Transcript HOW SWEET IT IS: - Hartford Hospital

HOW SWEET IT IS:
Managing Diabetes For A Healthy
Pregnancy And Beyond
Ruth Ferrarotti, MSN, APRN-BC, CDE
Assoc. Clinical Prof., Univ. of Conn.
Discussion Topics
Gestational Diabetes:
Diagnosis and management
Postpartum recommendations
Established Diabetes:
Pre-pregnancy counseling
Management of diabetes
Postpartum recommendations
Diabetes After Pregnancy
Classification of Diabetes
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Type 1 Diabetes – Beta cell
destruction
Type 2 Diabetes – Progressive insulin
secretory defect and insulin resistance
Other – genetic defects, diseases of
exocrine pancreas and drug/chemical
induced
Gestational Diabetes
Approximate Prevalence of Diabetes
in Pregnancy in the United States
4.022 Million Births in 2002
More than 200,000 type 2 diabetes mellitus + 135,000 GDM + 6000
type 1 diabetes mellitus = 341,000 pregnancies complicated by
hyperglycemia annually
Diabetes 8%
Diabetes 8%
50% GDM
24% Diagnosed T2DM
Nondiabetes
92%
GDM=gestational diabetes mellitus
24% Undiagnosed
T2DM
2% T1DM
The Impact of Maternal Hyperglycemia
During Pregnancy
Modified Pedersen Hypothesis
Fetal pancreas stimulated
Fetal
hyperinsulinemia
Placenta
Maternal hyperglycemia
Insulin
IgG-antibody-bound
insulin
Insulin resistance syndrome
Fetus
IgG=immunoglobulin G
Mother
Diabetes and Pregnancy
Type 1 and Type 2 Diabetes
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Preexisting diabetes diagnosis
Preconception care is essential
Treat with insulin
If untreated during first few weeks’ gestation, associated with
– Spontaneous abortion
– Birth defects
If untreated during second or third trimester, associated with
– Fetal macrosomia
– Birth injury
– Maternal hypertension
– Maternal preeclampsia
– Future diabetes and/or obesity in child
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78
Preconception Care of Established
Diabetes
Medical Assessment
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Duration and type of diabetes
Medical history and current medical
management plan
Chronic diabetes-related complications
– Retinopathy
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Dilated eye exam by trained ophthalmologist
– Nephropathy
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24-hour urine for creatinine clearance, total protein
excretion, and microalbuminuria
– Neuropathy
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Autonomic neuropathy, especially gastroparesis
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78
Preconception Care of Established
Diabetes
Medical Assessment
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Comorbid conditions (in addition to diabetic
complications)
– Hypertension
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Measure blood pressure
– Coronary artery disease
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Stress test
– Hyper- or hypothyroidism
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Free T4 and TSH
– Other autoimmune diseases
T4=thyroxine
TSH=thyroid-stimulating hormone
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78
Preconception Care of Established
Diabetes
Blood Glucose Goals
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SMBG
– Fasting/premeal: 70 to100 mg/dL
– 1 hour postmeal: <140 mg/dL
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A1C
– In normal range (<6%, but ideally <5%)
– Monitor until A1C is stable at <6%
SMBG=self-monitoring of blood glucose
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by
Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:1-19
Diabetes in Early Pregnancy (DIEP) Trial
Postprandial Blood Glucose Levels
Predict Macrosomia Risk
60
Risk for
macrosomia
50
(%)
40
30
20
10
0
80
90
100
110
120
130
140
150
160
170
1-hour postmeal blood glucose (mg/dL)
Adapted from Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1991;164(1 pt 1):103-111
180
Management of Diabetes
in Pregnancy
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Type 1
– Multiple daily injections
– Insulin pump
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Type 2
– Change to insulin if on oral agents
– Insulin pump
Multiple Daily Injections
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Combination of intermediate or longer
acting insulin with rapid insulin
– NPH
– Lantus
– Analog
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Usually require 4-6 injections daily
Management of Diabetes
in Pregnancy
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Monitor BG pre and 2 hrs post meal
Calculate premeal rapid insulin based
on carbohydrate intake
Calculate correction for premeal
elevated glucose
Discourage postprandial correction
Insulin Pump
Advantages:
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More physiologic than MDI
– Programmable bolus reduces risks for
hypoglycemia, post-meal hyperglycemia
and glucose excursions
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Allows for greater flexibility with diet
and lifestyle
Increased motivation promotes better
control
Insulin Pump
Disadvantages
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Requires increased patient
responsibility and motivation
Risk of rapid onset ketoacidosis if
catheter becomes dislodged or site
infection
Mechanical problems with pump
Infusion site limited in later pregnancy
Sensor Augmented Pumping
Advantages
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Decreased risk of glucose excursions
and hypoglycemia
Provides instant information
Allows for greater flexibility to diet and
lifestyle
Reduces number of self-monitored
glucose tests
Sensor Augmented Pumping
Disadvantages
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Not as accurate as glucose results by
fingerstick
“Too much data”
Expensive and not always covered by
insurance
Requires another site
Alarms
Diabetes and Pregnancy
Gestational Diabetes Mellitus
Glucose intolerance of variable degree
with onset or first recognition during pregnancy
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Mainstay of treatment is medical nutrition therapy (MNT)
Add insulin if MNT does not maintain normoglycemia
If untreated, associated with:
– Late-term intrauterine fetal death
– Fetal macrosomia
– Neonatal hypoglycemia and/or jaundice
– Maternal hypertension
– Future diabetes and/or obesity in child
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S88-S90
Metzger BE, Coustan DR. Diabetes Care. 1998;21(suppl 2):B161-B167
Gestational Diabetes
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Approximately 7% of all pregnancies are
complicated by GDM
Translates to over 200,000 cases
annually(1)
Approximately 42,000 births in
Connecticut in 2008(2)
2980 complicated by GDM
(1) Diabetes Care, Vol.33, Supp. 1, Jan. 2010
(2) Connecticut Vital Statistics, 2008
Gestational Diabetes
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Glucose intolerance of varying
severity, with onset or first recognition
during the current pregnancy.
Currently diagnosed using two step
method
Diagnostic screening between 24-28
weeks gestation
Diagnosis of GDM
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1998 Guidelines
– 1HR oral glucose
challenge
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135-185
≥ 186
– 3HR OGTT
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FBS ≥ 95
1hr ≥ 180
2hr ≥ 155
3hr ≥ 140
Carpenter and Coustan
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2010 Guidelines
– 2HR OGTT
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FBG ≥ 92
1hr ≥ 180
2hr ≥ 153
IADPSG Consensus
Panel
Managing GDM
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Lifestyle modifications:
– Medical Nutrition Therapy
– Exercise
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Self-monitoring blood glucose
FBS < 90mg/dl
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Medication
– Oral agents
– Insulin
2 hr postprandial <120mg/dl
Medications in GDM
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Insulin
– NPH
– Analogs
– Lantus
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Oral agents
– Glyburide
– Metformin
Physical Activity in GDM
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Can improve peripheral insulin resistance and
glucose levels
Can obviate need for insulin
Encouraged for women with no obstetric
contraindications
Avoid physical activity associated with maternal
hypertension or fetal distress (eg, resistance
training, lower-body weight-bearing exercise)
Upper-body cardiovascular training is a good
option
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed.
Alexandria, Va: American Diabetes Association; 2000:111-132
Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1989;161:415-419
Immediate Postpartum
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Insulin requirements disappear
Diabetes will disappear in 90% of GDM
cases.
Continue monitoring 24-48 hrs after
delivery, as indicated
Postpartum Considerations
Lactation and Nutrition
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Breastfeeding is recommended
– Decreased risk of type 1 diabetes and infection in infant
– Promotes infant growth and development
Maintain pregnancy meal plan or develop postpartum plan to meet
added caloric requirements of breastfeeding
Rapid weight loss is not advised; exercise is recommended
Insulin use must be continued if postpartum normoglycemia cannot be
maintained with MNT
Blood glucose concentrations may be variable in women with type 1
diabetes
– Test glucose frequently
– Snack and/or adjust evening insulin to avoid nighttime
hypoglycemia
– Watch for hypoglycemia due to missed or delayed meals
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes.
3rd ed. Alexandria, Va: American Diabetes Association; 2000:67-86
Postpartum
Recommendations
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Self-monitoring
– Fasting <100
– 2 hr post-prandial <140
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Glucose testing 6-12 weeks post
delivery
Reclassification of diabetes
Diabetes After Pregnancy
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40-60% risk of developing Type 2 DM
within 5-15 years
Approximately 20% continue with
abnormal glucose after delivery
66% risk of developing GDM in
subsequent pregnancy
Diagnosing Diabetes
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ADA 2010 Diagnostic Criteria
– A1C ≥ 6.5% or:
– FPG ≥ 126mg/dl or:
– Two-hour plasma glucose ≥ 200mg/dl
or:
– Classic symptoms of hyperglycemia or
hyperglycemic crisis, a random glucose
≥200mg/dl
Diagnosing Diabetes
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New classifications
Pre-diabetes
– A1C 5.7% to 6.4%
– 2 hr OGTT
FPG 100-126
 2 hr 140-199
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Refer for nutrition counseling, weight
loss and ongoing care