Gestational Diabetes Mellitus
(GDM)
Learning Objectives
• Discuss screening, diagnosis, and management
of gestational diabetes
Definition of GDM
• Glucose intolerance of any severity that has its
onset or is first recognized during pregnancy1,2
• It can include patients with and without risk of
developing diabetes2
– Women with a history of GDM have a 20-50% of
developing IGT and T2DM in the 10 years
postpartum.3
PERKENI Clinical Practice Guidelines. JAFES 2011.
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Reece et al. Gestational diabetes: The need for common ground. Lancet 2009.
Global Prevalence of GDM
• Worldwide prevalence is estimated at 3-15% of
pregnant women1
– Higher in certain ethnic populations, e.g. Asians2
– Southeast Asia – 7.6% for low-risk pregnancies;
31.5% for high-risk pregnancies3
• Increasing in prevalence due to increasing
frequency of T2DM4
World Diabetes Federation, 2009.
Reece et al. Gestational diabetes: The need for common ground. Lancet 2009.
ASEAN Federation of Endocrine Societies Study Group on Diabetes in Pregnancy (ASGODIP) 1996.
IDF. Gestational diabetes: an invisible and serious maternal health issue. 2011.
Diabetes in Pregnancy:
Epidemiology
• 2%-10% of pregnancies currently are
complicated by gestational diabetes
mellitus (GDM)
• New diagnostic criteria estimated to
increase rate to 18%2,3,4
• The prevalence of both GDM and type
2 diabetes mellitus have increased as
obesity and sedentary lifestyle have
increased in the United States5
• Pregnancies complicated by preexisting
diabetes have increased substantially;
most likely due to increased prevalence
of T2DM in younger patients6,7
1. Engelgau, MM, et al. Diabetes Care. 1995;18(7):1029-33. 2. CDC. National Diabetes Fact Sheet 2011. CDC.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 2011. Accessed: April 26, 2012. 3. ADA. What is Gestational Diabetes?
ADA. http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html. 2010. Accessed: April 26, 2012.
4. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 5. Chitayat L, et al. Diabetes Technol Ther. 2009;11:S105-111.
6. Pinhas-Hamiel O, Zeitler P. Pediatric Diabetes. 2007;8(9):16-27. 7. National Diabetes Education Program. Overview of Diabetes in
Children and Adolescents. NIH. http://ndep.nih.gov/media/Youth_factsheet.pdf. June 2011. Accessed: April 26, 2012.
Maternofetal complications
Macrosomia: 63 percent
Cesarean delivery: 56 percent
Preterm delivery: 42 percent
Preeclampsia: 18 percent
Respiratory distress syndrome: 17 percent
Congenital malformations: 5 percent
Perinatal mortality: 3 percent
Spontaneous abortion, third trimester fetal deaths,
Polyhydramnios, preterm birth, ?adverse
neurodevelopmental outcome
Risk for type 2 DM
Neonatal complications
Morbidity associated with preterm birth
Macrosomia ± birth injury (shouldeer dystocia, brachial
plexus injury)
Polycythemia and hyperviscosity
Hyperbilirubinemia
Cardiomyopathy
Hypoglycemia and other metabolic abnormalities
(hypocalcemia, hypomagnesemia)
Respiratory problems
Congenital anomalies
Congenital anomalies
2/3rd CVS or CNS,– 13-20 times common
Cardiac( including great vessel anomalies) : most
common
Central nervous system (spina bifida/anencephaly) :
7.2%
Skeletal: cleft lip/palate, caudal regression syndrome
Genitourinary tract: ureteric duplication
Gastrointestinal : anorectal atresia
GDM: Clinical Risk Assessment
Risk Category Clinical Characteristics
High risk Obesity
Family history
Personal history IGT
Prior macrosomic infant
Current glycosuria
Average risk Neither low or high risk
Low risk <25 yrs
Low-risk ethnicity
No family history
Normal pre-pregnancy weight and
pregnancy weight gain
No personal history of abnormal glucose levels
No prior poor obstetrical outcomes
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Screening for GDM
• Screen for undiagnosed T2DM at first prenatal
visit in those in high-risk category
• In pregnant women in average-risk category,
screen for GDM at 24-28 weeks’ gestation
– 75 g OGTT and specific diagnostic cut points
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Women with GDM History
Screen at 6-12 weeks’ postpartum,
using a test other than A1C
Lifelong screening for the
development of diabetes or
prediabetes at least every 3 years
If found to have prediabetes,
lifestyle interventions or metformin
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Screening for GDM
• Perform a 75 g OGTT, with plasma glucose
measurement fasting, and at 1 and 2 hrs,
at 24-28 weeks’ gestation in women not
previously diagnosed with overt diabetes
• Perform OGTT in the morning after an
overnight fast of at least 8 hrs
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15. Table 6.
Gestational Diabetes Mellitus Diagnosis
IADPSG Consensus on
Diagnosis of GDM
Recommendations: threshold values
for GDM:*
• Fasting: >92 mg/dL
• 1-hr post 75 g: >180 mg/dL
• 2-hr post 75 g: >153 mg/dL
* One or more abnormal values = GDM
IADPSG = International Association of Diabetes and Pregnancy Study Groups
Metzger BE, et al. IADPSG Consensus Panel. Diabetes Care 2010;343:676-82.
MANAGEMENT ISSUES
Patient education
Medical Nutrition therapy
Pharmacological therapy
Glycemic monitoring: SMBG and targets
Fetal monitoring: ultrasound
Planning on delivery
Antepartum Metabolic Management
• Main goal: obtain glucose levels that minimize
risk of perinatal complications
– Strategies: aim for recommended glucose levels
or tailor to growth pattern of infant or
combination of both
• Recommended interventions:
Medical Nutrition Therapy (MNT)
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Monitoring Effectiveness of Therapy
• Measure BG or fetal growth
• May include SMBG
Glucose targets for women
with GDM
Preprandial ≤95 mg/dL
1 hr post-meal ≤140 mg/dL
2 hrs post-meal ≤120 mg/dL
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Intensification of Treatment
• If maternal glycemia and/or fetal growth
indicate a risk despite nutritional intervention,
consider the addition of:
– Insulin therapy
– Aerobic exercise regimen
– Oral antidiabetic drugs (OAD),
e.g. glyburide or metformin
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Insulin Therapy for GDM
• No one regimen has been proven
optimally effective.
• Combinations of intermediate- or long-acting
preparations with short- or rapid-acting
preparations can be effective.
• Insulin should be stopped at delivery and
glycemic levels reassessed.
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
OADs for GDM: Glibenclamide
• Minimal transfer across human placenta
• Not associated with neonatal hypoglycemia
• Has been reported to achieve glucose control
and perinatal outcomes similar to insulin
• Useful adjunct to MNT/physical activity programs
Metzger BE, et al. Summary and recommendations of the 5 th International Workshop-Conference on Gestational Diabetes Mellitus.
Diabetes Care 2007;30(2).
OADs for GDM: Metformin
• Crosses human placenta, so fetal effects
are possible
• Large RCT compared metformin to insulin:
– Metformin achieved acceptable glycemic control
in 54% of patients; 46% required addition
of insulin
– Perinatal outcomes: metformin group had a
small increase in premature births, insulin group
had small increase in neonatal hypoglycemia
– Patients preferred metformin
Metzger BE, et al. Summary and recommendations of the 5 th International Workshop-Conference on Gestational Diabetes Mellitus.
Diabetes Care 2007;30(2).
Rowan JA, et al. Trial investigators: Metformin versus insulin for the treatment of gestational diabetes. N Eng J Med 2008;358:2003-15.
Obstetric Management
• GDM itself is not an indication for Caesarean
delivery before 38 wks gestation
– Over 38 wks, gestation has been associated with
increased rates of large/age infants, thus
recommended to target delivery within wk 38
• If PBG >120 mg/dL during labour and delivery,
continuous IV insulin may be needed
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Management of DM
During Pregnancy
• For women with pre-existing T1 or T2DM who
become pregnant, the following glycemic goals
are recommended:
– FBG=60-99 mg/dL
– Peak PPG=100-129 mg/dL
– A1C<6.0%
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Management of DM
During Pregnancy (cont’d)
• Frequent SMBG (4-7/day)
• 18-22 wks Level 2 ultrasound, follow-up every 4-
6 wks
• Biweekly clinical evaluation until 34 wks,
then weekly
• Monthly A1C
• Daily fetal movement counts
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Management of DM
During Pregnancy (cont’d)
• Non-stress tests 32-34 wks, then weekly
• Ophthalmologic evaluation
• 24-hr urine, initially and each trimester for
protein and CrCl
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Glicemic Biomarkers
DIRECT:
•Blood Glucose
Extracellular
INDIRECT:
glycation •HbA1C
•Glycated Albumin
•Fructosamine
intracellular
glycation •1,5 AG ( anhydroglucitol)
•AGE
Konsensus DM tipe-2 (2015) :
HbA1c mempunyai
keterbatasan pada berbagai
keadaan yang
mempengaruhi umur sel
darah merah
Glycated Albumin (GA)
dapat digunakan untuk
menilai indeks kontrol
glikemik yang tidak
dipengaruhi oleh gangguan
metabolisme hemoglobin
dan masa hidup eritrosit
seperti HbA1c.
Pregnancy (2nd trimester → 3rd trimester)
DIABETIC NON DIABETIC
• HbA1c increased due to iron deficiency • HbA1c increased due to iron deficiency
(Based on serum transferin and feritin values) (Based on serum transferin and feritin values)
•GA shows no significant change •GA shows no significant change
Kesimpulan : Tidak hanya pada wanita hamil non diabetes, tetapi pada wanita diabetes
yang hamil, cenderung terjadi defisiensi besi dan HbA1c meningkat di akhir trimester
kehamilan. Sebaliknya, GA tidak dipengaruhi oleh defisiensi besi sehingga sesuai
digunakan sebagai penanda monitoring kontrol glikemik selama kehamilan
Kunihiro Hashimoto et al , Diabetes Care 33:509–511, 2010
GA pada kehamilan
• Pada wanita hamil yang DM dan juga pada DM gestasional, sangat
diperlukan kontrol glikemik intensif selama kehamilan untuk menurunkan
risiko kematian janin intrauterin, gangguan pertumbuhan janin dan
komplikasi maternal
• Rentang nilai GA selama masa kehamilan pd ibu hamil sehat : 11.5%-
15.7% (HbA1c: 4.5%-5,7%)
• Risiko komplikasi Neonatal meningkat secara signifikan pada nilai GA >
15,8%.
• Pada akhir kehamilan (2ndTrimester - 3rd Trimester) terjadi defisiensi besi.
• HbA1c meningkat seiring dengan kondisi defisiensi besi sementara GA
tidak terpengaruh
GA tidak terpengaruh oleh kekurangan zat besi dan mencerminkan kontrol status
glikemik status jangka pendek , sehingga GA dapat digunakan untuk kontrol glikemik
selama kehamilan.
Management of DM During Pregnancy:
High Risk/Disease Severity
• Electrocardiogram, uric acid, liver function test,
fibrinogen, fibrin split product determination
• Fetal lung maturity studies and preterm
delivery as needed
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
Management After Pregnancy
• Mother:
– Continue MNT during breastfeeding
– Re-assess any pharmacological treatments at
delivery and follow-up 1-2 months postpartum
– Screen for development of prediabetes
• Test using A1C, FBG, or 2-hr 75 g OGTT and
repeat at least every 3 yrs
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Management After Pregnancy
• Child:
– Regular assessment of growth and development,
glucose assessment if overweight
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition. 2009.
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
Summary
• It is important to screen pregnant patients at
risk for GDM to achieve an early diagnosis.
– Diagnostic criteria (based on HAPO findings)
aims to decrease risk of hyperglycemia on both
mother and infant.
• GDM requires intensive follow-up during
pregnancy and postpartum.
– Interventions include nutritional therapy plus
pharmacological interventions and/or exercise
as needed.
• Women with pre-existing DM require frequent
monitoring and interventions to minimize risks.
