Diabetes in PregnancyGestational Diabetes Protocols in a Primary Care Setting DAC September 8, 2006 La Familia Medical Center Paula Devitt,RN,CDE Sylvia Ornelas,CHW
Maternal hyperglycemia Insulin Fetal pancreas stimulated Fetal hyperinsulinemia IgG-antibody-bound insulin Insulin resistance syndrome The Impact of Maternal Hyperglycemia During PregnancyModified Pedersen Hypothesis Placenta Fetus Mother IgG=immunoglobulin G
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% 2% T1DM GDM=gestational diabetes mellitus
In our practice many of the patients who were diagnosed during pregnancy were really undiagnosed type 2 diabetics • To address this is to screen all women of conception age for diabetes. • To educate all pregnant women on healthy nutrition and on exercise • We set up an integrated group prenatal class for all pregnant women. • First trimester, 2nd trimester (26-28 weeks) and third trimester.
Diabetes in Early Pregnancy (DIEP) Trial Probability of Pregnancy Loss by A1C Status Rate of pregnancy loss (%) Diabetes No diabetes Mills JL et al. N Engl J Med. 1988;319:1617-1623
Diabetes and PregnancyType 1 and Type 2 Diabetes • 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. 2006
Potential Complications inInfants of Mothers With Diabetes • Intrauterine demise • Spontaneous abortion • Stillbirth • Macrosomia • Visceromegaly • Cardiomegaly • Hepatic enlargement • Birth injury • Shoulder dystocia • Erb’s palsy • Diaphragmatic paralysis • Facial paralysis • Cerebral ischemia • Hemorrhage in brain, eyes, liver, genitalia Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:133-149
Potential Complications inInfants of Mothers With Diabetes • Asphyxia • Respiratory distress syndrome • Congenital malformations • Cardiac defects • Musculoskeletal deformities • Metabolic abnormalities • Hypoglycemia • Hypokalemia • Hypocalcemia • Hyperbilirubinemia • Erythrocytosis Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:133-149 Mills JL et al. Diabetes. 1979;28:292-293
Preconception Care of Established DiabetesBlood Glucose Goals • SMBG • Fasting/premeal: 80 to110 mg/dL • 1 hour postmeal: <155 mg/dL • A1C • In normal range (<6%, but ideally <5%) • Monitor until A1C is stable at <7 SMBG=self-monitoring of blood glucose Joslin Diabetes Center and Joslin Clinic; Guideline for Detection and Management of Diabetes in Pregnancy 9/14/2005
Preconception Care of Established DiabetesMedical Goals • Switch from oral agent therapy to physiologic basal-bolus insulin replacement (type 2 diabetes) • Prevent hypoglycemia and ketoacidosis • Blood pressure <130/80 mm Hg • Protein excretion levels <150 mg/24 hours • Free T4 >1.0 but <1.6 ng/dLTSH <2.5 IU/mL • Establish medical team for ongoing management American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78
Exception to discontinuing oral anti-diabetic meds during pregnancy • Metformin may be continued during first trimester on patients with PCOS or type 2 DM with anovulatory infertility. At first visit should begin increasing insulin to control blood sugar and taper off metformin.
Other Meds • ACE inhibitors must be stopped before pregnancy or first trimester due to risk of fetal injury or demise in 2nd and third trimester. • ARBs must be stopped prior to pregnancy • (Diltiazem in extended release may be a useful substitute. • Stop all cholesterol lowering agents. Joslin Diabetes Center and Joslin Clinic; Guideline for Detection and Management of Diabetes in Pregnancy 9/14/2005
Diabetes and PregnancyGestational Diabetes Mellitus • 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 Glucose intolerance of variable degree with onset or first recognition during pregnancy
180 mg/dL STOP Check Fasting BS >95 Diabetic Refer to HE, A1C Otherwise, administer 3-h 100-g OGTT (2 or more abnormal values, patient has GDM) 1 h 180 mg/dL 2 h 155 mg/dL 3 h 140 mg/dL 140–180 mg/dL Administer FPG and 3-h 100-g OGTT on separate day Rescreen later in gestation If FPG 95 mg/dL STOP Patient has GDM Refer to Health Ed 130 mg/dL STOP Patient does not have GDM If patient has GDM risk factors, rescreen at 24–28 weeks’ gestation GDM Screening and DiagnosisUniversal Screening Guidelines Average and high risk: Screen at intakeLow risk: Screen at 24 to 28 weeks’ gestation Screen with 1-h 50-g GCT FPG=fasting plasma glucose Jovanovic-Peterson L et al. Am J Perinatol. 1997;14:221-228 /ADA 2006 Diabetes Care
SMBG During Pregnancy Complicated by DiabetesBlood Glucose Goals and Testing Frequency *2:00–4:00 AM if nocturnal hypoglycemia is suspected
Medical Nutrition Therapy in Pregnancy Complicated by DiabetesGeneral Dietary Guidelines • Eat 3 daily meals; snack as needed • Eat a very small breakfast • Control carbohydrate intake Eat low glycemic foods. Do not restrict under 130Gm of CHO. • Choose foods high in fiber • Choose foods low in saturated fat • Avoid concentrated sweets • Take a multivitamin with iron, folic acid, and calcium
Nutrition Flags at a medical visit refer back to health education • Poor weight gain • Ketones in their urine Refer Back to Health Education: • Blood Sugars out of goal • Need additional support Karla calls each patient weekly for Blood Sugars.
Physical Activity in GDM • 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
Prenatal Management Pre-existing DM . First visit • A1C • collect 24 hr urine (protein, creatinine clearance, creatinine) • schedule EKG • Schedule eye exam • Eye exam each trimester with established eye care provider or refer for Joslin Vision Program in Health Education (Retinal Specialist on our team: Michael Seligson ) Class D-T renal evaluation each trimester.
Prenatal Mgt DM • Schedule ultrasound appointment • Dating scan at 10 – 12 weeks • Targeted scan including fetal echo at 18-20 weeks • Growth scan at 26 weeks and every 4 weeks thereafter • NST + AFI twice weekly starting at 32 weeks; start at 28 -weeks if poorly controlled or class D- T.
GDM Management • Diet controlled • • Follow fasting and 1 hr or 2 hr postprandial plasma glucose (1hour goal <130, 2 hour goal <120). • • Growth scan at 34-36 weeks to evaluate growth • Not controlled with diet alone • Follow fasting and 1 hr or 2 hr postprandial plasma glucose (1hour goal <130/120, 2 hour goal <120). • Growth scan every 4 weeks after insulin or oral medication started (but no earlier than 26 weeks) • Initiate twice weekly antenatal testing at 28 - 32 weeks
Insulin Therapy: GDM Current body wt in kg x (.2-1.0 units) = Total daily dose Total daily dose (TDD) is only a starting point. Insulin Should be adjusted PRN to control blood glucose. Use Lispro to cover meals, NPH to cover overnight Lispro should be taken 15 minutes before or immediately after each meal Units of Lispro TDD x .25 pre-breakfast TDD x .25 pre - lunch TDD x .25 pre – dinner TDD x .25 NPH at bedtime Give NPH at bedtime to cover morning fasting. NPH dose must be adjusted based on fasting blood sugars. NPH most common intermediate insulin used. Lantus offers a more constant basal coverage with less injections. UNM Protocol
Insulin Therapy: Insulin Bolus: (Humalog or Novolog) Current body wt in kg x (.6 to 1.0 units) =TDD Do not mix with other insulin Determine pre-meal insulin using rule of 1500 Premeal correction 1500/TDD = mg/dl that 1 unit of insulin will decrease blood glucose Insulin/CHO Ratio (1500/TDD) x .33 = grams of CHO covered by 1 unit of insulin We usually start with 1 unit per serving of CHO and titrate up to keep post-prandial <120 TDD x .5 = general rule for basal coverage dose. NPH titrated to maintain fasting at goal. Lantus daily (Not studied in pregnancy) Concern Lantus may stimulate insulin-like growth factor more than other insulins. Lantus:C
Insulin Delivery Throughout PregnancyCalculating Daily Insulin Dose for Pregnancy With Preexisting Diabetes Gestationalweek Insulin dose 4–12 12–24 24–38 38–42 0.7 U 0.8 U 0.9 U 1.0 U Multiplied by currentpregnant weight in kg Jovanovic L. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc; 2002:139-151
Insulin Delivery Throughout PregnancyInitiating Insulin Therapy in GDM • If glucose concentrations are not controlled by MNT alone, initiate stepwise insulin therapy • Administer insulin based on specific abnormal FPG, premeal, and 1-hour postprandial glucose readings • Treat high FPG with bedtime NPH • Treat pre-dinner hyperglycemia with pre-breakfast NPH • Treat bedtime hyperglycemia with pre-dinner NPH • Treat abnormal postprandial glucose with rapid-acting insulin (lispro or aspart) immediately before the offending meal • May need up to 6 injections/day (3 NPH, 3 lispro or aspart), same as protocol for preexisting diabetes • Evaluate regimen for 1 week; adjust as needed to maintain glucose <90 mg/dL before meals and <120 mg/dL 1 hour postmeal Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:111-132
Lunch lispro oraspart Breakfast lispro or aspart Dinner lispro or aspart Six Injections/Daily Insulin AlgorithmNPH Three Times a Day + Premeal Aspart or Lispro Plasmainsulin 24:00 4:00 24:00 16:00 8:00 12:00 20:00 NPH NPH NPH NPH Time
Insulin Lispro Controls Postprandial Hyperglycemia in GDM Plasmaglucose(mg/dL) Jovanovic L et al. Diabetes Care. 1999;22:1422-1427
Infant Malformations in Preexisting Diabetes Are Related to First-Trimester A1C Levels, Not Type of Insulin A1C standard deviation from mean at first prenatal visit correlates with major anomaly rate in insulin lispro–treated patients (5.4%, P=0.04) A1C standard deviation from mean 14 Percentwith major anomalies 12 10 8 6 4 2 0 <–2 –2 to <0 0 to <2 2 to <4 4 to <6 6 to <8 8 Wyatt JW et al. Diabet Med [online early]. Available at: http://www.blackwell-synergy.com/links/doi/10.1111/j.1464-5491.2004.01498.x/abs/. Accessed December 23, 2004
Insulin PreparationsAdvantages and Disadvantages During Pregnancy Advantages Disadvantages • Delayed and prolonged • action profile does not • match mealtime needs • Inexpensive Regularhuman insulin Lispro Aspart Glulisine NPH Glargine Detemir • Action profile matches • well with mealtime needs • Limited objective data • verifying safety in pregnancy • Long experience verifies • safety in pregnancy • Peak action profile requires multiple injections for smooth 24-hour effect • Flatter 24-hour profile • allows fewer injections • No objective data verifying safety in pregnancy
Advantages Programmable bolus dosing decreases risk of Glucose excursions Hypoglycemia Hyperglycemia No need for multiple daily injections Greater diet and lifestyle flexibility Increased patient enthusiasm and contact with health care team Disadvantages Complicated regimen requires high level of patient vigilance Mechanical problems with pump can lead to ketoacidosis or hyperglycemia Increased risk of infection at insertion site Catheter cannot be inserted in abdominal wall; alternate site required Rapid progression to ketoacidosis if catheter dislodges Continuous Subcutaneous Insulin Infusion (CSII)Advantages and Disadvantages ofInsulin Pump Use During Pregnancy Gabbe SG. J Matern Fetal Med. 2000;9:42-45
Basal Insulin Pump Regimen Basal requirement(hourly infusion rate) Basal (B/24) 50% less basal (B/24 x 0.5) 50% more basal (B/24 x 1.5) Period 10:00 AM– midnight Midnight– 4:00 AM 4:00 AM– 10:00 AM Rationale NA Maternal cortisol at nadir Overcome dawn phenomenon Basal (B)=one half of total daily insulin dose B/24=hourly rate Patient should perform SMBG at beginning of each period to determine if adjustments are needed Jovanovic L. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc; 2002:139-151
When to Deliver • Refer women at 37 weeks to health education for development of their labor plan. Copy will be placed in the chart. A copy will also be given to the patient to take to the hospital when she is in labor. • A. Diet and Exercise Controlled • • Labor spontaneously or induce 40-42 weeks • • Start antenatal testing at 40 weeks. • B. On Insulin ( good control with nml antepartum testing) • • induce at 39 – 40 weeks • C. Diabetes with Complications (ClassD-T) or Patients on Insulin(class A2 – C) with poor control • • dating scan ≤ 20 weeks deliver at 37-38 weeks • • dating scan > 20 weeks tap and deliver 37-38 weeks
Labor Support • Doula Program Prenatal Promotoras who are certified as doulas provide support to our patients in labor. Doula a specially trained woman that provides assistance, encouragement and support during labor.
Labor and Delivery • Induction • • Patient should take usual medication (insulin or glyburide) at bedtime. • • Eat nothing after midnight. • • Do not take morning medication. • • On arrival, check blood glucose and start insulin drip as described below
Spontaneous Labor • • On Arrival check blood glucose • • Ask when last took insulin or oral medication • • Insulin requirements drop during labor similar to exercise. • GDM patients don’t usually require insulin.
Scheduled Cesarean • Patient should take usual medication (insulin or glyburide) at bedtime • Eat nothing after midnight • Do not take morning medication • On arrival check blood glucose (patient should be fasting so should be normal if sugars have been well controlled) • Perform cesarean section within 2 hours • If unable to perform surgery immediately or patient in poor control, start insulin drip as described below. • Perform cesarean section after 4-6 hrs euglycemia.
Insulin Drip Protocol • If initial blood glucose >150 give 3 or more units of IV Humalog or IV Regular and start insulin drip at 2u/hr • If initial blood glucose 125-150 give 2 units of IV Humalog or IV Regular and start insulin drip at 1u/hr • If initial blood glucose 100 – 124 give 1 unit of IV Humalog or IV Regular and start insulin drip at 1u/hr • If initial blood glucose ≤ 100 and >65 start insulin drip at 1u/hr • If blood glucose < 65 start insulin drip at 0.5u/hr and D5NS at 125cc/hr at the same time. Check blood glucose in 30 minutes. • Start D5LR or D5NS at 125cc/hr when blood glucose = 100 • 1. 125 units of humalog in 250cc NS = 1 unit of insulin/2cc or • 50 units of Regular insulin in 500cc NS or LR = 1 unit of insulin/10cc UNM Protocol
Neonatal Hypoglycemia Is Inversely Related to Maternal Hyperglycemia at Delivery Glucose(mg/dL) 250 Type 1 diabetes 200 Type 2 diabetes GDM 150 100 50 0 Maternal glucose Neonatal glucose Jovanovic L, Peterson CM. Am J Med. 1983;75:607-612
Postpartum ConsiderationsLactation and Nutrition • Breastfeeding is recommended • Decreased risk of type 1 diabetes and infection in infant, Decrease incidence of type 2 by ½. • 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 ( type 1s ½ of previous requirement GDMs usually do not require insulin pp)
Postpartum ConsiderationsContraception Adapted from Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:21-28
Postpartum ConsiderationsGDM • Women with previous GDM have • 40% to 60% risk of developing type 2 diabetes in 5 to 15 years • 66% risk of GDM in future pregnancies • Monitor blood glucose levels • For 1 week postpartum • At first postpartum checkup , 6-12 weeks, 2 hour OGTT • Yearly thereafter (FPG) Studies in progress to check A1C • Encourage weight loss if patient is overweight or obese • Provide appropriate referrals if diabetes or IGT diagnosed • Continue insulin if normoglycemia cannot be maintained with MNT Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria,Va: American Diabetes Association; 2000:151-157 American Diabetes Association. Diabetes Care. 2006
3 lb, 5 oz 5 lb, 8 oz 7 lb, 11 oz 9 lb, 14 oz The U-Shaped CurveBirth Weight and Risk of Future Type 2 Diabetes Percent 25 20 15 10 5 0 1500 g 2500 g 3500 g 4500 g Birth weight • Jovanovic L. Diabetes Care. 2000;23:1219-1220McCance DR et al. BMJ. 1994;308:942-945
Sweet Success !!! • A Happy Healthy Birthday! • Special Thanks to a great team!! At La Familia Medical Center and to all the women who shared their pregnancy with us!