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Philippine Obstetrical and Gynecological Society (Foundation), Inc. CLINICAL PRACTICE GUIDELINES on DIABETES MELLITUS IN PREGNANCYDISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY + This i the Clinical Practice Guidelines (CPG) on Diabetes Melits in Pregnancy, Second Eaition, November 2011 «+ Thisisthe publication of the Philippine Obstenca and Gynecological Society (Foundation), Toc (POGS), + This isthe ownership ofthe POGS, ts offices, and its entire membership. “The obstetrician gynecologi, the general practitioner, the patient, the student, the allied medical practitioner, or, for that mate, aay capacity ofthe person trindividual who may read, quote, ite, fet, or acknowledge, any op, forthe enttety of any topic, subject matter, dagoosic condition or iden/s ‘wilful release and wave all the abies and responsible of the POGS, is offcers and general membership, a¢ well asthe Commie onthe Clinica, Practice Guidlines and its Edtorial Sal in any or all clinical or other Gisputes, disagreement, conference audts/conroversis, case dscusion/ ctguing “Therenderisencouragedto deal witheach clsialcaseas distinct and unique 50% mortality rate + vers, eta on a prospective study of diabetes mellitus in pregnancies reported that even ifthe genic contol is excellent (75% of the study population have Hibs te 75), complication rates (preeclampsia 12.7%, preterm delivery [PTD] 32%, cesaean section rate 49%, maternal morality rate €0/ 100,000) te sill considerably higher than the noudiabede pregnancies" Peal Eats + There is an important dierence concerning adverse fetal consequences of loyerl/pregestational versus gestational diabetes melts (GDM) beeaie risks ‘of complications are proportional to the duration and severity of the disease Unlike in those with overt diabetes melts, feta anomalies are not increased imap Likewise, those with over/pregestational diabetes metitus have greater tisk of having eal deat those with dettzeated postprandialGDM patients with clevated fasting blood sugar (EBS) have similar risk of having unexplained fetal deathe av those with overt/pregestationa diabetes ‘mellitus? Specifically, che American Diabetic Astociation (ADA) concluded that EBS) ‘of =108 mg/dL ie associated with sncreaed risk of unexplained fetal deaths ‘Suring the last 48 weeks of gestation” Improvement in fetal surveillance, neonatal jtensive care and maternal metabolic control have lowered peritatal morbidity and mortality in overt/ ‘regestational diabetes melas" Jn type 1 dahetes melites, there was dramatic decrease in perinatal mortality {ater (PMR) from 22% in the 1960s to 1% in the 1990s hut 90 change inthe {incidence of fetal overgrowth, ARerwhich, there was a plateau in the PMI ‘because hetwomajorcausesof fetal deaths Wwhichare congenital malformations "nd unexplained fetal death in tero (FDU) eemained unchanged by medical sternal Complications of Diabetes Melts ia Pregnancy Diab Nephropatoy + Pathophysiology of Diabetic Nephropathy: > excessive deposition of glycogen to the glomerular ‘basement membrane (BM) > BMihiekeing > diabeticglomerulosceross ‘nd papillary necrosis > albuminuria > progressive fenal destruction’ ‘Steriocaton > end stage renal disease and falore + Diabetic nephropathy will eventually appear in 30-40% of patents with ‘ype I diabetes mellitus and isthe leadingeause oP end stage renal disease {nthe United States. Incidence of renal failure in type 1 diabetes mel 52.30% compared to 42% among type? diabetes melts. + Clinicat Couree of Diabetic Nephropathy: SIS ears from onset of diabetes relitis > microalbuminuria (30-300 smg/24 hours) + Pioyear later > overt proteinuria 300 mg/24 hours) with or ‘without hypertension among those destined {© have end stage renal disease + 10°TS years later > renal falure + The prevalence during pregnancy has been estimated to range from 45-10% Pregnancies complicated by nephropathy are at increased Fisk for ‘maternal and fetal morbidity and perinatal mortality. + Microalbuminuria in easly pregnancy is a very sensitive predictor of possible onset of preeclampsia later in the course of pregnancy. Five Percent of pregnant women with diabetes mellitus have renal involvement (ivhice Classification F) wih signiicandy increased risk for developing ‘reeclampsia and low bith weights and indicated preterm delivery. + Pregnant women with chronic hypertension with diabetic nephropathy have 80% chance to develop preecampaia. + There appears t0 be no long term sequelae of pregnancy per se on iabesic nephropathy. Impact of pregnancy on diabetic nephropathy ‘Sepends on pre-preghant renal function, suc tat in those with markedly ‘compromised plomerula lation rate (GFR) prior to pregnancy, there Signifcant rik of permanent dectine in renal fenction later. + Pregnancy neither alter: the time course of renal disease nor increase the likelihood of transition to end stage renal disease.” Diabetic Retinoptiy + Most important cause of visual impairment among dhose < 60 years old in the United States However, the prevalence is elated tothe duration of the diseare'™ + Clinical Course/ Progression of Diabetic Retinopathy: Hyperpiycemia induce microvascular disease > micromnevrysms. > red blood cells (RBCS) extravasation > blot hemorthages “> leaked serous fluid will Form hand exudates (Nonprolifrative Retinopathy) > Progressive occlusion of retinal vessels > retinal schema nd infarction ‘withdevelopmentof cation wool exudates (PreproliferariveRetinopathy) SNcompensatory neovascularization in te retinal surface and viseous space Proliferative Retinopathy) > frou tse formation and retraction S"racconal souinal detachment with of withowt mactlar edema and retinal viueous hemorrhages > visual impairment and blindaess + Acconding the Diabetes Melitus Prevention Project (2007), 816 of those ‘vi impaired glucose test and 13% of ney ideatied abetes elias have reinopaah: + Almost alt become diabetic before 30 years old and/or Atusation ave retinopathy.+ Studies on the efects of pregnancy on retinopathy give diverse resus a Klein, etal ~ Pregnancy worsens proliferative renopathy” Pregnancy heen flea on retinopathy by showing {Bese prevalence of retinopathy inal snd malparous Women .e. Arun and Taylor In + pronpective postpartum 8-year fllow-up of 59 women with type 1 iets melts confirmed thc the baseline Fesinopathy was the only independent isk factor for progression * “+ Among those with early minimal reinapathy before conception, the ‘Ghance of progression daring pregnancy i 10% “+ Hypertension and preedampsla further Incease the risk of progressive ‘elnopathy during pesnancs Diab Neuropathy “+ Usually develops after 10-15 yeas fom onset of diabetes melts. “+ Peripheral and. symmetrical sensorimotor diabetic neuropathy is “uncommon in pregnancy. + Diabetic gastropathy (tisbetes meticus elated nerve disturbance inthe ‘putrointestinal tcl) fs particularly troublesome in pregnancy because {is associated with nausea, vomiag, nutiuonal disturbances and ificaty with glucose contol This may be teated with H2 blockers oF ‘metoclopramide, + Painfl insatin neuritis, are nonspecific aches felt secondary 10 rapid tightening of glycemic contol.” Canionscatar Completions (Choc Hypertesion,Prcanpsta, Aheolesis ‘nd Coronary ears ise) + Chronic Hypertension (0 Untally with arsociated underlying or preexisting renal or retinal ‘9 Associated complications: maternal stoke, preeclampsia, abruptio placenta, snauterne growth restction (UGH) + Preectampsia onthe nk is 4x higher in those with overt/pegestatonal disbetes telugu compared with nondiabede pregnant patient ‘9 Tein a major complication that most often forces preterm delivery in siabetic pregnancies. (© Clinically inthe presence of developing hypertension and worsening proteinuria, itis dificult to diinguish whether this ir due € $Superimposion of preeclampsia or due to worsening nephropathy. (© Theperinatalmonalityraeis increased 20x fom preeiampsia women wih dabetesmellius compared to those without hypertension, 1+ Atheroseteross and Coronary Heart Disease ‘Ov Coronary heart deste and myocardial infarction are sare event in pregnant diabetics. Affected diabetic pean women may have precinical cardiomyopathy and autonomic neuropathy. (© Diabetic patients with long standing disease who have developed Inypestenston and nephropathy are at higher rik to develop coronary artery disease (© The hemodyeamic changes associated with pregnancy increase myocardial tess. ‘© Epinephrine release in sesponse to hypoglycemia might exacerbate the risk for myocardial injury. (© Exaggerated lipid changes plus destructive and ehrombotic events in ‘the vascular beds during prepnancy may accelerate atherosclerosis 5 ions + Almost 80% of women with type 1 diabetes metus develop infection uring pregnancy compared wih only 28% in thous without diabetes + Most common infections are urinary tact infections (UTD, cervicovaginal snd wound infecdons felling delivery bat almost types of infections + Infecons are risk factors forthe development of preter iabor/ delivery BIC and progreson of picestng nephropathy mong tho wih 4 Other Endocrine Diturbanes +The incidence of thyroid gland diorder daring pregaancy and the fst ‘year postpartum ia type T dlabetes melts i aloost 3x her than that {Of the normal population. Operative Devry ste in women with diabetes mls i 20- Obsetecal practice. The diagnosisof diabetes mellitus or the knowlege tht the women are being treated ‘wih insulin rigger an increase i intervention among obstetricians ‘Common indications for cesarean delivery are prematurity, macrosomia and other diabetes melituselated complications. DKA + DKA alec only 1% of diabetic pregnancies but is one of the most Serious complications which significantly affects both the mother and the fetus wth etal os ate of > 20% + ‘This complication is unique to type 1 diabetes mellitus and the following fare the Known precpitants: byperemess gravidarum, S-mimetics fOr {ocoysis serids administration for feral ung maturity, infections + Pregnant wornen usually have DKA with lower blood glucose levels ‘Sompaced to nonpregnant worn, Trego nin action sib gt ass > functional CELLULAR HYPOGLYCEMIA > compenstory hepa obisation of cost El wih atsen toe dnp > pcos king nies sere tone SEL busty of cee in te boot Gypersyeoma) > meta ‘Sik + nomote dress "9 pound vse sole depen, es SF eecoler and fer ehypoheeni > mull nan system colapee > coma ad enh Fetal Complications of Diabetes Meili in Pregnancy 1 Barly Pagnancy Lawes (Abertion) + Barly abortion i associated with poor glycemic contol + Pathophysiology: Hyperlyeemia due w failure to deliver glucose (insulin resistance) to end-tssues > cellular hypogycemia and hypoxia ire of Oxygen delivery to. tesuer die 10” hypeesjcemia mediated shit of ‘oxsliemogioin disocaton curve othe et) > em jon ‘tnd death (eat pregnancy oss) 2. Preterm Labor ond Devery + Qven/pregesttional dnbetes mel 1 ith preterm births, secondary to susceptibility to infetion, polyhydramnios ‘nd fetal or maternal conditions indicating early pregnancy termination + Maternal and Fetal Medicine Units Network (Sib, el) showed a ‘9% preterm birth ate among pegetationa diabetes mellius versus 4.5% for nondiabetics 'b. Toincidenceof indicated petem deivery for pregestaonal diabetes smelt verses 2% for nondiabetics + Canadian Study (Yang and Wills)” showed thatthe incidence of pretenm bits among pregestational diabetes metus i 28% with Sold increase ‘compared to ondiabeacs Pobyydrommnics + Often associted with diabetes melts bu cause is unclear but probably secondary to fetal hyperalycemia with consequent polyuria and increased smote pressure duet increased ucse concentration in he amniotic + Polyhydramions > werine overdistenson > pretem labor and delivery Altered Fel Grath acrsomiaor IUGR) ant Assit Birth Traum (Shoulder Doc ond Brachial Pa ay) + 2040% of intams fsiabetic mothers have birth weights > 90th percentile for age of gestation (SOG) + Macrosomia develops from 20 weeks AOG onwards + Pathophysiology of a macrosomia asocnted with maternal diabetes ‘aera Mode ‘Maternal hyperglycemia > feal hyperglycemia > hyperplasia of the fetal pancreatic cell > fetal hyperinsulinemia ~ increased fat and slucose deposition to fal soft sree > anthropometric distinet pe ‘of macrosomia with excessive growth of the Shoulder area and trunk ompared tthe head “> more prone to shoulder dystocia + Macrosomic fetuses have significnty increased levels of pro-nsuinike polypeptides (nsube-lie growth factor IGE] IGP Tan I) which are oten stimulators of el dillerentation nd division + Postprandal blood glucose (PPBG) levels in the 3 trimester rather than BS is conelated ith weight,‘Mean PPG level of 120 mg/l above > 30% chance of macrosomia Diabetic pregnancies have 6times more prone to encounter shoulder ‘Sytoca compared fo nondiabese women 5. Congenital Malérmatons Incidence of major malformations in those with ovet/prepestational glee induced embryopathy (congenital abnormalities) 6 Uncplaina Fal Dose births without idencifiable cause area phenomenon relatively unique to pregnancies complicated by overt pregestatonal diabetes ellis Ponble explanations: fa Salvesen, etal (1992,1995)* did cordocentesis and studied the Seidbase metabolism of thewe fetuses and found decreased pit and Increased pCO. in the fea blood suggesting fotpan desrution and ultimately Richey, etal (1995) and Daskatais, eta (2008) ‘Hyperglycemia > osmotialy- induced villous edema in the diabetic ‘cent > impaired fal oxygen trangport > fetal ackemin and © Another concepts the possible hyperglycemia-mediated disturbance of the endothelist derived nivieanige (vasodilator) inthe diabetic placenta References Shelf 1, Bute Koster EL, Casey BM, Mcitire DD, Leveno KI. Maternal ies is natn mins. Ces Cs 2003 PES Jehinsone FD, Navat AA, Peso RL. The eet of exablshed and gestation “lees on pegnany outcome, Br Obes rma! 1950971) 103 ‘Ameran Dates Assocation, Cini Pace ecommendadons 1999 ‘Diate Cove 199.2380. Johnstone FD, Listy RS, ie. Type | sabes and peenany: end in bith ‘wept over 40 yea at single ine Obit ra 2006 1070) 1297 02, Gate Fetal. ype 1 DM in pregnancy. Lc 199546157. "ret IM de Vale, Viner GH. Risko complains of pregnancy in women with pe T dlabets! Nasonwate prospect stay ithe Netande A oi 3257485)915, Saivsen DR, Brudene! MJ, Niosies KHL tal polethemia and ‘Grombocytopenia In pegnancies completed y maternal dts mets, Oe Gar 192-15 128798, Satesen DR, Brodeell JM, Sods BU, tland RM, Ncolaes KH, Fea plasms erytoporin in pepancies complicated by raeaaldabes mali ‘an J Oba Gye! 19931681 P88 Reey 5D, eta Observations concering “unexplained” ft demise in regnany completed dates malitr/Matrs al Ne 19954168, DastalakeG, Macnopoioe es , Pap ‘A, PepatoniowN, al, Placental pathology ia women with potaina aes. des Oss Cal ‘Seon 2008714) Stanek Bs AL, Myatt L. Nézogrosine immunostaining comeates wih Increased exactly matrix evidence of pospacetl ypon Psens 200 22%uppl AS86882. Nuhan DBL Long tan complications of sibs slits, N Lag J Mod vssaasriereds Rossing K, cobsonF Hommel, MathicsenE, Sennigsen A a Prepay nd rapsson of dabei nephropathy. brings 208 45();364, Frank RN. Dbeticretnopathy. 9 ghd 20043504838 Bioomgarén 21. Neupay, womens health and soioncenonic aspects of| slates, Pah sions 100416, 1, 1 Sinai BM, oa, Rie of preeclampsia and adverse neonatal outcomes song ‘women wi pregesasonl diabetes tus. Am / Ose Ger 200, 18:34 ‘Young and Waly Tees EA, cal Prepancy cuore among women wit and without dbetic ‘Bows doene (What Chsticaton to FR) vests nondiabetic ‘Sino nena! 199615509. ‘nur BEK, cal Ble of preancy in progression of date retinopathy. ‘abs Cae 9801838, ‘Chori et a. The eatonsip ewe pognacy and long tera maternal ‘Somplzstions in the EURODIAS IDDM completions sal. Distt’ Mod isomizioe Ar CS et fence of pregency on ong term progestin of etinopaty i Pets wath pe | Saber, Data 2085 101, igme 1. Algorithmic Pathophysiology: DM-Relarea Materoat And Fetal Comlicaont re pepecan DIAGNOSIS AND CLASSIFICATION pmeseerearn rcenace ea Emmesto 8 Uichanco, MD and Ma, Cristina P. Crisologo, MD [eco] ence + Diabetes meliius is a group of metabolic disease characterized. by Inyperplycemia resulting fom defects in insulin secretion, inulin action oe oth” er] |e Pathogenic proceses involved in the development of diabetes melts |. Autoimmune destruction ofthe Sel of the pancreas, with consequent inslin deficiency 2, Abnormalities tha result resistance insulin ation on target sues ‘The American Diabetes Assocation (ADA) identifies three forms of glucose intolerance™ 1. Type Late mts dts mens dosed in chitnood [PE nought cae oy mano dean ee of he peneah ean ds bnuio oacenee —— Baie Leu (A) bre eon pte wih hi ype [Skee | Sabon 2. Type? dahl mis auton gsr ineleane Pals ih pe Dabs cei toe, ad the duc ea Shen be eomll wi weg ete ts Sealy Bode {is thought to res from insulin wesitance and exhaustion ofthe cells, ser tha their destacton 3. Gestational diabetes mellitus (GDM): glucose intolerance identified Alsing pregnancy In most patients, it subsides pospartm, although lucose intolerance in subsequent years occurs more frequent inthis group of patents + The diagnostic eles mellitus in the nonpregnant and the pregnant states ,2and3,‘abt 1. Ciera fr the dagen of eshte eu in the nonpregnant ‘Normal ipaied fasting Diabetes “ue | glacore/Imparet ‘netics flacose tolerance Taaag pares | vomerat | MOS merat. | — STR some Eicormome | 125 m9/ab >ormgat | >92mq/a (9 met/0) GArmmetit) | Gitmo) Tour i g/l Gommo/L) howe 140 ma/et sisamwat | 210 meat 8meel/T) G@smmoit) | @ammol/ot) Vals a bal neue data fon the HAO sy "SVates rbd on POGS Consensus Meeting References 1. American Diabetes Ascii, Diagncisand classeation af abs mei, Dinter Care 201 op 1562.50. 2, American Calle of Obtetncans and Gyoeclogts, Gestational dates ‘206 Pron Buen No.9 Obstet Gynecol 201980)525 538 3. Aettan Coleg of Onmisnns tnd Cyeesops Praca Bult rape inal Disb. Obit Oyneol 20510567 94. 4. labret 4 Begheta WV (ed). Materabfeal Evidence Based Gudetines. lfoona UK Leanoorass aes “en (6 Ray JG, Bee H, Lipscombe LL, Serer M, Gestational prelates: 4 new {em or eny prove Ind) Med Res 200,190281255, 1. Gaming Wn Obs do Merl Companies, US. doin, 8. TReHAPO Stuy Coopeatve Reach Grou. Hypephcemia and adverse ‘renany tomes N Engl] Med 200,58 199-2002 SCREENING AND DETECTION Waldo W, Sompsico, MD and Angelia R.Teotico, MD Recommendations on Detection and Diagnosis of Diabetes Mellitus Among. Filipino Pregnant Women |. Diabetes melts recognized during pregnancy should now be cassiied as either gestational diabetes meitus (GDM) or overt diabetes melt based plasma glucose levels! (Lee, Grade) 2. Universal screening for GDM i recommended fo Filipino gravis, Cee, Gnade 3, Atthe fist prenatal vist, determine if he gravida shih isk o not based on historical and pregnancy risk faces. Le! I, Grae) 4 All Ptipino gravidas are considered “high risk” by race of ethnic group (@acificIslande) and should be screened for type 2 diabetes melts in the frst prenatal visit (fasting blood sugar [FES] or pycoryated. hemoglobin [BbALe] or random blood sugar [RBS)) (Le! HT, Grade C) 5. A giagnosis of overt diabetes mellitus is given among women with any ofthe following resus in thei fst visit (Lot I, Gade 8) + EBS > 126 mg/L (7 mmol/L) + RBS 2 200 mg/dl (IL mmol/L) Hbaiczo5% how 75 nl on toleranoe est (OGTT) > 200 mg/L. (LL. mmol/L) 6. A diagnosis of GDM is made if any one ofthe following plasna values are ‘exceeded (based on American Diabetes Assocation [ADA] and International ‘Associaton of Diabetes and Pregnancy Study Group [IADPSG} consensts (hresold) Level, Grade C) + FBS> 92 mg/dl hour > 180 mgt. 183 mga 1. ForFtipino pregnant women, POGS CPG Consensus Panel recommends the following cutoff values joni of GDM. Any valu is considered+ FBS = 92 mg/dL. (adapted ftom ADA and IADPSGP consensus threshold) oF 2 hour S140 mg/d (adapted from World Health ‘Organization [WHO] recommendation) The nls wll be scad tf 10 minimize undergnests until ‘commendations om roof oa clined aidate hs aes ‘on Be made 8 For Pilipino gravis with no other risk factors aside fom race o ethnicity “and the inl text (@8S, HAT of RBS) is normal, sreening for\GDM ‘ould be done at 2428 week wing a2 howe 75g OG I there are other Nas tic, senag sbOUL proceed Mdiaey to 2 Bur (OGrT aes consul Lee 1, Grade) 9. Whe OGTT a 2428 wel is noma, he Woman hou be reese 2 "vceks or eater f cna signs and sympioms are present ‘ostin te mother and the Fets (eg. polyphala, polyhyéramsios accelerated ‘eal growth, etc). (Level F2, Gnede 10. The OGTT shouldbe performed inthe morning ater an overnight fst of § hous following the general strusions forthe tes, (Lee! , Grade B) 7° prepare forthe OOTT, the patent is advised to 1 NObserve an overnight (a east 8 hour, but not more than Té hous) fast prior to the testing + Have an unreacted diet 150 grams of arbohydrates per day) for atleast 3 days prior othe testing + Remmin seated und should not smoke during he test Summary of Evidence New Terminologies “The term “gestaonal diabetes melts" hasbeen used inthe past to define women with onset or fist recognition of abnormal plucose tolerance during pregnancy However 2010, tte JADPSG, an international consensws grup ‘wih representatives from male obretical and diabetes melts organizations, yreommended a change to thi terminology. They recommended that diabetes snelius diagnosed! during pregnancy shouldbe classified as overt or gestational. "The rationale for this change Is Betause of an increasing proportion of young, “Women with unrecogsized ype? diabetes melts due to the ineteasing prevalence Df obesity and lace of rottne plucose sreenng/testng in this age group. In January 2011, the ADA endorsed tis recommendation, Coilere ‘Of Obstetricians and Gyneenlogiss (ACOG) has nek on the proposed change A dlagnosis of over diabetes melas can be made in women who meet any ofthe following etera at ther inal prenatal vse? + BS 126 mg/dl. (7.0 mmol/L), of + HeAie26.9% using a sandandized aay or +) RBS 2 200 mg/dl: (11.1 mmol/L) that is subsequently confirmed by ‘levated FBS of HAL ‘These thresholds were chosen because they corelate with development of adverse vascular event such as retinopaly and coronary artery dense ‘AGiagnosisof GDM canbe madein women who met ee of he olowing “FBS 2 92 mg/dl (8.1 mmol/L), but < 126 mg/d (7.0 mmol/L) a any stational age (FBS > 126 mg/L. (7.0 mmol/L] i consistent with overt Siabetes metus) + (At 2428 weeks of gestation: 2 hour 78 gram OGTT with at last one abnormal resule FBS = 92 mg/d. (3.1 mmol/L), but <126 mg/d (.0 ‘mmel/L) or one hour= 180 mg/dl. (10.0 mmol/L) or 2 hour 183 ma/ (8:5 mmol/L) “The rationale for these thresholds was based on the Hypergveemia and ‘Adverse Pregnancy Outcome (HAPO) Study, which showed adverse perinatal ‘outcome even in plasma glocose values below the known normal cut of levels? or Filipino pregnant women, POGS CPG Consensus Panel recommends any one of the ellowing cu of values forthe diagnosis of GDM* SNRBS > 92 mg/dL (adapted ffom ADA and IADSP consensus threshold) ‘2 hour >140 mg/et (adapted ftom WHO recommendation) * hse values wll Be used as caf 10 mbinizewndebagnsts wit rmconmendaton fom ss ofa cline sud validate hse as cb made Why Seren? Since the Beginning he objective of sreening rested mainly on prediction of long-term type 2 diabetes melitus and ts maternal complications and fi only now that the focus has shifted tothe perinatal sks of GDM. Proponent for screening have put oth the folowing agement |. GDMis one of eGR SORIGH ULE OBIE prepnancy (5%) with significant maternal, fetal and neonatal isk. (fr w cpr on Maternal and ‘aa! Complain) 2 Adverse outcome ass ‘continuously a els during pregnancy increases value increase. This relationfs reported inthe HAPO Stay wherein adverse perinatal outcome were also ‘observed in pacients with plasma glucore valves below the previously set ‘normal cut of level 43. "Theres an increasing prevalence of diabetes mellitus worldwide, The number of peopl with diabetes mits is increasing dve to population growth, aging, ‘uanisation and ineeasing prevalence of obesity and physial inactivity 4. ‘Type 2 diabetes mellitus now outmumbers spe 1 diabetes mellitus ata 41 rato. In view ofthe severity and longterm complications of this disease, the health consequences of this disease threaten to overwhelm the health care systems of vulnerable counties. The Asi Pacific region which includes our ‘country ia the foeont af the current epidemic of diabetes mel Whom To Screen: Unveil or Selective Serening? Opinion is current divided as 10 whether universal o selective sreening for GDM should be done. Proponents for selective screening state that serening should belmited to women with any of the ik factors sted in Tale 1 ‘Table 1. Risk Factor for Dishes Metis daring Pregnancy Pregnant women with aay ofthe olowing appear tobe at increased riskoF Geelong cone > Byun ofa 125 yen of ape ad obese (> 20% oer deste body weight or body mass index ipa oa) esas) ‘Prepregnnt weight > 110% of ideal body weigh or BMI> 90kg/m or siicant Weigt gain neatly adultnood and beameen pregnancies amy sory of eae mein in ise dese ties Previous dtvery of aby eter han 9 pounds (411) ‘lve hintryof coral guceenteerenoe Monte of on cil qo th a highpass Hips Aneron Nae oman dono Aen Anon Ps nde) Previous unctlaned pert oss rit of «malformed chia ‘Matera ih ou rene than 9 pounds (41k) oes han 6 pound 2.7 kg) Gijcosuria atthe fest prenatal vise, Poles ovary sypdtome Cent seo orem Essential hypertension cr pregnancy raed hypertension ‘ACOG, the American Academy of Pediatrics (AAP) and the th International Workshop on Gestational Diabetes Mellitus (4th FIW.GDM) favor selective screening, The Assocation of South East Asian Naions (ASEAN) Study Group on Diabetes in Pregnancy (ASGODIP) shaving @ 3% prevalence of GDM in low-risk paints but has 38% prevalence rate of GDMin the highssk groups, the highest among its member counties. This high prevalence rat stats alone argue for mandatory or universal dentfcation of highs groups Table 2) among Pilipino gravida. Add to thi statisti the above ‘mentioned medical rss of GDM and the proposal for ever GDM screening ‘or Filipinos seems more tenable nt withstanding the problems of technology tvaiabiy and cost of testing. The American Colege of Physicians and the ADA, Caen favor universal serening 1s our consents that we locally advocate UNIVERSAL sereening. ALL Filipino gravidas are considered “high risk” by race or ethnic group (Pace Islander and should be screened for type 2 diabetes mellitus in the fist prenatal ‘able. Neatcation of High Rsk Groups for ODM 1 Past pregnancy nena use terance macro igh =) ‘sngeilmlormaton recuent abortons “expe astern death family history (it degree ration) ‘maternal bey > 180s or BMI >27 g/!) rage alfeccing earbohydcate metabolism (scrote, temic) "acl peection peiphyamios acon ft flab curt genta ct into + Obretinik cor When To Seren? ‘The following are based on IADPSG recommendations which was ater adapted byADA: ‘+ For women without the aforementioned risk variables, screening should be performed between the 24th and 28h weeks of gestation, * or women with rik factors, they are immediately screened at the first ‘prenatal visit IF initial test results are normal, repeat test are in order at 24-28 esks and again later at 32-34 weeks due o increasing glucose ‘seniiviy as pregnancy progresses “ see‘During tne POGS CPG Consensus Meeting, te following haveteen aged upon: The Pinos ate among the igh sk groups or developingsype 2 diabetes teas prevalence rates ave been estrated tobe between 810% + Because ofthis dat, te following i recommended by race or ethnic ae comer Dap ind see be ocr pe eres mets ne fst ena vist FBS or HPATC oF BD) ‘ow To Secon Srening vs Diagnostic Testing + There is no worldwide standard for screening and diagnosis of dlabetes smelt pregnancy. + Screning ie usualy performed aa two-step procedure where step 1 identifies Individuals a ak forte dseae followed by step ? which 0 diagnostic {esting that wil exabih te sare, Step 2 more complicated and cosy {equlting two clevted values for dagnosts Doing a two-step approach Wil ‘xtude ow vs Indvial. Te tvo-step test Is the one recommended by Keoe. + Another approsch i doing the one-step procedure which a diagnostic test to ‘MVindivists proposed bythe [ADPSG. end endorse by the ADA. +The one-step diagnostic test was smplie by giving a2-hour 75g OGTT and equitingonly ingle elevated vale for diagnosis. ‘Dus Sc Teng Namal Fils (ACG Reset “The screening test consis of 50 goal anhydrous lucorc load (ol gucose tatlonge est [OCCT followed by «pase lose determination 1 hou et ‘The peat nd ore fong betre the aor lod "Rrate of ihr 2140 mg/dl G18 mmoT) or 130 mg/d. (2.8 mmel/L) 1 nour ater te 50 pad, ents the ned fo 8 fll agnosis hou 100 ‘OG pestormed ihe ang sate "The dagnons of GDM rues any two ofthe fur plasm glucose valbes ‘trained Going the est fo met or exces the vas. Cae) “Table. Normal ais for OGCT / OGTT ‘Caspar and Cotaa 0 Sallvan and Naan /NDDG oer 0 mera 70 mala oorr Posing seat tar tio 2h ism 1 nya neice Tine / Noma Vas CCenain quarters WHO, ASEAN, ADA, IADSPG) are advocating a one-step ‘esting scheme. Basically the anhydrous glucose load ie 75 p an only 1 blood Supa talue measured 2 hours ser pucor loading taken, "A Value > 140 mg/l considered abaoral sad treatment is began, Que Tine / Noma Vas ew Recommendations)? Because of incemsng incidence of type 2 dees eli wives ey seting wen rout lal peal! abortory eae daw et dee sndconventen, TADPSG and ADA recommend universal en teingby ating HAC or [RBS of FBS at thei vs ad ding 973 BOUT at 8 wel the cay {St are oral er to Algo) (Nir emmendton ae ot ated by noe iat nanos of over iactes elite dei ryote following present (Table 4: aan Nhs > 126 mg/al. 7 mmo/ A) or HRAIe> 634 ring asta aay, RBS 200 g/t sim) subsequent cotimel by Senied Pas or Ale ‘diagnosis of GDM is made if ny ofthe lowing te ese FBS» 92 m/e han 136m [hour 73 gOGTT = 180 mat. 100 mol/1) or Dour 7s BOTT = 159 m/l Sl) "These recommendations sre supported by saul fom the HAPO study, which eva more chan 23000 pregnancies tsing a Zhou 7S g OGTT. The Ivestgators found contauamof incrssingi adverse outcomes cachof the three sting, how, and ou plasma pacore vals increased. Use adverse outcomes included macrosomia, cesarean delve, nents Bypepcemis, std ‘cord blood C peptide clevtons a wl as pescampsi, Dung the POGS CPG Consensus Mesto, the flowing have Been agreed ‘non: ALL Pilipino pregnt pens mas be screened during te st prenatal ‘oily requesting PHS HA Lor RBS, "A agoss of overt dahtes reli ven among women with ny ofthe fotning ols hes is 7 7 NPD 2 128 mq (ama) RS = 200mg/a Tm #200 mga (1.1 mote)‘A diagnosis of GDMs given based onthe following eto wales 'FBS> 92 mg/4l.(adaped fom ADA and ADPSGP consensis these) 2 hour > 140 mg/dL (adaped from WHO recommendation) ‘thee sahes miles excite tins anderdiagrosuni rcommendains fon rsa of le clea sues valdt the ales be made EBS value primarily predictive of perinatal outcomes (HAPO Stay) 2 2ihour 75 g OGTT value= primaaly pedi of maternal outcome (WHO data) 1f the result of iii est (78S, HDA Lc oF RBS) is normal and with no other risk acon aside ftom race or etic, a2 hour 7S g OGTT should be done at 24-28 week. I thee are oer rik actors identi, screening should proceed immediately 102 hour 75 g OGTT. Ifthe OGTT at 2428 weeks is normal, the woman should be retest at 32, weeks or erie if lina sign and symptoms of lyperlyeri are present both inthe mother andthe ftw (eg. plyphagia,polyayammios, accelerated fetal srowth e). “ee. Citra fora Posie 75g OGTT forthe Digs of GDM ‘WHO TADISO/ADA——_-POGS.CPG ens” cena” FOS 212s mg/dl > o2mg/sl > 92 mg/dl (@neL3 Giemovt) Gimnet/L) hoor 180 maa (id ae/L) oR Bhowr > e/a Dish e/a, > omg Gsmmavt) (Smo) Gimme) “asa ado nome da oh HAPO Sd Ves bed on POS Cones Cor Genera Tsao for OTT Pea sracions Te Thepatient shoul beon at as 3 days of noemal unrest diet containing 18 minimum of 180 mg catbolydat per day prio he test. 2, Teng should not be done while the patient is sick or under sites or on ‘medications tat can incense bod glucose lee i. 3. Nosmoking permite doring the est '§ The patient should remain a st ring the est 5. Glucose solution shou be consumed “Anhyous slucse should be prepared aowxding to directions ‘Timing of slcose measures based on sat ime of givese ingestion Sample shoul be venous plasma glucose Sample shoold be assayed by an enzyme method, suchas glucose oxidase, hexokinase of dehydrogenase 5. Glucose sing fr he purosofdgnosig told nt te one wing hn cose meters Atrative Tes for Patents Unable to Tolerate Oral Glucose ‘Some women may not tolerate the orl glucose solution due to pss iation and gutoinestnal osmotic imbalance reson co nausea and Yomiting. ther ‘ypesof glucose testing hae been proposed buc none ofthese have ben valida ‘nlage sues nor endorsed by the ADA and ACOG."" ‘The folowing canbe done: erodic monitoring by candor and 2 hour postprandial luce test Seunenow (1) goes lease ing 288 1 pace ‘REFERENCES 1. eration Asso Datos ad Pry Sua Or Cae Pt ‘iter, Siena Sten oe Pep ts Grau msmnrrton be apa nen ede ‘in pregnancy. Diabetes Care 201033:675. is 2 Ameen Bibs Asoc Dap nd Csi fake mei Bikers Com 4 Sup 2. 2. HAPOSid opener Group Msg BE, Lowe pee {noes ppg Caco ME Mel SET 4 FOGSCEG tebe Cnr 201 Phin Obeid Grobe Sea ‘Mla BE, Couns DR (Bie). Proseting ofthe ot train Wash.ALGORITHMS FOR DIAGNOSIS OF DIABETES MELLITUS IN PREGNANCY [Preanancies oss than 24 weeks of gestation ‘Draw blood orFBS, ROG STATS waren | RECOMMENDATIONS FOR FILIPINO WOMEN BASED ON FOGS CPO ‘CONSENSUS ON DIABETES MELLITUS IN PREGNANCY, 2011 [PROTOCOL FOR THE EVALUATION OF DIABETES IN PREGNANT "FILIPINO WOMEN mo Saag aie eee eee RE Re Rovian ses. cuore Sacre. Sg. a a waa _ ate | Se! ee aaa a ae fama Siam r Fa 5M ST | Fi 00 peters2 Conference on Gestation! Diabetes Metis Dnbees Care 198521(upp. 2B Si. oto CO. A promeine ey of regi determina of eto die “nctcun Diba Anis Report of hep committe gos and ‘SStiienor dancer elite Dales Cac boha5Sunn. SES. ‘Kopel lane € Reve EA: Gesral nts conroversi and ‘Senet opine Cur Onion Obs yee 199 57.68. ‘pir el Sastre sans optional abr tis N gl} Med isin 39:86 {Neos PAM, tal foward oie iti fo geo! dees: eatonsie ey and time ort cn sa eae Se ime Liv Does cette rete of regan oan ied tenod ofr Sesopng gun aes melt 6 nenpsanal ‘Du And Opes Gynecol an09401 oe Je A, Coes BG! a Rak psionic met women wt yn bay sndrone ase ew anda tana, et Ser 208 Sader eddeon MIM, Wlans MA, oy mae ine od nine © can andi guna eee eke Arn) Obet Gye see ‘eldanc tht Guntcson ea Gesaoona weigh in a8 Ta of poral dats mes tse Cyne 01011897 ‘AGOG Pectce Buln. Gesatonal Sab’ Cal manuprnent guts or ‘Secriingyessgit, Orit Cyne 2005098 328 {Soc Deel Repu ooe sr bast ep: A tc ‘eve Homan Reprod Up 3001518, [Br WS Global eae dees, xmas othe e200 a pesos fer ain, Dube: Cae 300427107188, Eisoy LC Pree a dermis of pe 2 dates among Fine ‘mean: Dates Ce 242050208, {eck STs epierlogy of bars athe Asa Paci aon. HEM Stonst a ME, bee eset iy an glasba eran Tomer HA Snpling fe enerous uc fleance test 1 Reprod Mad Des Sean FA Appcon of he neous a owe trees te ia prepnang: Dake 1120478 MANAGEMENT ISSUES: PREGESTATIONAL AND GESTATIONAL DIABETES MELLITUS, A. PRECONCEPTION EVALUATION AND PREVENTION ‘Marjorie 1. Santos, MD and Ma. Viewa V. Torres, MD (Generalizations for Pregestational Diabetes Melis ‘Women with type {and type 2 diabetes mellitus ae at greater ik or maternal morbidity and perinatal morbidity and motaliy, especially among those who have poor glucose control and vasculopathy. ‘The leading cause of perinatal mortality in pregnancies complicated by type 1 and type 2 diabetes melts isthe major congenital malformation, which can ‘be prevented by excellent contol of maternal glycemia before gestation and during the erica weeks of organogenesis (5-8 weeks after the last menstual peviod)? ‘The slycosyated hemoglobin level (HbAAte), which reflects average glucose control over the past2 3 months, canbe closely corelated with he frequency Finally, the goal of ur educational programs should be not only to improve pregnancy outcome but also 10 promote healthy liesyle changes for the flected women fr ehe rest of theives afer delivery” Generalizations for Gestational Diabetes Melts (GDM) ‘The detection of GDM requires a carefily developed plan for screening, Most ‘women with GDM wil respond to dietary therapy. The greatest perinatal risk Insuch eases is eal macrosomia, which has been asociated with higher ale ff eesaean delivery" ‘Women with GDM are at considerable risk forthe development of type 2 iabetes melitus ater nie and will requir careful follow-up GDM is characterizedin most eases by postrandial hyperglycemia, resulting from impaired insulin releve and an exaggeration of the insulin resistance seen in normal scan Be ieated with die therapy nd have not been rink fr intrauterine fetal death+ When fasting plucore levels in women with GDM are ovate, nt only will ‘insulin therapy be requied, bur such bypessycemia also places these women greater rk fora slit” Prevention of Maternal and Fetal Complications Prevention of maternal and fetal complications inthe periconception period {sbased on understanding ofthe nature and elects ofthese complications 10 the ‘ther and fetus. Compete explanations of these complicons maybe seen ia Chapter IV. Listed below aze some of the preventive measures That may be dane fn the periconception period of patients wih dabetes melts 1. Abortion sMMgceoeding to Diabetic Control and. Complication Tval, intensive Therapy for blood glucose cml porto pregnancy, duces the rate of spontaneous abortion.” + Gnly tose with Hb eof» 12% and persistently high fstingblood sugar (BS) of > 120.mg/aL ave at increase risk for abortion. 2. Congenital Anomalies + "Bath major malformations and spontaneous abortion ean be seduced ‘when excellent prepregnancy and ealy postconceptional diabetic contol Ssachieved, Ii therefore imperative that paiets with diabetes melitus be encouraged to seek preconceptionalcare™ “+ -Meta analysts of 7 studies concded that preconceptionallycontolled ‘lucose levels with lower HbAle associated ith lower risk for ‘congenital malformations with arate of 5% among those wth optimized ‘control before pregnancy as compared to 9% 8 those who presented aller ‘completion of orgsnogenesi'” + Hale of <8 5% inthe fist eimester as a congenital anomaly rate of ‘3.4% compared wih 22.4% 1f HgbAleis> 859" + Fora woman with diabetes melas, any visio a health care provider ‘shouldbe used asan opportunity toreviw "patient spans or pregnancy. ‘The dicyssion should focus on obtaining excellent pucove contol and achieving 3 healthy exe Belere conception Giucose levels should be ‘fabled and an HbA le = I above the normal range achieved! + Patents with ype 2 diabetes mellitus wh are using oral agents should be ‘converted ro istlin. In addin, an evaluation for vasculopaty should be ‘secompished® 3. Retinopathy er keconing 1 the EURODIAB Prospective Complication the duration of diabetes melas and high BAT lee thr saan rk tor for enopathyprogrion, wheres, ing ‘The presence and the severity of retinopathy can be atuibuted eo poor syeemic control. ‘The rapid institution of src glycemic control during pregnancy has also ben associated with shorter progression of retinopathy. Worsening of retinopathy is also more likly occur in hypertensive patient" ‘Active proliferative retinopathy might worsen in pregnancy and should ideally be controlled wih laser therapy before conception “Allpaiens should be schedule for srening retinal examinations at thee Tis prenatal visit I retinopathy present, then follow-up examinations during peegnancy and poripartum are recommended. phuopathy ‘According to the Diabetes Contol and Complication ‘Tvs (2002), there 15.25% decrease in te ate af nephropathy for every 10M decrease in HDALclevels” All patients wih a history of microtbuminerin oF those with diabetes metus of greater tan 10 ears duration should be seened with a 24 hhour urine coection for ftal protein and creatinine before pregnancy of atthe init prensa visi, Decreased creatinine clearance and peoteinusa are the best prdictors of poor perinatal outcome. Although proteinuria will increase during {estaton, most studies have led a demonstrate a permanent worsening in pregnancy. Ina sia subset of women with advanced renal disease those with & serum creatinine exceeding 1.5 mg/L, pregnancy might accelerate progression to end-stage renal disease Cantiovascular Complications (Hypertension, Preeclampsia, Coronary tery Disease) ‘Preeclampsia was relate to plucse control based on HbA monitoring starting at 24 weeks age of gestation (AOG).” Preeclampsia is predicied if there i any of the following: progressive proteinuria, urea of > 6 mg/d (+) hemolysis, levated liver enzymes, fow platelet (HELL parameter. ‘Renal fection tests must be performed in each trimester in those with repestacionl labees mellitus with vascular disease and in those with ‘ration. eal arterial ditease i seen ding+ Coronary hear disease and myocardial infarction are are evens in pregnant diabetes.” + Tnpatents with diabetes melitue reed cardiac involvement, pregnancy ‘outcome is distal with matecal morality rate of > 50% and perinatal mortality rate of > 309, making it a potential contraindication to pregnancy, These patients should undergo preconception counseling and te informed of these risks before attempting pregnancy, Therefor, its prdent to obtain detailed cardiovascular history and cardiac clearance mong those who are > 30 yearsold with ype 1 dabets mellitus of > 10 years duration. 6, Neuropathy Peripheral neuropathy should be assessed a the preconception visit oF catly in gestation bya careful examination ofthe patent’ feet for sensory Toss. Instructions on safe foot are shoud be provided forall women with slates ellis ‘Reconimendations by the American Diabetes Association 4+ HAL levels should be as dose to normal as possible (= 7%) in an individual patient before conception is attempted, (Lev! I, Grade B) «Staring t per, preconception coursing soul be incorporated in the coun dete melita cine vist forall Wome of childbearing potent Gade) + Women who ate diabetic and contemplating pregnancy should be crated and if indicated, shouldbe treated for etinopathy, nephropathy land cardiovascular disease. (Lev! 1, Gade) + Medications taken by such women shouldbe evaluated prior toconception ‘Sine drugs commonly sed to teat betes melts and its complications nay be contraindieted or not recommended in pregnancy, including ‘Satins, angiotension converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB) and most nonnsulin therapies. Level I, Grade o + Since many pregnancies ae unplanned, consider the potenti risks and benefits of medications which are contraindicated in all pregnancy ‘women of childbearing potent, and counsel women cations accordingly. (Low I, Gade) + Hypertension: (© A goat of systolic blood pressure (BP) < 130 mmlgis appropriate for ‘most patients with dtbetes melts. Lee IT, GrodeC) ‘© Patients with diabetes malls shovld be rated witha diastolic BP of < 80 mmllg. (Lael 1-2, Grae B) + Nephropathy: (0 To reduce the risk or slow the progression of nephropathy, optimize cose and blood pressure contol. (Lev! Gade 4) (© Perform test to assess urine albumin excretion and serum ceaiaine Intype I diabetes metus patient with disease duration of 5 yeas ot more and in al type 2 diabetes mellitus patients staring at diagnosis (Lee il, Grade) + Retinopathy: (© To reduce the risk or slow the progression of retinopathy, optimize slyoemicand blood peesute contr (Level, Gride d) © Women with preexisting. diabetes meliius who are planing pregnancy or who ave become pregnant should havea comprehensive ‘ examination and be coursced on the risk of progression of retinopathy. Bye examination should occur in the firs wimester with close follow-up throughout pregnancy and for year postpartum, eve 12, Grade 8) References |L_ Kitmler JL, Buchanan TA, Kj, Combs CA, Ratner RE, Preconeption care of diabetes, congenial malformations and spontaneous abirtons. Dishes Coe 9619140 2 Laueabrg J Mathiesen E, Ovesen 2 Westerpard 1G, Ekbom P, Moise Feder, el, Audit onstibis ia women with regesttional type | abet. Diab Coe 2003; 2613853. 3. Matigr BE, Cotsan DR, and the Oxpasising Commie. Summary snd ‘acommendatons ofthe 4 Iteraatioeal Workshop Confrence on etal Aiba, Dada Ca1998;1(Sup 29 3161-7. 4. “Amerian Collegeof Obseicias and Gynecologist Comminse on Practice Buletns-Obsets, Cousan DR. Gesatonal diets ACOG prac bulin 190. Washington American College of Obsetiin an Gynecologists 20, 5. US Preventive Srvies Task Foce.Scening fo etatonal diabetes seis Recommenditios and ratio. bt Gyr 2003 1012) 3954 6 Ameren Diets Asociaion, Gesstonl diabetes melts. Dies Cae d ThexpeetComnitoeontheDiagnoisand hss Ihe exert commie on the diagnosis and ie 199720518397.2 18 2, Es 2. 2. ‘American Diabses Asocton, Evitecetased auton principles and ‘Reommendatons for the eestnont and prevention of Ubetes and renee Complications, Dah Cue 200326Supqt SST. ‘Gordon M, Landon Mi, Sarl &, Hsieh 8, Gabbe SG, Perinatal outcome Sef fongicnn fllow-op sociated wih moder management of diabetic nephropathy, Obstet Cel 1996;874019. ‘Gordom MG: Larton MB, orle J, Stewart K, Gabbe 8G. Coronary artery ‘dscns in nen dependent abet mts of pregnancy (Cass Hy A revi ofthe erature Ose Gyre Sar 19965107 Sirasin! KE, Aacta LM, Lisalooto MK, Joupyla Pt, Takknen JT, Satine PI. Autonome fluence on pregnancy outcome in IDDM. Diss Cae om Ls186-1 Landon MB, Catalano PM, Gabbe SG. Datetes melis, In: Gabbe $0, Niet 5K Simpson Us ede, Csi: Normal and problem pregnancies. Phiadephis {Chri Livingstone, 200109100. interes Conte and Complications Te. Research Group: The efcs of Intesie enent of dares on the development and progression of long term Complications a nun dopendent ates elt 1 ge 998 329977 Siba BM, ct al Rist of preeclampsia and averse neonatal outcomes among ‘women with preetatona ibeter melts or JO! Cyne! 200,182.36, ‘Yang era Pea and pena outcomes of dabete pregnancies, Ob Cyl ave isu Fay 1G, eal Preconsption core an te rk of congenital anomalies inthe ‘ring of women with dabes A Meta-analysis QF Med 2001435 Recs EA, eta Popoansy outcomes among worsen with and without dibetic Inisrovstla ene (White's Clase 0 FR) sera no diabeti cont. at FPoinae 198.1538, Miter Fetal Elevated maternal HgbAte in early pregnancy end major {oneal anomalies infant of dabei moter Bg! ed 1981 304131, Biahers Prevention Pret The peealeceof retinopathy in impaired aco {olerne and ect “ont abs the Dates Prevention Program, Die ae 2007251. ers FL, ea Treatment of dabei einopthy. 1 Eng Met 1909667668 ‘Kin BEX, cal llc of pregnancy on pogesion oF labtic etinopaty. Diab Core 9801334 Chaturvedi Net al. The reasionip between pregnancy and fng tem maternal ‘Smpicaions in the EUPODIAB IDDM complications study. Die Med oma ‘Arun CS eal nlvnce of pregnancy on fog tem progression of renopathy I patend wih ype eter Disttge 2008;51104 {Ch Yer al. Metab coal and progression of retinopathy: The diabetes In ealy pregency study. Diary Cre 1985 1851-697 LoyestamAdian M, ca Preeclampsia 2 ptent ik factor Frdterioration ff ecnapady an ype diabetic ptr, Dab da 1997110895063. eror eta i pregnancy ak coe or micas tions? TBeEURO Dias pesce compiaton sa 1303 i" a. ‘Temple RC, ca. Giyemic contol thoughout pregacy and sk prcetameria {in wemen With ype I abe. Br be Ce 20081131308 Stamler Efe a High neous mobi in pregnant women wit insulin Aependent DM: Aa unrated compiaton. mJ Ose Gis 1090,168:1217 ‘teresa Dues Atwaaton, Sars of Nal cate a Dabs = 200 iat Cre 201 1 4S1)SH1 SSLB, ANTEPARTUM MANAGEMENT 1, Blood Glucose Management ‘4, Nutritional Management Cecilia C, Satos-Acuin, MD Introduction “+ Inantepartum nutritional management, she goal st achieve and maintain normal blood glucose levels during pregnancy a safely as posible ‘Outcomes incude: 1. glucose and ketone levels 2, maternal weight change 43, fetal size and other adverse nconaal outcomes (neonatal hypolycemia, respiratory distress syndrome, sibs, morality, congenital mal formations, ee) Recommendations | Medical Nutriion Therapy (MNT) shouldbe an itera part of gestational Aiabetes melts (GDM) management. I shouldbe provided forall diabetics ‘and forall women with GDM by a nutrition profesional en MNT conssts of an asessment of food intake, physical acvity and ‘medication history and intake, as well s Weight statu, during and ater pregnancy, + Teimay be administered as a sole management approach, if sufficient to maintain normal glycemic contol or it may be combined with ‘Pharmacologic treatment and other ancillary measures o achieve normal seemia! (Lvl, Grade A) + Ieisa consensus that nutton requirements are the same for pregriant ‘omen with and without GDM +The characteristics of the GDM dit are: 4, itmeets the dietary principles fr diabetes melts management th ieprovdes forthe nucconal requirements of pe its individualized for maternal pregravid body om ‘and weight gain goals 4 its cutralyacceptabie Surman of Eade Provision of MINT as part of intensive therapy for GDM reduces the isk of preeclampsia, macrosomia and perinatal morbidity (shoulder dystocia, bone fracture and nerve palsy, although such intensive therapy is also associated with higher races of labor induction, (Level Grade 4) + Ieisrecommended that if glycemic contol snot achieved within 2 weeks ‘of MNT then insulin therapy shouldbe State” (Le! 1, Gade + ‘Theuse of MNT for GDM results ina sigiican reduction in the number of patents requiring insulin 246465. 31.7%;p 005), andalaterintiation (oF inslin therapy for those who need it (31.6% vs 30.4%). Glycosylated hemoglobin (HDALe) was lower during delivery (5.0 vs 5.2%) and a smaller but aonsignficant proportion of women (8.1% vs 13.6%, p 0.25) had HDA Ie above normal (Lew! Grade A) + MNT hasbeen shown to decease HbA ein type 2 diabetic patients fom 10.25% o 2.9% at 36 months, with follow-up from a registered dietician (Gunging from monthly 3 tesa year) ‘Weight management and energy intake need to be monitored throughout pregnancy, especialy for women with GDM. Summa of idence + Pregnancy weight gin recommendations for women with GDM who hd normal weight or were underweight prepregnancy isthe same as for women without GDM? (Lev! Il, Grade). Energy intake for overweight orobese women with GDM maybe modesty restricted as long as weight gain is appropiate (relative to the pregravid BMI) while minimizing the risk of maternal ketosis? (Ll I, Grade C) + More than weight gain, i€ is glycemic contol that is predictive of ite. * + Maternal weight reduction during pregnancy had no flect on pregnancy induced hypertension or preeclampsia and may be harmfl tothe fetus {gesting in low brthveigh). High protein supplementation (which is sometimes resorted to in attempts to adhere toa “low-carbohydrate diet”) twas associted with a significant increased isk of small for gestational age (SGA) babies® (Level, Grade A)3, Caibohydeate consumption: Consumption of cxibolydrtes with ow instead ‘of high eycemic index (GI) is ecommended' Lee IE, Grade C) Sumsmarral Buiee ‘Monitoring of eubobydrates (being the primary contributor to Blood luce), By strategies such as carbohydrate counting, food exchange ‘Shoices, or experience-based estimation, is a key stategy to achieving ‘Bcemic contol (LeutZ Grade + Thetype and amount of earbohyats can be individualized, depending fon glucose and/or Ketone level response, gestational Weight gaia, and Serum wigerides? Lent I, Grade C) + A.recent systematic view’ cts only | intervention study with evidence that low Gl vs high GI dct n GDM significa reduced the need for insulin by half, but found no sgaicantdiferences in Feal and obstetric tvtcomes. One epidemiologic tidy found that prepregnancy high GI Jntakes increased thers for GDM. + niake of supa substutes such ae acersfime potassium, aspartame and steralose are acceptable doing pregnancy and lactation within accepable tly intake Limite. These substances should not replace more nutitioss options. Sicchiin and cycamates are not recommended during pregnancy? ae I, Grade C) 4. Lifestyle changes: | Offering advice eparding alcohol consumption and smoking cessation is recommended: (Lee I, Gre) 1b Inthe absence of containdications, maintain asufcent ve of physical actvgy and exercise t0 improve glucose contr, reduce cxedivascular ‘isease (CVD) risk, contribute to weight management gals, and overall wellbeing, (Le! Grade 3) Summarvof Bride + Epiemiologcal evidence suggests higher lvls of physical activity may roduce the rk of developing GDM! (lve 2, Grad B) + Moderate exercise has been shown in randomized con to lower maternal bod glucose evel in GDM (Lev + Evidences on smoking cesaton and alobol consumption are the same Tr pregnancy in general References 1, American Dies Asoiton, 2011 linia Practie Recommendtos 2. Canadian Dabetes Association CnkalPracice Geliee Expert Commie, ‘Gestational aes mois. CanJet 205.7989 S105, 3. Alvan N, Tlfed Di, West Trestmets for gestational ibe, Chane aise Syn 2009, 53. 4. Reader e206, 5. The HAPO Stuy Cooperative Reseach Group. Hypehcemia and adverse eanancy ovtcomes, 1g J Mel 208358: 191 2002, 46. Kramer MS, Katuma Ru Energy and protein inte i pregnancy. Cine Data Sy Ris 203 Ise 7. Lovie JC, Brand Mile C, Mackovie TP, Ros GR, Moses RG. Glycemic index ‘sd pregnancy: Anteaters ee Nut Mt 200, 2910-38246 8, ColbergsR, alright AL BlsmerB, BraunB, Chan TaterL, ctl Er nd ‘ype? dae: American Coleg of Spc Medicine an he Anes Diabetes ‘Associaton i poignant Ne Sy Spr En 201042(12}2282 208,'. Blood Glucose Management Nemesio A. Nicodemus, MD Introduction Randomized controlled trials (RCTS) ada meta-analysis show that eating ‘gstaional diabetes melitos (GDM) sigiicanly reduces the likelihood of $eriows maternal and neonatal morbidity compared wit routine prenatal 1+ Treatment in these studies included ingivdvalized medical nutrition therapy (MNT), dally seifmonitoring of blood glucose (SMBG), and pharmacologic ‘therapy with insulin, i necessary. + A randomized tal showed that using a low glycemic index (GD diet for ‘women with GDM effectively halved the number needing to we insulin, with no compromise of obstetric or fetal outcomes * Pharmacologic therapy is most commonly instituted once diet and exercise Ihave filed a evidenced by abnormality it move than haf of self:monitored leo values or an abnormal value in thse women tested weekly ‘Tradionally insulin has been the deug of choice because ofits safety in pregnancy lack of significant transplacental passage, and history of se, Most ‘women can be weated as oupatiens.> Recommendations ntti Glace Tart for Pregnant Women ‘For GDM, treatment goals ae (Lee I, Grade) © prepraniial glucose concentation of < 9S mg/l. (6.3 mmol/L) (© Trhourpostmeal glucose value of = 140 mg/AL (7.8 mmol/L.) ‘9 2hour postmeal glucose valve of 120mg/al (6.7 mmol/L) + Forwomen with preexisting ype 1 ortype 2 diabetes melas who Become pregnant, yer goals are: (Level I, Grade) 1 prema, bedtime, and overnight slucose values of 6099 mg/L (3.3 54 mmol/L) ‘peak pesipranil glucose value of 100129 mg/dl (S4=7.Ammol/) Ficlets ow + oni cab civ ny 2 Treatment of operate ts Penancy ‘The optimal therapy for women with GDM or type 2 iabetes melitus ‘who are not able to maintain normoplycemia with a caohyérate- resected det insulin, ‘+ Insulin administration shouldbe individualized to achive the glycemic _poals stated above ‘+ Human segular insulin or rap acting insulin analogues are the preferred ‘teatment for postprandial hyperalycemia in pregnant women. ‘+ Basal insulin needs can be provided by using new potamin hagenom (NPE inst + ‘Theiniial insulin dose for pregnancy isbased on materal weight and can be caleulated bythe following guidelines to determine ttl daily inslin needs: + 07-08 U/kg actual body weight in the fist rimester + 1.0 U/kg actual body weight in the second trimester + 12 U/ig actual body weight in the tid trimester ‘+ However, clinical judgment and experience must asi inthe election of the starting dose of insulin, + Once thetota daly insulin dose icalculated, ewe thirds ofthe diy dose is given before breakfast and the remaining one-third before dinner, if [PH insulin i used. Human regular insulin and rapi-actng insulin are best dsed with each mea. + Unt more information sobained regarding longterm safety and efficacy ‘of metformin usein pregnancy, the best approach isto not use metformin for treatment of GDM. Women on metformin for teatment of type 2 diabetes mellitus are best changed to inulin if unexpected. pregnancy 4 Monitoring + Dally SMBG using meter: appears to be supesior t less lequent ‘monitoring in the cline for detection of glucose concentrations that may ‘warrant intensification of therapy beyond individualized MNT Women with GDM on dct treatment alone may monitor capillary ‘blood cose levels 4 times a day (sting blood glucose once a day and postprandial blood glucose thrice a day)|b Women on pharmacological therapy may monitor to 6 times a day and ince prepranda aloes “+ Utne Ketone testing i recommended in GDM patents with severe hperlycemia, weight fost during treatment, orotherconcers of possible seation ketosis” “+ ingertick Hood ketone testing is more representative of laboratory reasurement oF ketosis Semmary of Evidence “The Hyperglycemia and Adverse Pregnancy Outcome (HAFO) Stuy showed ‘that there are stong, continua associations of maternal goose levels with ‘verse pregnancy outcomes. The odds ratios fr birth weight above the Okh percentile cond bod serum C-pepie level above the 90* percentile and primary ‘oarea delivery were sgn higher with an increas inthe esting plasma lice level of 6 9 mg/d an increase inthe -hovr plasma glucose eel of 309 ‘g/dl and an increase inthe 2-hour plasma glucose level of 23.8 mg/dL. The ‘odds were computed compated to the following values: fasting blood sugar (HS) <75 mg/GL, hour plasma glucose = 105 mg/dL. and 2-tour plasma cose <90 mga Tn an RCT comparing two forms of teatment for GDM, fasting capillary ducove predicted neonatal complications and postprandial glucose predicted preclampela and large for gestational age (LGA) infants. HbA values during freniment also predicted LGA infants "The rapid acing isin analogues that havebeen studied pregnancy include lino and apare.An RCT of subjects with typeI diabetes elit found similar safegyin the tse of aspar insulin compared with regular human inulin. The dara ‘hat demi is sale tn pegaancy are convincing, There are sill no conclusive reporson the sfty’of agin insulin, “Athough insulin i the prefered tweatment approach, metformin and “shri have been shown to be efleive alternatives without adverse effects in References 1 Crowther CA, Hier FE, Mos JR, MePhse Al, elites WS, Rion #8, or the Austins Carola Inlerance Ss in Prepant Wem (ACHOIS) “el Groop. Et of texte of gestatsoal aes mel 7 cones Efe 205, 3822477 286, anion MB, Spong C¥, Thom E, tal. The National Iatiue of Child Heal tnd Haman Devopment Matera Peat Medi Unis Newark randomize ‘Mca: sandr therapy v0 therapy Fr al gestational ees elit IN aegl J Mig 209361159-48 rath. Kock Kier Kea, Estsf teatmentin women wih station! finttes sli: sytem view and et anal, BA 7010-01395, ‘Mons RG, Baer M, Winter Mel. Can alow gyemicindex dit ce the Ded fr invlin in estatonal bees mati? Dit Care 200932:96-1000 Pian , Benin BD, Updste on pexatonal dbs, Ose Gt Ci 7 ‘dm 201031258207 ‘AACE Task Force for Developing a Distes Cmprtenive Care lan Weng Commie EnsonePactig Mart 201112 (Supp 215. ‘Arran Diabetes Asoiston. Dies Ci Jory 201 94 (Spp SL ‘Metger BE, Bshanen TA, Cousin DR, eal. Summary and commendations Ofte fithteatonal woxkshoponrene on gestational dats mes, Dias Co 207 Sopp 2)5281 8280. izle J, Block IM, Brown FM, etal Managing pevising diabetes for Peete: summary of evince and conensr recommendations for cae Dyas Co 200831106010. Rowan IA, Hagie WH, Gao W, Mente HD. Gjcenia ands relationship © ‘utomes inthe evr a posal dabetes Wil. Dabs Co 2010339 1. Cop, Soba, Resa Marczvska Mea Pregnancy complains ‘ed prinial outcome in dishes women reaed with Hualg (insti spo) ‘egies nen ring peony. ed Si Mont 200410 P2922 {apolaA Dala MO, Sper cea, Outcome of prepaancy in ype | dabei teat wih nin poor our iui” A alan experience. Drake 206A 86 Masson ZA, Prtnore J, Brash PD, etl Pegnancy outcome in ye dees ‘elites ced within pr (al) Dit Md 20520460, ‘Hod M, Ver GHA, Damm ta Safety sod pers outcome in prepane: {randomized wal cosparng inant with human inn n 32 aber ‘wipe | dabes Dabs 20883 Supp DAI? ‘Mathiesen ER, Kindy 8, Amiel SA, etal, Natal gmc conrel and Inypogyemiainype| tc peogaancy- A randomized wal of sui asp. ‘es human inn 32 pregan women, Disbrs Coy 2007 30-77-76 Sete L, Marea Inalae Feta Use of isla dete wing peancy. ‘Nr Mab Code Ds 21025262. Antepartum Fetal Surveillance Pil. LagmanDy, MD Introdaction etal surveilance can be divided into: 1, Screening for congenital anomalies ‘The America Diabetic Assocation (ADA) recommends sreeing {or congenial anomalies in women with gestational diabetes mellius (GDM) who present with evidence of preening hypergieemia (Glycosylated nemogibin [ERAlc] of > 7%, @ fasting Blood sugar {BS} > 120 mg/d, ora diagnosis of GDM inthe fist wimeste).” + Women ith these findings are more likely to have unrecognized pregetational ciabetes mellitus and_are at higher risk of feal ‘malformation fiom exposure to hyperglycemia during organogenesis 2. Monitoring for feta well-being (etal movement counting, nowsees test INST, contraction sre test [CST], Doppler velocimety, biophysical profile BPP) 3. Ulrasound assesment for estimated fetal weight (macrosomia or Inuauterine growth esticion[TUGR)) Fetal Monitoring Techniques ‘Monitoring for fal weltbeing is genealy based on local practice. ‘The equancyofanteatal monitoring is dependent on: |. patents dee cf metaboic control 2. types therapy she isreceving 5. presence of ther isk factors, ike hypertension Geneclly the hee importa goals of antenatal surveillance are 1; 1h pret pel moran ray 2 dete al heath compomie eco ie 4 onde apprope gan fr sb ate numa repeny Techniques of monitoring 1. Peroened fetal movernents 2 csr 3. NST 44. Ultasound evaluation ‘4 Congenitalanomaly scansng al 2D echocardiography if indicated) Ber ¢ Fetal growth velocity monitoring Doppler velocimery studies orev Fetal Movements © OH ad inlet mtd of monitoring feta wellbeing in the second hal of pregnancy (Studies have showna posivecomrelionberween the numberof combined torso and lower extremity movements perceived and these confirmed by ‘razon, © The “count 1 1 commonly used method (10 movemens in 2 hous) i the most Limitations ofthe method: he inability to detect malformations, multiple stations, and growth abnormalities, oto anticipate stilts * Maternal aspogyeemia, although generally believed tobe associated ‘with decreased etal movement, has been reported o stimulate fetal aati. + Wihadvancesin tal survival ateatier gestational ages theming of the intation of texting has change. Fetal Kick-counting monitoring isbepun at 26 to 28 weeks in diabetic pregnancies. Contraction Sires Tet © CST is a text of fetal wellbeing in response co suess denoted by uterine contractions, © Prindpleof the test ‘+ Myometial pressure during a, ontacson causes ocksion of the spiral ae and ow oF oxypenated Boot into the vilos space dering eps pressure of eta ony, I he eclrations willbe apparent + cs IST of BPP of detecsing subtle proto the onse of acidosis(© Interpreting CST findings ‘NegatisCST-nolntedecelerationswithadequateuterinecontactons (ehre conations within 10 minates) Positive CST late deceleratons with adequate ueine canzone coneactony wii 10 mito) sociated With higher incidences of abnormal perinatal outcome including moray, fal distress in labor, low APGAR score and reduced bith weight + frequency of & posine CST requiring. delivery in diabetic regnancy ranges from I-10 % of patient tests. ‘able 1 Positive Conracion Sst Testa Dnbtc Pega Gate 16 2a 7 fel dst Kermiler 2 109 2ow APGAR cousan 1 7T2low APGAR Fade z B = Lava 5 a SGA, 21ow APGAR © Sues on CST "Ray etal evaluated 31 inslindependent and 7 GDM patent with CCST. Eight insulin dependent patents and one GDM patent with sevece preeclampsia had positive CST: 2/9 > fetal death in wero (FDU) and 3/9 > low 5 minute APGAR score ‘Gabbe, etal observed no invauteine deaths within 1 week of a ‘negative CST in 21] insulin-dependent diabetic patent Four additional studies of 282 insulindependent diabetic women confirmed thata negative CST predicts fea well beingin metabolically Stable patient for one week. (© A negative CST result in type 2 diabetics predicts fetal well-being ina ‘etaboically stable patent for | week, Up 050% of postive CST results ae ultimately considered filse positive. ‘Table 2, Frequency of Silbinhn Insulin Dependent Diabetic Peprancy Nepative CST) No Patents stile Gitte 21 7 ‘amie 4 0 Costin 2 Fadel a Lavin 58 6. Nonstres Test Principe of he st. 'NST ishased onthe assumption thata nonacidoti, non neurologically ‘depressed fetus wil produce heat ate acceleration as it moves. + Absence of accelerations associated with fetal movement > may ‘mean fetal sleep cycles or an abnormality suchas fetal acidosis central nervous sjstem (CNS) depression, oF congenital abnormalities + Theabsence of ese accelerations inthe resting fetal heat rate (FER) smay bea sgn of fetal compromise Interpreting NST. 1 Reseeve > (215-15-20) two accelerations of the FER, rising 15 beats ‘above baseline, lasting 15 seconds within 20 minutes. The tracing ‘maybe continued upto 40 minutes if enteia ace not met. Acoustic stimulation ofa nonacdotc fetus may elicit FR accelerations. ‘+ Nonseacive- none of the criteria for reactive test was met Its ease of performance and absence of contraindications make the NST ‘popular antepartum et. Because the predictive values ofa reactive NST appears equal to that of a negative CST, NST has now become the prefered antepartum fetal east fe tet for screerng fetal condition in dabetc pregnancies. tis recommended that NST be done twice weekly in insulin-dependent Aiabetice being tested beyond 32 weeks age of gestation (AG) based on ‘dats fom several published series “Table 3 Weeky Reactive NST in tn Dependeat Diets ‘Ne Patents Ne Real Deke Bare as @ Lavery » Mile an orp 8 3 D. Ulresound Examination Indications of wleasound in pregnancies complicated by diabetes melts: ‘Confirmation of fea viality Accum dato pane Detection of congenial as esl a at 18-20 weeks of gestation acaiEB, Biophysical Profle 0 Parameters: 1. NST 2. Fetal breathing movements 3 in 30 seconds duration 5, Fetal movements: thre or more body movements ‘4 eta one with an extremity going fom extension to flexion or vice 5, Amioti Mud index (APD) > S em (© Fach of the $ components i scored at 0 (doesnot meet itera) of 2 (meets eters), with a maximum score of 10. © The BPP is a measure of the probability of acute and chronic etal ‘yp ai asphynia. NST, fetal breathing, fal movements, and fal tone markers monitor acute asphyxia, while AFTisthe marker fr chronic asphya (© The normal fetus will have a soore of 8 or 10. A fetus that may be compromised will havea score of 6 ores ‘6 Although each component is weighted equally, clinical management shouldbe based not only onthe absolue score, but also on the score ‘composition and clinical etext. (0 Modified BEP includes NST and AFI ony, 0 Golde eta observed that 430 of 434 BPPs done afer areatve NST ina Aiabeti population were associated with reassuring scores of 8 o rete. (0F25BPPs done afer a nonreactive NS, 21 had scores of 8,4 werebeiow 8, The BPP did not appear t add more information about fal condition if the NST was reactive, but a sore ofS based on ultrasound parameters ‘was as reliable jn predicting good fetal outcome as was a reactive NST. ‘© Ina stay of 98 insulin dependent diabetic patients, a normal BPP was conflmed as predicting normal APGAR scores in 9% of patients; only 22.9% of 978 BPPs were abnormal, Ten patents had an abnormal BPP just before deivery; in 6 ofthese cases, neonatal asphyxia or depression was reset ‘0 Johnson, etal! described wice-weeky tests on 50 spendent ‘diabetic women and weekly BPPs in 188 GDMs. There bits inthis seis. The incidence of abnormal BFP was 0f 238 test), however, 37.5% hd significant neonatal morbidity. Although this study didnot demonscate the superiority of the BPP over the NST alone, itd establish that the BPP may also be used for feta surveillance wit ew ‘unnecessary interventions, thereby allowing prolongation of pregnancy beyond 37 weeks in most of the patients studied. Detecting Mocrosomia (0 Obstetricians ae motivated to predit macrosomia before beth because of ‘he potential for tauma and other related morbidity. 9 Definition: fetal weight in excess of 4,00 or 4,500 (Incidence of 16-45%) ‘weight abore the 90th percentile for AOG © Predictors: 1. Landon, ct a1? found that abdominal cicumference (AC) growth was accelerated after 32 week’ pesatonal age na group of lage for trstational ge (LOA) feses of diabetic gravidas 2. ‘An absominal gt change of 21.2 em /Wweek detected LGA fetuses swith 8% sensitivity and 85% specifiy 13, Using difrence betwecn te fetal trun diameter and the biparetal iamete (BPD) with [om asthe threshold beeween macrosomia fand non-macrosomia, Elo, eal. were able to detect 87% of such Tetuses, witha false postve rat of 39% 4. ACand exited eal neigh (EFW) Py uleasound [AC valves > 90th percentile ~ macrosomia can be correctly predicted in 78% of cases ‘+ EPW> 90th percentile ~ predicted macrosomia in 74% of eases Both ACand EFW > Soh perensile~ macrosomia was diagnosed correc in 88% of eases (© Of clinical importance, cesarean delivery rate for disproportion in fetuses predicted to be macrosomic was 28 3% (10.7% fetuses predicted not tobe macrosomi), ‘0 Using the BPD and AC, the best-fc equation fr estimating fetal weight was: BFW = 002597AC + 0216IBPD - 0.1999 (AC x BPD ) 1000 “$1.2659 which i the formula useé to target LGA fetuses with reports of statistically significant reduction in random error of birth weight cestimation ‘Note: However, even if all infins destined to be macrosomic at bith could be identified ‘only about 50% of all shoulder dystoias ‘would be obviated,. Doppler Stuies ‘© Doppler velocimetry ofthe umbilical artery may be wef ia monitoring pregnancies with vascular complications and poor fetal growth, because women with insulin-dependent diabetes melitas are at increased rik for the development of preeclampsia and fetal growth restrietion, © Bracero, et aP, in a stdy on 25 patents with vasculopaty, found a significant postive correlation berween umbilical artery systolic asole (6/D) ratiosand serum glucose levels ‘© Landon and Gabbe’, in 291 studies in 38 insulin dependent diabetic patents, umbilical artery waveforms were abnormal i $0% of fetuses fof women with vascular disease compared with 12% of those withost hypertension or nephropathy. Semmary + Antepartum surillance isthe standard of care in diabetic pregnancies, with tlther ice weekly NST or weekly CST. +A study reported that vicewerkly modified BPP is likewise succesfol in preventing sib, + Absence of FH reactivity and the presence of dcelerations were predictive ‘of the diagnosis of fetal distress in labor requting cesarean secon delivery. + No diferences were observed between various classes of diabetics; 88% of {he tents were teslive and 12% had decsertions. No difenees in AFT were cen between dibetie dasiicatons, thus this study dos not support the use of routine amaiotie ui assesement in the well contolled term diabetic. Since ‘hey commonly have elevated AFI, monitoring those patients for a decline in volume isnot help. + Atsome institutions, CST is used as primary surveillance because it provides {constant marker of wteroplacental reserve. Class Ror F diabetic patents ‘wih small for gestational age (SGA) fetuses ora concomitant diagnosis of Ihypertension may require commencement of testing as early as 26 wecks ‘gestion. However the incidence of false-positive CST range from 400% ‘therefore intervention nthe preterm diabeue should occur when er sever Table. False neptve and Fae positive Rates for Antepartm Tess Tabenepave Taktepostve (eer 1000) or ta Sim Nsr 32 ‘0% BrP as 7% + Maternal fetal kick counting ie started a 28 weeks for al diabese gravidas + Because welhcontoled class Al diabetics are at low risk for in-wero etal death, antepactum surveillance may begin a 0 weeks, with weely NST + Those with complications lke hypertension, previous sibith, preeclampsia class A2, and al pregestational abetis should begin antenatal esting at 32 ‘week, with twice weekly NTS References 1. Barete J, Sayer Sl, Boehan FH The nostess est an eatation of 1,000 patients J Obes Gyn! 1981 141:133. 2, Bracco Salman, leicher A et a Unbilaartery velocimetry in dates td peghancy. Ott Cyne! ORG HS, 4, Dimond MP, Vaugin WK, Saier Stal. Antpartm fal monitoring ia ‘suli-dependencabetc pregnancies, mJ Obst Gn! 1985138528, 44. Dicker Dy Fetdeorg D Yeshayn A. et Fetal surveillance in inslin-ependent ‘abet regancy peice use of te bapa ote AJ Os Gre toes sao 5. Blt JP, Gace, Peenaa RK, el, Urasonie edition ff macroroia ‘dab patents. Csr Cyc! 1982; 6138, {6 GabbeSG, Mestmin, Preeman RK etal Management and outcome of pegnaney In abeee mei clases Bo Rn J Oe Cyt 197; 129723 1. Golde SH, Montoro M, Gooe-Andetso Bye al The role of sosess tts, ‘nti! poe and conteacion ste tts othe cupatient management of Inet requring dete regnncies n J Oster Cy 984108209. 8, Johnson J, Lange IR Harmeaa CR ea. Blophysical profile scoring in the ‘management of te diabetic prognancy. Oss Gynec 188,724 9, Landon MB, Gabte SG. antepartum tal surveilaace in pstatons diabetes elit Disk 985 3450, 10, Landon MB, Gabe SG, Beaoner JP, et al. Doppler umbilical anery ‘elocimety in pregnaney complicated inslindependent diabetes metus bse cl 198973964 11, Landon MB Gabbe $6, Fea surveilance inthe pregnancy complicated by ees missin Ober Qc! 1991 3:53,Landon MB, Mintz MC, Gabbe SG, Sonographicevluation of ftaabdomial ‘row: predicior of the lnrgefor gestational age infant in pregnancies ‘complicated by diabetes nlite im Obstet Gynec 1989;160:115, Lavery IP. Nonsrese fetal heatate testing. Cir Obstet Gyneal 198; 28:69, “Miler 1M, Horge EO. Antepartum heat rate testing in diabetic pregnancy. “Reprod Nd 1885 30515. Nyland L, Labell NO. Uteroplaental blood low in diabetic pregnancy ‘measurements with indium 115 anda computerlinked gamma camera mJ bse Gynec 1982144298, [Ray M, Freeman R, Pine S. Clinical experience wit the oxytocin challenge test. doe J Ober Gynecol 197251141 Sabbagha RE, Minogue J, Tamora RK, Hungerford SA. Estimation of birthighe by we of uleasonograpic formulas ageted o large. apperite- and small or-gestatonal-ape fetuses. 4m J Obst Gyno 1989; 160854, Spong CY. Astepsttum fetal monitoring: when, what, and how. Contemp (Obst Gyntco 998;3-85 C, INTRAPARTUM MANAGEMENT 1, Intrapartum Glucose Management [Nemesio A. Nicodemus, MD Recommendations ‘Women with gestational diabetes mellius (GDM) requiring pharmacologic therapy are best managed with intavenous (IV) insulin drips and. glucose monitoring protools during labor similar to women with pregestationa diabetes melts, ‘Women with very mild GDM may notrequre insulin cherapy but should have blood glucose assessment during labor ing Late ‘The last insulin doses given subcutaneously the night before o that morning. ‘Monitor plasma gluco every 1 hours Give shortacting insulin via IV infision ata dose of .5-1 unit per hour for plasma glucose above 120 mg/dL. ‘Targets of control dering labor are: plasma glucose 80-120 mg/dL (4.46.7 imol/L) or eapilay glucose 7010 mg/L. (396.1 mmol/L), Discontinue IV insulin immediately prior to delivery. For Cesaeon Sexton Patios "The as insulin dose is given subcutaneously the night before. ‘Determine random plasma glucose immediatly prior to cesarean section, Infuse shor acting insulin (0.51 unit per hour) if plasma glucose is above 120, mg/d. Discontinue IV insulin immediatly prior to delivery. ‘Check plasma glucose hos pos cestrean section upto 24 hours,‘inte Joma Parca Pad + Monitor plasma glucose every 46 hous for 24 hours. + Administer insulin subcutancousy when indicate. References I ‘crower CA, Hier FE, Moss JR, MePhoe Al, Jfties WS, Robinson FS; for {he Australian Carbone itleraee Stay in Pregnant Women (ACHOIS) ‘Teal Group, Pf of teament of gestational diabetes mes on pregnancy tomes, Bx Me 2008; 352.247 2386, Landon MB, Spong, CY, Thom E, etal The National Insitute of Child Teas and Human Development Materal-Feal Medicine Unis Network ‘randomized cla ia standard therapy sno therapy for mil gestational Aiabets mellitus 8 Bgl J Med 2009-361:1339-48, Horvath K, Koch K, leer K el Eles of teatment in women with etaonal diabetes mellitus systematic review and metaanalysis, BMD 2010;30:c1398, ‘Moses RG, Barker M, Winter M, ea, Can ow glycemic index diet educe ‘he need fori gestational abe mel? Paste Car 200952996. 1000. Prijian G, Benjamin BD. Update on gestational diabetes, Obes Gyms Chi 1 on 20137 255.25). ‘AACE Task Fore for Developing 2 Diabetes Comprehensive Care Plan ‘Waking Cooumites, Ende Prac, Marck Api! 2011 12 (Suppl 2}. ‘American Diabetes Assocation. Dish Core Jerry 2011;34 (Sopp St ‘MeeaperBE,BuchananTA, CoostanDR, tal Summaryandsecommendations fof the fith international workshop-conference on gestational diabetes ‘melts, Dae Cave 2007,9(Supp 2)8281 8200. ‘Kazmir JL, Block IM, Brow PM, ct a. Managing preexisting diabetes for pregnancy: summary of evidence and consensus fecommenéations for care Dias Cre 2083110601078. Rowan JA, Hague WH, Gao W, Melasyre HD, Glycemia anit eatonship {0 outeomes in the medormin in gestational diabetes tl, Dishes Cae 2010;35:9.16, Cypryk Ky Sobesak M, Porgy: Marezewska M, cal. Pregnancy ‘complications and perinatal outcome ia diabetic women tested. with amalog inguin ixpro) or regula humsn sla during pregnancy. Me So Moni 2004102129. Lepolla A, Dalia MG, Speia , esl. Outcome of pregnancy in type 1 ‘Gabee pets teated with insulin spr of regula” insulin: An Kalan ‘experience. de Dic 200845 61-5 Masson A, PatmoreJE, Brash PD al Home intype betes elit treated with asl ipo 200820346 1M, Hod M, Visser GHA, Damm F, et al. Safety and perinatal outcome in pregnancy: 3 randomized tial comparing insln aspart with human insti 1n 322 subjects with ype {dabetes, Dies 200353 (Suppl 14417 15, Mathiesen ER, Kinsey B, Amel SA etal. Matera! glycemic contol and Ibyporyeemia in type 1 dabei pregnancy: A randomized tril of isin spare versus human insulin 322 pregnant women. Diabaes Care 207 30:771-776 16, Sencea L, Marous V, Tsalaco F, eta. Use of insulin detemir during pregnancy, Nie Metab Centonse Des 201020015162, Intrapartum Fetal Monitoring, Timing and Mode of Delivery Rosa Ninez B, Velante, MD Intrapartum Fetal Surveillance: Recommendations + Diabetes mellitus in pregnancy i sted among the insapartum conditions ‘sociated with inoease sk of adverse fetal outcome where intrapartum, ‘estrnic fetal surveillance maybe beneficial + During labor and detivery continuous electronic feta heart rate FHR) ‘monitoring is recommended and fea blood sampling should be avaiable ‘when requested * + There are some evidence that vocomplicated gestational diabetes metus (GDM), welkcontzolied with it may pose minimal risks to both mother and fetus and maybe monitored like tha of alwssk or aormal preg. ‘Timing and Mode of Delivery ‘When shoul delivery ocar npregroncis complied by diabetes melas? + Thetiming ofthe delivery should be individualized depending on whether the patent as any concomitant maternal and/or fetal complications." “+ Selec the ining of delivery to minimize morbidity for the mother and fess, + There are no data supporting delivery of women with GDM before 38 weeks _estaton ia the absence of oecv evidence of matemal or fetal compromise. (sel, Grade) +n optimal time for delivery of most diabetic pregnancies is typically on ‘or afr the 38° werk, Dever a patient wit diabetes mellitus before 38° ‘weeks gestation onl for compelling maternal or feta indications without ocureatng fetal lng mata + Patents with wellcontoled diabetes melitw and no complicating fctors ‘may await spontaneous abo and be allow o progress to tir expected date fof delivery a longa antenatal esting reas easrig andthe fetus snot smacrosomic® Pregnant women with diabetes melitus who have a normally grown fetus should be offered lective though induction of labor or cesarean section, itingicte, ater 38 completed weeks "Lee IL, Grade C) + Therishsof eta macrosomia; bit injury, and inatero demise increase asthe due date approaches. Routine induction of women with diabetes mellitus 00, “orbefre 39° weeks gestation doesnot increase the ate of cesarean delivery and may reduce the risk of macrosomia. ‘+ If am elective cesarean section isto be performed, it shouldbe at 39 weeks rather han 38 weeks gestation to rede neonatal respiratory morbidity" + Eapectant management beyond the estimated due date generally is not recommended.? ‘+ Aer 40 or more weeks, he benef of continued conservative management ar likely to be outweighed by the danger of fetal compromise. Induction of labor before 41 weeks gestation in pregnant women with diabetes melius, regardless ofthe readiness of the cervix is prudent? + In the presence of cbstetric or diabetes mellius related complications (asculpatiy, nephropathy, poor glucose contol ora prior sili) elective Aeivery should be considered at 38 weeks gestation *+ Assessment of fal lng maturity by means of amniocentesis in a diabetic pregnancy is no longer requied with delivery afer 38 week. I is also not Indicated in wellcontrolled patients who have Indication for induction of labor or cesarean section as long as hee is reasonable certainty about the ‘estimation of gestational age. (Level, Grade C) + Assessment of fetal lng maturity should rarely be needed even at an eater fastation.” When delivery is neessary at an ear gestational age for ‘maternal or fetal reasons, delivery shold be effected without regaed (lung maturity testing “How should deliver ocurin pregnancies compiaed by dabetes melts? + Vagina dover term i possible i women have documented dating criteria and good glyeemic contol + GDMis notin sel an indication for cesarean delivery!the estimated eal weight EFW) atthe ime of delivery is < 4,000 vaginal delivery is usually appropiate unless there ae other obstetic indications for “Therisk of macrosomia, shoulder dystocia and fetal injury in labor isincreased {ol in diabetic pregnancy. These risks shouldbe taken into account when planning mode of delivery (ae Gade A) ‘Using ultrasound EFW or abdominal circumference (AC) to make decisions regarding timing and rout of delivery may be associated witha lower rate of Shoulder dystocia, bu lager tudes are needed to determine if this approach iets the rte of neonatal injury: (Level HI, Grade) Despite # lack of conclusive evidence, it appear tha cesarean section may be beneficial when fetal overgrowth is suspeced. However any benefits must be caeflly weighed agains the maternal rsks/costs associated with cesarean fection deliveries. lective cesarean section shouldbe considered ifthe fetus is suspected tobe significantly obese. IF fetal weights estimated tobe 4,500 g or more, the risks and benefits of cesarean delivery should be discussed. with the patent. The ‘American Cllege of Obstetricians and Gynecologists (ACOG) recommends “offering cesarean delivery to dabetc patient ifthe fetal weight is estimated 0 bbe 4.500 gor mare’ (Low! 7, Oude #) (ou: Ths weight ex? may nx be epleabe in the ce eng) ‘When EFW is 40004500 g consider past delivery history, linia pelvimetry, titrasound determined body to head disproportion (eal AC weeks ahead of| bipaietal diameter (BPD) and progression of labor to determine mode of Avery” (Level, Grade A) Inthe event of a planned cesarean section, delivery should be carted out nul in the morning to prevent prolonged fisting and to maintain optimum syeemic conto Delivery should take place in a hospial with fall obstetric and anesthetic ‘cies and ith acces neonaral intensive care facies (Lev! I, Grade) Women donot nee to fis for induction of labor? Induction of labor with prostaglandins may be undertaken according tothe ‘normal regimen used fr nondiabetic pauens maintaining diet and the dose of insulin. + Dever shouldbe actively supervised by experienced obstetric and pete sat! Diabetes melts should not ia itself be considered a contraindication to attempting vaginal bn after a previous eesarean section (VBAC). (Lee Grade) “Table. Mode of Delivery Based on Estimated Fetal Weight ACOG) =a000 00-9 a4 “Tilo ibor | Conse past dtvery story, ‘Cesaean section may lial plvimeny, evidence of teconsderes tay oad disgroporion ett [AC shea of BPD) and progression tiabor Speciat Circumstances 1. Preeclampsia + Pr-eclampsais approximately four mes more common in pregnancies complicated by diabetes melts than i the background population, + Management should be as for the nondiabetic population with preeclampsia, 2 Preterm Labor and Delivery + de prterm labor or delivery before 36 weeks is indicated, betamethasone ‘o promote fetal lung maturity shouldbe administered if possibie*" + Antenatal steroids adversely afet maternal lcemic contol and increase insula requirements. The patient shouldbe admitted tothe antenatal unit Intensive insulin therapy and frequen glucose monitoring are required to prevent hyperglycemia.” + Toco drugs are not contraindicated in diabetes melts but S-agonist rugs should be avoided as they can cause severe insulin ressance and licose intolerance? 3 Analgesia and Anesthesia + Effective pain eli is important and al forms of pain relief used in labor ‘ean beused |If general anesthesia is used in women with diabetes melitus, blood lcose shouldbe monitored regularly (very 30 minutes) fom induction Of general anesthesia unl afer the baby is orn and the woman i fully Summary of Evidence Iurapartun eal Surveance + Iasulinseguiing GDM is listed among current pregnancy condiions associated. with inceased perinatal morbidity and’ moral: The most portant aspecs of eal suvelance involve fal monitoring in an effort to detec fetal compromise and the risk of stilbirt. However, theres stil no cleat evidence or consensus on which methods) of Fetal surveillance ace the ‘most effective in detecting fetal risks" + 4.2009 review ofthe irate on 14 screening and monitoring interventions in pregnancy on stilbth found that there ae aumerous research gaps and large, adequately controled tial are sll needed for mos ofthe interventions examined. Numerous studies indicated that positive tests were associated ith nereased perinatal moti but while some testshad good sensitivity in etetng dises, fuse positive rates were high for mot tess, and questions remain about implications of esting. + Continuous fetal monitoring is recommended when risk factors for fetal compromise such as diabetes melts are detected during labor. When combined with fea seaip Blood sampling ras of cesarean section and operative vaginal deliveries are reduced compared with cazditocogram (C16) alone + There is no objective evidence that Fetal monitoring in uncomplicated GDM. alfecs feal outcome. A 2006 review and opinion paper (Ihe Avstralan Diabetes in Pregnancy SocietMansgement Guideline on GDM) on appropriate Fea survelince or women with diet contolled GDM concluded that ao evidence leatly support the practice of ieee fetal sorvelance in these pregnancies! Timing and Moe of Delivery + Prefered method and timingof delivery in omen with GDMare determined by expert opinion because ofthe lack of define data. aot Delaying delivery to as near as possible tothe expected date of confinement helps maximize cervical maturity and improves the chances of spontaneous labor and vaginal livery ‘A 2006 study to estimate the gestational age ranges that result in optimal birth futcomes found that forthe habetes melts group it was 0 weeks 3 daysto 4 weeks I day" Although delivery as easly as 37 weeks might reduce the risk of shoulder Aystocia increases the likelihood of fled labor induction and poor neonatal plllmonary satus Beause fetal growth fom 37 weeks onward may be 100- 150g/ wee, the reduction in net etal weight and the risk of shoulder dystocia ‘by inducing labor 2 weeks erly may theoretically improve outcome. Inthe seting of GDM, macrosomia (Le. estimated fetal weight greater than 45008) ‘serves as. sucroate marker of adverse maternal and neonatal outcomes “The effect of induction or clectivecestean section on outcomes i unclear” Ina study in which insulin treated GDM women with aonmacrosomic fetuses ‘were randomized to labor induction at 38 weeks oF gestation, there was no diference in cesarean delivers: Two Cochrane reviews have assessed the ole (of bor induction in preventing pregnancy complications, including shoulder {ystcia Bath reviews conclude that there i insufficient evidence regarding the beneficial effec of induced labor on shoulder dystocia. prevention. However, induction of labor reduces the risk of macrosomia in pregnant ‘women with insulin zequirng diabetes melts Some authors recommend Inborinduction at ppreximately 3839 weks in insuln‘reated GDM patents, since it flowered the shoulder dystocia rk from 10 t0 1% In 2009 systematic review (S studies) to estimate benefits and harms of the choice of timing of induction or clecve cesarean delivery based on [BFW or gestational age in women witt GDM, the proportion of newborns ‘with birth weight greater thn the 90th percentile was significantly greater in the expectant management group (23% compareé with 10% with active induction). There were no significant ferences in ats of cesarean delivery, shoulder dystocia, neonatal hypoglycemia or perinatal eats Data areaotavaiabletoindicte whether or nt theres greater sskof perinatal orbidity/morality in the infats of woren with wel-controlled GDM if prgnancy i allowed to proceed past 40 weeks gestation, Nevertheless, ice reasonable to intensify fetal surveillance when pregnancy i alowed €2 ‘continue beyond 40 wees station.” Pnned. Cesuean Section Guidelines (FiNh,Inetnaonal Workshop- Conference on GDM: Sai rfc he kof bch injury includeIiberal poticy towasd cesarean delivery when fetal overgrowih is suspected Homeren nocontalledtialsaresvalabletosupportthisapproach. Inplanning the timing and route of delivery, consideration of fetal size using clinical fad ltiasound estimation of fetal weight, despite iaerent inaccuracies, i fequently used." Clinicians shouldbe avvare thatthe accuracy of eal weight textmation ie 20% in erm babies and that accuracy decreases with increasing, Birth weight? Prevention of shoulder dystoc 10" In a study, this complication occurred in 31% of neonates weighing ‘more than 4000 g wha were delivered vaginally by mothers with dabetes nell of any type. A study found a 3% prevalence in GDM. women ‘versus 1% in normogijeemic women (p = 0.001). Clinical estimation of Fetal size tough ultrasonography is wed co detect fetal macrosomi, Wich ean be identified by increased AC. The 13% error rate (22 standard ‘deviation (SD) in estimating fetal weight dough ultrasonography should bbe considered, A recent cosceffectiveness analysis showed that overall ‘expectant management isthe preferable approach, iespective of EFW. ‘Avrandomized contolled Wil (RCT) in Israel compared induction of labor with expectant management inthe presence of macrosomia (4000- ‘4500 grams). There were no significant difference inthe mode of bisth ‘enwoen the groups nor in the mean birthweight. There were Sve cases of Shoulder dystocia inthe induction group compared to sx in the expectant ‘management group. Study concluded that EFW between 4000 and 4S00 {rams should note considered an indication for inducing bith. However, {the study was not explicidy conducted on women with diabetes melitus* © The commonly used formulas derived from a multivariate regression Inukiply multiple coefficients together, with the resultant product (EF W) ‘iealy having an acuracy thats seldom fess than within 15%. Ferases predicted co weigh 2000-4500 gbased on ultasonogeaphic findings actually neigh that much oly 50% ofthe ime, A sensiity of approximately 80% Js typically associated witha specificty of $060%. This means a flke positive rate of 30-50% occur even with che more predieave formula, possibly requring an unnecessary cesaean delivery of more than 100 Feeses in onder to prevent 1 from having permanent Eeb palsy. Curent data do not supports policy of early induction of labor in eases of posible fetal macrosomia, Ione accept thal 620% of ifn of diabetic others born weighing 450 g or more will expetienee shoulder dystocia, 15.30% (of these will have recognizable brachial plexus injury, and 5% of these {njures will sulin petmanent deficit approximately 333-1667 cesarean deliveries would have tobe performed for posible macrosomia t prevent {case of permanent injury due (0 s¥-pulder dystocia. Howere, i etal “weights extimated to be 4500 gor mort, the risks and benefit of cesarean 126mg/dl or7.0 mmol/L) ‘or postprandial glucose (> 200 mg/l. oF 1.1 mmol/L} In such patents, medical suiion therapy (MINT) and, if necesary ‘Pharmacological therapy, should be cotined to maintain good glyeem ‘contol and provide suliient calories fo acation and infant well-being! + Allypes of insulin, glyburide, or lipizde canbe safely used by breastfeeding + Limited data suggest chat metformin, while excreted into breast milk, does not appear to have harmful neonatal effects. Larger studies are still neded ro ‘demonstrate the safety the infant of breastfeeding women using mesformin ‘as well as acarbose and gtazones! Postpartum “+ Because some cases of gestational diabetes mellitus (GDM) may represent preexisting undiagnosed type 2 diabetes meltus, women with 2 history of GDM should be screened for diabetes melinus 6-12 weeks postpartum using ‘non-pregnant oral lucose tolerance test(OGTT) exiteria.® (Level, Grade A) “+ Women witha history of GDM have a greatly increased subsequent risk for diabetes melita?+ Women with a history of GDM should have lielong sreening for the evelopment of diabetes melits a least every 3 years? (Lee I, Grade) ‘esting to detect type 2 diabetes melitus and asses sk for future diabetes ‘melts in asymptomatic individuals should be considered in adults of any {ge who are overeight (body mas index [BMI] > 25 kg/m?) and who have ‘ne of tore additional rik factors for diabetes mellitus (Table 1). Ta those ‘without these ik fcr, testing should begin at age 45 years? Lee I, rade 8) “Table 1, Criteria for Testing foe Diabetes Melis in Asymptomatic Adult advil! Tang Seat fe conned aT awh ae ore COME 1g ad deal ak aie Hedge ae wit Nall cutie. i rndey ‘woman nb deed why weighing >9 1 wee agnor wits GDM [preven 1050 malta oy rapes FB ose eve 5.90 mo) andra tree el 290 mg G9 ml) oth peace ye #COS) yen Renglh (ts) >S ype gs kee (GT) imp ‘seg pace FG) on pines com fine sonny ad Wi la ese, eee obey, HAIRCAN “yal ty feaoaclar sse(CVD) Inte snc ofthe ahve ii ting tts lish ein ata 48 es nr nm sings be epee oe ine wh oie ‘re gue ing apt al esta rote + teats are normal, repeat testing carried out atleast at 3-year intervals is reasonable? (Le il, Grade) (0 Mathematical modeling studies suggest that screening independent of isk factors begining at age 30 or 4 years is highly cost fective («$11,000 per quality. adjusted i-year gained. The ationae for the eur itral that false negatives wil be repeated before substantial time elapse, tnd thee is lite Hieibood that an individual will develop significant ‘Complications of diabetes melts within 3 year of a negative ts result Inthe modeling study, repeat screning every 8 OF S years was cost: sffeive! + Tes fr dbs mais o oa iabetes melts, syeosylated hemoglobin HbA), FPG, wappropiate (able 2)? Ler ha, Gre 2) Table 2, Categorie of Increased Rik for Dios Melis Pedabes Mins” FPG 100125 mg/L 6669 l/l): IEG oR ‘2a plasma uote nthe 7g OGTT 140.199 mg/L (7.8:11.0 mamal/L): IGT oR MAres 66% "Feral es a, otc, eighth Ki of gad ong eion aera higher eh the age + In those identified with increased ss for fture diabetes melts identify and, if appropiate, wear other cardiowascular disease (CVD) rik factors? (Level 12, GoieB) ‘Long Term Prevention / Delay of Type 2 Diabetes Melitus + Patients with Impaired Glucose Tolerance (IGT) Lael, Grade 4), mpaies Fasting Glucose (IG) (Lav I, Grade O, oF an HDA eof §7-6.4% (Lee I, Grade C) should be refered to an effective ongoing support program targeting ‘weight loss of 7 of body weight and increasing physical activity atleast 180 minutes/week of moderate activity such as walking (© Randomized controled trials (RCTS) have shown that individual at high risk for developing diabetes melitus (those wih IG, IGT, or both) canbe ‘ven oterventions that significantly decrease the rae of onset of diabetes felis" Thee intervention incide intensified style modification Programs that have been shown tobe very elective (38% reduction ater 5 yenrs) and wie of pharmacologic agents metformin, a-gucosidase inhibitors, onstat and tiazolidnediones (TDs), each of which hasbeen shown to decease incdent diabetes mellitus to various degrees? + Follow-up counseling appears to be important for success? Metformin therapy for prevention of type 2 diabetes mellius may be ‘considered in those atthe highest sk for developing diabetes mellitus, such as ‘hose with multiple ik factors, especially i they demonstrate progression of Iypersycemia (eg, HDA le> 6%) despite ilestyle modifications? (Loe! I-2 Grade 8) + Monitoring forthe development of diabetes mellitus in those wih prediabetes nellitus shouldbe performed every yea? (Lvl I, GradeBreastfeeding Breastfeeding is recommended by numerous health agencies as the prefered method of feeding for infnts fOr at east one year because ofits multiple jmmediate and long term benefis for beth mothe and child (The American Academy of Pediatrics (AAP) strongly endorses ‘breastfeeding athe primary source of nutiton for infants witha strong, family history of diabetes melitus ‘© A study onthe effect of lactation on glucose metabolism in women with recent GDM showed that postpartum glucose values were significantly ower in the breastfeeding group 0.01). Nonlactating women developed ‘postpartum diabetes elit at fold higher ae than acting Women (9 The association between infin feding pracices and type 2 diabetes melts in ater fe was examined in a large longitudinal diabetes melicas study among a population witha very high prevalence of type 2 diabetes mellitus, Type 2 dabetes melitus was $9% les common n exclusively breasted people compared with those who were exclusively bottled." ‘oAspartof the sume study, te longterm effects of diabetes mellitus during pregnancy and the influence of ily hfe events on ofsprings of both others wit diabetes mellitus and those without were also examined. ‘The researchers found that diabetes mellitus in the next generation was less common among breasted chen than among botefe children, ‘Therefore, in theory, increased infant breastfeeding rates may lessen or prevent long term adverse outcomes such as diabetes mellius during pregnancy in the next generation.” ‘© The asteciation between lactation duration and incidence of the metabolic syndrome among women of reproductive age was assessed ‘mong 1599 women inthe Coronary Artery Risk Developrent i Young ‘Aduls (CARDIA) Study, a mulicenter, popultionbased, prospective ‘observational cohort sy conduced in the United States. twas found that longer duration of lactation was associated with lower incidence of the metabolic syndrome Yeats afer weaning among women with & history fof GDM and thus, may have persistent fvorable eflecs on Women’ ‘rdiometabalic health," ‘Better prenatal education and counseling about breastfeeding shoud be made svllable to pregnant women with GDM ot pe 2 diabetes metus. + Hospital staff should be knowledgeable with respect to the beneis of breateeding and confortable assisting higher sk women wih iaton + Theeffect of breastfeeding pers on subseuent riko nis not cleat. Limited staies show lower rates of pos and fasting glucose eves in breateing women with prior GDM and a prone) ‘fet with lower diabetes melts rates in healthy women who breastfed, Pending clarification of these isues, all women, including those with prior GDM, shouldbe atively encouraged to eacusvely breastfeed to the greatest extent possible during the fs year of fe! (Lee, Grade C) A fe Barer Methods ‘Barrier methods, which include condoms, diaphragm, cervical cap, and spermicides, are well sulted for women with por GDM because oftheir inok of systemic sie effects or influence an glucose tolerance. + Strong patent partner motivation an efficient patent edvcation improve ‘ontaceptivesocoess. “+The use of condoms shovld be encouraged in all women with prior GDM. ‘who appear at rik fr sexwalytransmited dscases (STD) and human Immunodeicency virus IV)" 12 Intrauterine Devies + ‘The intrauterine device (UD) is a very effective and reversible contraceptive method without metabolic disturbances and therfore isan {deal eontacepive for women wit prior GDM." The World Health Organiation (WHO) Medical Eligibility Criteria for Contraceptive Use report does not coasider peor GDM as a contraindication to IUD prescription.” ‘0. Their safety i reamed by studies in women with type T or pe 2 eiabetes mellitus sing copper releasing IUDs, which showed no increased risk of pelvic indammstory disease PID) or flare” © Only few studies have been published with data on the use of fevonorgestrel releasing IUD in women witha history of GDM. A recent randomized tal of the use in women with type diabetes fnelitus did not show any influence on blood glucose, HALE, oF ally insulin dose ‘Based on the avalable evidence, both copper and levonorgestrel eeasing TUDs can be used safely Wihout any speci retcton in women with prior GDM."Combination Oral Contracpuves Combination orl contraceptives (COCs) contain estrogen and progestin, “and are the most widely used type of hormonal contraception. Generally, ethinyl estradiol has no net effect on glucose tolerance and ingulin sensitivity" but even the lowest etinyl estradiol dosage may adversely inflience hemostatic and renin angiotensin systems 0 increase ‘thrombi rik and blood pressure” Ethinyl estradiol affects lipid metabolism, increasing triglycerides and cholesterol levels and decreased cholesterol The metabolic effets ace dose dependent with respect to the amount of estrogen used inthe COC. Smoking and maternal age > 35 years add risks wo these events” It is important to use the lowest dose possible, or low-dose COCs" ‘containing 20-35 jg doses that have proven sficient to maintain satisfactory cycle contro. ‘The progestin components most widely used in today’s COCs are either "second generation” (eg, levonorgesrel or norgestimate), “thir generation’ (eg desogestrel or gesoden), or the newest progestin, rosperinone. (© Spero and Darney (2005) sated that in general, the effecton glucose metabotism is mainly relate ro dose, potency and chemical structure ofthe progestin. Less androgenic progestins increase glucose tolerance and insulin, sensitviy?™ (© Olderprogetins have no influence on blond pressure or clotting actor although they may modify the effets of estogen by mechanisms still tobe explained, (Curent information on the drosperinone-containing COCs shows no increase in blood presure in those susceptible because of its ant aldosterone and antimineralocorticoidsctivity (© Although progestins tend to antagonize the estrogen effet, ie lowering of wiglycerdes and HDL cholesterol and inereasing LDL. cholesterol, Sperof's review illustrated that the use of the less androgenic progestins increase HDL, decrease LI with litle ‘change ia cholestrol, increase triglycerides 58 ‘he meabol es of sen COC ENN ee effec of the type and/or dosage of cach hormonal component, smoking fand maternal age" (© In heathy populations, epidemiological studies in curent or previous (COCisers have not established an increased risk of diabetes melicus and short term studies have found no clinically zelevant damaging effect on iid metabolism, (© Newer COC formulations actually demonstrate a beneficial effect on lipid profes + The majority of women with prior GDM likely alin the category of low absolute risk of cardiovascular and venous thrombotic events and fow- dose COC can be prescribed taking into account that the absolute risks Increase with age 2" ‘The magnitude of other isk factors i.e. hypertension, migraine, smoking, hyperlipidemia, coagulation disorder, and family history of thrombosis (presence of Leen factor V mutation), which increase the odds ratios for Arterial and venous thrombotic evens by 2 to 12-fld in COC users must always be considered." +A petiole risk assessment of cardiovascular risk factors in women with prior GDM shouldbe done ‘+ When hypertension or migraines are present in women with prior GDM, ‘it would be most cautious otto prescribe a COC." + Ina cases, the fowest ethinyl estradiol with newer progestins shouldbe presrbed and clse attention shouldbe pad to ineeases in blood pressure and weight" + All women should receive mutitional counseling, be encouraged to ‘exercise daly achieve a healthy weight, and receive appropriate medical therapy to control blood pressure and/or lipid i ifestyle interventions a (. Nomonel Combination Hormonal Methods + Nonoral combination hormonal methods are available and can be administered as a monthly injection or an intravaginal ing © Available epidemiologieal data ar fimited to healthy women only ‘and in the absence of specific data relating to GDM, the risk benefit should be consiered similar to those of COCs"S.. Progstin-Only Ora Contraceptives + Progestinonly oral contraceptives OCS) ate taken continuously and contain low dose norethindrone, Jevonorgestel or desogestrel (2 Lessepidemiolgical and clinical data areavalablesince POCsare les widely prescribed than COCs, largely because oftheir higher actual flue rates and breakthrough bleeding rates. They are wellsited far those with type 1 diabetes mallius where estrogen-containing methods ae contmindicated and for women with prior GDM wo ‘often have several cardiovascular risk factors, making non esrogen- ‘containing contraception favorable” ‘0 Ina large cohort study in poetpartim Latin Women, those who wore breateeding and therefore prescribed POCs were found to have an adjusted three fld increase in the proportion of development of type 2 diabetes melts during tir frst 2 years compared with lowsose {COCs and noahormonal methods. These findings have yet to be confirmed in women of other ethnic backgrounds bu indicate that POC shoul no be the frst choice of contraception fr thee women uring lactation” 6 Long-Actng Progestins + Progestin agents can be administered intramuscularly or subcutaneously a an implant to deliver longacting and efficacious contaceptive Drotecion. They offer the same metabolic advantage a3 POC with 90 let on maternal coagulation factors or bio pressure + Use of longacting progestin in women with diabetes melts or women, at high sk of diabetes melts is very limited. (© In an observational cohort of Hispanic women with prior GDM, tue of depot medroxyprogesterone acetate (DMPA) was asociated swith an increased rik of diabetes melas (unadjusted hazard ratio [HAR] 1.58) compared with women who used COCS. The increased incidence appeared to be explained by increased baseline diabetes ‘meus ris, weigh gain during use and higher baseline uilyceries| and/or beaten, * ‘+ DMPA should be used with caution in breaseeding women and those ‘ith lerated wiglyerde levels > 150 mg/4L) + Close attention should be paid to weight gun, which also has been demonstrated to increase the risk ofsibsequent diabetes melts ® + The Food and Drug Authority (FDA) cautions DMPA use for more tha 2 years Because ofthe associated decrease in bone mineral density. + Studies examining the eet of implant systems on diabetes melita jn women with prior GDM are stil lacking ® + Long-actng progestin methods are not a firstine choice in women with por GDM unless compliance wit aking daly medication isa problem, + tfestogen containing contacepies are contraindicated, the POC woul betheistchoice hormonal method or ether typeof intrauterine device." SarglelSeiation + Operative sterzation ean excellent cate for women who are no lager ‘desirous of subsequent childbearing. The option should be offered to ‘arovs women, especialy those delivered by cesarean section, where the ‘teilization can be performed during the surgical proces." Summary ‘Women with prior GDM have many contraceptive options and generally an seal forms of contraception, The only significant excecionithat progestin ‘only methods durin lactation should be avoided or used with caution. When prescribing hormonal methods, cardiovascular sks and baseline health should always be considered. A progestinonly method or a metabolically ‘neutral method such a8 an TUD would be desirable in cases of multiple rik factors ‘Women with prior GDM require effective and safe contraception that suits their ifesyle and doesnot enhance the risk of developing diabetes melius, ‘metabolic syndrome, or cardiovascular complications. ‘Care plas shovld be individualized and should indde surveillance of slucse tolerance and screening fr lp disorders and other cudiovascular Fisk factors folowing sandard guidelines. Blood pressure and weight shouldbe measured at cach visit anda healthy lifestyle shoul always be renforoed.*Reference 10, Metae BE, Buchinan TA, Cousan DR, etl. Summary and recommendations Of te fit nerntional woskhopsoaeoce on gettional Sabet mel Dishes Cae 207, S0STSI1-S20. ‘American Diabets Asocaon. Smadars of media cr in diabetes 201), Dishes Coe 2011341813511 S61, Ki C, Newton KM, Kaopp RE. 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Gm Burial nd Infri pioe as Wiig 2005 851-92, Suthingpongse W, Tansepanechstl S.A open label asdoized comparative study of oaleonacepevesteraeea medion containing mgdrosprenone/ 30 ‘nisg tila and 150 micro eenorpestel/ 30 microgetunyestadio in Tha women. Conran 2004092326 Tideaat, Kier S Contraceptives and cerebral homboss five year maton ‘ae coil tidy. Conon 20248: 197-208. Tidegand, Eds mB, Reiner Contraceptives an vemos romboembaism: ‘fines atonal eate-sontl dy Contig 20026187196, [ajon Shs ers RK, Xing A. et. Contraception sod the risk of type? diabetes ‘lu’ ia Lain’ women wi poor getational dlabees mois, JANA [Woe.aosta-838, “Xiang Al, Knvalobo M, Kjs SL and Buchanan TA. Longing injectable ‘popstin comaceton and kof type 2 dates in Latin wore Wh prior (etna! bees mains Dias Cae 2106290) 613417 eters RK, Kjo SL, Xiang A, Buchanan TA. Long em diabetogenic ei of ‘sine pregnancy i women with previous pestaona abet melts. Lana Iooe;307227280INFANT OF A DIABETIC MOTHER Jose B, Salazar, MD Introduction “The strict control of maternal glucose levels may limit or ameliorate the ri ‘of certain complications inthe newborn, especialy those associated with etal macrosomia. Strict contol of maternal glucose levels, may also reduce the incidence of congenital malformation. + Diagnosis ofan infant of a diabetee mother (IDM) is made by maternal ‘istry, including an abnormal glucose tolerance ts. (Care of the Infant ofa Diabetic Mother A. Review Maternal sory + "Type of diabetes mellius Degree of maternal contol + Prior bstetichistory ‘Other pregnancy complications {Maternal medications, especialy insulin o oral hypoglycemic agents Intrapartum medications, glucose drip insulin et. Fetal assessment B. Inthe Delivery Room (DR), ose for: ‘+ Bssental Newborn Cae ‘Skintoskin contact at bith, breateeding within the fist hour (oles the neonate sequzeswansfer to the nursery intensive care ‘ity [NICUD) ‘kintoskin contact aids in thermoregulation and. promotes breasteeding ‘Teach mothers to ecognee and respond to feeding cues ‘Macrosomia 4k some > 4.5 kp) ih injury “Anomalies cardia, matculoskeeta, central nervous syste (CNS) + Restor distress | Clinical Presentation 1. Typical somatic featares + NTage or gestational ap (LGA) 1 Hlead circumference appropiate for gestational age + Hepatomegaly Cardiomezaly + _Excesvesubeutancous fa tse 2. Other features Finfans offen alkernate beeween lethargic and intable sates not rnecesailyconelated with serum goose levels. “+ Tnflans may fed poory during the ist days oft Morbiditiss Seen in Tafants of Diabetic Mothers 1. Macrasomia( dh some > 45 kg) and LCA so Rte fr birt injures, suchas: (Clavie factres lamers atures Brachial plexus injury ‘Cephalhematoma Subdaral hemorthages Phrenic nerve injury, ie diaphragmatic paralysis Increased rik of adrenal hemorrhage (organomegaly) Instrument deliveries Tnereasd risk for cesarean section, ie tasientachypnea ofthe snewbora (TTN) + Asphyxia 2. Intasterne growth restriction (TUGR) 1 Tneeased incidence of preeclampsia 1 Severe diabetic nephropaty (White's Class F), protein amino acid fos {Diabetic vascular disease > decreased uterine artery blood flow and seroplacentalinsullency Hypoglycemia. + Blood pcos level < 40 mg/l {May develop Ito 2 hours afer bh and may persist o recur during the fit 48 hous wth or without sraptomsGiterines lethargy) + Blood glucose levels shouldbe taken a1, 2,3, 6, 12,24, 26 and 48 hours 4 Respro stress syndrome (RDS) + Occurs 5.6 ies higher nthe IDM.‘+ Insulin antagonizes cortisol nduced lsthin synthesis + Decreased surfactant production by insulin + ‘May occuri the fist hours o days 3. Hypocalcemia + During pregnancy, a mother in a hyperparatyroi state > transfered caleium to fetus (agaist a concentration gradient) Parathyroid hormone (PTH) and calitonin do nt erss placenta Inthe neonate, deceased PTH and 1,25 dinydrony vitamin D at ~24 hes alterbirth ‘Occur jn -17% (0% historically) of inns born to insulin-lependent mothers, and in those with poor contol and longer duration; may be potentiated by prematusty or asphyxia Hypocalcemia develops usualy between 48-72 hours afer birth ‘Transient (2-3 day), improves spontaneously Plasma calcium ofen <7 mg/dL iCa2+ hypervssosity coupled with (possible) decreased cardiac output fom cardiomyopathy Imbalance of po and ant-agarege}ory prostaplandins 10 Cardiac onomalis + Cardiomyopathy Septal hypertrophy Ventricular hypertrophy (bor un) May cause ote tract obstrction or hypertrophy may be so severe and essemialy result in hypoplastic lef heart syndrome physiology ‘May present as heart failure (Congested lng flds,hepatomepaly, low output sate) Ital management dependent on physiology (pressor, volume) [Long-term management may include digoxin and/or flocker ‘Usuily transient and resolves spontaneously by 6 months ar birth “Tunes rteriosus (wth or withou aoc arch anomalies) Double ute right ventricle (DORY) Ventricular sepa defect (VSD), eansposiion of great arteries (TGA), dextrocardin 1 Cogent noma 23x higher compared with population without diabetes melis “+ Most susceptible period daring fetal development 3-8 weeks gestation Geprovedglyemie contro! after It wimestr has no impact on incidence ‘of congenital anomalies) + Correlates with poor control in ey pregnancy as evidenced by elevated ‘sbcosyated hemoglobin (HbA) ‘Small ef colon syndrome + Obstruction and feeding ificules; may require surgery ‘Upually resolves with ime Caudal regression/sacrl agenesis (caudal dysplasia sequence) ‘Complete or partial agenesis of sterum and lumbar verebrac Ribanomalie oceue Femoral hypoplasia, clubbed fet, and flexion contractures of let extremity Often asocited anomalies of gasuointestinal tact, genitoarinary trac and heart and neural tbe defects ‘May be identified or suggested) very ealy wit 9-10 week ultrasound ‘Most cases are sporadic, some with genetic component Correlates with poor glycemic contol (elevated HAIe) in exly pregnancy ¢ Neural ube defects TO increase in IDM Anencephaly holoprosencehaly, hydrocephalus‘Management A. Bopoatycmia + Glucose blood sugar monitoring prosoco: ‘0 Testing: Check blood sugar within 30 minutes of delivery, at 1 hour of ‘312 bouts of if and thereafter Infant will eed sable blood ‘sugars prior to discontinuing bod sugar checks. 0 Trentment Biood sugar > 45 mg/dL. Tf blood sugars normal on 4 consecutive blood sugar testing. ‘no further testing is required Tf blood sugar 30-15 mg/dL and baby is asymptomati, Inkiate appropriate feeding i If = 45 mg/dL, continue blood sugar testing and age ppropeate feeding eS mg/dL, or baby nor breastfeeding wel give 1015 mt standard term formula by cup/dropper feeding and repeat ood sugar in 30 minutes ii, 1 <-45 mg/dL. ater formula, transfer infant to NICU, begin inravenous (IV) glucose infusion of DIOW at 4 ml/kg/ hie 7-mg/kg/min of glucose) and repeat blood sugar in 30 iL Give 10-15 ml sandard crm formula by botle and repeat blood sugar in 30 minutes li. If = 45 mg/aL, continue blood sugar testing and age appropriate feeding ii, Th-= 48 mg/dL, transfer infant to NICU, begin IV glucose infusion of DIOW at 4mg/kg/r (7 mgke/min of lucose), and repeat blood sugar in 30 minutes Blood sugar < 30 mg/L, or < 45 mg/L and baby is symptomatic "Trans infan to NICU ‘Administer 1V glucose bolas of2g/gof DIOW, and begin 1V glucose iafsion of DIGW at 4 mg/kg/h (7 ma/ke/ min of glucose) etek od sarin 39min bls) ©) blood sugar 243 mg/dl recheckin | hourand resume aS hour testing 19 ood svat 45 g/d repeat 2 mg/kg DIOW bolus and increase D10W TV sate by 1 mi/Ag/n repeat blood sugar in 30 minutes and continue bolus/IV increase with 30 minutes or the placement of central catheter (to allow for the infusion of an elevated concentration of cose) soas to avid uid overload BIV Glace Weaning + Continue or inate q3 hous feeds ut infants feeding wel + Tr blood sugar 248 mg/L, decrease TV ate by | ml/kg/b and continue to decrease IV rateby 1 mike thereafter foreach blond sugar 45 mg/ SE, Some sey see pee nae may net be weed more + Once IV glucose is discontinued, continu testing until 3 blood sugar values >45 mg/l indcae infantis ready to come of treatment protocol Summary “+ -Maternal hyperglycemia can lead to fetal hyperinsulinemia and pathogenic ‘vents resulting in neonatal mobiites. IF maternal hyperglycemia oocurs Peiconceptvally and/or during the inital 7-8 weeks of gestation, congenital anomalies inthe fetus can occu + Improved diabetes melitus contr! in the mother results in fewer morbiiies| inthe DM, including improved fong term neurodevelopment. + High isk neonates shoud be screened carly for hypoglycemia and managed sppropnately References 1. Comath M, Hawson J etal. Contoveses rearing deinton of nena ypoyemi.Sogested operational deal Petr 00105-14115, 2, Hernandez E, Dag A, Santos W. Manual on standards of newborn cate. Phi Soe Newboen Med and Phi ets Soe 3. Kote $8 Bud ine H Neat econ malig. Mosk Yoo Is 1583. 4 Merenstin GB, Gardner SL, Handbook of neonatal intense cae. St. Loa ‘Mosby, 2010 5 Rall, Yor MC. Wok i pace moog: Pais Sane,SUMMARY OF RECOMMENDATIONS Diagnosis and Sereening Diabetes metus recognize during pregancy should now be classified as either gesttional diabetes melitus (GDM) ar overt abees melts based on ‘plasma glocose levels (Lae 1, Grade C) ‘Universal scesning for GDM is recommended for ALL Filipino gravida [As Filipino gravid are coasideed “high risk” by race or en group, they ‘Should be screened for type 2 abetes melts inthe fis prenatal vs ether ting fisting blood sugar [FBS gyeosyited hemoglobin [HAT] or random ‘lod sugar (RBS) (Len Grade) Atheist prenatal vst, determine ifthe gravid has ober high isk actos ter than by race or ethnicity (Let, Gras B) +A dingnosis of overt diabetes melitusis given among Women with any ofthe folowing results in hs fst vsc © FRS2 126mg/dl. (7 mmol/L) 8 RBS > 200 mg/dL (U1 mmol/L) © Hbales 65% (© Zhour75 oa gucsetleraneetst(OGTT)>200 mg/L (11.1 mto/L) + A diagnosis of GDM is made if any one ofthe following plasma values are ‘exceeded: (Lvl I, Grade) © FES>92mg/aL. © Uhour> 180 me’. (© 2hour> 183 meal + ForFipino pregnant women, POGS CPG Consensus Pane! ecommendsthe following cut off values x the diagnosis of GDM: (Lev Il, GPP) © FBS>92mg/al. © 2hour> 140 mg/dL +" Foc Filipino gravida with a0 othe sk factors aside fom ace ox ethnicity and the nial test (FBS or FDALe or RES) i normal, screening for GDM shouldbe repeated a 24.28 weeks using a2 hour 75 g OGTT. I there are ‘ther rik actors identified, inital sreeningshoud proceed immediately (0 2 hour 75 gOGTT (Le, Grae) | 1 1rtne OCT at 24-28 weeks is normal the woman shouldbe retested at 32 pees o ei if clinical signs and symptoms of hyperglycemia ae present oth in the mother and the fetus, polphagia, plyySrainsaceerated fal growth, et) (Leve! 12, Gade) +The OG shouldbe performed in the morning after an overnight at of § owes follwing the genera instructions for the test. (Lee I, Grade 8) Preconception Cosnsling and Management + starting at puberty, preconception counseling shouldbe incorporated inthe touting hbetes melts cin visi fo all women of ei bearing potent (tev I Gide) «+ HbAtclevels shouldbe as close to normal as possible (<7) in an individual pent before conception is atemped. (Let 1.2, Grad B) Women who are diabetic and are contemplating pregnancy should be alusto, and if inated, shouldbe serened and treated for retinopathy, ‘nephropathy and cardowscular disease (CVD), (Lee I, Grade ‘Medications taken by soch women shouldbe evaluated prior conception ince drugs commonly wsed fo teat daberes melitus and is complications nny be conteindicated or not recormmende in pregnancy, including tatns, nploensin comering enzymts (ACE) inhibitors, angiotensin TI receptor tsekers (ARB) and most on-nslin therapies. (Lee, Grade C) since many pregnancies ar unplanned, consider dhe potent risks and panels of medications whic ae contraindicated in pregnancy in. all women Sfeldbeaing potential and counsel women ving medications acosdingy. (enti, Grade) + Management of pressing labete meliaselated complications: 1. Hyperension: PaPApal systolic Blood peste (BP) < 130 mun is appropiate for ont pants with diabetes melita. (Lee 1, Grade ©) «+ auens wih diabetes mel shouldbe treated if diastole BP falls < SO lO) 2 Neon MFRS me ik oral he opsion neritic ‘csc nd ond ramen a Get)+ Perform testo ases urine albumin excretion and serum creatinine inte I dabetes melts patients with disease duration of5 yes or ‘mote and in all ype 2 diabetes melites patients starting a diagnosis (Govt I, Gade) 3. Retinopathy: 1+ To reduce the risk slow the progresion of retinopathy, optimize yeemic and blood pressure conto. Let, Grae A) + Women with preexisting diabetes melitus who ae planting pregnancy or who have become pregnant should havea comprehensive je examination and be coursed on he risk of progression of ‘etnopathy. Bye examination sould occur inthe ist imeser with close follow-up throughout pregnancy and for 1 year postpartum, (eve 12, Grade B) Antepartnn Management Metcl Nutrion Therapy NT) MNT shoul be an integral part of GDM management. ‘+ MNT consists of an asessment of food intake, physical activity and medication history and intake, as well as weight status, during and alter pregnancy 1 Tshould te provided for diabetic ravi by a ntition profesional + emay be administered as a ole management approach or in combination with pharmacologic tentment to achieve normal ajeemia. (Lent Grade) + Nutrition rquiement aze the sme for pregnant women with and without GDM, (© Weight management and energy intake aed tobe monitored throughout pregnancy, especially fr women with GDM. + Pregnancy weight gin recommendation for vomen with GDM who had normal weight or were uerweght prepregnancy isthe same as for women without GDM. (Low! I, Gre) + Berg intake for overweight or obese women with GDM may be modest restricted as ongas weight gains appropriate wth her pre ‘ravi body mass index (EMI) while minimizing the rsk of matemal Keto. Lent, Gade) ‘More tan weight gun, itis glycemic conto chat i prev of borhwcih 4+ Maternal eight redction during pregnancy bad on pre clampsnandmaybebarrflioefeus (suing lah High protein supplementation (ohare “low associate with asian increased risk of smal age (SGA). Le Graded) Carbohydrate consumption "Consumption of carbohydrates with low instead of high slycemle index (GD irecormmended (Lvl 1, Grade ) 1+ Monitoring of carbohydrates by scateges such as carbohydrate founding, bod exchange choices, or experience based estimation, is ey strategy to achieving ghyemiccontl Let, Grade A. 4+ Tntke of sugar subsites suchas acesulfame potssiom, aspartame and suralose ate acepiable during pregnancy and lactation within ccepable daly intake imi. + Stecharia and cjlamates ave not recommended during pregnancy (Cael, Gide) Lifes changes ‘One must offer advice regarding sleshol consumption and smoking cessation, (Lot I, Gnd ©) + Inthe absence of contraindication, manana suficient level of physical activity and exerci to improve glucose contol, reduce CVD Tis, cone to weight management goal, and overall wellbeing, Ged Grade) _Anteartam Blood Glucose Cota (o” Pharmacologic therapy is instituted once det and exer have filed as evidenced by abnormality in more than half of sefmonitored glucose ‘aes or an abnormal valve those women teed weekly ‘Traditonaly insulin hasbeen the drug of chcice because of is safety in pregnancy, lck of sgnfcant transplacental pasag, and history of use, ‘Most women canbe teatd as outpatients, Guidelines for ovtptent glucose monitoring and targets for pregnant siabetics For GDM, weatment goals are (Lo i, Gnade C) 1 Prepandialglacote concentration of #8 mg/dL (6.3 mmol/L) 1 hour postmeal glucose valu of <0 mg/L (78 mmol/L) + 2hourpostmea lucore value of <120 mg/l. (67 mmol/L) —" |For women with preexisting type I or type 2 diabetes metus who become pregnant, glycemic goals are 2 paemea, bedtime, and overnight glucose values of 60:99 mg/l (3.3 ‘Saimmol/L) ‘+ Peakportrandial glucose value of 100-129 mg/al(5.4~7.1mmol/L), 2 HbAlcvalve of £6.0% only they can be achieved safely (© Insulin administration shovld be individualized 0 achieve the glycemic goals stated above. Homan regular iasulin or rapid-acting. insulin Enalogues (if postprandial eels re high) or neutral protamine hagedorm, (NPE) inaulia may be vee for contol of basal insulin needs GEFBS ives re high). ‘Tal daly insulin needs maybe computed as follows: 2°07 to 8 Ug actual boy weight i the fist eimester 110 U/Ag actual body weight inthe second timostr + 1.2 Ug actual boat weight inthe did trimester (© Although insulin isthe prefered teatment approach, metformin and hburde have been showa to be elective alternatives without adverse fects in some women, ‘© In women with GDM, metformin (alone or with supplemental insulin) i rot aswclated with increased perinatal complications as compared with, Insolin. The women preleeed metformin to insulin treatment. Howeves, further follow-sp data are needed o establish longterm afety ‘0 Urine or fingersick ketone testing i recommended in GDM patients with severe hyperglycemia, weipht loss during eatment, or other concerns of ossibie “starvation ketosis ‘© Patients already needing pharmacologic treatment should be refered toa Specials -Perinatologit or an Eadocrinologst who has coafidence and ‘perience in insulin therapy Antepatuoy Fetal Sureance Suggested fetal surveillance modalities are: 1) Sercening for congenital snomaies (Ist and late 2nd meses) 2. Monitoring for fetal well-being (etal movement counting, nonstess fest (NST, contraction ses test (CST), Doppler yelosimety, biophysical profile (SPP) | 5, Ultrasound asessment fr estimated fetal weight roma ‘or ineauterine growth restzction [TUGR)) Maternal tat ek counting started at 28 week frail dabei wav ‘Because well-contolled GDMs are at low esk fr in-utero fetal death, [Zmcpariam survellace may begin at 40 weeks with weckly NSS ‘Those with complications lke hypertension, previous stibirth, preeclampsia, las A2, and all pregestational diabetics should begin renatal testing at 32 weeks with twice-weekly NST “Absence of fetal hear rat (HR) reactivity andthe presence of persistent ‘End consistent ate deceerations were predictive of fetal dite in labor Feuting cesarean section delivery. Dopnler velocimetry is only useful in diabetes meltus with vascular caoeeications which predisposes the patent io develop preeclampsia and orlUGR, Intrapartum Management Ta nC oe insulin therapy are best managed with intravenous (QV) insulin drips and glucoee monitoring prorocls dering labor similarto ‘women with pregestational diabetes melts “Women with yery mild GDM may notequire insulin therapy but should fhe blood glucose assessment during labor. Insulin management doring labor, delivery and immediate postpartum Should be handled by a specialist adept in giving such a therapeutic rodalie ‘The folowing are clinical strategies that the obstetrician must know: + During Labor Tr Monitor psn lucas very 14 hous 2. Targets of contel doring labor: 2 Plasma ghicose 80.120 mg/L. (4.46.7 mmol/L) or 1B Capilany glucose 70-110 mg/a @.9-6.1 mmol/L) + RorCesarean Section Patients and Immediate Postpartum Pesog 1." Determine audom plasma glucose immediately prior to cesarean 2, Pasi glucose should be kept Below 120 mg/d 3). Discontinue I insulin immediately prior to delivery —_ - — |4 Check plasma glucose 2 hours postcesarean section Up t0 24 tours (every 4 hous) 5, Adminster inulin subetaneously when indicated (for levels S120 mg/d) Intrapartum Fetal Survilnce and Delivery Isenpatum eal Saree ‘Diabetes melts in pregnancy is associated with increased isk of adverse feral outcome and thus, intrapartum electronic etal survellance may be beneficial, (© During labor and delivery continous elecronic FHR monitoring js recommended and fetal blood sampling should be available when requested, ‘© Uncomplicated GDM, wellcontole with diet may pose minimal sks tolboth mother and fete and maybe monitored like at of a lowrsk or ‘normal pregnancy ming of Delivers 19 "Thetiming ofthe delivery should be individualized depending on whether the patient has any concomizane maternal and/or fetal complications. (© There are no dita supporting delvery of women with GDM before 38 weeks gestation in the sbsence of objective evidence of maternal a Feat compromise, (Let I, Grae) (© Ian elective daivery has tobe performed among diabetic pregnancies, it {is ypiclly on or afer 39 wecks rather than 38 Wecks gestation nor easier to race neonatal respiratory movi. (© Patients with well-controlled disbetes melitus and no complicating factors, may avait spontaneous labor and be allowed to progres to their expected date of deve as long a antenatal esting remains reassuring fan the fetus aot marosomi. (© However expectant management beyond the estimated dve date generally is nor recommended because after 40 or more week, the benefits of ‘ontined conservative management are kel to be outweighed by the ‘danger of fetal compromise. Induction of labor before 41 weeks gestation Jnpregnant women wit diabetes mel, regards. osamiee sof the crv, is proden. Assessment of fetal lng matuiy by means of amniocentesis ina Gabel pregnancy snolongerequired with delivery after 38 week. IC sao not Tncteated in wellcontlled patents who have indications for induction of labor or cesarean section a long as there i reaonable certainty about the fstimation of gestational age. (Lee, Grade C) ‘GDM isnot itself an indication for cesarean delivery and that vaginal ‘every at emi posible f women have documented dating cteriaand 00d gee coal, ‘The sk of macrosomia, shoulder dystocia and feta injury in boris increased old in diabetic pregnancy These sks shoud be taken into fecount when planning mode of delivery. (ave! rode d) ‘Using vrasound EFW or abdominal cicumference (AC) to make decision regarding ing and route of delivery may be asociated with a Tomer ate of shoulder dystocia, but larger studies are needed to determine itthis approach afets the rte of neonatal injury Level, Grade C) Ifthe EFW athe time of delivery < 4000, vaginal delivery usually appropriate less tere are other obsietc indications for cestean Elective cesarean section shouldbe considered if the fetus is suspected to be significantly obese. If eal weight i estimated to be 4500 g or more, the rks and benefits of craren delivery shouldbe discussed with the patient The American Congress of Obstetricians and Gynecologists (COG) recommends ofering cesarean deiery o diabetic patient i the ‘eal weight estimated toe 4500 gor more (Lew, Gide) ‘When EFW is 4000-4500 g, consider past delivery history, clinical pelvinetry, ultrasound determined body to head disproportion (eal AC techs ahead of biparical diameter [SPD]) and progression of labor to Aetermine mode of delivery. Lee Grade 8) (iw: Ts weight catcff may at be apleable she oe sing. The uency 1 ol vl efelweghsoish fo dysteca pater isat had ode ‘mabe cur own comendasins) Delivery shoul take place in «hospital wit full obsttic, nesthetic and onal intensive care fits, (Lee I, Grad C) Diabetes mellitus should notin tel be considered a contraindication to afempling a vaginal birth after a previous cesarean section (VBA), eve, Grade) —Seacal Croumsances reselamosia ‘0 Management should be as for che nondiabetic population with pe eclampsia. retcrm Labor and Delivers (If preterm labor or delivery before 36 weeks is indicate, betamethasone ‘o promote fea lung maturity should be administered if posible. (0 Antenatal steroids adversely affect maternal lycemic control and incense insulin requirement. Patients should Ye admited tothe antenatal unit; intensive insulin therapy and frequent glucose monitoring are require 0 prevent hypersycemia. ‘0 Tocolytic drug re not contraindicated in diabetes meiius but 8 agonist drags shouldbe avoided a they can cause severe insulin resistance and slucose intolerance. ‘0 Eiecve pin ele is important and all forms of pain rele used in abor can be administered, ‘0 Basedonthenszativsytematicreview that pain/sess folowing sugery and trauma impair insulin sensitivity by afecting nonoxidatine glucose ‘metabolism, it might be surmised tha lucose regulation canbe improved ‘with administration of analgesia in stressful sta (0 If general anesthesia is used in women with diabetes melits, blood _lvcose should be monitored egualy (every 30 minutes) fom induction (of general anesthesia uni ater the Baby is bor and the woman is uly Postpartum Management Stats of Glucose Meats Posters ‘0 Elevated values should be confirmed wit fisting plasma glucose > 126 ames ee mmol/L), In such patients, MNT and if necesary pharmacological thecapy, sould ‘be continued t9 mainain good glycemic control and provide sufcent calories for lactation and inant wel being Al pes of insulin, glyburide, or glipizide can be safely used by treasteding women. Limited data suggest hat metformin, while exceed into breast milk, does not appearto have harmfel neonatal elles. Larger studies are stil needed to demonstrate its safety to the infant of breastfeeding women, ‘Because some ses of GDM ima represent preexisting undiagnosed type 2 diabetes melitus, women with a history of GDM should be seeened for diabetes melitus 6-12 weeks postpartum using nonpregnant OGTT citeria. (Level Grade 4) ‘Women wit a history of GDM should have littong screening forthe development of diabetes mellitus or prediabetes melts atleast every 3 years? Level I, Grade) ‘Testing to detect type 2 diabetes mellitus and assessing risk fr future diabetes mellitus in asymptomatic individuals should be considered in adults of any age who are overweight (BMI> 25 ka/m?) and who Ihave one or more additional ris factors fr diabetes mel. In those ‘without these ik factors, testing should begin at age 45 years. Level TE, Grade 8) 1 tet are normal, repeat testing carried outa least at 3-year interval is reasonable? (Lael I, Grade) ‘To tes for diabetes melius orto asses isk of fru diabetes melts, HbAle FPG, or? hour 75g OGTT is appro L122, Grad 8) ‘FPG 100-125 mg/dL. (5.669 mmol/L). > Impaired Fisting Glucose (EG) OR 2 hour plasma givcose inthe 18 g OGTT 140-199 mg/dl. (7.11.0 ‘mmol/L) > Impaired Glucose Tolerance IGT) OR = HBAleS.664%% In those identified with increased risk or futuce diabetes metus, identify and, if appropriate, tea other CVD risk factors? (Level F2, Grade 8)‘Long Term Prevention or Delay of Type 2 Diabetes Metlitas Patients with IGT (Level Orde 4), FG (Lee I, Grade, oF an HDAC of 1 ssh (Le Il, Gade) should berelered to weight management program {arpetingwelght oe of 7% of bodyweight and increasing physical activity to tt least 150 minutes week of moderate activity suchas walking. Follow-up counseling appears to be important for success. ‘Metformin theeapy for prevention of pe 2 diabetes mellitus may be ‘Considered in thos the highest sk for developing diabetes metus, suchas those with multiple sk ors, especialy they demonstrate progesion of Iypersncemia (eg HbAte> 6) despite iesyle modifications. (Lee! 1-2, omte®) “Monitoring forthe development of diabetes mellitus in hose with predibetes ‘elt should be peformed every yar. (Lee IM, Grade ©) Breasfeeing arte dtc effect of breastfeeding per se on subsequent risk of diabetes ‘relitus is not cleat Limited stidies show lower rates of postpartum Giabets melts snd fasting pscote evs in breastfeeding women with Dior GDM and a protective effect wih lower diabetes melts rates Tn healthy women who breasted aswell as among the ofoprings who rented (© Pending clasication of these issues, all women, including those with Prior GDM, should be atively encouraged to excusivey breastfeed ro the retest extent possible during the fist year of Ue. (Lew! I, Grade) Contraception Race Methods (condoms, daphragm, cervical cap, and spermicis) (Barrier methods are well tuted fr women with prior GDM because of their lack of systemic side effects inluenceon glucose tolerance, MSUD sa very effective and reversible contraceptive method without rretabotic disturbances and theefre isan eal contraceptive for women ‘wih pior GDM, © The World Health Organization (WHO) Medical wea for Contraceptive Use repost does not consider prior GDM at ‘ontrandication to TUD preston. ‘Based on the available evidence, both copper and evonorgste leasing TUbs can be used safely withou any specific restriction in women with rior GDM. nate and maternal age > 35 yes ad sks to these evens “The metabolic effects of a given COC formation will depend on the net Tree St ne spe andor dosage of each Hormonal component, SmOKINE ‘Sad maternal ope ‘In healthy populations, epidemiological studies in current or previous Coe unre have not eablshed an increased sk of diabetes metus and Stow term studies have found no clnieally relevant damaging effect on Tip metabolism, “The majority of women with prior GDM likely flim the category of ow Tole tak of cardiovascular and enous thrombotic events and Tow Fee Oe can be prescribed faking into account that the absolute risks ‘ekcse sri ag and that pevndc isk assessment of cardiovascular sk factors in women with prior GDM should be done. “The magnitude of oer tisk actor 4 hypertension, migraine, smoking, Tcilipidemia,conguation disorders, and amily history of thrombosis [peescnec of Leiden factor V mataion, which increase dhe os ati for (Piette venous tombotie events by 2-t0 12fod ia COC users mist sivays be coasiere. Wien hypertension or migraines are present in women with prior GDM, would be most eautious narto presribe a COC. Ina cases, he fowest thayl estradiol with newer progestins should be ‘rcsess and close atfenion shouldbe pa to increases a blood pressure End weight ‘All women should receive nutional counseling, be encouraged {© ‘Auiocta, achieve n heathy weight and receive appropiate medial ‘hetopy acento blood pressure and/or lips if Use interventions fa[Non-oral Combination Hormonal Methods (0 These products can be administered as a monthly injection or an intravaginal ring got yet widely avilable locally Progetn-only Oral Coaroceptves (POC) fo POCe ate taken continuously and contain low-dose norethindrone, levonorgestrel or desogestrel = Lest epidemiological and clinical data available [ess widely prescribed than COCs, largely because of their higher actual flute rates and breakthrough bleeding rate. = Wellzuited for those with type 1 diabetes melitus where esrogen- ‘containing methods are containdicated and for women with prior GDM who often have several cardiovascular isk ctor, making non- ‘stogen-contining contraception fvorable. ong stig Popes ‘Long. acting, progestins can be administered intramuscularly (M)/ subcutaneously (SO) orasan implant deliver long-acting and efficacious contraceptive protection, (© They offer the same metabolic advantage as POC with no effect on maternal coagulation fctrs or blod pressure, (© Use of longeacting progestins in women with diabetes mellitus or ‘women at hgh risk of diabetes mellitus is very limited oT an observational cohort of Hispanic women with prior GDM, uve of depot medeoxyprogesterone (DMPA) was associated with dan increased risk of diabetes mellitus compared with women Who used COCs. ‘9. DMPA shouldbe wsed with caution ia breastfeeding women and those ‘with elevated teglyceride levels (> 150 mg/d, ‘9 Close attention should be paid to weight gain, which also has been demofistrated to increase the risk of subsequent diabetes. (© The Food and Drug Authority (FDA) cautions DMBA ase for more than 2 yeats because of the atsacinted decrease in bone mineral sensity. ‘0 Long.acting progestin methods ary not a fes-line hole fa women ‘with prior GDM unless compliance with taking nina problem, (© If estrogen-containing, contraceptives ae contraindicated, the POC ‘would be the first-choice hormonal method or either type of IUD. ‘Surscal Sterilization O- An excellent choice for women who are no longer desitous of Subsequent childbearing especially among parous women particularly those who deliver by cesarean section Infante of Diabetic Mothers + Monitoring and management of Ayposivcemia aftr delivery Blood sugar monitoring protocol Testing: ‘0 Check blood sugse within 30 minutes of delivery, at 1,2 hours oF ie, and thereafter ‘© Tafant will need 4 stable blood sugars prior to discontinuing blood sugar checks. ‘Treatment Blood sugar > 45 mg/dl. > normal x 4 (consecutively), no further testing required, [blood sugar 3045 mg/dL: Step-by-step procedure is done to increase blood sugar levels L. Breastfeeding 2, Formula feding by cup or dropper 3. Transer to nursery intensive cae Unit (NICU) and give TV glucose infsion of DIOW at 4 ml/Ig/hr and repeat blood sugar in 30 min (© IF blood sugar < 45 mg/dL repeatedly > consider switching to ‘DIZ or the placement of a ental ether (to allow for the infusion of an elevated concentration of glucose) as to avoid fluid overt.

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