Post on 07-Apr-2018
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Mera desh mahaan
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India
The Diabetes Capital of the world!
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GDM
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Every fourth diabetic in the world is an Indian!
Diabetes - Shift from cure to prevention!!
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GDMrevention at the Pre- diabetic stage
By identifying people in the Pre-diabetic stage,
implementing lifestyle modifications and reducing the
weight by 7% it is possible to reduce the incidence of DM
by 58%
Since pregnancy is a diabetogenic state, it provides an
opportunity to identify pre diabetic women
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GDM
Dr. Susheela Rani
Bengaluru
Screening for Gestational DM
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GDMestational Diabetes Mellitus is
Carbohydrate intolerance with recognition or
onset during pregnancy
irrespective of treatment with diet or insulin
Whether or not condition persists after pregnancy
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GDM
Why should we screen?
Whom should we screen?
How should we screen?
When should we screen?
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GDM
Why should we screen?
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GDM
Does GDM pose serious risks?
Does treatment reduce those risks?
Why should we screen?
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GDMMinor adverse health effects for offspring
Birth Wt (g) 330364 364951 384972
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GDMCNS 6.4% 18.4%
Congenital heart disease 7.5% 21.0%
Respiratory disease 2.9% 7.9%
Intestinal atresia 0.6% 2.6%
Anal atresia 1.0% 2.6%
Renal & Urinary defect 3.1% 11.8%
Upper limb deficiences 2.3% 3.9%
Lower limb deficiences 1.2% 6.6%
Upper + Lower spine 0.1% 6.6%
Caudal dysgenesis 0.1% 5.3%
Normal DM
Major adverse health effects for offspring
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GDMaternal Morbidity Polyhydramnios
Hypertension
Preeclampsia and Eclampsia
Abruptio placenta
Pre term labour
Cesarean delivery
Post-partum uterine atony
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GDM
Does treatment reduce those risks?
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GDM
Increasing evidence that
identifying women with GDM is
important because appropriate
therapy can decrease fetal and
maternal morbidity, particularly
macrosomia
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GDMWhom should we screen?
Selective Screening
Universal Screening
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GDMWhom should we screen?
Risk factors:
>25 yrs
Ethnicity (Hispanic, Native American, South or East Asian, PacificIslands, African American)
BMI >25
Previous H/o glucose intolerance
Past H/o GDM
H/o diabetes in a first degree relative
Selective Screening
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GDMRisk Stratification for GDMHigh Risk Group (Indians mostly)
BMI 30; PCOD; Age > 35 years
F h/o DM; Ethnic predisposition; Acanthosis
Previous h/o GDM, IGT, Macrosomic baby
Low Risk Group
Age < 25, BMI < 23, No F h/o DM or IGT
No bad obstetric history; No risk ethnicity
Intermediate Risk Group
Not falling in the above two classes
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GDMWhom to Screen?Low Risk Group
No screening required for GDM
Intermediate Risk GroupScreen around 2428 weeks of gestation
High Risk Group
As soon as possible after conception
Must - before 2428 weeks of gestation
If negativescreening in 3rd trimester
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GDMWhom should we screen?
In the Indian context, screening is essential in all
pregnant women as the Indian women have 11 foldincreased risk of developing glucose intolerance inpregnancy as compared to Caucasians
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GDMPrevalence of GDM in
our country is 16.55% by
WHO criteria of 2 hr
PG>140mg/dl
Seshaiah V, Balaji V, J Obstet
Gynecol India 2005
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GDM
How should we screen?
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GDMScreening tests
RBS
FBS
50 g glucose challenge test (GCT)
75/100 g oral glucose tolerance test (OGTT)
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GDMScreening test - RBS
Value greater than 200mg/dl repeated and
confirmed on second day is diagnostic of overt DM
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GDMScreening test - FBS
>125mg/dl is diagnostic of overt DM
> 95mg/dl is cut off for GDM
High False positive rate - 30 to 57%
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GDMScreening test GCT
50gm glucose at any time of the day
Blood sugar after 1hour
>180mg/dl
GDM
>140mg/dl
Suspicion of GDMOGTT
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GDMScreening test OGTT
Both screening and diagnostic
Previous 3 days of unrestricted CHO diet (>150gm)
Overnight fast for 8hours
No smoking before the test & should remain seated
75gm oral glucose in 150ml of water
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GDM
ADA - two-step procedure
WHO - one-step procedure
Recommendations for 75gm OGTT
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GDM
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Criteria for Diagnosis of GDM with 75gm OGTT
Organization Fasting 1hPG 2hPGDiagnostic
criteria
ADA 95mg/dl 190mg/dl 160mg/dl2 or moreabnormal
WHO 126mg/dl Notmeasured
140mg/dl Oneabnormal
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GDMDIPSI Recommended method
One step procedure
Irrespective of previous meal
75gm oral glucose load
2 hrs later Plasma Glucose
Simple, economical and feasible
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GDM
The term IGT should not be used to indicate any glucose intolerance
in pregnancy (as this terminology is used outside pregnancy)
2hr PlasmaGlucose
In PregnancyOutside
Pregnancy
>200mg/dl Diabetes Diabetes
>140 -199mg/dl GDM IGT
120-139mg/dl GGI
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GDM
3times more pick up than with two step Suitable for Indian setting Saves time Saves cost Avoids repeated visits Reduces repeated invasive sampling
One step 75gm OGTT - Advantages
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GDMIncreased birth weight of neonates was observed even
when the mothers glucose tolerance was less than the
glycemic criteria recommended by WHO for diagnosing
GDM. The occurrence of macrosomia was continuum as
the 2 hr Plasma Glucose with 75 gm OGTT, increased
from 120mg/dl
Gestational Glucose Intolerance
Seshiah et al. Maternal glycemia and neonatesbirth weight in Asian Indian Women. Diabetes Res Clin Pract 2006;
73: 223- 4.
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GDM
When to screen?
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GDMhen to screen?
First Trimester or at booking
2428wks
32 wks
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GDMhy first trimester?
Insulin is first detected in fetal Pancreas at 9wks Fetal hyperinsulinemia in response to maternal
hyperglycemia occurs by 16wks This leads to accelerated growth despite good
metabolic control in later pregnancy Unrecognis ed Type II DM can be picked up
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GDMhen to screen?
A pregnant woman found to have NGT in the first
trimester should be tested for GDM again around24th 28th week and finally around 32nd 34th week
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GDM
Why should we screen? Explained
Whom should we screen? All pregnant women
How should we screen? 75gms2hr Blood sugar
When should we screen? At booking, 24wks, 34wks
To summarise,
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GDMhe primary motivation for screening is the
concern for pregnancy outcome
Early Foetal lossCongenital anomalyMacrosomia- GTI from one generation to nextSudden IUFDMaternal complications PEMedical Complications of diabetes
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GDMhe secondary motivation for screening is to
identify and prevent
The increased risk of progression to Diabetes in
mother
30% - 5 - 10 yrs
50% - 24 - 25 yrs
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GDMhe ultimate objective is.
Preventing the perpetuation of Diabetes!!!!
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GDMate effects on the offspring
Risk of developing Type II DM in offspring at Age 24yrs
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Franks PW et al. Gestational glucose tolerance and risk of type 2 diabetes in young Pima Indian offspring.Diabetes 2006; 55: 460- 5.
III trimester Plasma Glucose Risk
120-139mg/dl 19%
140-199mg/dl 30%
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GDMGlu Intolerance and Cardiometabolic risk inAdolescents Exposed to Maternal GDM
A 15-year follow-up study
In utero hyperinsulinemia was associated with a 17-fold
increase in metabolic syndrome and a 10-fold increase in
overweight at adolescence, independent of birth weight,
Tanner stage, maternal GD status, & mothers BMI
Diabetes Care 33:13821384, 2010
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GDMate effects on the offspring
Increased risk of IGT, Type II DM
Increased risk of Obesity
Increased risk of Metabolic syndrome
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J d Adi S k h
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GDMpunarapi jananam punarapi maranamOnce again is the birth, sure follows the death
punarapi jananee jaTarae shayanam |
Yet again, is the slumber in the uterine filth
iha samsaarae bahu dustaarae
he! what to say of this miserable trothkripayaa paarae paahi muraarae ||
O! lord, save us from this cyclical myth
Jagadguru Adi Sankaracharyas
Bhaja Govindam
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Punarapi GarbhamYet another conception
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Punarapi PrasavamYet another child-birth
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Punarapi JananeeOnce again for the mom
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Sisuvau KaTinamand the babe, the miseries
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Iha Madhu maehaeThis Diabetes you see
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Bahu DustaraeTerrible to the core
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Kripaya NivaaarePlease put an end to this
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Nipunarae vaidyaeO! Doctor, the expert !
DIPSI declaration Diabetes free generation
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GDMDIPSI declarationDiabetes free generation
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Focus on the Fetus for the Future
Feb, 2010, Kolkata
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GDMLets break the cyclical perpetuation of Diabetes
Lets screen & take care of our mothers