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Gestational Diabetes: A Big Problem Now and A Bigger Problem Later

Gestational Diabetes: A Big Problem Now and A Bigger Problem Later. Steven G. Gabbe, M.D. Dean, School of Medicine Professor, Obstetrics and Gynecology Vanderbilt University Medical Center. Gestational Diabetes: A Big Problem Now and a Bigger Problem Later. Learning Objectives:

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Gestational Diabetes: A Big Problem Now and A Bigger Problem Later

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  1. Gestational Diabetes: A Big Problem Now and A Bigger Problem Later Steven G. Gabbe, M.D. Dean, School of Medicine Professor, Obstetrics and Gynecology Vanderbilt University Medical Center

  2. Gestational Diabetes:A Big Problem Now and a Bigger Problem Later Learning Objectives: 1. Identify the increased risk of gestational diabetes mellitus and type 2 diabetes mellitus in African American, Hispanic, Asian, and Native American women 2. Describe the short-term and long-term morbidities for these women and their infants 3. Discuss the need to detect gestational diabetes in pregnancy, and methods presently in use for screening and diagnosis

  3. Gestational Diabetes:A Big Problem Now and a Bigger Problem Later Learning Objectives: • Explain the use of dietary therapy, the indications for insulin and glyburide, and strategies for monitoring maternal glucose control • Describe strategies to prevent or delay the development of type 2 diabetes mellitus in women who have had gestational diabetes mellitus

  4. Epidemiology 4-7% of pregnancies in the United States complicated by diabetes mellitus: GDM: 90% Types 1 and 2: 10%

  5. Maternal Metabolism in Late Pregnancy • Reduced insulin sensitivity • Insulin resistance due to: • Hormonal changes • Human placental lactogen (hPL), leptin, TNF α • Progesterone, prolactin, cortisol • Increased placental insulin clearance

  6. Carbohydrate Metabolism in Pregnancy • Beta-cell function in normal pregnancy • Beta-cell hypertrophy and hyperplasia • Increased beta-cell responsiveness • Insulin action • Reduced hepatic insulin sensitivity • Increased hepatic glucose production

  7. Carbohydrate Metabolism in Pregnancy • Postprandial hyperglycemia • Accelerated starvation

  8. Effect of Maternal Diabetes Mellitus On the Fetus

  9. DefinitionFrom the 4th International Workshop, 1997 Gestational diabetes is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. The definition applies regardless of whether insulin is used for treatment or the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy. Incidence: 7%

  10. Consequences of Gestational Diabetes:Why Bother to Screen? Maternal Subsequent diabetes mellitus, >50% with type 2 diabetes mellitus 15 years postpartum; shortened life expectancy

  11. Incidence of Type 2 Diabetes MellitusAfter Pregnancy Complicated by GDM Cumulative incidence of diabetes in high-risk and control participants. Yellow squares indicate overweight control subjects; orange triangles, normal-weight control subjects; green squares, overweight high-risk subjects; blue triangles, normal-weight high-risk subjects. J.B. O’Sullivan, Body Weight and Subsequent Diabetes Mellitus, JAMA 1982;248(8):949-52

  12. Consequences of Gestational Diabetes:Why Bother to Screen? Fetal and Neonatal Maternal hyperglycemia leads to fetal hyperglycemia and hyperinsulinemia Macrosomia and trauma including shoulder dystocia; Hypoglycemia, Hypocalcemia, Hyperbilirubinemia Increased perinatal mortality associated with fasting hyperglycemia Long term morbidity: obesity, carbohydrate intolerance

  13. Follow-Up Studies of Infants of Gestational Diabetic Mothers (IGDM) at Age 12 Metzger B., et al. ADA Annual Meeting, 1995

  14. Gestational Diabetes MellitusApproaches to Screening and Diagnosis

  15. Gestational Diabetes MellitusApproaches to Screening and Diagnosis

  16. Gestational Diabetes MellitusApproaches to Screening and Diagnosis

  17. Gestational Diabetes MellitusApproaches to Screening and Diagnosis

  18. Relative Risk of GDM by Race Adjusted for Maternal Age and Prepregnant PIBW *** * * P<0.05 *** P<0.001 Dooley, SL. Et al., Int. J. Gynecol Obstet 1991;35:13-18.

  19. Detection • Screening with a 50g glucose load or in high risk women, a diagnostic OGTT • 50g oral glucose load, administered between the 24th and 28th week, without regard to time of day or time of last meal, to all pregnant women who have not been identified as having glucose intolerance before the 24th week • Venous plasma glucose measured one hour later. Value of 130-140 mg/dL or above in venous plasma indicates the need for a full diagnostic glucose tolerance test

  20. Gestational Diabetes Mellitus100g OGTT Diagnostic Criteria Two or more of the following venous plasma concentrations must be met or exceeded:

  21. Gestational Diabetes Mellitus Treatment • Visits every 1-2 weeks until 36 weeks; then weekly • Dietary management: • 2000-2200 calorie, no-concentrated-sweets diet • Capillary blood glucose monitoring

  22. Exercise and GDM • A program of moderate physical exercise is recommended • 20 minutes, 3 times/week

  23. Surveillance of Maternal Diabetes • Check fasting and 1-hour or 2-hour postprandial glucose levels daily to assess efficacy of diet with self monitoring of capillary blood glucose. • Check fasting urine ketones in patients on caloric restriction. • If fasting capillary value > 95mg/dL and/or 1-hour value > 140 mg/dL or 2-hour value > 120mg/dL, insulin or glyburide therapy is required.

  24. Glyburide vs. Insulin • 404 women with GDM randomized to insulin or glyburide (Micronase, DiaBeta) • Both therapies showed comparable improvement in glucose control • 8% of glyburide patients required insulin • Hypoglycemia (<40 mg/dL) more frequent with insulin (20% vs. 2%, p=0.03) • No differences in maternal complications, Cesarean delivery rate, neonatal outcomes • Conclusion: In women with GDM, glyburide is a clinically effective alternative to insulin therapy Langer O, et al. N Engl J Med 2000;343:1134-8

  25. Effect of Treatment of GDM on Pregnancy Outcomes *P = 0.01 **P = < 0.001 Crowther, C.A., et al. N Engl J Med 2005;352:2477-86.

  26. Effect of Treatment of GDM on Pregnancy Outcomes Crowther, C.A., et al. N Engl J Med 2005;352:2477-86. **P = < 0.001

  27. Effect of Treatment of GDM on Pregnancy Outcomes Conclusions: Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman’s health-related quality of life. Crowther, C.A., et al. N Engl J Med 2005;352:2477-86.

  28. Evaluation for Carbohydrate IntolerancePostpartum Care • At 6-12 weeks postpartum, all patients who had carbohydrate intolerance during pregnancy (GDM) should be evaluated and reclassified as follows:

  29. Evaluation for Postpartum Carbohydrate Intolerance

  30. Gestational Diabetes and the Incidence of Type 2Diabetes – A systematic literature review • Women of different ethnic groups progress to type 2 diabetes at similar rates after a diagnosis of GDM, 5-10%/year. 2. Incidence of type 2 diabetes increases markedly in first 5 years after delivery; plateaus at 10 years. 3. Elevated fasting glucose during pregnancy most important risk factor for type 2 diabetes. Kim C, et al. Diabetes Care 2002;25:1862-68 Reed S, et al. Clinical Journal of Women’s Health 2002;2:29-33 Kjos S, et al. Diabetes 1995;44:586-91

  31. Factors Associated with Accelerated Onset of Type 2 Diabetes Mellitus • Another pregnancy, especially complicated by GDM • Weight Gain; non-pregnant BMI ≥ 30 • Use of progestin-only oral contraceptives in lactating Latina women with prior GDM • Hypertension • Family History of Diabetes Mellitus

  32. Prevalence of Type 2 Diabetes in VariousUS Ethnic Groups Abate N., Chandalia M. The impact of ethnicity on type 2 diabetes. Journal of Diabetes and Its Complications 2003;17:39-58.

  33. Strategies for Prevention/Delaying Onset ofType 2 Diabetes Mellitus • Weight Loss • Healthy Diet • Exercise • Drugs: Metformin Troglitazone (TRIPOD Study)

  34. Cumulative Incidence Rates Cumulative incidence of diabetes (%) Buchanan T.A., et al. Preservation of Pancreatic β-Cell Function…Women, Diabetes, 2002;51:2796-803

  35. Gestational Diabetes MellitusKey Points 1. Pregnancy has been characterized as a diabetogenic state because of increased postprandial glucose levels in late gestation. 2. GDM is an important health care problem affecting approximately 200,000 women annually. 3. Perinatal mortality is not increased in most cases of GDM, although increased morbidity, primarily macrosomia, is found in the offspring of women with GDM.

  36. Gestational Diabetes MellitusKey Points 4. Universal screening for GDM using measurements of blood glucose should be performed at 24-28 weeks gestation except for women identified as low risk based on clinical attributes. 5. To better guide therapy, we must define the level of glycemic control which poses a risk for fetal and neonatal complications such as macrosomia. 6. The key element in treating gestational diabetes mellitus is dietary therapy. Moderate exercise may also be valuable.

  37. Gestational Diabetes MellitusKey Points 7. Insulin or glyburide are utilized when significant fasting or postprandial hyperglycemia occurs despite dietary treatment. 8. A program of fetal surveillance is appropriate for patients with GDM requiring insulin or glyburide, or those with hypertension or a previous stillbirth. 9. Women with GDM are at high risk for developing type 2 diabetes. Regular medical evaluations are therefore recommended.

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