to the

International Scientifical Diabetology community:

1. To dramatically reduce risk in diabetic women as that in non diabetics

2. To early detect GDM For preventing adverse outcome in Mother and

Babies by an adequate screening in “ women at risk “

THE JOINT INTERDEPARTMENT DIABETOLOGIC-OBSTETRIC SERVICE for DIABETES and PREGNANCY- AOUP-PISA

G. Di Cianni, L. Volpe, A. Bertolotto, C.Lencioni, A. Ghio, V. Resi L. Battini

Dietologist: M. Corfini Nurses: M. Carnevale, A. Civitelli, A. Favati, S. Nuvola, L. Tesi

Saint Vincent Declaration, 1989 (OMS)