Slide 1

Lecture:
Gestational Diabetes and Ketoacidosis
 Slide 2

Gestational Diabetes and Ketoacidosis

Lecture

Main Learning Points

• Being able to diagnose GDM

• Being able to prescribe adequate
treatment for GDM patients based on
BG monitoring and/or HbA1c
• Understand the PERKENI guidelines
on GDM treatment
• Understand the importance of on-
going screening for GDM
• Understand the treatment guidelines
and being able to treat diabetic
ketoacidosis
 Slide 3

Gestational Diabetes
Definition

Glucose intolerance with onset or first recognition

during pregnancy

ADA Position Statement. Diabetes Care 2003; 26 (Suppl. 1); 103-5

Context

Long-standing consensus that overt diabetes increases the risk of

severe adverse pregnancy outcome

Major contention about what level of glucose intolerance during

pregnancy, short of diabetes, is associated with the risk of adverse
outcome, and can treatment alter this morbidity?
 Slide 4

Gestational Diabetes
Risk Factors
Glucose Examination
Risk Group
Recommended

Low Risk (Fulfill all Criteria)

- Ethnic with low GDM prevalence
- (-) DM History at first degree relatives
- Age below 25 years
Not Needed
- Normal Weight before pregnancy
- Normal Weight at delivery
- (-) history of glucose metabolic disorder
- (-) history of bad obesity

Middle Risk (Fulfill all Criteria)

At 24-28 weeks of pregnancy
- Not included in low or high risk Group

High Risk (Fulfill > 1 of these Criteria)

- Obesity
- (+) DM History at first degree relatives
- (+) history of glucose tolerance disorder
- (+) history of baby delivered with macrosomia
- (+) Glukosuria
Do at the first meeting or as
soon as possible. If the result is
normal, re-do after 24-28
weeks of pregnancy

Kjos et al. New England Journal of Medicines 1999


Gestational Diabetes
Diagnostic Criteria (1)
(A)
Two Step Way (O’Sullivan &
Mahan, Carpenter & Coustan)
1. Screening: Glucose 50g
Glucose 1 hour post meal:
<150 mg/dl  Normal
>150 mg/dl  Diagnostic Test
2. Diagnostic Test: Glucose 100g
FPG > 95 mg/gl
1 hour > 180 mg/dl
2 hour > 155 mg/dl
3 hour > 140 mg/dl
If >2 abnormal score -> GDM
diagnosed
Slide 5
(B)
NNDG / WHO (Non-pregnant
Glucose Tolerance)
1. Screening (Non-pregnancy Glucose
Tolerance Disturbance): Glucose
75g
2 hour glucose:
>200 mg/dl  GDM
>140-199>  Gestational
Glucose Tolerance Disorder
< 140  Normal
 Slide 6

Gestational Diabetes
Diagnostic Criteria (2)

(C) (D)

PERKENI (Criteria similar to

NNDG / WHO) ADA

1. Only examine 2 Hour post-meal 1. Screening: Glucose 75g

Glucose: FPG > 95 mg/dl
2 hour glucose: 1 hour > 180 mg/dl
>200 mg/dl  GDM 2 hour > 155 mg/dl
>140-199>  Gestational If >2 abnormal score -> GDM
Glucose Tolerance Disorder diagnosed
< 140  Normal
 Slide 7

Maternal and Fetal Complications of GDM

 Slide 8

Pregnancy Planning is key, but often under-utilized

Women with diabetes and childbearing potential should

be educated about the need for good glucose control
before pregnancy and should participate in effective
family planning

Kitzmiller et al. Diabetes Care 2008;31;1060-79. Pregnancy in woman with T1 and T2 diabetes in 2002-03. London. CEMACH, 2005
 Slide 9

GDM Management Scheme

Gestational Diabetes

IF FPG < 130 IF FPG > 130

mg/dl mg/dl

1 Week Nutrition
Therapy

IF FPG < 105 IF FPG > 105

mg/dl OR BG 2 mg/dl OR BG 2
Hour < 120 Hour > 120
mg/dl mg/dl

Nutrition Therapy +
Nutrition Therapy
Insulin Therapy

PERKENI GDM Konsensus

 Slide 10

Recommended glycemic targets are stricter than for

regular diabetes patients

Glucose PERKENI American ADA CDA Glucose

(mg/dl) (1997) College of level for
Obs. Gyn non-T2

Fasting < 105 60-90 < 105 - 75 ± 12

Before Meals - 60 - 105 - 95 78 ± 11

After Meals

1 Hour < 130-140 < 155 < 140 105 ± 13

2 Hour < 120 < 120 < 130 < 120 97 ± 11

Average - 100 - - 84 ± 18

Night (23-06) - 60 - 90 - - 68 ± 10

Hod M and Yogev Y. Diabetes Care 2007, and Perkeni.

 Slide 11

Insulin Therapy in GDM

• Many different Insulin regimes can be given:

• Fast-acting (3 times / day)
• Long-acting (1-2 times / day)
• Premix Insulin (1-2 times / day)
• Basal-bolus regimes

• Treatment must be individualized in order to obtain

best possible glucose control taking into account
convenience and physiological factors

• (Self-)Monitoring required to optimize GDM

management

Kitzmiller et al. Diabetes Care 2008;31;1060-79

 Slide 12

(Optimal) Treatment of pregnant women with type 1

diabetes

• Basal-bolus insulin regimes are recommended for

optimal glycemic control in pregnancy in women with
pre-existing diabetes

Kitzmiller et al. Diabetes Care 2008;31;1060-79

 Slide 13

(Optimal) Treatment of pregnant women with type 2

diabetes

• Basal-bolus insulin regimes are recommended for

optimal glycemic control in pregnancy in women with
pre-existing diabetes

• OAD’s should be discontinued and insulin titrated to

achieve the recommended glycemic control prior to
conception

Kitzmiller et al. Diabetes Care 2008;31;1060-79

 Slide 14

Diabetes Ketoacidosis
 Slide 15

What is Diabetes Ketoacidosis

 Acute decompensated metabolic state due to

 severe insulin deficiency
 over-activity of glucagon & other counter-regulatory
hormone

 Common in Type 1; Rare in Type 2

 Potentially life-threatening

 High mortality

 Incidence : 5-8 /1000 diabetic persons/yr

 Mortality rates 9-14 % - Has improved with insulin use 2%

Watkins et al. In: Diabetes and its Management 2003

 Slide 16

Why are patients developing ketoacidosis

The most common events that cause a person with

diabetes to develop diabetic ketoacidosis are:

 infection such as diarrhea, vomiting, and/or high

fever (40%)

 missed or inadequate insulin (25%)

 newly diagnosed or previously unknown diabetes

(15%)

 Various other causes may include a heart attack,

stroke, trauma, stress, alcohol abuse, drug abuse, and
surgery.

 Approximately 5% to 10% of cases have no

identifiable cause
 Slide 17

How to Diagnose Diabetes Ketoacidosis

Symptoms Signs

 Anorexia  Tachycardia

 Nausea  Hypotension

 Vomiting  Hypothermia

 Thirst
 Impaired consciousness
 Polyuria
 Warm dry skin
 Weakness
 Kussmaul respiration
 Abdominal pain
 Acetone odour on breath
 Weight loss
 Slide 18

Diabetes Ketoacidosis Definitions

DKA is defined as:

 Increase serum concentration of ketones

greater than 5 mEq/L (beta
hydroxybutirate acid > 0,6)

 Blood glucose level greater than 250

mg/dL (although it is usually much
higher),

 Blood pH less than 7.3

 Ketonemia and ketonuria are

characteristic, as is a serum bicarbonate
level of 18 mEq/L or less (< 5 mEq/L is
indicative of severe DKA)

Diabetes Care, Vol. 29, Number 12, December 2006

 Slide 19

Three Stages of Severity for Diabetes Ketoacidosis

A 2006 American Diabetes Association statement (for

adults) categorizes DKA into one of three stages severity:

 Mild: blood pH mildly decreased to between 7.25 and

7.30 (normal 7.35–7.45); serum bicarbonate
decreased to 15–18 mmol/l (normal above 20); the
patient is alert

 Moderate: pH 7.00–7.25, bicarbonate 10–15, mild

drowsiness may be present

 Severe: pH below 7.00, bicarbonate below 10, stupor

or coma may occur

Source: ADA
 Slide 20

Pathogenesis of DKA and HHS

Stress, Infections and/or insufficient use of Insulin
 Slide 21

Diabetes Ketoacidosis Diagnostic Criteria

 Slide 22

Objectives and Management of DKA Treatment

Objectives Management

1. To normalize blood 1. Search & treat

glucose as soon as precipitating cause
possible with Insulin
2. Insulin iv
2. To replace fluids and
reverse ketoacidosis 3. Replacing fluids

3. Monitoring: 4. Replacing electrolytes -

potassium & magnesium-
• Vital signs if required

• Fluid and electrolyte

balance

• Glycaemia
 Slide 23

DKA Therapy

 Potassium: replacement is (almost) always

necessary
• if value on arrival is high: delay replacement till reversal of
ketosis
• if values are low: give K early
• if values are very low: hold insulin for 60-90 min. till 40-50
mmol of K are given

 Bicarbonate:
• indicated in sever acidosis (pH 7.0 or below) or with
hypotension (that can be caused by acidosis alone)
• stop the infusion at pH 7.2 to avoid alkalosis upon reversal of
ketosis

Gestational Diabetes and Ketoacidosis
Lecture
Summary
• Women at risk of diabetes should be
screened for GDM, treated and followed
closely if diagnosis is confirmed
• Women with diabetes and
childbearing potential should be
educated about the need for good
glucose control before pregnancy
• Recommended glycaemic targets are
stricter than for regular diabetes
patients
• DKA should be regarded as an
emergency situation and prompt
treatment with insulin is vital
Slide 24
Main Learning Points
• Being able to diagnose GDM
• Being able to prescribe adequate
treatment for GDM patients based on
BG monitoring and/or HbA1c
• Understand the PERKENI guidelines
on GDM treatment
• Understand the importance of on-
going screening for GDM
• Understand the treatment guidelines
and being able to treat diabetic
ketoacidosis