Clinical Practice Guideline: Gestational Diabetes

Clinical Practice GuidelineGestational Diabetes

Iris Thiele Isip Tan MD, FPCP, FPSEMMS Health Informatics (cand.)

Clinical Associate Professor, UP College of MedicineSection of Endocrinology, Diabetes & Metabolism

Department of Medicine, Philippine General Hospital

18 March 2010

DisclosureNone ...

ADA

IDFAS

GO

DIP

CDA

NICEHAPO

IADPSG

Where guidelines disagreed, I picked the one I agreed with ☺

AACE

31/F obese pregnant (pre-pregnancy BMI 30)20 weeks AOG

Referred for rapid weight gain of 5 kg in the last 4 weeks

Her mother has type 2 diabetes

Screen for GDM?

There is not sufficient high-level evidence to make a recommendation for, or against, screening for GDM.

US Preventive Services Task Force 2008 UK National Health Service 2002

Canadian Task Force on Periodic Health Examination 1994

“Screening, diagnosis and treatment of gestational diabetes is cost-effective.”

UK National Institute for Health and Clinical Excellence 2008

No consensus on GDM screening

Who? When? How?

1998

Umbrella organization to facilitate

collaboration

International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care Mar 2010; 33(3):676-82.

“This report represents the opinions of individual members of the IADPSG Consensus Panel and does not necessarily reflect the position of the organizations they represent.”

First prenatal visit Measure FPG, A1c or random plasma glucose in all or only on high-risk women

IASDPG Consensus Panel Diabetes Care Mar 2010; 33(3):676–682.

FPG >7 mmol/L A1c >6.5%

RPG >11.1 mmol/L

Overt Diabetes in Pregnancy

If results not diagnostic of overt diabetes and

FPG 5.1-6.9 mmol/L (92-125 mg/dL) → GDMFPG <5.1 mmol/L → 75-g OGTT at 24-28 wks AOG

75-g OGTT at 24-28 wksOvert diabetes if FPG >7.0 mmol/L (126 mg/dL)GDM if one or more values equals or exceeds thresholdsNormal if all values on OGTT less than thresholds

Benefit of early testing?IASDPG Consensus Panel

Diabetes Care Mar 2010; 33(3):676–682.

75-g OGTT thresholdsFPG 5.1 mmol/L (92 mg/dL)1-h PG 10.0 mmol/L (180 mg/dL)2-h PG 8.5 mmol/L (153 mg/dL)

First prenatal visit Screen women at very high risk using standard* diagnostic testing.

ADA Standards of Medical Care 2010

* FPG, HbA1c, 75-g OGTT or random plasma glucose

Very high riskSevere obesityPrior history of GDM or delivery of LGA infantPresence of glycosuriaDiagnosis of PCOSStrong family history of Type 2 diabetes

Greater than low risk womenTest for GDM at 24-28 weeks AOG

Low risk (must fulfill all)

Age < 25 yearsWeight normal before pregnancyEthnic group with low DM prevalenceNo known diabetes in first-degree relativesNo history of abnormal glucose toleranceNo history of poor obstetrical outcome

Low risk womenNo testing required

ADA Standards of Medical Care 2010

IADPSG

FPG, HbA1c or random plasma glucose

First prenatal visit

ADA ASGODIP

FPG, HbA1c, 75-g OGTT or random plasma glucose

50-g GCT (low risk) or 75-g OGTT (high risk)

Thresholds FPG >7.0 mmol/L Overt diabetes

75-g OGTT FPG 5.1 mmol/L (92 mg/dL) 1-h 10 mmol/L (180 mg/dL) 2-h 8.5 mmol/L (153 mg/dL)

Further testing 24-28 wks

75-g OGTT if FPG <5.1 mmol/L

GCT ➝ 100-g OGTT100-g OGTT (1-step)

If GCT <130 If 2-h OGTT <140

100-g OGTT FPG 95 mg/dL 1-h 180 mg/dL 2-h 155 mg/dL 3-h 140 mg/dL

75-g OGTT 2h 140 mg/dL

1996

at least 2

any value


Referred for rapid weight gain of 5 kg in the last 4 weeks

Her mother has type 2 diabetes

FBS or 75-g OGTT?


75-g OGTT:Fasting 1021 h PG 1922 h PG 155

⤳ GDM by FBS criterion

Diet prescription in GDM?

“Initiate MNT immediately

once diagnosed.”AACE 2007

“All women with GDM should receive nutritional counseling by a registered dietitian when possible.”

ADA GDM Position Statement 2004

Choose where possible CHO from low GI sources

Lean proteins including oily fishBalance of poly- and monounsaturated fats

NICE 2008

If pre-pregnancy BMI >27, restrict caloric intake to <25 kcal/kg/day ...

... and take moderate exercise (>30 min daily).

NICE 2008

Obese women (BMI >30):

30-33% calorie restriction (to ~25 kcal/kg

actual weight/day)

Restrict CHO to 35-40%

of calories.ADA GDM Position Statement 2004

3 meals and 3 snacks

50-60% complex high fiber carbohydrates

18-20% protein or at least 75 g<30% fats

Monitor urine ketones before breakfast to detect starvation ketonuria

ASGODIP 1996

“Non-caloric sweeteners

may be used in moderation.”



Ht 165 cm Wt 90 kgTCR = 90 x 25 kcal/kg = 2250 kcal/day

3 meals and 3 snacksCHO (50%) 281 gCHON (20%) 112 gfats (30%) rest

Urine ketones at ff-up

Blood glucose monitoring?

“SMBG is essential during pregnancy.”

Canadian Diabetes Association 2008

“Daily SMBG appears to be superior to intermittent office monitoring of plasma glucose.”


“For women treated with insulin, limited evidence indicates that postprandial monitoring is superior to preprandial monitoring.”


Both preprandial and postprandial testing are recommended.

If on insulin, test at night because of increased risk of nocturnal hypoglycemia.


Patients should intensively monitor BG

AACE 2007

Diet onlyMonitor BG 4x a day (prebreakfast and 1 h after the first bite of food at each meal)

Insulin therapyMonitor BG 6x a day (before each meal* and 1 h after the first bite of food at each meal)

* to determine insulin dosage correction

“Urine glucose monitoring is not useful in GDM.”


“Urine ketone monitoring may be useful in detecting insufficient or caloric or CHO intake in women treated with caloric restriction.”



Diagnosed GDM

MNT startedMonitor CBG 3x a day, alternate between- prebreakfast and 1 h after breakfast & lunch- 1 h after meals


Diagnosed GDM

After 2 weeksPreprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dL

How long can we wait before declaring diet therapy a failure?

Consider insulin when ...

Diet and exercise fail to maintain glucose targets during a period of 1-2 weeks

Ultrasound suggests incipient fetal macrosomia (AC >70th percentile)

NICE 2008

Glucose targets

Between 60 to 90 mg/dL (fasting) and less than 120 mg/dL (1 hour after the first

bite of food at each meal)

AACE 2007

“HbA1c should not be used routinely for assessing glycemic control in the second and third trimesters of pregnancy.”

NICE 2008


Diagnosed GDM

Preprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dLStart insulin to bring down postprandial CBGs

Can we give Metformin in GDM?

How about Glibenclamide?


Use of metformin or glibenclamide during pregnancy not an approved indication

Discuss with patients

Off-label use

Option of giving metformin or glibenclamide

NICE 2008

“... tailored to glycemic profile of, and acceptability to, the individual woman.”

Obtain and document informed consent.

Metformin in Gestational Diabetes (MiG) Study

Combination therapy

MiG study

Women taking metformin (who had insulin added) required lower insulin dose

? metformin + glibenclamide

IDF 2009

Insulin remains the agent of choice

“In poorly resourced areas of the world, the theoretical disadvantages of using oral glucose-lowering agents ... far less than the risks of non-treatment.”

IDF 2009

Recommended insulin regimens?

Prandial, basal bolus, split-mixed? Analogues?

Initiate a basal-bolus regimen if a patient cannot maintain glucose targets with diet alone.

NPH insulin (basal) and rapid-acting insulin at meals

Subcutaneous insulin infusion with an insulin pump

AACE 2007

Insulin regimens in GDM

Intermediate-acting insulin

30 min prebreakfast and presupper + rapid-acting insulin3 injections of rapid-acting

insulin given 30 min before

each meal + intermediate-

acting OR long-acting insulin at bedtime

ASGODIP 1996

Insulin therapy in GDM

ASGODIP 1996

Initiating dose depends on the blood glucose

May start daily insulin dose 0.1-0.3 u/kg BW

“ ... rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy ...”

NICE 2008

Which type of insulin and which regimen? Discuss with patient.


Diagnosed GDM

Preprandial CBGs 70-80 mg/dL1h Postprandial CBGs 130-150 mg/dLStart prandial (regular) insulin i.e. 4-6 units premeals tid

Ht 165 cm Wt 90 kg

How often to follow-up?

ASGODIP 1996

Subsequent Visits

Every 2 weeks for

Glycemic control: check 2-h PPBGObstetric complications:

macrosomia, IUGR, preeclampsia, and hydramnios

Ultrasound

At first visit to determine age of pregnancy

At 20-22 wks to detect malformations

At 32-34 wks to monitor growth

ASGODIP 1996

Management during labor and delivery

Protocol for Spontaneous Delivery

Infusion of 500 ml 5% dextrose/saline x 4 h

CBG q 4hGive short-acting insulin for

CBG >140 mg/dL

- Dose equal to mmol of CBG

i.e. 12 u for 12 mmol/L

- Dose equal to 1/20th of mg/dL of

CBG i.e. 12 u for 240 mg/dL

Omit insulin for CBG <140

mg/dL ASGODIP 1996

Maternal hyperglycemia is the main cause of neonatal hypoglycemia

Insulin is still required before

active labor; SC or IV to maintain BG 70-90 mg/dL

Infuse glucose 2.5 mg/kg/

minMeasure CBG q hourly

Double the glucose infusion

for the next hour if BG <60

mg/dLGive regular insulin SC or IV

for BG >120 mg/dL AACE 2007

ASGODIP 1996

After delivery

Resume diet

GDMs with high insulin requirements during pregnancy should have glucose profiles

Give insulin if BG persistently

high (>200 mg/dL)

Postpartum follow-up

Reclassify at least 6 weeks after delivery

Reassess q 3 years if normal BG postpartum

Test for diabetes annually if with IFG or IGT postpartum


All patients with prior GDM should be educated re: lifestyle modifications

Maintain normal body weight: MNT and physical activity


Women with IFG or IGT postpartum: intensive MNT and individualized exercise program

Planning subsequent pregnancies

Plan future pregnancies in consultation with health care provider

Assess glucose tolerance prior to conception to assure normoglycemia at time of conception


“As always, solutions of an immediate problem raise questions

for the future.”

Robert G. Moses, MD

Thank You

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Clinical Practice Guideline: Gestational Diabetes

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