Gestational Diabetes

    .

     

    3 Macro

    - Head (DVA)

    - Chest (CVS)

    - PVD

    3 Micro

    - Retinopathy, Nephropathy, Neuropathy

    - Peripheral glove/stacking symmetrical sensory

    - Autonomic neuropathy

    - Mononeuritis multiplex (ocular nerve - ddx multiple sclerosis)

    - Diabetic amyotrophy

    3 Other

    - Emergencies

    - Infection (Immunocompromise)

    - Autonomic dysfunction

     

    Pre-Conception Advice

    (Dr. Wijeratne 2017 Jan)

    1. Attain a preconception HbA1c of ≤ 7.0% (if safe)
      • Do not recommend pregnancy with HbA1c > 7.0 (higher risk = higher HbA1c)
    2. Optimize Diabetes:
      • Non-Pharmacological: Weight loss, dietary management etc..
      • Metformin is safe (CDA has not yet adopted this)
      • Switch to insulin if on oral agents
    3. Folic Acid - 5mg/day (at least 3mo prior to pregnancy to 12w post conception) (just like antiepileptics, hx of NTD)
    4. Assess and manage any complications (pregnancy worsens retinopathy/nephropathy)
    5. Stop teratogenic meds
      • ACE inhibitors, ARBs
      • Statins

     

    NOTE: DPP4 inhibitors (gliptins) have not been studied, glyburide seems to be safe as an alternative to insulin. 

    Diagnosis/Screening

    • ALL pegnant women should be screened for GDM 24-28w gestation.
      • (If there is high risk, screen at any stage)
      • If screening @ 24w is negative --> Rescreen 24-28w.
    • Risk Factors:
      • Previous diagnosis of GDM
      • Prediabetes
      • High Risk Population (Aboriginal, Hispanic, South Asian, Asian, African)
      • Age >= 35yo
      • BMI >= 30 kg/m2
      • PCSO, acanthosis nigricans
      • Corticosteroid use
      • Fetal Macrosomia or polyhydraminos (current or previous)
    • After birth - repeat testing at 6w post-delivery.
    • Screening:
      • 50g GCT to non-fasting patient.  Measure PG 1hr later.
      • NOTE: In old test, 75g OGTT (need two values abnormal, but new guidelines: need two abnormal)
        •    
          <7.8 mmol/L Normal
          7.8 - 11.1 mmol/L

          Proceed to 75g test

          >= 11.1 mmol/L Diabetes
        •    
             
             
             
          • < 7.8 mmol/L --> Normal 
          • 7.8 - 11.1 mmol/L --> FASTING 75g OGGT
            • Fasting   --> 5.3
            • 1 hour Value  --> 10.6
            • 2 hour Value  --> 9
          • >= 11.1 mmol/L = DIAGNOSIS.
    • Diagnosis
    • 75g OGTT
      • PG 1hr > 10.6
      • PG 2hr > 9
      • Fasting > 5.3

     

    GDM Monitoring

    • Monitor:
      • Fasting Blood Glucose
      • 1-hr Post-Meal sugars
    • CDA Guidelines Targets:

      • FBG > 5.3 start NPG 4-6u
      • 1-hour Post-meal > 7.8  --> start humalog 4u before the meal with elevation (titrate up).

       

      Delivery Target

      • Target: 4-7  (less than in-hospital targets 5-10 and 8-10 to avoid neonatal hypoglycemia)

     

     

    POSITIVE OGTT

    • 1: Try to control with diet first!
      • Avoid diet in simple sugars
    • 2: If unable to keep to targets
      • FBG > 5.3 --> Start insulin 0.1-0.3 u/kg
        • Insulin Glargine is preferred due to slow release
        • Insulin Aspart for mealtime due to low risk of postprandial hypoglycemia

     

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