Post on 05-Jan-2016
description
Managing Gestational Diabetes
Cynthia V. Brown, RN, MN, ANP, CDESoutheastern Endocrine & Diabetes
Managing Gestational Diabetes• The management of gestational
diabetes is necessary for a healthy baby and mom.
• Managing this disorder well is a….
Richard Shafer:Richard Shafer:
…CHALLENGE!!!
Definitions
Gestational DiabetesPre-gestational Diabetes
Gestational diabetes...
• May have its’ onset or be first recognized during pregnancy
• Diabetes may have previously existed but not diagnosed
Pre-gestational diabetes...
• May be present and undiagnosed
• Evolving
• Already present and under treatment
Why is this important?
• Pre-existing diabetes at conception can lead to congenital anomalies
• Gestational diabetes leads to macrosomia and premature delivery
Congenital Malformations
• Cardiovascular: transposition, vsd, asd, hypoplastic left ventricle, anomalies of the aorta
• CNS: anencephaly, encephalocele, meningomyelocele, microcephaly
Malformations...
• Skeletal: caudal regression, spina bifida
• GU: Potter syndrome, polycystic kidneys
• GI: tracheoesophageal fistula, bowel atresia, imperforate anus
First Trimester Miscarriages
0
5
10
15
20
25
30
35
40
<6.05 6.05-7.2 7.2-8.3 8.3-9.5 >9.5
HbgA1c
Per
cent
of
wom
en
Complications by Trimester• First
– Still births– Miscarriages– Congenital defects
• Second and Third– Hyperinsulinism– Macrosomia– Delayed lung development
Complications...
• Delivery– Injuries– RD– Pregnancy loss– Neonatal hypoglycemia
Hormonal Influences
Decreased glucose levels
• Due to passive diffusion to fetus
• Causes hypoglycemia, even in non-diabetic patients
• Greatly decreases insulin need in first trimester
Accelerated starvation...
• Due to glucose diffusion
• Leads to elevated ketone production
• Unsure if this hurts baby or not
• Use as guide for increased calories
Decreased maternal alanine• Gluconeogenic amino acid
• Results in further lowering of FBS
Counterregulatory hormones• Suppressed responses to hypoglycemia• Study found BS as low as 44 did not
elicit a response• Level at which glucose & GH released
5-10 mg/dl lower in pregnant women with Type 1 DM
• Hypoglycemia aggravated by lower intake due to AM sickness
Prolonged hyperglycemia
• Enhances transplacental delivery of glucose to fetus
• Resistance to insulin x 5-6 hours PC
• Resistance related to several anti-insulin hormones
• Results in hyperglycemia
Hormones affecting blood sugar• Insulin • Glucagon• Epinephrine• Steroids• Growth hormone• Progesterone• Human placental lactogen
Peak Times of Hormonal Activity• Hormone Onset Peak
Potency• Estradiol 32 d 26 wk 1• Prolactin36 d 10 wk 2• HCS 45 d 26 wk 3• Cortisol 50 d 26 wk 5• Progesterone65 d 32 wk 4
Risk Factors
• Over 25 years of age• Family history of Type 2 diabetes• Obesity• Prior unexplained miscarriages or
stillbirths• History GDM or baby >10 pounds• PCOS
Dietary Modifications
• Decrease carbohydrate content• Frequent small feedings• Small breakfast meals• Bedtime snacks• No > 10 hours overnight fast• NO JUICE• Adequate calorie intake
Blood Sugar Goals
• Fasting: < 90 mg/dl• Premeal: 60-90 mg/dl• One-hour post-prandial: <120
mg/dl• Two-hour post-prandial: <120
mg/dl• 2AM-6AM: 60-90 mg/dl
Estimated insulin needs
• Prepregnancy 0.6 U/kg• Weeks 2-16 0.7 U/kg• Weeks 16-26 0.8 U/kg• Weeks 26-36 0.9 U/kg• Weeks 36-40 1.0 U/kg• Postpartum <0.6 U/kg
When to Start Medications
• Allow 1 week of dietary changes• Continue with diet if BS in target• First week with 2 elevated sugars,
insulin starts• Frequent testing so as not to miss
elevation• Anticipate need increasing• Do not be afraid!
Medications
• Sulfonylureas:– Glyburide typically used– Anecdotal evidence – Not very effective– Unable to achieve higher insulin
levels for meals– No long-term studies for safety
Medications
• Insulin:– NPH:
• BID dosing• Can start only at HS if FBS elevated• Long history of safety• Inconsistent absorption
Medications
• Lantus:– 24 hour coverage– Sometimes hard to affect dawn rise
without nocturnal low BS– Does not rise to meet meal-time rise
of BS
Medications
• Insulin analogs:– Humalog, Novolog, Apidra– Very rapid acting– Very effective pre- and post prandial– Less risk of hypoglycemia
Medications
• Regular insulin:– Slower onset– Longer duration– May be necessary in those who do not
want to take as many injections
Insulin Dosing During Labor• Need decreases dramatically• BS must be perfect in 72 hours
prior to delivery• May not need insulin during labor• Type 1 needs only basal insulin
with PRN supplementation
Postpartum
• Continue periodic testing • Aim to lose weight• Glucose challenge @ 6 wk check• Breast-feeding lowers BS, leads to
hypoglycemia
Managing Gestational Diabetes
THANK YOU!
Cynthia V. Brown, RN, MN, ANP, CDE
Southeastern Endocrine & Diabetes