management in gestational diabetes Dr. Tanja Groten - - PowerPoint PPT Presentation

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

• Dr. Tanja Groten

Maternal and fetal predictors of therapy- management in gestational diabetes

Kompetenzzentrum Diabetes und Schwangerschaft Universitätsfrauenklinik Abteilung Geburtshilfe Direktor: Univ. Prof. Dr. med. E. Schleußner Klinik und Poliklinik für Innere Medizin III Direktor: Univ. Prof. Dr. med. G. Wolf

• Dr. Tanja Groten

Note: for non-commercial purposes only

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Background

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Glucose intolerance of the mother Hyperglycaemia of the mother Hyperinsulinaemia of the fetus Inhibition of surfactant production Hypoxia leading to polycythaemia Macrosomia Hyperglycaemia of the fetus postnatal hypoglyceamia postnatal icterus postnatal respiratory distress Fetal programming elevated risk for diabetes and

• besity

Normoglycaemia of the mother

Cascade of pathophysiologic events in gestational diabetes

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Background

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Treatment of GDM:

 The preliminary goal of intervention in GDM is the

prevention of fetal hyperinsulinaemia by monitoring and controlling maternal blood glucose levels.

 The preliminary therapeutic strategies are medical

nutrition therapy (MNT) and physical activity.

 Patients who fail to maintain glycaemic control

should receive additional pharmacological

• treatment. In Germany this means: insulin.

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

When to start insulin therapy – goals for glucose control

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Previous German guidelines New German guidelines ADA ACOG

fasting < 95 mg/dl < 5.3 mmol/l (≤ 5.0 mmol/l) < 95 mg/dl < 5.3 mmol/l < 95 mg/dl < 5.3 mmol/l < 95 mg/dl < 5.3 mmol/l 1 h pp < 140 mg/dl < 7.8 mmol/l < 140 mg/dl < 7.8 mmol/l < 140 mg/dl < 7.8 mmol/l 2 h pp < 120 mg/dl < 6.7 mmol/l < 120 mg/dl < 6.7 mmol/l < 120 mg/dl < 6.7 mmol/l < 120 mg/dl < 6.7 mmol/l Start insulin if more than three elevated measurements at two different days within one week Start insulin if 50%

• f the values in one

week are elevated If euglycaemia isn`t achieved by nutrition therapy and exercise within 10 days, insulin therapy is started

… or/and in the case of accelerating or macrosomic growth of the fetus

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

German guidelines: … incorporating fetal growth parameters

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However, here therapeutic intervention starts when fetal hyperinsulinaemia already caused growth acceleration in the fetus… and prevention of fetal hyperinsulinaemia failed?

• Individual definition of blood sugar goals depending on fetal growth

(abdominal circumference, asymetric growth favouring the abdomen)

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Study population – perinatal outcome

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267 pregnant women presenting for 75 g oGTT Exclusion: 5 x Twins. 7 x decline study participation 255 pregnant women to analyse GDM was diagnosed in 135 women Insulin therapy 60 1 case of IUFT Analysis of 59 perinatal

• utcomes

75 medical nutrition therapy (MNT) Analysis of 75 perinatal

• utcomes

120 healthy pregnant women Lost of follow up: 5 Analysis of 115 perinatal outcomes

Insulin group MNT group Control group

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Perinatale Outcome

Healthy controls (n = 115) GDM (n=134) GDM MNT (n=75) GDM Insulin-therapy (n=59) Mode of delivery (%): Vaginal planned caesarean Secondary caesarean 74.1 11.2 14.7 64.9 20.9 14.2 67.5 20.8 11.7 61.4 21.1 17.5

Birth weight (g) 3452 ± 485 [2260-4620]

3330 ± 701

[695-4680] 3242 ± 769 [695-4430] 3470 ± 571 [1380-4680]

Birth weight > 95 percentile (%) 11.3 10.4 7.7 14.3 SGA (%) 6.1 6.0 6.0 Neonatal hypoglycaemia (%) 3.5 14.9** 5.3 27.1** Neonatal hyperbilirubinaemia (%) 21.9 26.3 23.4 30.4 Respiratory distress (%) 6.1 9.0 9.1 8.9

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** p<0.01

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Further questioning

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 Why is the outcome of GDM patients receiving

insulin therapy less sufficient? Is therapy started to late?

• In 14% (n=8) of the insulin cases insulin therapy was started due to

fetal growth parameters. In these cases treatment was started after fetal hyperinsulinaemia occured and effected abnormal fetal growth.

 How can we identify patients who need insulin

earlier? Are there parameters at the time of GDM diagnosis predicting the necessity of insulin therapy?

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Results: Maternal predictors of insulin therapy at the time of diagnosis of GDM

MNT (n=79) Insulin group (n=60) p BMI before pregnancy (kg/m²) 25.0 ± 5.2 29.0 ± 6.2 <0.001 BMI before pregnancy ≥ 25 kg/m² (%) BMI before pregnancy ≥ 30 kg/m² (%) 41.0 16.7 66.7 40.0 <0.01 <0.01 History of GDM (%) 5.1 22.8 <0.01 HbA1c at diagnosis (%) 5.2 ± 0.4 5.6 ± 0.6 <0.001 Maternal age (years) 30.8 ± 5.7 31.2 ± 6.7 n.s. Wait gain during pregnancy (kg) 14.6 ± 6.6 15.3 ± 6.3 n.s.

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Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

20 15 10 5 Anteil ohne Insulintherapie 1,0 0,8 0,6 0,4 0,2 0,0 >= 25-zensiert < 25-zensiert >= 25 < 25 BMI vor der Gravidität (kg/m²) p<0,01 02.04.2014 10

Results: Kaplan-Meier Analysis HbA1c at diagnosis and BMI prior to pregnancy

20 15 10 5 Anteil ohne Insulintherapie 1,0 0,8 0,6 0,4 0,2 0,0 > 5,2-zensiert <= 5,2-zensiert > 5,2 <= 5,2 HbA1c-Wert bei Diagnosestellung (%) p<0,01

Time from diagnosis of GDM to start of insulin therapy (weeks)

Percetage of GDM patients without insulin therapy

Discriminated for HbA1c > 5.2% at the time of diagnosis

10

Time from diagnosis of GDM to start of insulin therapy (weeks) Percetage of GDM patients without insulin therapy

Discriminated for BMI > 25 prior to pregnancy

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

02.04.2014 11

MNT (n=78)

Insulin therapy (n=57) p Estimated fetal weight >75. percentile (%) >90. percentile (%) 26.7 13.3 44.0 26.0 <0.05 n.s. Abdominal circumference >75. percentile (%) >90. percentile (%) 14.9 5.4 24.1 11.1 n.s. n.s. Fetal fat layer (mm) 3.1 ± 0.6 3.5 ± 0.9 <0.05

Fetal fat layer = 63% variability of abdominal circumference

Results: Fetal predictors of insulin therapy at the time

• f diagnosis of GDM

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Results: Predictive value

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Logistic regression analysis revealed the combination of

• Maternal age >30 years
• BMI > 25 prior to pregnancy
• History of GDM.
• HbA1c > 5.2% at diagnosis

and

• estimated fetal weight >75. percentile at diagnosis

as predictors for the need of insulin therapy.

 The positive predictive value is 77.6%.

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Conclusion and Discussion

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• The presented data show, that maternal and

fetal parameters at the time of diagnosis could predict the need of insulin therapy.

• These predictors may help to identifying

women in whom therapy should be started earlier.

Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

Discussion and open Questions

? Is it possible to completely prevent fetal alteration in

cases of impaired Glucose tolerance of the mother by initiating insulin therapy earlier?

? Do we need to more extensively rule out the

possibilities of medical nutritional therapy (MNT) and exercise or start insulin earlier? Do we need more strict indications for insulin therapy?

? Will the general screening of all pregnant women

lead to prevention of delay in diagnosis and therapy initiation?

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Universitätsfrauenklinik Jena

Kompetenzzentrum für Diabetes und Schwangerschaft

PD Dr. W. Battefel

• Dr. F. Weschenfelder
• C. Helbich (diabetes advisor)
• B. Milke (diabetes advisor)
• C. Spreda (midwife)
• A. Fiedler-Pape (midwife)
• S. Nestler (midwife)
• C. Mantschew (diabetes advisor assistence)

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Thank you for your attention!

02.04.2014

… and the team of the Kompetenzzentrum für Diabetes und Schwangerschaft Jena for their contribution.