diabetes mellitus in pregnancy - opqic.org · diabetes effects 8% of pregnancies in theunited...
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Diabetes Mellitus in PregnancyKAELY JACKSON, RD/LD, CDEOU PRENATAL DIAGNOSTIC CENTER
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Learning Objectives
Describe the differences in the pathophysiology of Type 1, Type 2, and gestational diabetes and the expected effect these differences will have on glycemic control
State the rationale for the goal of tight glycemic control in pregnancy and discuss collaborative measures to attain this goal in the hospitalized antepartum, intrapartum, and post- partum patient
Review methods of treating diabetes in pregnancy
Discuss present technology associated with diabetes management
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Introduction
Diabetes effects 8% of pregnancies in the United States 90% of these cases are Gestational Diabetes
Diagnosis of diabetes during pregnancy has increased in recent years and continues to rise
From 2000 to 2010, the percentage of pregnant women with gestational diabetes increased 56% and the percentage of women with type 1 or type 2 diabetes before pregnancy increased 37%.
DIABETES RISK FACTORS• Overweight/obese• Sedentary• AMA• Family history• Ethnicity
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Definitions
GESTATIONAL DIABETES (GDM)- any degree of impaired glucose tolerance with onset or first recognition during pregnancy
PRE-EXISTING DIABETES OR PREGESTATIONAL DIABETES-diagnosis of diabetes prior to pregnancy
Type 1 Diabetes , Type 2 Diabetes
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Pathophysiology- GDM
Gestational Diabetes Pregnancy hormones cause insulin resistance
The body isn’t able to make enough insulin for the pregnancy
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Pathophysiology- GDM
Pregnancy HORMONES
insulin resistance
not enough insulin for pregnancy too much glucose
from the liver
High Blood
Glucoseor
hyperglycemia
+ +
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Diagnosis of GDM
2-step approach (preferred method at OUHSC):
To be done 24-28 wks (unless risk factors present indicating earlier screening)
1. 50 gram glucola screen:
Normal <135. If > 135 <200, do 3 hr GTT below
If > 200, do not do GTT and proceed with treatment for GDM
2. 100 gram, 3-hr GTT (Carpenter & Coustan)
Parameters for diagnosis:
meet or exceed: 95 / 180 / 155 / 140
2 or more abnormal values: GDM
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Pathophysiology- Type 2 Diabetes
Most common type of diabetes in reproductive aged women
Insulin resistance
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Pathophysiology- Type 1 Diabetes
No insulin production
Dependent on insulin
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Why Is This AConcern?
As pregnancy progresses, insulin resistance increases Caused by increased hormones of pregnancy
Insulin production is more than twice non-pregnant levels
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Why is this a Concern?
Maternal glucose crosses the placenta and increases baby’s glucose levels
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Maternal and Fetal RisksGestational Diabetes
Fetal Risks Growth disturbances
Intrauterine fetal demise
Neonatal Hyperbilirubinemia
Hypoglycemia
Obesity
Diabetes
Maternal Risks
Pregnancy induced hypertension
Preeclampsia
Polyhydramnios
UTI/pyelonephritis
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Maternal and Fetal RisksPre-Existing Diabetes
Fetal Risks Growth disturbances
Congenital anomalies
Intrauterine fetal demise
Miscarriage
Neonatal Hyperbilirubinemia Hypoglycemia Obesity
Diabetes
Maternal Risks
Pregnancy induced hypertension
Preeclampsia
Polyhydramnios
UTI/pyelonephritis
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Maternal Morbidity
Creasy and Resnik, Maternal Fetal Medicine, 2004
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How to Treat Diabetes in Pregnancy
Nutrition / Meal Planning
Exercise
Medicine
Monitoring
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Diabetes in PregnancyGoals of Treatment
Achieve normal blood glucose and hemoglobin A1C levels
Prevent and/or minimize maternal and perinatalmorbidity/mortality
How? Diabetes Education: Nutrition, Exercise, Monitoring
Medication
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Diabetes Education is Important!
Any pregnant patient who has diabetes or develops GDM should have outpatient diabetes education.
When hospitalized, if available, a diabetes educator can reinforce outpatient education and/or help manage blood glucose while in the hospital.
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Diabetes Education
Teach glucose monitoring Help facilitate getting glucometer Insulin or oral medication teaching Diet teaching Exercise education Hypoglycemia precautions Identifying patterns and altering treatment plan
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Diabetes Education: Who does it?
Inpatient CDE or Diabetes Nurse
Dietitian (RD) should be informed when patient is admitted
Nurse caring for patient (YOU!)
If patient is discharged while still pregnant, should follow up with educator or RD
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http://www.mybotanicalbaby.com/gestational-diabetes-diet/
Diabetes Management: Nutrition Education
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Diabetes Management: Calorie Requirements
Pregnancy requires an additional 300 kcal/day An extra apple with peanut butter and half an English muffin 1 bowl of soup, 1 small salad with 4 crackers 2 mozzarella cheese sticks and 1/4 cup almonds
Caloric recommendations for pregnancy 30 kcal/kg/d if at ideal body weight 24 kcal/kg/d if >20-50% above ideal body weight 12-18 kcal/kg/d if >50% above ideal body weight 36-40 kcal/kg/d if >10% below ideal body weight
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Diabetes Management: Dietary Composition
Diet composition: 40% CHO (no less than 150 grams), 20% protein, 30-40% fat
10% of calories for breakfast 30g CHO 30% of calories for lunch 45g CHO 30% of calories for dinner 45g CHO 30% of calories for snacks (3) 15-30g CHO = TOTAL: 165-210g CHO
Avoid periods of longer than 4 hours without food during the day and longer than 10 hours overnight
Bedtime snack of 15-30g of complex carbs plus protein helps to decrease risk of nocturnal hypoglycemia and prevents overproduction of glucose overnight in women with Type 1 and Type 2 diabetes
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Diabetes Management: What happens if you don’t eat
carbs?
Possible ketosis Constipation Quick weight loss Lack of energy Decreased consumption of fruits and vegetables May interfere with insulin sensitivity (no
improvement in BG control) No studies on low carb diets/pregnancy
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Diabetes Management: Exercise
Exercise decreases insulin resistance, may delay or negate need for insulin in GDM or Type 2 DM
Once diagnosed with GDM, it is difficult for patients to begin an exercise program if they have not already been exercising
Patients on bedrest have harder time controlling BG
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Diabetes Management: Exercise in the Hospital
If post-prandial BG is elevated, walking for 10 minutes after each meal is helpful
If fasting BG is elevated, after dinner exercise is recommended
LE exercise is contraindicated in some situations
UE exercise has no effect on uterine contractility
Order for PT may be helpful
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Diabetes Management: Monitoring
ACOG Guidelines - GDM, T2DM Fasting and Pre-prandial <95 One hour postprandial <140
Two hour postprandial <120
Type 1 DM- 7-8x daily testing, Fasting, Pre-meal, Post-meal, and HS, occasional 0300
Hospitalized patients admitted for glucose control: 7-8x daily 3AM if nighttime hypoglycemia is a problem
Avoid blood sugars less than 60
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Diabetes Management: Monitoring
Hemoglobin A1c Assess every 4-6 weeks during pregnancy
Pregnancy goal is A1C <6 %
If A1c is elevated in first trimester, patient may have undiagnosed diabetes
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Medication Treatment: Oral Hypoglycemics
SULFONYLUREAS (GLYBURIDE)
BIGUANIDES (METFORMIN)
No oral agents are FDA approved for treating gestational diabetes
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Glyburide for Gestational Diabetes
More cost effective than insulin
Patients prefer it over insulin injection therapy
Category C in pregnancy
Hypoglycemia precautions needed
Not recommended at bedtime
Crosses the placenta marginally
More research needed
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Glyburide: Dosing Recommendation
Should be taken 30-60 minutes prior to meal Initial dose 2.5 mg in the AM
5 mg in the AM 5mg twice a day 10 mg AM/5 mg PM 10mg AM/10 mg PM
Maximum dose 20 mg/day
Adjustments made every 3-7 days
Significant interprandial hypoglycemia can occur
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Biguanides: Metformin
Inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissues
If a patient is taking Metformin prior to pregnancy, usually can continue
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Metformin Use in Pregnancy
Continue through the first trimester if a patient conceives on Metformin
May be an adjunct to insulin therapy in cases of extreme insulin resistance
May be an option in a patient who refuses insulin therapy (esp. with fasting hyperglycemia)
May cause GI upset
**Little risk of hypoglycemia**
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Insulin Treatment in Pregnancy
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Insulin Treatment in Pregnancy
Insulin dose not cross placenta in pregnancy First Trimester
Often necessary to reduce insulin dose by 10 - 25%
Second and third trimester Doses will need to be increased Type I 10-20% Type II 30-150%
After 35-38 weeks insulin requirements may decline
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Insulin Treatment in Pregnancy:Insulin Regimens
NPH insulin
Intermediate- Acting
Starts working in 2-4 hours, Peaks at 4-8 hours, Duration: 8-16 hours
Increased risk of nighttime hypoglycemia
Regular insulin
Short-Acting insulin
Starts working in 30-60 minutes, Peaks at 2-3 hours, Duration: 5-8 hours
Most often taken together
Do not need regular insulin dose with lunch
**Can purchase at Walmart for $25**
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Insulin Treatment in Pregnancy: Rapid Acting Analogs
Insulin lispro (Humalog) Insulin aspart (Novolog) Can be used instead of Regular insulin
Needs to be given with EACH meal
Doses can be a “set dose” with each meal Doses can be given for the amount of carbohydrate eaten (Insulin-to-carb
ratio) Carbohydrate counting
Correction Factor for pre-meal blood glucose Replaces “sliding scale”, corrects BG before meal so patient is not chasing
high BG, goal is for BG to return to normal
Used in insulin pumps
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Insulin Treatment in Pregnancy: Rapid Acting Insulin Analogs
Pregnancy Class B Does not cross placenta No increase in congenital anomalies
Increased risk of diabetic retinopathy
Appears safe for use in pregnancy
Reduces frequency of interprandial hypoglycemia compared to regular insulin
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Insulin Treatment in Pregnancy: Long-Acting Insulins
Insulin glargine (Lantus) Pregnancy Class C
Insulin detemir (Levemir) Pregnancy Class B
Peakless activing lasting 24 hours
Lowers fasting glucose levels
Lowers Hemoglobin A1c levels
Lower risk of nighttime hypoglycemia vs. NPH insulin
Can be given in the morning or evening
Available in vials and pens
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Insulin Treatment in Pregnancy
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Insulin Pumps
https://www.youtube.com/watch?v=Crkyl9bqfC0
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Insulin Pumps
Advantages Disadvantages
Convince of changing basal and bolus rates Pump malfunctions/battery failure
No medication vials/pens unless emergency Abscess formation
Worn discreetly Poor uptake from infusion site
No need for needles Need to have compliant and motivated patient!
Cn preset for after delivery
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Continuous Glucose Monitors
A CGM works through a tiny sensor inserted under your skin, usually on your belly or arm.
The sensor measures your interstitial glucose level, which is the glucose found in the fluid between the cells.
The sensor tests glucose every few minutes.
A transmitter wirelessly sends the information to a monitor.
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Continuous Glucose Monitors
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Intrapartum Management
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Intrapartum Management:GDM
Diet Controlled BG on admission and every 2 hours
Carb controlled diets
IV: LR with D5 piggyback prn BG <100 mg/dl
Insulin-requiring BG on admission and every 2 hours
Insulin not usually needed in active labor
Insulin drip if BG >110 mg/dl
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Intrapartum Management: Type 1 or Type 2 DM
Target BG 60-110 mg/dl (best 110)
Insulin infusion or insulin pump (if allowed)
IV fluids (maintain LR, Kcal needed or BG <100 mg/dl: dextrose IV)
Check BG on admission and every hour
NPO or carb free liquids
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Intrapartum Management: Insulin Drip Protocol
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Intrapartum Management: Elective Cesarean Section
Take usual intermediate acting insulin on the evening prior to delivery Take half of dose of long acting insulin
Ideally first case in the morning
Measure blood glucose level in OR prior to anesthesia
Postoperatively use sliding scale
Check BS q2-4h until oral intake established
fasting and 2h postprandial once eating
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Intrapartum Management: Timing of Delivery
Depends on fetal size and glucose control Usually 37-39 weeks gestation
Diet controlled, AGA fetus – may be able to deliver at 39-40 weeks
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Intrapartum Management:Betamethasone Use in Preterm
Labor
Glucocorticoids (Corticosteroids)
Increase hepatic glucose production
Inhibit glucose uptake into muscle
Affect beta-cell function Day 1: double all insulin (IV or subQ) within 4 hours of
injection
Day 2: continue increased doses, modify prn
Day 3: decrease by 50%, add to original dose
Day 4: revert to pre-Betamethosone dose
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Intrapartum Management: BG Control During Admission
Follow Hospital Policy and Procedure
Use hospital monitor, not patient’s
Factor’s affecting accuracy: Hematocrit, fluid status, temperature, meds, hypotension, pH, oxygenation, user error
Frequency Before meal, HS (if correcting pre-meal)
Before meals, 1-2 hours post-meal, HS
Type 1 or 2 may include 3 AM
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Postpartum Care: Type 1 and Type 2 Diabetes
Insulin requirements decline sharply after delivery (honeymoon period after placental delivery)
Glycemic goals less stringent: FBG <100, 1 hour PP <150,
2 hour PP <140 mg/dl
Type 2: D/C insulin @ placental delivery, may need SC insulin
Type 1: convert IV insulin to SC insulin Usually require 40-50% of pregnancy dose
Re-initiate pre-pregnancy regimen after delivery
Sliding Scale insulin for additional coverage
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Breastfeeding: Type 1 and Type 2 Diabetes
Type 2: assess oral agents
Insulin safe, Metformin safe in breastfeeding
Hypoglycemia precautions important, especially with Type 1 (frequent monitoring, may be able to snack with no insulin)
Good control necessary for milk production
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Postpartum Care: GDM
Discontinue insulin (or oral agent) after delivery Blood glucose monitoring for 48 hours If fasting blood glucose levels are persistently elevated (>126)
after 48 hours, consider restarting insulin or oral hypoglycemic
TESTING ACOG recommends a 2 hour (75 g) GTT at 6-12 weeks
postpartum for all women with gestational DM
Up to 60% of women with insulin requiring gestational DM will develop Type II diabetes later in life
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Breastfeeding GDM
May reduce risk of diabetes in child
Promotes weight loss (burns 500 kcal/day) while exclusively breastfeeding)
Lowers BG, may delay need for medication
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Diabetes Technology Use During Delivery
Can be ideal for Type 1 DM management Common guidelines
Alert, oriented, Demonstrate Knowledge Discontinue for decreased cognition Physician orders Non-suicidal Furnish own supplies Remove for surgery, MRI/CT scans/Xrays Possible release form Must not be off pump for >1 hr, risk of DKA
Continuous glucose monitor: not approved for hospital use, helpful with Type 1/pregnancy, measures glucose in interstitial fluid
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Conclusions
Early, aggressive treatment of diabetes during pregnancy is important to improve outcomes (maternal, fetal, neonatal, and possibly lifelong)
All people caring for the patient with diabetes are responsible for teaching, and altering treatment plan as necessary
Long term follow up of women who had gestational diabetes is recommended
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Questions?