gestational diabetes

GESTATIONAL GESTATIONAL DIABETESDIABETES

DR.RISHIKESAN K.VDR.RISHIKESAN K.V

VENNIYIL MEDICAL CENTREVENNIYIL MEDICAL CENTRE

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Gestational DiabetesGestational Diabetes

This diagnosis is given when a woman, who This diagnosis is given when a woman, who has never had diabetes before, gets diabetes has never had diabetes before, gets diabetes or has high blood sugar, when she is or has high blood sugar, when she is pregnant. pregnant. Its medical name is Its medical name is gestational diabetes gestational diabetes mellitusmellitus or GDM. or GDM.It is one of the most common health problems It is one of the most common health problems for pregnant women.for pregnant women.The word “gestational” actually refers to The word “gestational” actually refers to “during pregnancy.”“during pregnancy.”

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It occurs in about 5% of It occurs in about 5% of all pregnancies. all pregnancies.

If not treated, gestational If not treated, gestational diabetes can cause diabetes can cause health problems for the health problems for the mother and the fetus.mother and the fetus.

Glucose MetabolismGlucose Metabolism

Normal pregnancy Normal pregnancy : Diabetogenic state: Diabetogenic state*increase in pc BG*increase in pc BG

*insulin resistance*insulin resistance

Early Pregnancy : Early Pregnancy : Anabolic stateAnabolic state

*increase in maternal fat store*increase in maternal fat store qsqs

*decreased FFA concentration*decreased FFA concentration

*decrease in insulin requirements*decrease in insulin requirements

CHO MetabolismCHO MetabolismEffects of Pregnancy Effects of Pregnancy **Mild fasting hypoglycemia;Mild fasting hypoglycemia; *Post prandial hyperglycemia *Post prandial hyperglycemia Due to increase in plasma volume in early Due to increase in plasma volume in early

gestation and increase in fetal glucose gestation and increase in fetal glucose utilization.utilization.

As pregnancy advances As pregnancy advances -Progressive increase -Progressive increase in tissue resistance to insulinin tissue resistance to insulin– Increase insulin secretion to maintain Increase insulin secretion to maintain

euglycemiaeuglycemia– Suppressed glucagon responseSuppressed glucagon response– Inc. prolactin, cortisolInc. prolactin, cortisol– HPL has GH like effectsHPL has GH like effects

CHO MetabolismCHO Metabolism


Risk FactorsRisk Factorsmaternal age >25maternal age >25

Family historyFamily history

glucosuriaglucosuria

prior macrosomiaprior macrosomia

previous unexplained stillbirthprevious unexplained stillbirth

ethnic group: Hispanic, Black, ethnic group: Hispanic, Black, AsiansAsians

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Insulin from the Insulin from the pancreaspancreas

Vad happens to the carbohydrates from the Vad happens to the carbohydrates from the food? food?

- -- -

- -- -- -

Fat/muscle cellFat/muscle cell

Stored sugar in the Stored sugar in the liver (glycogen)liver (glycogen)

Carbohydrates Carbohydrates from foodfrom food

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Why didn’t I have diabetes before?Why didn’t I have diabetes before?

During pregnancy, many During pregnancy, many physiological changes take place. physiological changes take place. Changes in metabolism can be Changes in metabolism can be seen. Insulin may not be as effective seen. Insulin may not be as effective in moving sugar into the cells during in moving sugar into the cells during pregnancy. Therefore, the cells can’t pregnancy. Therefore, the cells can’t get the sugar they need for energy. get the sugar they need for energy. Increased sugar levels in the blood Increased sugar levels in the blood can lead to many problems.can lead to many problems.

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Why isn’t insulin doing its job?Why isn’t insulin doing its job?

The placenta is a system of vessels that The placenta is a system of vessels that passes nutrients, blood, and water from passes nutrients, blood, and water from mother to fetus.mother to fetus. The placenta makes certain hormones The placenta makes certain hormones that may prevent insulin from working the that may prevent insulin from working the way that it should.way that it should. When this condition happens, it is referred When this condition happens, it is referred to as to as insulin resistanceinsulin resistance.. In order to keep metabolism normal during pregnancy, In order to keep metabolism normal during pregnancy, the the

body has to make three times more insulin than normal body has to make three times more insulin than normal to to offset the hormones made by the placenta.offset the hormones made by the placenta.

Placenta

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Why isn’t insulin doing its job?Why isn’t insulin doing its job?

For most women, the body’s extra For most women, the body’s extra insulin is enough to keep their blood insulin is enough to keep their blood sugar levels in the healthy range.sugar levels in the healthy range.But, for about 5% of pregnant women, But, for about 5% of pregnant women, even the extra insulin is not enough to even the extra insulin is not enough to keep blood sugar levels normal.keep blood sugar levels normal.These women end up with high blood These women end up with high blood sugar or gestational diabetes at around sugar or gestational diabetes at around the 20the 20thth to 24 to 24thth week of pregnancy. week of pregnancy.


ScreeningScreening

– 24-28 weeks routine24-28 weeks routine– no need to fastno need to fast– screen at 1st prenatal visit if hx of screen at 1st prenatal visit if hx of

previous GDMprevious GDM– screen earlier (12-24 weeks ) if risk screen earlier (12-24 weeks ) if risk

factorsfactors

MATERNAL RISKMATERNAL RISK Birth traumaBirth trauma

Preterm LaborPreterm Labor

PIHPIH

Operative deliveryOperative delivery

50% lifetime risk in developing Type 50% lifetime risk in developing Type II DMII DM

Recurrence risk of GDM is 30-50%Recurrence risk of GDM is 30-50%


Will GDM hurt my baby?Will GDM hurt my baby?Most women with gestational diabetes give birthMost women with gestational diabetes give birthto healthy babies; this is especially true forto healthy babies; this is especially true forwomen who have kept their blood sugar underwomen who have kept their blood sugar undercontrol, maintained a healthy diet, engaged incontrol, maintained a healthy diet, engaged inregular, moderate physical activity, and regular, moderate physical activity, and had a healthy weight throughout thehad a healthy weight throughout thepregnancy.In some cases, however, pregnancy.In some cases, however, the condition can affect the pregnancy.the condition can affect the pregnancy.

GDM GDM Associated ConditionsAssociated Conditions MacrosomiaMacrosomia

In this condition, the baby’s body is larger than normal. Large-In this condition, the baby’s body is larger than normal. Large-bodied babies may be injured during natural delivery bodied babies may be injured during natural delivery through the vagina, so the baby may need to be delivered through the vagina, so the baby may need to be delivered through cesarean section. through cesarean section.

HypoglycemiaHypoglycemia

In this condition, the baby’s blood glucose is too low. In this condition, the baby’s blood glucose is too low. Breastfeeding may need to be started right away to get Breastfeeding may need to be started right away to get more glucose into the baby’s system. If breastfeeding is not more glucose into the baby’s system. If breastfeeding is not possible, then the baby may need to get glucose put possible, then the baby may need to get glucose put directly into the blood through a thin, plastic tube in his or directly into the blood through a thin, plastic tube in his or her arm.her arm.

JaundiceJaundice

In this condition ,the baby’s skin turns yellowish. The white In this condition ,the baby’s skin turns yellowish. The white parts of the eye may also change color slightly. If treated, parts of the eye may also change color slightly. If treated, this is not a serious problem.this is not a serious problem.

GDM GDM ASSOCIATED CONDITIONS….ASSOCIATED CONDITIONS….

Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS)

In this condition, the baby has trouble breathing. In this condition, the baby has trouble breathing. The baby may need oxygen or other help The baby may need oxygen or other help breathing if he or she has this condition.breathing if he or she has this condition.

Low Calcium and Magnesium Levels in Baby’s Low Calcium and Magnesium Levels in Baby’s BloodBlood

In this condition, spasms in the hands and feet, or In this condition, spasms in the hands and feet, or twitching and cramping of muscles can occur. twitching and cramping of muscles can occur. The condition can be treated through The condition can be treated through supplementation with magnesium and calcium supplementation with magnesium and calcium supplements.supplements.

Keep in mind that just because you have GDM it does not mean that these problems will occur

Could GDM hurt my baby in other ways?Could GDM hurt my baby in other ways?

Gestational diabetes usually does Gestational diabetes usually does notnot cause birth cause birth defects or deformities.defects or deformities.

Most developmental or physical defects happened Most developmental or physical defects happened during the first trimester of pregnancy, between the during the first trimester of pregnancy, between the 11stst and 8 and 8thth week, and gestational diabetes typically week, and gestational diabetes typically develops around the 24develops around the 24 thth week of pregnancy. week of pregnancy.

Women with gestational diabetes typically have normal blood sugar levels during the first trimester, allowing the body and body Systems of the fetus to develop normally.

The fact that you have gestational diabetes will not cause diabetes in your baby.However, your child will be at a higher risk for developingtype 2 diabetes in adulthood and may get it at a youngerage (younger than 30).

As your child grows, taking steps such as: eating a healthy diet, maintaining a healthy weight, and getting regular, moderate physical activity can help to reduce his or her risk.Macrosomic, or large-bodied babies are at higher risk for childhood and adult obesity.

Magnetic Resonance Image of Pregnancy Complicated by Diabetes

Normoglycmia Hyperglycmia

Jovanovic L et al. Am J Perinatol. 1993;10:432-437

Macrosomia

Gestational Diabetes

Fetal RisksFetal Risks

no increaseno increase in congenital anomalies in congenital anomaliesincreased risk of stillbirth if fasting+ increased risk of stillbirth if fasting+

pc hyperglycemiapc hyperglycemiamacrosomiamacrosomiabirth trauma-shoulderbirth trauma-shoulder dystocia and related dystocia and related complications complications


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A Treatment Plan for GDMA Treatment Plan for GDMMay include these items:May include these items:

Knowing your blood sugar (glucose) level and keeping it Knowing your blood sugar (glucose) level and keeping it under controlunder control

Eating a healthy diet, as outlined by your health care Eating a healthy diet, as outlined by your health care providerprovider

Getting regular, moderate physical activityGetting regular, moderate physical activity Maintaining a healthy weight gainMaintaining a healthy weight gain Keeping daily records of your diet, physical activity, and Keeping daily records of your diet, physical activity, and

glucose levelsglucose levelsTaking insulin and/or other medications as prescribedTaking insulin and/or other medications as prescribed

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Know your blood sugar level Know your blood sugar level & keep it under control: & keep it under control: OverviewOverview

There are two parts:There are two parts:– Knowing your blood sugar levelKnowing your blood sugar level

Test to see how much glucose is in your bloodTest to see how much glucose is in your blood– Keeping your blood sugar level under controlKeeping your blood sugar level under control

Keep the amount within a healthy range at all timesKeep the amount within a healthy range at all timesThis is important to do because your blood sugar level change This is important to do because your blood sugar level change

throughout the day based on what foods you eat, when you throughout the day based on what foods you eat, when you eat them, and how much you eat. Your level of physical activity eat them, and how much you eat. Your level of physical activity and when you do physical activity also influences blood sugar and when you do physical activity also influences blood sugar levels.levels.

Management Management

Goal is to optimize BG Goal is to optimize BG

levels to minimize risk levels to minimize risk

of adverse perinatal of adverse perinatal

outcomesoutcomes Diet Diet

ExerciseExercise

Insulin therapyInsulin therapy


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Know your blood sugar level Know your blood sugar level & keep it under control & keep it under control

Although your glucose Although your glucose levels change during the levels change during the day, there is a healthy day, there is a healthy range that is normal. If range that is normal. If your glucose level is your glucose level is outside of the healthy outside of the healthy target range, speak with target range, speak with your health care your health care provider.provider.

Time of Blood Sugar

Test

Healthy Target Levels (in

mg/dl)

Fasting glucose

level

No higher than 95

One hour after eating

No higher than 140

Two hours after eating

No higher than 120

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Knowing your glucose Knowing your glucose levels at specific times of levels at specific times of the day may become very the day may become very important if insulin important if insulin therapy becomes therapy becomes necessary.necessary.Insulin resistance can Insulin resistance can increase as a pregnancy increase as a pregnancy progresses indicating a progresses indicating a need for additional insulin need for additional insulin to control glucose levelsto control glucose levels. .

Measuring your blood sugar will

give you information

about…

For example

The amount of food you can eat

Can you have that extra ½ bagel for breakfast?

Foods that affect your glucose

level

Does your body process different foods differently?

Times when your glucose level is

high or low

You might have high blood sugar in the morning after breakfast; other women may have high blood sugar after dinner.

Times that physical activity is more likely to

keep your glucose level in

target

Does walking for 20 minutes after breakfast or dinner help to keep your glucose level within the healthy range?

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You may have to test four times a day:You may have to test four times a day:

1.1. In the morning before eating breakfast, In the morning before eating breakfast, referred to as the referred to as the FastingFasting glucose level glucose level

2.2. 1 or 2 hours 1 or 2 hours after breakfastafter breakfast

3.3. 1 or 2 hours 1 or 2 hours after lunchafter lunch

4.4. 1 or 2 hours 1 or 2 hours after dinnerafter dinner

You may also have to test your glucose level before you You may also have to test your glucose level before you go to bed at night. This is referred to as your go to bed at night. This is referred to as your nighttime nighttime oror nocturnal nocturnal glucose test. glucose test.

Management : DietManagement : Diet

patients without fasting patients without fasting hyperglycemiahyperglycemia

average 8000-9000 kj/day.average 8000-9000 kj/day.BMI >27 25 kcal/kg/IBW /dBMI >27 25 kcal/kg/IBW /d

BMI 20-26 30 ; BMI 20-26 30 ;

BMI <20 38 ; BMI <20 38 ;


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Eating a healthy dietEating a healthy dietOverviewOverview

A healthy diet is one that includes A healthy diet is one that includes a balance of foods from all the a balance of foods from all the food groups, giving the nutrients, food groups, giving the nutrients, vitamins, and minerals necessary vitamins, and minerals necessary for a healthy pregnancy. for a healthy pregnancy. For women with gestational For women with gestational diabetes, a healthy diet can help to diabetes, a healthy diet can help to keep blood sugar levels in the keep blood sugar levels in the healthy target range.healthy target range.Carbohydrates are often the center Carbohydrates are often the center of a healthy diet for a woman with of a healthy diet for a woman with gestational diabetes.gestational diabetes.

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Eating a healthy dietEating a healthy diet CarbohydratesCarbohydratesCarbohydrates are nutrients which come Carbohydrates are nutrients which come

from foods like grain products, fruits, and from foods like grain products, fruits, and vegetables. vegetables. During digestion, the body is able to break During digestion, the body is able to break down most carbohydrates into simple down most carbohydrates into simple sugars, like glucose.sugars, like glucose.Eating carbohydrates affects blood sugar Eating carbohydrates affects blood sugar levels. Eating a large amount of levels. Eating a large amount of carbohydrates at a meal will have a larger carbohydrates at a meal will have a larger effect on blood glucose levels than eating a effect on blood glucose levels than eating a small amount of carbohydrates.small amount of carbohydrates.It is important to balance between eating It is important to balance between eating enough carbohydrates to receive the enough carbohydrates to receive the necessary amounts of energy and resultant necessary amounts of energy and resultant glucose, and not consuming too much to glucose, and not consuming too much to where blood sugar levels are out of where blood sugar levels are out of controlcontrol..

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Eating a healthy dietEating a healthy dietMeal PlansMeal Plans

CHO counting

With this meal plan, the number of grams of carbohydrates that is eaten at each meal or snack is counted to make sure that they are within a certain range. A meal plan may be very specific, allowing a specified amount at each meal or snack, or it may be more general, with a daily carbohydrate total.

The exchange

system

The exchange system groups each food consumed into one of the following food groups: bread/starches, fruits, vegetables, proteins, milk, and fats. Each food within a group has very similar amounts of carbohydrate, fat, protein and calories, but the amounts of vitamins and minerals may vary. In this plan, the number of items from a food group that is eaten at each meal is counted. There is a designated amount for each group every day.

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Eating a healthy dietEating a healthy dietto keep blood sugar in check:to keep blood sugar in check:

Eat meals and snacks on a regular

schedule throughout the day

Researchers recommend that women with gestational diabetes should eat at least three small-to-medium sized meals and two to four snacks every day.

Eat smaller amounts of carbohydrates at

each meal

It is preferable to eat several small meals every day rather than one large meal. Carbohydrates will increase blood glucose level directly, therefore, eating a small amount of carbohydrates all through the day will help keep blood sugar from rising too high.

Add a nighttime snack to your meal

plan

A snack of one or two servings of carbohydrates before bedtime will keep blood sugar at a healthy level during sleep. Some healthy examples could include: a piece of fruit, a handful of pretzels, or crackers.

Diet : general principlesDiet : general principles

55% CHO / 25% Protein / 55% CHO / 25% Protein / 20% fat20% fat

Normal weight gain 10-12 kgNormal weight gain 10-12 kg

Avoid ketosisAvoid ketosis

Liberal exercise program to Liberal exercise program to optimize BG controloptimize BG control


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Role of physical activityRole of physical activityWomen with gestational diabetes often Women with gestational diabetes often need regular, moderate physical activity need regular, moderate physical activity to help control their blood sugar levels to help control their blood sugar levels by allowing insulin to work better.by allowing insulin to work better.

Examples include:Examples include:– WalkingWalking– Prenatal aerobics classesPrenatal aerobics classes– SwimmingSwimming

However, a consultation and approval However, a consultation and approval by a health care provider is needed by a health care provider is needed before beginning any physical activity before beginning any physical activity during pregnancy.during pregnancy.

Caution

Keep in mind that it may take 2 to 4

weeks before physical

activity has an effect on blood sugar levels.

If persistent hyperglycemiaIf persistent hyperglycemia

after one week of dietafter one week of diet

control proceed to insulincontrol proceed to insulin

6-14 weeks 6-14 weeks 0.5u/kg/d 0.5u/kg/d

14-26 weeks14-26 weeks 0.7u/kg/d 0.7u/kg/d

26-36 weeks 0.9u/kg/d26-36 weeks 0.9u/kg/d

36-40weeks 36-40weeks 1 u /kg/d 1 u /kg/d

Gestational DiabetesGestational DiabetesINSULININSULIN

If fasting hyperglycemia start with If fasting hyperglycemia start with NPHNPHhs hs

initial dose initial dose 6-8 U 6-8 U

if only pc hyperglycemia use if only pc hyperglycemia use HHumalogumalog 2-4u ac the specific meal 2-4u ac the specific meal

adjust adjust 2u/time2u/time ; 1 formula /time ; 1 formula /time

BG target BG target ac <5.3 (90mg.)ac <5.3 (90mg.)

2 h pc <6.7 ( 120 mg)2 h pc <6.7 ( 120 mg)

Gestational DiabetesGestational DiabetesINSULININSULIN

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Role of moderate physical activityRole of moderate physical activityResearchers are uncertain about the Researchers are uncertain about the exact amount of physical activity required exact amount of physical activity required to control blood sugar during gestational to control blood sugar during gestational diabetes.diabetes.The amount that is usually recommended The amount that is usually recommended is based on how active an individual was is based on how active an individual was before the pregnancy and whether or not before the pregnancy and whether or not there are any other health concerns.there are any other health concerns.For some women with GDM, regular For some women with GDM, regular physical activity can include walking, physical activity can include walking, swimming, or light running; whereas, for swimming, or light running; whereas, for other women only slow walking may be other women only slow walking may be recommended. recommended. A health care provider can offer advice on A health care provider can offer advice on appropriate activities, and their duration appropriate activities, and their duration and frequency to assure a healthy and frequency to assure a healthy pregnancy. pregnancy.

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Role of moderate physical activityRole of moderate physical activityGeneral Guidelines For Physical ActivityGeneral Guidelines For Physical Activity

Do Don’t

Participate in moderate and regular physical activity unless prohibited by a health care

provider

Get too tired while working out or doing physical

activity

Choose activities like swimming, that

don’t require a lot of standing or balance

Do any activity while lying on your back when you are in your 2nd or

3rd trimester of pregnancy

Wear loose, light clothing that won’t cause excessive sweating or

increased body temperature

Perform activities in very hot weather

Drink a lot of water before, during, and after your activity

Perform activities that may bump or hurt your belly, or that may cause you to lose your balance

Eat a healthy diet and gain the right amount of

weight

Fast (skip meals) or do physical activity when you are hungry

Watch your level of exertion (Can you talk easily?)

Over-exert yourself

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Maintain a healthy weightMaintain a healthy weightOverviewOverview

Healthy weight gain can refer to Healthy weight gain can refer to your your overall weight gainoverall weight gain or your or your weekly rate of weight gainweekly rate of weight gain..

Some health care providers Some health care providers focus only on overall gain or focus only on overall gain or only on weekly gain, but some only on weekly gain, but some keep track of both types of keep track of both types of weight gain.weight gain.

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Maintain a healthy weightMaintain a healthy weightWeekly Rate Of Weight GainWeekly Rate Of Weight Gain

Time Frame Expected Weight Gain

In the first trimester of pregnancy

(the first 3 months)

Three to six pounds for the entire three

months

During the second and third trimester

(the last 6 months)

Between ½ and 1 pound each week

If you gained too much weight early in the

pregnancy

Limit weight gain to ¾ of a pound each week (3 pounds

each month) to help get your blood sugar level

under control

A weight gain of two pounds or more each week is

considered high.

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Maintain a healthy weightMaintain a healthy weightThings to Keep in MindThings to Keep in Mind

1.1. A weekly rate of weight gain may go up and down A weekly rate of weight gain may go up and down throughout the pregnancy.throughout the pregnancy.

2.2. A physician can assess whether weight gain is A physician can assess whether weight gain is appropriate or not.appropriate or not.

3.3. A A weight lossweight loss can be can be dangerousdangerous during any part of during any part of the pregnancy, therefore any weight loss needs to the pregnancy, therefore any weight loss needs to be reported to a health care provider right away.be reported to a health care provider right away.

4.4. If weight gain slows or stop, and does not increase If weight gain slows or stop, and does not increase again after one-to-two weeks, it should be reported again after one-to-two weeks, it should be reported to a health care provider immediately. Adjustments to a health care provider immediately. Adjustments in your treatment plan may be necessary.in your treatment plan may be necessary.

Maintain a healthy weightMaintain a healthy weightAdditional tipsAdditional tips

Try to get more light or moderate physical Try to get more light or moderate physical activity, if your health care provider says activity, if your health care provider says that it is safe.that it is safe.

Use the Use the Nutrition FactsNutrition Facts labels on food packages labels on food packages to make lower-calorie food choices that fit to make lower-calorie food choices that fit into a healthy meal plan.into a healthy meal plan.

Eat fewer fried foods and “fast” foodsEat fewer fried foods and “fast” foods..

Eat healthy foods that fit into your meal plan, Eat healthy foods that fit into your meal plan, such as salads with low-fat dressings and such as salads with low-fat dressings and broiled or grilled chicken.broiled or grilled chicken.

Use less butter and margarine on food, or don’t Use less butter and margarine on food, or don’t use them at alluse them at all..

Additional tipsAdditional tips

Use spices and herbs (such as curry, garlic, Use spices and herbs (such as curry, garlic, and parsley) and low-fat or lower calorie and parsley) and low-fat or lower calorie sauces to flavor rice and pasta.sauces to flavor rice and pasta.

Eat smaller meals and have low-calorie snacks more Eat smaller meals and have low-calorie snacks more often, to ensure that your body has a constant often, to ensure that your body has a constant glucose supply, and to prevent yourself from getting glucose supply, and to prevent yourself from getting very hungry.very hungry.

Avoid skipping meals or cutting back too much on Avoid skipping meals or cutting back too much on breakfast or lunch. Eating less food or skipping breakfast or lunch. Eating less food or skipping meals could make you overly hungry at the next meals could make you overly hungry at the next meal, causing you to overeat.meal, causing you to overeat.

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Keep daily records of your diet, physicalKeep daily records of your diet, physicalactivity, and glucose levelsactivity, and glucose levels

Keeping records refers to writing down your blood sugar numbers, Keeping records refers to writing down your blood sugar numbers, physical activities, and everything that you eat and drink in a physical activities, and everything that you eat and drink in a daily record bookdaily record book..

Recording everything that you eat and drink really means Recording everything that you eat and drink really means everything everything that you eat and drink. This refers to bites, nibbles, that you eat and drink. This refers to bites, nibbles, snacks, second helpings and all liquids.snacks, second helpings and all liquids.

It’s easy to forget or underestimate how much snacking you really It’s easy to forget or underestimate how much snacking you really do.do.

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Keep daily records of your diet, Keep daily records of your diet, physical activity, and glucose physical activity, and glucose

levelslevels

Keep track of the followingKeep track of the following

Blood sugar levelBlood sugar levelFoodFoodPhysical wellnessPhysical wellnessPhysical activityPhysical activityWeight gainWeight gain

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Keep daily records of your diet, physical Keep daily records of your diet, physical activity, and glucose levelsactivity, and glucose levels

It’s a good idea to follow a schedule for It’s a good idea to follow a schedule for writing in the record book.writing in the record book.

This lets you get used to writing in it and This lets you get used to writing in it and helps you to remember to do it.helps you to remember to do it.

Daily records help to keep track of how well your Daily records help to keep track of how well your treatment plan is working and what, if anything, treatment plan is working and what, if anything, should be changed.should be changed.

The information also reveals whether or not The information also reveals whether or not you will need insulin, and if so, how much you will need insulin, and if so, how much will be needed.will be needed.

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Take insulin and/or Take insulin and/or other medications as prescribedother medications as prescribed

Even if you do everything your health Even if you do everything your health care provider recommends to manage care provider recommends to manage your gestational diabetes, you may still your gestational diabetes, you may still need to take insulin during your need to take insulin during your pregnancy to keep it under control.pregnancy to keep it under control.

The only way to get extra insulin into The only way to get extra insulin into your body is to inject it under your skin your body is to inject it under your skin with a needle.with a needle.

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Take insulin and/or Take insulin and/or other medications as prescribedother medications as prescribed

You may have to include small amounts of insulin in You may have to include small amounts of insulin in your treatment plan if:your treatment plan if:Your blood sugar level is too high.Your blood sugar level is too high. You blood sugar level is frequently too highYou blood sugar level is frequently too highYour blood sugar level remains high, and you are not Your blood sugar level remains high, and you are not gaining much weight even with proper eating habit.gaining much weight even with proper eating habit.You cannot safely add physical activity to your You cannot safely add physical activity to your treatment plantreatment plan

Take insulin and/or Take insulin and/or other medications as other medications as

prescribedprescribed

Things to know about insulin:

1. If you need to take insulin, it does not mean that you didn’t try hard enough or that you failed at taking care of yourself.

2. Taking insulin does not mean that you have Type 1 diabetes.

Things to know about insulinThings to know about insulin3. An increase in the amount or dosage of 3. An increase in the amount or dosage of

insulin needed does not mean that your insulin needed does not mean that your pregnancy is in danger.pregnancy is in danger.

4. You may need more insulin if you are 4. You may need more insulin if you are under high amounts of stress or if you are under high amounts of stress or if you are sick because your blood sugar level gets sick because your blood sugar level gets higher on its own in these cases.higher on its own in these cases.

Neonatal Malformations Are Not Related Neonatal Malformations Are Not Related to Type of Insulinto Type of Insulin

0

2

4

6

8

10

12

14

16

GDM Preexisting diabetes

Regular human insulin

Insulin lisproCongenital malformation rate (%)

Bhattacharyya A et al. Q J Med. 2001;94:255-260

7.9%

6.6%

15.8%

3.8%

N=213 N=97

P=0.79

P=0.16

Malformations Are Related to Malformations Are Related to Glucose Not Type of InsulinGlucose Not Type of Insulin

Wyatt JW, Frias JL, Hoyme HE, Jovanovic L, et al. Congenital anomaly rate in offspring of pre-gestational diabetic women treated with insulin lispro during pregnancy. Diabetic Medicine 21:2001-2007, 2004.

Take insulin and/or Take insulin and/or other medications as other medications as

prescribedprescribedSpecial instructions for women taking insulin are to:Special instructions for women taking insulin are to:

Follow a regular eating scheduleFollow a regular eating schedule The timing of insulin shots and of eatingThe timing of insulin shots and of eating meals needs to be correct. Yourmeals needs to be correct. Your healthcare provider can tell you whenhealthcare provider can tell you when to do both. It is very important not toto do both. It is very important not to skip or delay meals and snacks when skip or delay meals and snacks when taking insulin because this can affect your glucose taking insulin because this can affect your glucose

insulin balance.insulin balance.

Know the symptoms of hypoglycemiaIf your blood sugar level drops below 60 at any time, you have hypoglycemia. This can be very dangerous. Hypoglycemia is already common in all women with gestational diabetes, but for women taking insulin for this condition, they are at greater risk.

Before any physical activity is begun, you should test your blood sugar. If it is low, do not begin the activity. Eat something and test again to make sure it is higher before beginning

Why does low blood sugar occur?

Too much exerciseSkipping meals or snacksDelaying meals or snacksNot eating enoughToo much insulin

How might I feel if I have How might I feel if I have low blood sugar?low blood sugar?

Very hungryVery hungryVery tiredVery tiredShaky or tremblingShaky or tremblingSweating or clamminessSweating or clamminessNervousNervousConfusedConfusedLike you’re going to pass out or faintLike you’re going to pass out or faintBlurred visionBlurred vision

* Report any abnormal blood sugar level to your health care provider right away, in case a change in your treatment plan is needed.

Hypoglycemia Hypoglycemia Prevention StrategiesPrevention Strategies

Consistent MonitoringConsistent Monitoring

Before All Meals & Snacks

Pre/Post Exercise

Bedtime

3 a.m. (occasionally)

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Things to keep in mind about deliveryThings to keep in mind about deliveryBlood Sugar and Insulin Balance

Keeping blood sugar levels under control during labor and delivery is vital for both you and your baby’s health. If you did not have to take insulin during the pregnancy, then you won’t need it during labor or delivery; however, if you did have to take insulin during pregnancy, then you may receive an insulin shot when labor begins or during labor.

Early Delivery

Gestational diabetes puts women at higher risk for a condition known as preeclampsia late in pregnancy. Preeclampsia is a condition associated with sudden blood pressure increases, which can be quite serious. Unfortunately, the only cure to preeclampsia is delivery of the baby, but delivery may not be the best option for your health or for the health of your baby. Your health care provider will keep you under close watch if this condition develops, determining whether early delivery is safe and needed.

Cesarean Delivery

This is a type of delivery used to deliver the baby, as opposed to natural delivery through the vagina. Cesarean delivery is also referred to as a cesarean section, or “C” section. Simply having gestational diabetes is not reason alone to have a C section, but your health care provider may have other reasons for choosing this option, such as changes in your health or your baby’s health during delivery.

PostpartumPostpartumoften will not require insulinoften will not require insulin

if fasting hyperglycemia – if fasting hyperglycemia –

more likely to develop persistent Diabetesmore likely to develop persistent Diabetes

6 weeks post partum 75g OGTT6 weeks post partum 75g OGTT

yearly fasting BGyearly fasting BG

emphasize importance of maintaining N emphasize importance of maintaining N weight, exerciseweight, exercise


Will I develop Type 2 diabetes in the Will I develop Type 2 diabetes in the futurefuture? There are ? There are CERTAIN TRAITS CERTAIN TRAITS ::

1.1. You developed gestational diabetes before your You developed gestational diabetes before your 2424thth week of pregnancy. week of pregnancy.

2.2. Your blood sugar level during pregnancy was Your blood sugar level during pregnancy was consistently on the high end of the healthy range.consistently on the high end of the healthy range.

3.3. Your blood sugar levels after the baby was born Your blood sugar levels after the baby was born were higher-than-average, according to your health were higher-than-average, according to your health care provider.care provider.

4.4. You are in the impaired glucose tolerance category.You are in the impaired glucose tolerance category.5.5. You are obese, according to your health care You are obese, according to your health care

provider.provider.

……....CERTAIN TRAITS CERTAIN TRAITS which increase which increase the chancesthe chances

66.You have diabetes in your family..You have diabetes in your family.77.You belong to a high-risk ethnic group (Hispanic, .You belong to a high-risk ethnic group (Hispanic,

African American, Native American, South or East African American, Native American, South or East Asian, Pacific Islander, Indigenous Australian).Asian, Pacific Islander, Indigenous Australian).

88.You have had gestational diabetes with other .You have had gestational diabetes with other pregnancies.pregnancies.

With one or more of these traits, you should talk to your doctor about Type 2 diabetes.

Should I breastfeed having gestational Should I breastfeed having gestational diabetes?diabetes?

Yes, women with gestational diabetes should Yes, women with gestational diabetes should breastfeed their babies, if possible.breastfeed their babies, if possible.Breastfeeding is not only beneficial to the baby, Breastfeeding is not only beneficial to the baby, but it is also beneficial to the mother. but it is also beneficial to the mother.Breastfeeding allows the body to use extra calories Breastfeeding allows the body to use extra calories stored during pregnancy, allowing for weight loss.stored during pregnancy, allowing for weight loss.A weight loss after having the baby not only A weight loss after having the baby not only enhances overall health, but also helps to reduce enhances overall health, but also helps to reduce the risk of developing type 2 diabetes later in life.the risk of developing type 2 diabetes later in life.

Breastfeeding is also believed to help lower fasting blood glucose levels in mothers.

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Will I have diabetes after Will I have diabetes after having my baby?having my baby?

Shortly after the baby is born, the placentaShortly after the baby is born, the placenta is “delivered.”is “delivered.”

Since the placenta is what was causing the insulin resistance, Since the placenta is what was causing the insulin resistance, when it is gone, gestational diabetes usually resolves as well.when it is gone, gestational diabetes usually resolves as well.But, just by having had gestational diabetes, you have a 40% But, just by having had gestational diabetes, you have a 40% higher chance of developing type 2 diabetes later in life than higher chance of developing type 2 diabetes later in life than women who did not have the condition during pregnancy.women who did not have the condition during pregnancy.Keeping your weight within a healthy range and keeping up Keeping your weight within a healthy range and keeping up regular, moderate physical activity after your baby is born can regular, moderate physical activity after your baby is born can help lower your risk for developing type 2 diabetes.help lower your risk for developing type 2 diabetes.

101101 gdmgdm

What should I do after delivery?What should I do after delivery?

Six weeks after your baby Six weeks after your baby is born, you should have a is born, you should have a blood test to find out blood test to find out whether your blood sugar whether your blood sugar level is back to normal. level is back to normal.

Based on the results you Based on the results you will fall into one of the will fall into one of the three categories:three categories:

If your category is…

You should…

NormalGet checked for diabetes every 3 years

Impaired Glucose

Tolerance

Get checked for diabetes every year and talk with your health care provider to learn about ways to lower your risk for developing diabetes.

DiabeticWork with your health care provider in setting up a treatment plan for your diabetes.

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Importance of checking oftenImportance of checking often

Getting checked for diabetes is important Getting checked for diabetes is important because Type 2 diabetes shows few because Type 2 diabetes shows few symptoms.symptoms.The only way to know for sure is to have a The only way to know for sure is to have a blood test that reveals a higher-than-normal blood test that reveals a higher-than-normal blood sugar level.blood sugar level.If you notice any of these things, you should If you notice any of these things, you should tell your health care provider right away:tell your health care provider right away:– Being very thirstyBeing very thirsty– Urinating oftenUrinating often– Feeling constantly or overly tiredFeeling constantly or overly tired– Losing weight quickly and/or without Losing weight quickly and/or without

reasonreason

Gestational DiabetesGestational DiabetesIntra partum managementIntra partum management

Check bloodCheck blood

Glucose hourly Glucose hourly

Maintain BG Maintain BG

4-6mmol/L ( 70-4-6mmol/L ( 70-110mg /dl )110mg /dl )

PostpartumPostpartumoften will not require insulinoften will not require insulin

if fasting hyperglycemia –if fasting hyperglycemia –

more likely to develop more likely to develop

persistent Diabetespersistent Diabetes

6 weeks post partum 75g 6 weeks post partum 75g

OGTTOGTT

yearly fasting BGyearly fasting BG

emphasize importance of maintaining emphasize importance of maintaining Normal weight, exerciseNormal weight, exercise


Preexisting Preexisting DiabetesDiabetes

Preconception CounsellingPreconception Counselling

risk of NTD ~1-2%risk of NTD ~1-2%

Folic Acid 1-4 mg /dayFolic Acid 1-4 mg /day

BG 3.5-5.3 (65-95 mg/dL)prior to mealsBG 3.5-5.3 (65-95 mg/dL)prior to meals

switch to MDI regimen (insulin ac meals switch to MDI regimen (insulin ac meals and HS)and HS)

keep track of cycles keep track of cycles

Normoglycemia prior to conception Normoglycemia prior to conception Ideally Ideally HBA1C 6% or lessHBA1C 6% or lessTeam approachTeam approachGlucose monitoring qidGlucose monitoring qidACE contraindicated : should be D/C at ACE contraindicated : should be D/C at conception or use Diltiazem insteadconception or use Diltiazem insteadBaseline HBA1C, 24h urine for protein Baseline HBA1C, 24h urine for protein Creatinine Clearance , opthalmology Creatinine Clearance , opthalmology reviewreviewSwitch from OHA to insulinSwitch from OHA to insulin

Preexisting DiabetesPreexisting Diabetes

AdviceDiet : Maintaining a healthy diet and preventing or reducing overweight willhelp you control your diabetes

Exercise : Regular exercise will help to maintain an optimum weight and will benefit all members of the family

Smoking : It is widely accepted that smoking causes heart and lung disease. Most diabetic complications are worsened by smoking

Weight control : There is a greater risk of Developing diabetes and heart disease with increasing waist circumference

Finnish Diabetes StudyThis study was conducted to determine the

effects of a programme of changes in lifestyle in patients with ‘Pre’ diabetes

Lifestyle changes included

•Weight reduction greater than 5% (if needed)•Fat intake less than 30% of calorie intake•Saturated fat less than 10% of calorie intake•Fibre intake greater than 15grams/ 1000 calories•Exercise greater than 4 hours per week (brisk walking)

Carrying out this programme resulted in less diabetes by 58%

Are you eating healthy foods?How often do you exercise?

Do you smoke?Do you know your target weight?

Blood Pressure140 / 80

Very good control of blood pressure is required!

Raised blood pressure can increase all complications of diabetes

It is important that it is checked regularly

Tablets maybe taken to control blood pressure

You may need to change what you eat and exercise more

UK Prospective Diabetes StudyUK Prospective Diabetes StudyBlood Pressure Control Study

Aggressive blood pressurecontrol reduces the risk of

most complications inDiabetes

It’s as simple as that!

Remember your target is 140/80 Have you hit the bulls-eye?

Target :

Ret

ino

path

y p

rog

ress

ion

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

any

dia

bete

s re

late

den

dpoi

nts

Dia

bete

s re

late

dde

ath

Hea

rtfa

ilur

e

stro

ke

Mic

rova

scul

ar

dis

ease

Los

s of

vis

ion

24%

32%

56%44%

37%34%

47%

P=0.004

P=0.019

P=0.004

P=0.013

P=0.009P=0.004

P=0.004

Ret

ino

path

y p

rog

ress

ion

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

any

dia

bete

s re

late

den

dpoi

nts

Dia

bete

s re

late

dde

ath

Hea

rtfa

ilur

e

stro

ke

Mic

rova

scul

ar

dis

ease

Los

s of

vis

ion

24%

32%

56%44%

37%34%

47%

P=0.004

P=0.019

P=0.004

P=0.013

P=0.009P=0.004

P=0.004

Any diabetes 0

10

20

30

40

50

60

problemHeartFailure

Stroke

CholesterolThis is the amount of fat in blood

Some blood fats are necessary to provide important energy sources

Too much fat can cause you to beoverweight, making it much more difficult to control your diabetes

It can also cause heart problems

How much fat does your blood contain?

The optimal target for blood cholesterol level is

LESS THAN 5

1 2 3 4 5 600

20

40

60

80

100

Riskreduction

55%

Simvastatin

Number of years on

Pro

port

ion

wit

hout

maj

or

Hea

rt p

rob

lem

s (%

)

1 2 3 4 5 600

20

40

60

80

100

Riskreduction

55%

Placebo

Number of years on simvastatin

Pro

port

ion

wit

hout

maj

or

Hea

rt p

rob

lem

s (%

)

SCANDINAVIAN SIMVASTATINSURVIVAL STUDY

This study showed that long-term simvastatin (cholesterol lowering drug) therapy reduces chances of dying and heart problemsin patients with diabetes

Do you know what your level is?Are you on target?

FAT

BLOOD

SERUM

D i a b e t e s C o n t r o lB l o o d g l u c o s e n e e d s t o b e k e p t w i t h i n

a c o n t r o l l e d r a n g e

4 – 7T h i s c a n b e h e l p e d b y r e g u l a r b l o o d g l u c o s e m o n i t o r i n g a t h o m e a n d k e e p i n g a n a c c u r a t e w r i t t e n r e c o r d . B r i n g i t t o c l i n i c !

W h a t i s H b A 1 c % ?

T h i s v a l u e t e l l s y o u t h e a m o u n t o f g l u c o s e s t i c k i n g t o y o u r b l o o d o v e r t h e l a s t 6 0 d a y sI t r e f l e c t s h o w w e l l y o u r d i a b e t e s h a s b e e n c o n t r o l l e d

T h e a i m i s t o h a v e a v a l u e o f l e s s t h a n 7 . 0 %W h a t d r u g s h e l p t o c o n t r o l d i a b e t e s ?

M e t f o r m i n , G l i c l a z i d e , G l i m e p i r i d e , P i o g l i t a z o n e , R o s i g l i t a z o n e , I n s u l i n a n d

m a n y o t h e r d r u g s

U K P r o s p e c t i v e D i a b e t e s G l u c o s e C o n t r o l S t u d y

T h e U K P D s t u d y s h o w s t h a t g o o dT h e U K P D s t u d y s h o w s t h a t g o o dg l u c o s e c o n t r o l c a n d e c r e a s e t h e g l u c o s e c o n t r o l c a n d e c r e a s e t h e

r i s k s o f :r i s k s o f :

H e a r t a t t a c k b y 1 6 %C a t a r a c t b y 2 4 %K i d n e y p r o b l e m s b y 3 3 %

-

-

-

-

-

-

-

-

-

-

A r e y o u i n c o n t r o l o f y o u r d i a b e t e s ?W h a t i s y o u r H b A 1 c % ?

0

1

2

3

4

5

6

7

8

9

1 0

H b A 1 c %> 1 6 0 1 4 0 t o 1 5 0 1 3 0 - 1 4 0 < 1 3 0

< 6

6 t o 7

7 t o 8

> 8

B l o o d P r e s s u r e

R i s k o f D i a b e t e s C o m p l i c a t i o n s

I n c r e a s i n g

E y e sH o w y o u r e y e s w o r k

Y o u r e y e h a s a l e n s a n d a n o p e n i n g a t t h e f r o n t , w h i c h a d j u s t t o b r i n g o b j e c t s i n t o f o c u s o n t h e r e t i n a a t t h e b a c k o f t h e e y e .

T h e r e t i n a i s m a d e u p o f d e l i c a t e t i s s u e t h a t i s s e n s i t i v e t o l i g h t r a t h e r l i k e t h e f i l m i n a c a m e r a .

A t t h e c e n t r e o f t h e r e t i n a i s t h e m a c u l a , w h i c h i s a s m a l l a r e a a b o u t t h e s i z e o f a p i n h e a d . I t i s v i t a l b e c a u s e i t e n a b l e s y o u t o s e e f i n e d e t a i l .

W h e n w a s t h e l a s t t i m e y o u h a d y o u r e y e s c h e c k e d ?

I s D i a b e t e s s l o w l y s t e a l i n g y o u r v i s i o n ?

• A p e r s o n w i t h d i a b e t e s c a n h a v e e y e d i s e a s e a n d n o t e v e n k n o w i t u n t i l s e r i o u s , i r r e v e r s i b l e v i s i o n l o s s h a s o c c u r r e d

• T h e o n l y w a y t o d i a g n o s e e a r l y s i g n s o f d i a b e t i c e y e d i s e a s e i s t h r o u g h a d i l a t e d e y e e x a m a t l e a s t o n c e a y e a r

D I A B E T I C E Y E D I S E A S ED i a b e t i c E y e D i s e a s e ( D i a b e t i c r e t i n o p a t h y ) i s t h e c o m m o n e s t c a u s e o f b l i n d n e s s u n d e r t h e a g e o f 6 5 i n t h e W e s t e r n W o r l d3 7 % o f d i a b e t e s p a t i e n t s h a v e r e t i n o p a t h y a t d i a g n o s i s o f d i a b e t e s1 5 0 0 n e w c a s e s o f b l i n d n e s s c o u l d b e p r e v e n t e d b y y e a r l y s c r e e n i n g i n U K 2 0 y e a r s a f t e r d i a g n o s i s 9 5 % w i t h T y p e 1 d i a b e t e s h a v e r e t i n o p a t h y2 0 y e a r s a f t e r d i a g n o s i s 6 0 % o f p a t i e n t s w i t h T y p e 2 d i a b e t e s h a v e r e t i n o p a t h y L a s e r t r e a t m e n t c a n s a v e e y e s i g h t g e t t i n g w o r s e i n 9 0 % o f p a t i e n t s

N o r m a l r e t i n a D i a b e t i c R e t i n o p a t h y

M a c u l a O p t i c D i s c F a t t y H a e m o r r h a g eD e p o s i t s

F e e t• D u r i n g a l i f e t i m e , y o u r f e e t m a y w a l k t h e e q u i v a l e n t o f f o u r

t i m e s a r o u n d t h e w o r l d ! • T o e n s u r e t h a t t h e y c o n t i n u e t h e i r t r i p t h r o u g h l i f e w i t h o u t

c o m p l a i n t , i t p a y s t o l o o k a f t e r y o u r f e e t !

I t i s i m p o r t a n t t h a t y o u e x a m i n e y o u r f e e t r e g u l a r l y . Y o u s h o u l da l s o f e e l i n s i d e a l l s h o e s f o r a n y s e a m s o r s t i t c h i n g w h i c h c o u l d r u b t h e f o o t a n d l e a d t o p r o b l e m s . I t i s i m p o r t a n t t h a t y o u r e c e i v e r e g u l a r f o o t a d v i c e o r t r e a t m e n t .

P e o p l e s u f f e r i n g f r o m d i a b e t e s c a n o f t e n e x p e r i e n c e l o s s o f s e n s a t i o n i n t h e i r f e e t . E v e n t h e s m a l l e s t i n j u r y c a n l e a d t o i n f e c t i o n , w h i c h i f

n o t t r e a t e d p r o m p t l y , m a y l e a d t o s e r i o u s c o m p l i c a t i o n s .

F o o t P r o b l e m s

1 5 % o f p a t i e n t s w i t h d i a b e t e s w i l l d e v e l o p f o o t u l c e r s d u e t o n e r v e d a m a g e a n d r e d u c e d b l o o d f l o w

F o o t u l c e r s c o m e b e f o r e 8 5 % o f a m p u t a t i o n s i n p e o p l e w i t h d i a b e t e s . F o o t u l c e r s a r e t h e c o m m o n e s t c a u s e o f a m p u t a t i o n i n t h e U K

L i v e r p o o l D i a b e t e s C l i n i c : F o o t P r o t e c t i o n P r o g r a m m e

W h e n p a t i e n t s w i t h d i a b e t e s a n d f o o t d e f o r m i t i e s a t t e n d e d r e g u l a r c l i n i c s w i t h a t r a i n e d p o d i a t r i s t a n d f o o t e d u c a t i o n , i t w a s f o u n d t h a t

A t 2 y e a r s u l c e r a t i o n w a s r e d u c e d t o 2 . 4 % c o m p a r e d w i t h 3 . 5 % A m p u t a t i o n w a s r e d u c e d b y 3 t i m e s

W h e n w a s t h e l a s t t i m e y o u h a d y o u r f e e t c h e c k e d ?

Guardian Drugs

30

25

20

15

10

5

0Any cardiovascular Heart Attack

problem

- 14%

-29%

ASPIRIN

Diabetes UK recommends taking aspirin to prevent against heart problems in all diabetes patients (greater than 30yrs) with any of the following:

Heart attack, angina, high blood pressure, eye problems, blood vessel diseases and kidney problems

Also if: Indo - Asian, overweight, high cholesterol, Heart Disease risk greater than 15%, family history, history of heart disease, smokers

ACE -inhibitors are drugs that have a special role in preventing diabetic complications.The HOPE study showed that one ace inhibitor, ‘Ramipril’ reduced:

The names of these drugs end in ‘PRIL’

Do you know if you are taking any of the guardian drugs?

ACE INHIBITORS

% D

ecre

ase

in E

vent

s

Heart Disease Stroke Kidney Eye disease

What are Guardian Drugs?Guardian drugs are given to protect you from further diabetes

complications

D i a b e t e s C a r e 4 U !W e l c o m e t o D i a b e t e s C a r e 4 U ! H e r e y o u w i l l f i n d p o s t e r s p a c k e d f u l l o f i n f o r m a t i o n a n d i n n o v a t i v e i d e a s t o e n s u r e y o u h a v e g r e a t D i a b e t e s

C a r e ! B e f o r e y o u e n t e r i n t o t h e u n i q u e e x p e r i e n c e l e t u s g o o v e r t h e p r o b l e m s o f d i a b e t e s .

D I A B E T I C E Y E D I S E A S EM o s t c o m m o n c a u s e o f

b l i n d n e s s i n p e o p l e o fw o r k i n g a g e

H E A R T a n d B L O O D V E S S E L S2 t o 4 f o l d i n c r e a s e d r i s k o f

h e a r t d i s e a s e a n d s t r o k e7 5 % h a v e h y p e r t e n s i o n

D I A B E T I C K I D N E Y D I S E A S E

2 0 % o f a l l n e w p a t i e n t s n e e d i n g r e n a l d i a l y s i s t h e r a p y h a v e d i a b e t e s

F O O T P R O B L E M S1 5 % o f p e o p l e w i t h d i a b e t e s d e v e l o p f o o t

u l c e r ; 5 - 1 5 % o f t h e s e n e e d a m p u t a t i o n

I f y o u t h i n k a n y a r e a o f y o u r c a r e n e e d s t o b e a d d r e s s e d p l e a s e m a k e a n o t e a n d d i s c u s s t h i s w i t h y o u r D i a b e t e s C a r e T e a m .

E n j o y t h e P o s t e r s !

S t r o k e

E y e D i s e a s e

H e a r t D i s e a s e

H i g h B l o o d P r e s s u r e

K i d n e y D i s e a s e

R e m e m b e r w i t h g o o d c a r e a l l

c o m p l i c a t i o n s c a n b e r e d u c e d

o r e v e n p r e v e n t e d !

P a i n o r l o s s o f t h e l o w e r l e g s d u e t o i m p a i r e d b l o o d f l o w

P e r i p h e r a l N e u r o p a t h y( n e r v e d i s e a s e )

Assess for end organ diseaseAssess for end organ disease

Assess for nephropathy – Assess for nephropathy –

inc risk of PIH. inc risk of PIH.

Assess & Rx.retinopathy :Assess & Rx.retinopathy :

may may PROGRESS.PROGRESS.

Assess for neuropathy :Assess for neuropathy :generallygenerally

remains stable during pregnancyremains stable during pregnancy

Assess and treat Assess and treat

Vasculopathy.Vasculopathy.CAD is a relative CAD is a relative

C/I for pregnancyC/I for pregnancy

Pre existing DiabetesPre existing Diabetes

Maternal RisksMaternal Risks– PIH /PETPIH /PET– polyhydramniospolyhydramnios– preterm labourpreterm labour– operative delivery ~50%operative delivery ~50%– birth traumabirth trauma– infectioninfection– increase in insulin requirementsincrease in insulin requirements– DKADKA


Fetal RisksFetal Risks

congenital anomalies 3X inc. riskcongenital anomalies 3X inc. risk

unexplained stillbirth unexplained stillbirth

shoulder dystociashoulder dystocia

macrosomiamacrosomia

IUGRIUGR


Neonatal Risks Neonatal Risks hypoglycemiahypoglycemiahypocalcemiahypocalcemiahyperbilirubinemia/polycythemiahyperbilirubinemia/polycythemiaidiopathic RDSidiopathic RDSdelayed lung maturitydelayed lung maturityprematurityprematuritypredisposition to diabetespredisposition to diabetes


Congenital anomaliesCongenital anomalies

3x the general population risk 3x the general population risk

approaches the gen. pop.risk (2-3%) approaches the gen. pop.risk (2-3%) if optimal control in periconception if optimal control in periconception periodperiod

related to glycemic control during related to glycemic control during embryogenesis embryogenesis


CVSCVS :ASD/VSD, :ASD/VSD,

CoA :Transposition, :CoA :Transposition, :CardiomegalyCardiomegaly

CNSCNS

:Anencephaly,:Anencephaly,

:NTD,:NTD,

:Microcephaly:Microcephaly

GI GI ::duodenal atresia, duodenal atresia, anorectal atresia, situs anorectal atresia, situs inversusinversus

GUGU : :renal agenesis renal agenesis

:Polycystic kidneys:Polycystic kidneys

MSKMSK

:caudal regression:caudal regression

:siren:siren

Congenital anomalies


Maternal SurveillanceMaternal Surveillance

Blood pressureBlood pressure

Renal function *Renal function *

Urine culture **Urine culture **

Thyroid functionThyroid function

BG control HB A1C*BG control HB A1C*

* q trimester * q trimester • ** monthly** monthly


Fetal SurveillanceFetal Surveillance

U/S for dating/viability ~ 8 weeksU/S for dating/viability ~ 8 weeks

Fetal anomaly detectionFetal anomaly detection

nuchal translucency 11-14wnuchal translucency 11-14w

maternal serum screenmaternal serum screen

anatomy survey 18-20 wanatomy survey 18-20 w

Fetal echo 22 w Fetal echo 22 w


Preexisting Diabetes

Multidose InsulinMultidose Insulin

breakfastbreakfast 25% H 25% H

lunch lunch 15% H 15% H

suppersupper 25% H 25% H

hs hs 35% NPH 35% NPH

Indicates insulin as aIndicates insulin as a% of total daily dose% of total daily dose

Gabbe Obstet Gynecol 2003

Insulin TherapyInsulin Therapy

onset (h) peak(h) duration onset (h) peak(h) duration (h)(h)

insulin analogs insulin analogs .25 .25 0.5-1.50.5-1.5 6-86-8rapid acting rapid acting 0.5 0.5 2-42-4 8-8-

1212intermediate intermediate 1-1.51-1.5 4-84-8 12-12-

1818

Insulin PumpInsulin Pump– Allows insulin release close to Allows insulin release close to

physiologic physiologic – Use short acting insulinUse short acting insulin– 50-60% of total dose is basal rate50-60% of total dose is basal rate– 40-50% given as boluses40-50% given as bolusesPotential complicationsPotential complicationsPump failure, Infection , Pump failure, Infection , Increased risk of DKA if aboveIncreased risk of DKA if abovehappenshappens

Insulin Insulin TherapyTherapy

Peripartum ManagementPeripartum Management

Withhold subcutaneous insulin from Withhold subcutaneous insulin from onset of labour or inductiononset of labour or induction

IV D10 @50cc/hIV D10 @50cc/h

IV short acting insulin inIV short acting insulin in

NS usually starting atNS usually starting at

0.5-1u/h*0.5-1u/h**10u insulin in 100 cc NS(1U=10cc)*10u insulin in 100 cc NS(1U=10cc)

Timing of Delivery Timing of Delivery GDM Diet controlledGDM Diet controlledSame as non diabetic Same as non diabetic

Offer induction at 41 weeks Offer induction at 41 weeks

if undelivered if undelivered

GDM on Insulin/Type II/Type IGDM on Insulin/Type II/Type IIf suboptimal control deliver followingIf suboptimal control deliver following

confirmation of lung maturity if <39confirmation of lung maturity if <39

weeksweeks

Otherwise deliver by 40 weeksOtherwise deliver by 40 weeks

Generally do not allow to go posttermGenerally do not allow to go postterm

Mode of DeliveryMode of Delivery

*Macrosomic infants of diabetic*Macrosomic infants of diabetic

mothers have higher rates mothers have higher rates

of shoulder dystocia than non of shoulder dystocia than non

diabetic mothers diabetic mothers

*Ultrasound estimates of fetal*Ultrasound estimates of fetal

weight become significantlyweight become significantly

inaccurate after 4000ginaccurate after 4000g

*Reasonable to recommend C/S *Reasonable to recommend C/S delivery if EFW is >4500gdelivery if EFW is >4500g

insulin rate usually based on BG and pre-insulin rate usually based on BG and pre-delivery insulin requirementdelivery insulin requirement

eg. For each 75-100 total units /24h of pre-eg. For each 75-100 total units /24h of pre-delivery insulin, 1 unit per hour neededdelivery insulin, 1 unit per hour needed

measure capillary BG hourly / VPG q2-3hmeasure capillary BG hourly / VPG q2-3h

target: 4-6mmol/Ltarget: 4-6mmol/L

Peripartum Peripartum ManagementManagement

Following deliveryFollowing delivery

stop insulin infusionstop insulin infusion

Begin sub Q insulinBegin sub Q insulin

Resume previous MDIResume previous MDI

schedule at 1/2 -2/3 theschedule at 1/2 -2/3 the

pre pregnancypre pregnancy dose dose

Maintain IV D5W @50cc/h Maintain IV D5W @50cc/h

until oral feeds tolerateduntil oral feeds tolerated

Peripartum Peripartum Management Management

Oral HypoglycemicOral Hypoglycemic agents agents

Traditionally not Traditionally not

recommended in pregnancyrecommended in pregnancy

Recent RCT of Recent RCT of oral oral glyburide vs insulin glyburide vs insulin for GDMfor GDM

440 patients440 patients

BG measured 7x dailyBG measured 7x daily

Treatment started after 11 weeks Treatment started after 11 weeks gestationgestation

Glyburide Glyburide InsulinInsulin

Achieved N BGAchieved N BG 82%82% 88%88%LGA infantsLGA infants 12%12% 13%13%MacrosomiaMacrosomia 77 44C SectionC Section 2323 2424HypoglycemiaHypoglycemia 99 66PreeclampsiaPreeclampsia 66 66Anomalies Anomalies 22 22

Oral Hypoglycemic agents Oral Hypoglycemic agents

Langer NEJM 2000

THE END

gestational diabetes

Health & Medicine