Gestational Diabetes Melitus

Cut Meurah Yeni

Divisi Fetomaternal FKUI



Pembimbing

Dr. Handaya, SpOG-K
Gestational Diabetes Mellitus
(GDM)

Defined as a glucose intolerance that develops
during pregnancy
About 7% of pregnant women affected
200,000 cases each year in the U.S.
Generally occurs in the 20
th
24
th
week of
gestation
30 40% of obese women with GDM will develop
Type 2 diabetes within 4 years after giving birth
Diabetes Overview
Digestion: CHO glucose bloodstream cells??

Insulin:
Produced by pancreas
Guides glucose into cells

During Pregnancy
Placenta produces hormones
-- Estrogen
-- Cortisol
-- Human Placental Lactogen
Placenta excretes more of these
hormones in the 2
nd
and 3
rd

trimesters as it grows
Pancreas Overloaded

Signs and Symptoms
Polydypsia
Polyuria
Polyphagia
Whos at Risk
Age : >25 years
Weight : BMI >26
Personal History
Race / Ethnicity
Family History
Testing for GDM
At 1
st
pre-natal visit
or
For women at high risk:
-- ASAP
-- if GDM not detected right away,
test again at 24 28 weeks
gestation
Diagnosis
At 24 weeks gestation, 1092 participants
underwent a 50-g, 1-h glucose challenge
test, and a 75-g, 2-h glucose tolerance test.
Participants were given a 100-g, 3-h oral
glucose tolerance test if blood glucose levels
140 mg/dL .
2 abnormal values classified GDM
Santos-Ayarzagoitia, M., Salinas-Marinez, A., & Villarreal-Perez, J. (in press). Gestational
Diabetes: Validity of ADA and WHO Diagnostic Criteria Using NDDG as the Reference
Test. Diabetes Research and Clinical Practice.
Diagnosis
Time NDDG ADA WHO .
Fasting 105 mg/dL > 95 mg/dL ---
1 h 190 mg/dL > 180 mg/dL ---
2 h 165 mg/dL > 155 mg/dL 140 mg/dL
3 h 145 mg/dL > 140 mg/dL --- .


Following this criteria:
- NDDG found 35 out of 1092 participants to have GDM
- ADA found 45 out of 1092 participants to have GDM
- WHO found 64 out of 739 participants to have GDM


Medical Nutrition Therapy
Nutrition intervention: #1 treatment plan
Nutrition counseling by an RD is
recommended by ADA
Individualized for mother & baby
RDs Fagen, King, and Erick state, The
registered dietitians most crucial and
important goal is achieving normal blood
glucose levels while maintaining
appropriate nutritional status and adequate
dietary intake for fetal growth and
development
1 Fagen, C., King, J., & Erick, M. (1995). Nutrition Management in Women with Gestational
Diabetes Mellitus. Journal of American Dietetic Association, 95, 460-467.
Goals of Medical Nutritional Therapy
Achieve and maintain normoglycemia
Consume adequate calories to promote
appropriate gestational weight gain and
avoid maternal ketosis
Consume food providing nutrients
necessary for maternal and fetal health
Decrease and avoid nutrition related
complications
According to Thomas and Gutierrez (2005):
Medical Nutrition Therapy
Energy
- Enough to achieve necessary weight gain

Recommended
Category Prepregnancy BMI Weight Gain (lbs)
Underweight < 18.5 28 40
Normal Weight 18.5 24.9 25 35
Overweight 25 29.9 15 25
Obese 30 34.9 15

Medical Nutrition Therapy
Energy:

ADA recommends using pre-
pregnancy weight to determine
energy needs:
<90% desirable body weight: 36-40 kcal/kg
Desirable body weight: 30 kcal/kg
>120% desirable body weight: 24kcal/kg
** Energy intake should never be <1800kcals
Medical Nutrition Therapy
Estimated energy requirements (EER)
from the Institute of Medicine:

EER = 354 (6.91 x A) + PA x (9.36 x Wt + 726 x Ht)


PAL PA
* A = age in years Sedentary 1.0
* PA = physical activity coefficient Low Active 1.12
* Wt = weight in kg Active 1.27
* Ht = height in meters Very Active 1.45




MNT: Energy
EER for pregnant women with normal body
weight:

1
st
trimester = Adult EER + 0
2
nd
trimester = Adult EER + 160kcal (8kcal/wk x 20 wk) + 180 kcal
3
rd
trimester = Adult EER + 272kcal (8kcal/wk x 34 wk) + 180kcal
Energy Calculation
Using the Institute of Medicine equation,
calculate the energy needs for a 32 year
old woman who is in her 2
nd
trimester,
initially weighed 137lbs, is 5 7, and has
low activity.
EER = 354 (6.91 x A) + PA x (9.36 x Wt + 726 x Ht)
A = 32
PA = 1.2
Wt = 62 kg (137 2.2)
Ht = 1.7 m (57 = 67in 67in x 2.54 170cm 100)

Energy Calculation
EER = 354 (6.91 x 32) + 1.2 x (9.36 x 62 + 726 x 1.7)
EER = 2165 kcal

2
nd
trimester:
Adult EER + 160kcal (8kcal/wk x 20 wk) + 180kcal
2165 + 160kcal + 180kcal

Energy Needs = 2505kcal
MNT: Carbohydrate
Carbohydrate
-- RDA: 175 g/day
-- 40 45% total energy
-- 3 4 small to moderate sized meals daily
-- 2 4 snacks (1 in the evening to prevent
overnight ketosis)
Not very well tolerated in the morning
-- increased hormones
-- recommend 30 45g CHO
-- replace with protein to satisfy hunger
MNT: Protein
Protein
-- Needs increase throughout pregnancy
-- Both mom and baby use 70% of protein
consumed
--1.1 g/kg/day (using desirable body weight)
Additional 25 g/day in 2
nd
and 3
rd
trimesters
46 g/day (non-pregnant)

MNT: Fat
Factors to consider with fat intake:
- Affect on body weight
- Individuals plasma lipoproteins

Decrease Increase
Saturated fatty acids Omega-3 fatty acids
Trans fatty acids Omega-6 fatty acids
High cholesterol foods

MNT: Fiber
Fiber
-- DRI: 28 g/day
-- Whole grain breads, leafy greens,
yellow vegetables, fresh and dried
fruit
-- Monitor blood glucose levels with
CHO intake
MNT: Vitamins
Vitamins as supplements can be
obtained from diet
Pre-conceptual multivitamin
supplementation has been shown to
lower the risk of heart defects by 43% in
infants
Not effective or recommended to take
while pregnant
MNT: Folic Acid
RDA: 600 g/day
Non-pregnancy: 400 g/day
Recommended 2/3 (400 g/day)
come from foods fortified with folicin
Deficiencies:
-- Spontaneous abortions
-- Low birth weight/pre-term labor
-- Neural Tube Defects: Spina Bifida
MNT: Folic Acid
Each year approximately 2500 infants are
born with NTD
240 g/day: double the risk of LBW or
premature labor
Mothers are 2-10% more likely to have
another baby with NTD if had one during
index pregnancy
Neural tubes close within 28 days
MNT: Ascorbic Acid (Vitamin C)
RDA: 80-85 mg/day
+ 10 mg/day than
non-pregnancy
Deficiency suggests:
-- preeclampsia
-- premature rupture
in membrane

MNT: Vitamins A and B6
Vitamin A:
-- RDA: 770 g/day
-- Females taking accutane are at an
increased risk for fetal
underdevelopment
Vitamin B6:
-- RDA: 1.9 mg/day
-- + 0.6 mg/day than non-pregnancy
-- Manages symptoms of nausea and
vomiting
MNT: Vitamin D
RDA: 5 g/day
Helps maintain calcium balance
Crosses placenta so fetal blood concentrations
are the same as the mother

Deficiency Toxicity
- hypocalcemia - hypercalcemia
- hypoplasia
- bone mineralization
MNT: Vitamin K
RDA:
-- 18 years: 75 mg/day
-- >18 years: 90 mg/day
Important for proper bone health
MNT: Calcium
AI: 18 years: 1300 mg/day
>18 years: 1000 mg/day
Important for bone formation and
mineralization
Approximately 30g of Ca builds up
during pregnancy
-- About 25g in fetal skeleton and 5g in
maternal skeleton
MNT: Iron
RDA: 27 mg/day
+9 mg/day more than non-pregnancy
Throughout pregnancy a woman consumes
an additional 700-800 mg
-- 500 mg for hematopoiesis
-- 250-300 mg for fetal & placental tissues
Supplementation
-- +30 mg/day during 2
nd
and 3
rd
trimesters
MNT: Fluid and Caffeine
Fluid
- Encourage 6-8 glasses of fluid per day
- Prevents constipation

Caffeine
- Consume <300 mg/day
- Crosses placenta
- May affect fetal heart rate &
breathing
Sample Menu
Breakfast: 3 CHO
2 wheat toast
Margarine and diet jelly
Hard boiled egg
Skim milk
Morning Snack: 1 CHO
Apple/banana with peanut
butter
Lunch: 4-5 CHO
Chicken tortilla wrap w/
romaine
Steamed rice
Cup vegetable beef soup
Vegetables with FF dip
Green Tea
Afternoon Snack: 1 CHO
Cheese and crackers
Supper: 5-6 CHO
Roast beef
Baked potato
Corn
Tossed salad with dressing
SF Vanilla pudding
Skim milk
Evening Snack: 2 CHO
Oatmeal with blueberries
Skim milk

Benefits of MNT
Fatty Acid Study:
Thomas, B., et. Al (2006) compared 44
women with GDM who received
individualized nutritional therapy with
44 women without GDM who did not
receive nutritional counseling.
Advised to:
- Decrease energy, fat (total &
saturated), and refined CHO
- Increase complex CHO and fiber
Benefits of MNT
Fatty Acid Study (2006):

Control GDM
Energy (kcal/day) 2213 521.9 1955 551.0
CHO (g/day) 282.30 75.1 260.99 87.5
Complex CHO 150.40 38.4 175.0 75.4
Refined CHO 61.19 36.93 26.62 31.37
Protein (g/day) 81.08 23.2 84.9 28.8
Fat (g/day) 91.02 27.2 69.7 25.1
SFA 32.57 12.23 19.89 8.59
MUFA 26.79 8.97 21.18 8.20
PUFA 13.55 5.57 14.29 7.15
Trans Fats 2.67 1.60 1.40 0.85
Fiber 12.25 4.9 14.9 6.1

Benefits of MNT
Fatty Acid Study (2006):
Control GDM
Age (y) 28.02 5.8 31.25 5.3
Height (m) 1.64 0.06 1.64 0.07
Prepregnancy weight (kg) 61.4 10.8 74.59 20.4
Prepragnancy BMI (kg/m) 22.82 4.1 27.97 6.9
Ethnicity
Caucasian 31 13
Afro-Caribbean/African 8 23
Asian 2 4
Others 3 --
Info not given -- 4
HbA1c (%) 4.52 0.21 5.72 0.69
Monitoring
Self-monitoring:
- Primary test for
determining blood
glucose levels
- Goal of blood
glucose levels with
medical nutrition therapy:
Fasting Blood Glucose 95 mg/dL
2-hr postprandial 120 mg/dL


Monitoring: Insulin
Insulin Therapy:
Needed when MNT alone is unable
to maintain:
- Fasting blood glucose 105 mg/dL,
- 1-hr postprandial 155 mg/dL, or
- 2-hr postprandial 130 mg/dL.


Monitoring
Hemoglobin A1c:
- Shows individuals blood sugar
control over last 2-3 months
- Hemoglobin is irreversibly bound
with glucose in the blood
-- glycated or glycoslated hemoglobin
Monitoring: Ketone Testing
To determine if patient is under-eating to
maintain glucose levels to avoid insulin
therapy
Ketone formation
Blood and Urine tests
-- ketonemia and ketonuria
Ketonemia results in lower IQ scores
-- Human and animal data have shown that
ketone bodies transfer to the brain of the
fetus at various times during pregnancy



Individual Responsibility
- Follow appropriate diet
- Monitor blood glucose
- Exercise
Individual Responsibility


Affects if GDM is NOT controlled or goes
undetected:
To Baby: To Mother:
-Macrosomia -Preeclampsia
-Hypoglycemia -Cesarean Delivery
-Respiratory Distress Syndrome -Repeat GDM
-Jaundice -Type 2 Diabetes
-Stillbirth/Death
Rates & Recurrence Study
Purpose: to determine the recurrence rates of
GDM in subsequent pregnancies of women who
have been diagnosed with GDM in previous
pregnancies
Participants: 651 women diagnosed with GDM in a
previous pregnancy
Methods:
-- pre-pregnancy weight: index &
subsequent
-- birth weight: index
-- pre-delivery weight: index &
subsequent
-- weight change between pregnancies
-- weight gain during index pregnancy

MacNeil, S., Dodds, L., Hamilton, D., Armson, B., & VandenHof, M. (2001). Rates and Risk
Factors for Recurrence of Gestational Diabetes. Diabetes Care, 24, 659-662.

Rates & Recurrence Study
Results:
-- 232/651 women who had GDM during index
pregnancy had it in subsequent pregnancies
-- Of 232 participants, 16 developed diabetes
between index and subsequent pregnancy

Rates & Recurrence Study
Factors forecasting GDM recurrence:
-- Infant birth weight (index)
-- Pre-pregnancy weight (subsequent)
Women who birthed a baby 4,000 g at
index pregnancy had a 40% greater
chance of GDM recurrence
Women who weighed 190 lbs before
subsequent pregnancy had a 70%
greater chance of GDM recurrence
Ethics
Conduction of research
Initial checking for GDM in expecting
mothers
Proper medical nutrition therapy
Individualized Support
-- Nutritionally
-- Emotionally

Standards of Care
Anthropometrics:
- Ht, Wt (current & pre-pregnancy),
BMI, UBW
Lab Values
- Fasting blood glucose, A1c,
ketones, creatinine, serum protein
Analyze risk factors
Individualized counseling
Carbohydrate counting instruction
Follow-up
References
American Diabetes Association. (n.d.) Gestational Diabetes. Retrieved
September 7, 2006, from http://www.diabetes.org/gestational-
diabetes.jsp
Fagen, C., King, J., & Erick, M. (1995). Nutrition Management in
Women with Gestational Diabetes Mellitus. Journal of American
Dietetic Association, 95, 460-467.
Kaiser, L. & Allen, L. (2002). Position of the American Dietetic
Association: Nutrition and Lifestyle for a Healthy Pregnancy
Outcome. Journal of the American Dietetic Association, 102, 1479-
1490.
Gillen, L. & Tapsell, L. (2004). Advice that includes food sources of
unsaturated fat supports future risk management of gestational
diabetes mellitus. Journal of the American Dietetic Association, 104,
1863-1867.
Grayson, C. E. Ed. (2004). Pregnancy: Gestational Diabetes. In WebMD
Medical Reference in collaboration with The Cleveland Clinic,
Pregnancy & Family. Retrieved September 7, 2006, from
http://www.webmd.com/content/article/51/40831.htm
MacNeil, S., Dodds, L., Hamilton, D., Armson, B., & VandenHof, M.
(2001). Rates and Risk Factors for Recurrence of Gestational
Diabetes. Diabetes Care, 24, 659-662.
References
Mahan, K. L., Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy
(11th ed.). Philadelphia: The Curtis Center.
Mayo Clinic Staff. (2005). Gestational Diabetes. Retrieved September 7,
2006, from http://www.mayoclinic.com/health/gestational-
diabetes/DS00316
Santos-Ayarzagoitia, M., Salinas-Marinez, A., & Villarreal-Perez, J. (in
press). Gestational Diabetes: Validity of ADA and WHO Diagnostic
Criteria Using NDDG as the Reference Test. Diabetes Research and
Clinical Practice.
Reader, D., Splett, P., & Gunderson, E. (2006). Impact of Gestational
Diabetes Mellitus Nutrition Practice Guidelines Implemented by
Registered Dietitians on Pregnancy Outcomes. Journal of the
American Dietetic Association, 106, 1426-1433.
Thomas, A. M., Gutierrez, Y. M. (2005). American Dietetic Association
Guide to Gestational Diabetes Mellitus. United States: Library in
Congress Cataloging-in-Publication Data.
Thomas, B., Ghebremeskel, K., Lowy, C., Crawford, M., & Offley-Shore,
B. (2006). Nutrient Intake of Women With and Without Gestational
Diabetes With a Specific Focus on Fatty Acids. Nutrition, 22, 230-
236.


Quiz
Which of the following is not a risk
factor for developing gestational
diabetes mellitus?
a. Age
b. Weight gain during pregnancy
c. Family history
d. BMI
Answer: b
Quiz
_______ daily intake should come from
carbohydrate.
a. 20 25%
b. 30 35%
c. 40 45%
d. >50%

Answer: c
Quiz
Needs of ________ increase in the 2
nd

and 3
rd
trimesters.
a. protein
b. iron
c. energy
d. all of the above
Answer: d
Quiz
True or False:
Necessary weight gain during
pregnancy should be determined
on pre-pregnancy weight.
Answer: False, determined on BMI
Quiz
True or False:
Ketosis should not be a concern
for dietitians as long as desired
blood glucose levels are
maintained.
Answer: False