diabetes and pregnancy - northpugetsoundpec.org€¦ · " gdm is diabetes diagnosed in the 2nd...

Emily Holing, PhD, ARNPUniversity of Washington

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Diabetes and Pregnancy !

Emily Holing, PhD, ARNP�Department of Obstetrics and Gynecology �

University of Washington

[email protected]

Classifications of Diabetes Mellitus

Type 1 Diabetes (5-10% of all diabetics)

§  Failure of pancreatic insulin secretion

§  Tend to have most variable blood sugars, highest risk of severe hypoglycemia, greatest risk of DKA

§  Onset usually <30 years age (former name juvenile onset diabetes)

§  Most prevalent in people of Northern European ancestry

Classifications of Diabetes Mellitus

Type 2 Diabetes (90+% of all diabetics)

§  Resistance of muscle, adipose tissue and liver to glucose lowering effects of insulin

§  Failure of pancreatic cells to secrete sufficient insulin to overcome insulin resistance

§  More prevalent non-European ancestry

§  Often develops over many years; frequently asymptomatic (Clinical: must be assessed for undiagnosed complications)

Gestational Diabetes

n  “Because of the number of pregnant women with undiagnosed type 2 diabetes, it is reasonable to test women with risk factors for type 2 diabetes at their initial prenatal visit, using standard diagnostic criteria”

n  women with diabetes in the first trimester would be classified as having type 2 diabetes

n  GDM is diabetes diagnosed in the 2nd or 3rd trimester that is not clearly overt diabetes

ADA Classification and Diagnosis of Diabetes: 2015

Priscilla White, MD 1900-1987

White Classification !-Gestational Diabetes-

Class A1

n  Nutrition therapy

Class A2

n  Insulin or oral hypoglycemic agents


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White Classification � Pregestational Diabetes Without Vascular Disease

Onset > 20 yrs old and Duration < 10 years

Onset < 20 yrs old or Duration 10-19 years

Onset under 10 yrs or Duration >20 yrs or

Background retinopathy

Class B:

Class C:

Class D:

White Classification �- Pregestational Diabetes- ! With Vascular Disease

Class R: Proliferative retinopathy

Class F: Nephropathy with > 300 mg/24hrs proteinuria

Class R/F: Criteria for both R and F

Class H: Heart Disease

Epidemiology of Type 2 Diabetes and GDM The Effects of the Supersizing of America

Diabetes and Obesity

In the United States, approximately 8.5% of all women aged 20 and over

have diabetes


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…about one fourth of them are unaware they have the disease !!!!Buchanan TA and Kjos SL.. Diabetes in Women: Early Detection, Prevention and Management. ACOG Clinical updates in Women’s Health Care: 2006

Screening for Gestational Diabetes

Women at HIGH risk for GDM

n Obese n Family history of DM n Latina, Native American, African American, Asian,

Pacific Islander n Impaired glucose tolerance in prior pregnancies n History of poor pregnancy outcome n >25 years old

Two-step Screening for GDM:�

n  Screen at first visit with risk factors such as obesity, family history or h/o prior birth with GDM or macrosomia, glycosuria. Screen all women at 24-28 weeks.

n  Step 1:n 50 gram OGTT (any time of day; does not need to be fasting)n Positive screen if > 140 mg/dl Proceed to Step 2

n  If negative at initial prenatal, Screen again at 24-28

Two-step Screening for GDM:�

n  If screening test result > 140 mg/dl *n  Schedule 3 hr GTT* ASAP (following day if possible)n  Step 2: 100 gram glucose load

n Fasting <95n 1 hour <180n 2 hour <155n 3 hour <140

One abnormal value, treat with diet and exercise. Retest at 32-34 wksn  Two abnormal values = GDM

* If 50 gm screen is > 185, do not order a 3 hour GTT (patient should be diagnosed with GDM)


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1 STEP Screening Protocol for Gestational Diabetes

� A1C 5.7-6.4 ORFPG > 92 mg/dl OR

RPG > 126 mg/dl

A1C <5.7 or fasting < 92 or

RPG < 126

A1C > 6.4 ORFPG > 126 mg/dl OR

RPG > 200 mg/dl

Dx GDM; treat nowNo Dx DM; screem@ 24-28 wks

Dx type 2 DM; treat now

1 STEP GTT: Fasting, 1 & 2 HOUR 75 gm. (not 50 gm.)

DX GDM if ONE or more values > the following:Fasting: 92, 1hr 180, 2hr 153

Fetal Risks from Maternal Diabetes

Structural Functional Anthropometric

Weeks of Pregnancy

Pre-Gestational Diabetes

Gestational Diabetes

HgA1C and Malformations

Diabetes Care 2007;30:1920.

Periconceptional A1c %

Copyright ©Radiological Society of North America, 2004

Stroustrup Smith, A. et al. Radiology 2004;230:229-233

INFANT WITH CAUDAL REGRESSION SYNDROME

To prevent malformations in infants of mothers with diabetes, glycemic

control must begin before conception


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Everything’s Big in Texas

16 lbs 1 oz (born 7/8/11)

Obesity CycleHyperglycemia in pregnancy means much more than a large-for-gestation baby .

The uncontrolled diabetic intrauterine environment also has long term effects, such as an increased risk for adult chronic disease such as obesity, htn, type 2 diabetes and metabolic syndrome

Maternal Risks from Diabetes

n  Difficult labor

n  Vacuum/forceps delivery

n  Trauma to birth canal

n  Cesarean delivery

n  Pregnancy Induced Hypertension

n  Future risk of diabetes

Long Term Problems with Having an Overweight Fetus

Obesity in pregnancy causes fetal metabolic dysregulation

Fetal/Newborn Obesity

Childhood Obesity

Adult Obesity, type 2 DM

Diet/Activity Diet/Activity

Management of Diabetes during Pregnancy


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Target Glucose Levels in Pregnancy

§  Fasting and premeals: 70-90 mg/dl

§  One hour after meals: <120mg/dl

Dietary Management

n  3 meals + 3 snacks (smaller, more frequent meals)

n  Inclusion of protein in snack promotes between meal euglycemia

Dietary Management, cont’d

Breakfast

n  Restrict milk, fruits/juices, cold cereal, bagel, rice cereals

n  Insulin resistance greater in the am due to overnight release of cortisol and hormones

n  Restrict carbs to 15-30 gms

Dietary Management, cont’d

n  Lunch and Dinner each contain 45-60 gms of carbohydrates with fat/protein

n  Bedtime snack should contain at least 7 grams of protein and 15-30 grams of carbs

n  Carbohydrates have greatest effect on blood sugars. Must be consistent and/or use carbohydrate counting

Carbohydrate Counting

n  Most pts will need ~ 1 units rapid insulin (novolog or humalog) for every 10-15 grams of carbohydrate

n  15 grams carbohydrate ~ 1 fruit or 1 bread or 1 milk (e.g. 1 piece bread, 1/4 bagel, 6” tortilla, 1 cup milk, 1/2 cup cereal, 1 med apple/orange, 1/2 small banana, 1/3 cup rice)

n  Read labels for carbohydrate content

Glucose Monitoring§  Correlate Pt. Meter with quality control meter

§  Wash hands/wipe off first drop of blood (lotions can change value)

§  Side of finger usually less painful


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‘Really….you want me to test how many 1mes a ?????’

n  GDM and Type 2 DM: at least 4x/dayn  Before and 1 hr. after breakfastn  Before and 1 hr after dinner

n  Type 1 DM: 7-8 X dayn  Before and 1 hr. after breakfast, lunch, dinnern  Bedtimen  Overnight for hypoglycemia safety

Forearm blood not accurate enough for pregnancy

What did you do that made your blood sugar so high after breakfast?!

If on diet control, glucoses often exceed :

§  Fasting >90 mg/dl

§  1 hour postprandial > 120 mg/dl

When to Start Insulin or Oral Agents

Oral Antidiabetic Agents

Sulfonylureas: ↑ Insulin secretion by beta cells �in response to glucose stimulusExample: Glyburide

Biguanides: ↓Hepatic glucose production ↑ Muscle Glucose uptakeExample: Metformin

§  Starting dose: 500 mg qd or bid

§  Maximum dose: 3000 mg daily

§  No Hypoglycemia risk (unless on orals or insulin)

§  Side Effect: GI (nausea, diarrhea, loss of appetite)

§  Take with food to reduce GI side effects

§  D/C 24 hrs before C/S or IOL

Metformin (Glucophage®)


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n  Works by pushing pancreas to increase insulin

n  Side Effects: hypoglycemia (must have hypoglycemia education)

n  Not used as much in our practice

GlyburideCharles Best(medical Student)

Frederick Banting(Orthopedic Surgeon)

Marjorie

Outside their Lab at the U of Toronto

Grinding pancreas to make insulin at Eli Lily’s Indianapolis plant, 1923

Patient J.L., December 15, 1922 February 15, 1923

Insulin: Discovered in 1922

Bolus Insulins

Humalog® Insulin Lispro <20 minutes 1-2 hours 4-5 hours

Novolog® Insulin Aspart <20 minutes 1-2 hours 4-5 hours

Apidra Insulin Glulisine <20 minutes 1-2 hours 4-5 hours

Humulin® R Regular 1/2 - 1 hour 2-4 hours 6-8 hours

Novolin® R Regular 1/2 - 1 hour 2-4 hours 6-8 hours

Brand Name Generic Name Onset Peak Duration

Rapid Acting Insulins

Regular Insulins

U-500 R Regular 1-2 hours 2-8 hours 6-10 hours

Basal Insulins

Lantus Insulin Glargine 2-4 hours No Peak > 24 hours

Levemir Insulin Detemir 1-2 hour Minimal Peak 18-24 hours

Brand Name Generic Name Onset Peak Duration

Intermediate Insulins

Long Acting Insulins

Humulin N NPH 2-4 hours 4-8 hours 10-16 hours

Novolin N NPH 2-4 hours 4-8 hours 10-16 hours

Pre-Mixed Insulins (Bolus + Basal)

Novomix ® = 70% aspart protamine/30% aspart = 70% intermediate/30% rapid

70/30 = 70% NPH + 30% regular


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Profiles of Human Insulins and Analogs

0 2 4 6 8 10 12 14 16 18 20 22 24

Plas

ma

insu

lin le

vels Regular (6–8 hours)

NPH (12–20 hours)

Hours

Glargine/Detemir (20-26 hours)

Aspart, Lispro (4–6 hours)

“Standard Split” with NPH and lispro/aspart

��Lispro/Aspart before meals

Insu

lin E

ffect

Breakfast Lunch Dinner Bedtime

NPH before breakfast and at bedtime

4:00 16:00 20:00 24:00 4:0012:008:00

Time

glargine/detemir*

Basilar insulin programPl

asm

a In

sulin

*glargine and detemir cannot be mixed with any other insulin

Apart, lispro, apidra before meals

4:00 16:00 20:00 24:00 4:0012:008:00

Time

Basal: glargine/detemir at night with AM NPH for day

Plas

ma

Insu

lin

AM NPH

detemir/glargine hs

Basilar insulin program - variation

Apart, lispro, apidra before meals

Choosing an Insulin Syringe

30 unit (.3ml)Ø  each hash mark = 1 unit

50 unit (.5 ml)Ø  each hash mark = 1 unit

100 unit (1 ml)Ø  each hash mark = 2 units

•  Use and teach the correct syringe!!!!


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Insulin Pens

•  Prime with needle on 1-2units-look for bubble at end of needle.

•  After injecting insulin hold in place to the count of 10 seconds.

How to give a “shot”

n  The abdomen is the preferred site for fast acting insulin; thigh for long acting

n  No need to clean the site with an alcohol swab

n  OK to re-use syringes n  Avoid over-used sites n  Hold syringe like a dart n  Pinch or don’t pinch…… n  Quickly push the needle through skin n  Push plunger in, deliver the insulin n  Count to 5, then withdraw the needle

• Abdomen most rapid site of absorption (Best for premeal insulin)

• Anterior thigh slowest site of absorption (Best for bedtime insulin)

• Be consistent (Don’t rotate sites)

Don’t use “same old site”

InsulinPumps

24 hr. help line on back of pump

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

8:0012:008:00

Time

Basal infusion

Bolus Bolus Bolus

Plas

ma

insu

lin

Variable Basal Rate: Insulin Infusion Pump Patient Education


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Signs ands

symptoms of

hypoglycemia

Hypoglycemia

n  s/s – reviewn  Treatment: per hospital protocol Please don’t

over treat!n  Make sure patient has snacks available to her at

all timesn Care package of juice/crackers/pb should be in pt’s room

at all times!n  If postpartum – make sure mom has snacks to take to

NICU AND that handoff occurs with NIUC RN

Must have hypoglycemia safety “buddy” system

Hypoglycemia

n  Give Glucagon ONLY if pt cannot take oral sugar OR no IV access

n  Glucagon inhibits GI motilityn  Can deplete glycogen stores if used too oftenn  Not often helpful in pts with chronic hypoglycemia (type 1 diabetics

may have depleted glycogen stores and not respond to glucagon)n  Beta blockers may inhibit glucagon usefulnessn  Check BS frequently to assess for rebound low blood sugar!!!n  Follow with protein/fat/carb snack

Sick Day Guidelines

§  Continue insulin (stress of illness may cause increase in insulin needs)

§  Stop Metformin in case of lactic acidosis

§  Frequent glucose monitoring

§  Small frequent feedings/fluids

§  One barf rule: If vomit more than once and/or unable to take food/fluids, call health care provider

Intrapartum Management


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Inpatient Management

n  Oral Agents:n  Metformin

n D/C before labor induction (24-48 hours prior to planned C/S or IOL)

n  Glyburiden  may take while in early labor; change to IV insulin when

active

Pts on Insulin - Planned C/S

n  Schedule C/S in early AM, may take evening NPH, NPO @ midnight, and NO AM insulin.

n  If hypoglycemic in early hours, should take glucose tabs/gel, clear juice to stabilize cbg

n  Early admit to L&D if hypoglycemia occurs

Glycemic Control: Induction of Labor

n  Maintain euglycemian  Maternal glucose > 144 correlates with neonatal blood

glucose < 45 (Taylor et al. 2002)

n  Monitor cbg ac/pc meals while in latent labor and treat with orals (except Metformin)/SQ insulin prn until active labor

n  IV insulin as needed in active labor

Patients on Insulin Pump

§  If continuous insulin pump: may continue on pump with boluses during meals until active labor (4cm » then NPO and convert to IV drip)

Intravenous Insulin L&D

n  IV insulin order set (OB IV Insulin)

n  Protocol per institution

n  The goal of intrapartum management is to maintain normoglycemia (80-110mg/dl)

UWMC IV Insulin


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Use of IV Insulin Algorithm

n  Order Set defines:n  Standardized insulin dosage (1unit/1ml)n  IV fluid requirementsn  Mealtime coveragen  Hypoglycemia care

n All hypoglycemia <60 mg/dl tx with Dextrose 50%

n  Contacting MD

POSTPARTUM

Postpartum Insulin Management �

§  Transition down algos once patient is trending down in BG values

§  Breastfeeding improves lipid/glucose metabolism in GDM (Kjos,Henry et al 1993)

§  1° postprandial cbg of 150-160 mg/dl acceptable (particularly during breastfeeding)

Postpartum Insulin Management

§  Maintain on IV insulin (and NPO) until patient “hungry” and passing gas

§  Transition to SQ insulin

§ Begin SQ injections/pump 1-2 hours prior to d/c of IV gtt

Breastfeeding

Patients on Insulin

n Caloric needs are increased - check blood sugar and snack (prior to breastfeeding) to prevent hypoglycemia

Patients on Oral Agents

n Glyburide and Metformin not contraindicated for breastfeeding

Postpartum Caren  Reassess pt’s insulin requirementsn  Don’t run PP patient too low (breastfeeding and

pumping burn 300-500 extra calories/day)n  BS goals 80-160mg/dL: try to keep pt in low-mid 100’sn  Make sure she snacks/checks BS if she has a baby in the

NICU n  Alert NICU RN that pt is diabetic!


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Postpartum Follow-up

n  Follow-up patients on insulin in office within 1 week

n  Pts with gestational diabetes who do not require medication (orals or insulin) at discharge should have 75 gram OGTT at 6-12 weeks

Postpartum Evaluation For Carbohydrate Intolerance

n 75 g oral glucose load at 6 weeks postpartumn Venous plasma glucose measured fasting and at 2 hours:

Normal Impaired Diabetes

Fasting <100* mg/dl 100–125 mg/dl ≥126 mg/dl2-hour <140 mg/dl 140–199 mg/dl ≥200 mg/dl

Summary and recommendations of 4th Int Workshop Conf. on Gestational Diabetes. Diabetes Care, 1998;21(2):B162 *ADA 2006 position statement states pp evaluation OGTT or fasting only

Pregnancy with Diabetes …

At no other time in a woman's life is glycemic control more important…

Pregnancy …

… and at no other time in her life is a

woman more motivated to achieve it!!

diabetes and pregnancy - northpugetsoundpec.org€¦ · " gdm is diabetes diagnosed in the 2nd...

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