Diabetes Mellitus in PregnancyKAELY JACKSON, RD/LD, CDEOU PRENATAL DIAGNOSTIC CENTER

Learning Objectives

Describe the differences in the pathophysiology of Type 1, Type 2, and gestational diabetes and the expected effect these differences will have on glycemic control

State the rationale for the goal of tight glycemic control in pregnancy and discuss collaborative measures to attain this goal in the hospitalized antepartum, intrapartum, and post- partum patient

Review methods of treating diabetes in pregnancy

Discuss present technology associated with diabetes management

Introduction

Diabetes effects 8% of pregnancies in the United States 90% of these cases are Gestational Diabetes

Diagnosis of diabetes during pregnancy has increased in recent years and continues to rise

From 2000 to 2010, the percentage of pregnant women with gestational diabetes increased 56% and the percentage of women with type 1 or type 2 diabetes before pregnancy increased 37%.

DIABETES RISK FACTORS• Overweight/obese• Sedentary• AMA• Family history• Ethnicity

Definitions

GESTATIONAL DIABETES (GDM)- any degree of impaired glucose tolerance with onset or first recognition during pregnancy

PRE-EXISTING DIABETES OR PREGESTATIONAL DIABETES-diagnosis of diabetes prior to pregnancy

Type 1 Diabetes , Type 2 Diabetes

Pathophysiology- GDM

Gestational Diabetes Pregnancy hormones cause insulin resistance

The body isn’t able to make enough insulin for the pregnancy

Pathophysiology- GDM

Pregnancy HORMONES

insulin resistance

not enough insulin for pregnancy too much glucose

from the liver

High Blood

Glucoseor

hyperglycemia

+ +

Diagnosis of GDM

2-step approach (preferred method at OUHSC):

To be done 24-28 wks (unless risk factors present indicating earlier screening)

1. 50 gram glucola screen:

Normal <135. If > 135 <200, do 3 hr GTT below

If > 200, do not do GTT and proceed with treatment for GDM

2. 100 gram, 3-hr GTT (Carpenter & Coustan)

Parameters for diagnosis:

meet or exceed: 95 / 180 / 155 / 140

2 or more abnormal values: GDM

Pathophysiology- Type 2 Diabetes

Most common type of diabetes in reproductive aged women

Insulin resistance

Pathophysiology- Type 1 Diabetes

No insulin production

Dependent on insulin

Why Is This AConcern?

As pregnancy progresses, insulin resistance increases Caused by increased hormones of pregnancy

Insulin production is more than twice non-pregnant levels

Why is this a Concern?

Maternal glucose crosses the placenta and increases baby’s glucose levels

Maternal and Fetal RisksGestational Diabetes

Fetal Risks Growth disturbances

Intrauterine fetal demise

Neonatal Hyperbilirubinemia

Hypoglycemia

Obesity

Diabetes

Maternal Risks

Pregnancy induced hypertension

Preeclampsia

Polyhydramnios

UTI/pyelonephritis

Maternal and Fetal RisksPre-Existing Diabetes

Fetal Risks Growth disturbances

Congenital anomalies

Intrauterine fetal demise

Miscarriage

Neonatal Hyperbilirubinemia Hypoglycemia Obesity

Diabetes

Maternal Risks

Pregnancy induced hypertension

Preeclampsia

Polyhydramnios

UTI/pyelonephritis

Maternal Morbidity

Creasy and Resnik, Maternal Fetal Medicine, 2004

How to Treat Diabetes in Pregnancy

Nutrition / Meal Planning

Exercise

Medicine

Monitoring

Diabetes in PregnancyGoals of Treatment

Achieve normal blood glucose and hemoglobin A1C levels

Prevent and/or minimize maternal and perinatalmorbidity/mortality

How? Diabetes Education: Nutrition, Exercise, Monitoring

Medication

Diabetes Education is Important!

Any pregnant patient who has diabetes or develops GDM should have outpatient diabetes education.

When hospitalized, if available, a diabetes educator can reinforce outpatient education and/or help manage blood glucose while in the hospital.

Diabetes Education

Teach glucose monitoring Help facilitate getting glucometer Insulin or oral medication teaching Diet teaching Exercise education Hypoglycemia precautions Identifying patterns and altering treatment plan

Diabetes Education: Who does it?

Inpatient CDE or Diabetes Nurse

Dietitian (RD) should be informed when patient is admitted

Nurse caring for patient (YOU!)

If patient is discharged while still pregnant, should follow up with educator or RD

http://www.mybotanicalbaby.com/gestational-diabetes-diet/

Diabetes Management: Nutrition Education

Diabetes Management: Calorie Requirements

Pregnancy requires an additional 300 kcal/day An extra apple with peanut butter and half an English muffin 1 bowl of soup, 1 small salad with 4 crackers 2 mozzarella cheese sticks and 1/4 cup almonds

Caloric recommendations for pregnancy 30 kcal/kg/d if at ideal body weight 24 kcal/kg/d if >20-50% above ideal body weight 12-18 kcal/kg/d if >50% above ideal body weight 36-40 kcal/kg/d if >10% below ideal body weight

Diabetes Management: Dietary Composition

Diet composition: 40% CHO (no less than 150 grams), 20% protein, 30-40% fat

10% of calories for breakfast 30g CHO 30% of calories for lunch 45g CHO 30% of calories for dinner 45g CHO 30% of calories for snacks (3) 15-30g CHO = TOTAL: 165-210g CHO

Avoid periods of longer than 4 hours without food during the day and longer than 10 hours overnight

Bedtime snack of 15-30g of complex carbs plus protein helps to decrease risk of nocturnal hypoglycemia and prevents overproduction of glucose overnight in women with Type 1 and Type 2 diabetes

Diabetes Management: What happens if you don’t eat

carbs?

Possible ketosis Constipation Quick weight loss Lack of energy Decreased consumption of fruits and vegetables May interfere with insulin sensitivity (no

improvement in BG control) No studies on low carb diets/pregnancy

Diabetes Management: Exercise

Exercise decreases insulin resistance, may delay or negate need for insulin in GDM or Type 2 DM

Once diagnosed with GDM, it is difficult for patients to begin an exercise program if they have not already been exercising

Patients on bedrest have harder time controlling BG

Diabetes Management: Exercise in the Hospital

If post-prandial BG is elevated, walking for 10 minutes after each meal is helpful

If fasting BG is elevated, after dinner exercise is recommended

LE exercise is contraindicated in some situations

UE exercise has no effect on uterine contractility

Order for PT may be helpful

Diabetes Management: Monitoring

ACOG Guidelines - GDM, T2DM Fasting and Pre-prandial <95 One hour postprandial <140

Two hour postprandial <120

Type 1 DM- 7-8x daily testing, Fasting, Pre-meal, Post-meal, and HS, occasional 0300

Hospitalized patients admitted for glucose control: 7-8x daily 3AM if nighttime hypoglycemia is a problem

Avoid blood sugars less than 60

Diabetes Management: Monitoring

Hemoglobin A1c Assess every 4-6 weeks during pregnancy

Pregnancy goal is A1C <6 %

If A1c is elevated in first trimester, patient may have undiagnosed diabetes

Medication Treatment: Oral Hypoglycemics

SULFONYLUREAS (GLYBURIDE)

BIGUANIDES (METFORMIN)

No oral agents are FDA approved for treating gestational diabetes

Glyburide for Gestational Diabetes

More cost effective than insulin

Patients prefer it over insulin injection therapy

Category C in pregnancy

Hypoglycemia precautions needed

Not recommended at bedtime

Crosses the placenta marginally

More research needed

Glyburide: Dosing Recommendation

Should be taken 30-60 minutes prior to meal Initial dose 2.5 mg in the AM

5 mg in the AM 5mg twice a day 10 mg AM/5 mg PM 10mg AM/10 mg PM

Maximum dose 20 mg/day

Adjustments made every 3-7 days

Significant interprandial hypoglycemia can occur

Biguanides: Metformin

Inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissues

If a patient is taking Metformin prior to pregnancy, usually can continue

Metformin Use in Pregnancy

Continue through the first trimester if a patient conceives on Metformin

May be an adjunct to insulin therapy in cases of extreme insulin resistance

May be an option in a patient who refuses insulin therapy (esp. with fasting hyperglycemia)

May cause GI upset

**Little risk of hypoglycemia**

Insulin Treatment in Pregnancy

Insulin Treatment in Pregnancy

Insulin dose not cross placenta in pregnancy First Trimester

Often necessary to reduce insulin dose by 10 - 25%

Second and third trimester Doses will need to be increased Type I 10-20% Type II 30-150%

After 35-38 weeks insulin requirements may decline

Insulin Treatment in Pregnancy:Insulin Regimens

NPH insulin

Intermediate- Acting

Starts working in 2-4 hours, Peaks at 4-8 hours, Duration: 8-16 hours

Increased risk of nighttime hypoglycemia

Regular insulin

Short-Acting insulin

Starts working in 30-60 minutes, Peaks at 2-3 hours, Duration: 5-8 hours

Most often taken together

Do not need regular insulin dose with lunch

**Can purchase at Walmart for $25**

Insulin Treatment in Pregnancy: Rapid Acting Analogs

Insulin lispro (Humalog) Insulin aspart (Novolog) Can be used instead of Regular insulin

Needs to be given with EACH meal

Doses can be a “set dose” with each meal Doses can be given for the amount of carbohydrate eaten (Insulin-to-carb

ratio) Carbohydrate counting

Correction Factor for pre-meal blood glucose Replaces “sliding scale”, corrects BG before meal so patient is not chasing

high BG, goal is for BG to return to normal

Used in insulin pumps

Insulin Treatment in Pregnancy: Rapid Acting Insulin Analogs

Pregnancy Class B Does not cross placenta No increase in congenital anomalies

Increased risk of diabetic retinopathy

Appears safe for use in pregnancy

Reduces frequency of interprandial hypoglycemia compared to regular insulin

Insulin Treatment in Pregnancy: Long-Acting Insulins

Insulin glargine (Lantus) Pregnancy Class C

Insulin detemir (Levemir) Pregnancy Class B

Peakless activing lasting 24 hours

Lowers fasting glucose levels

Lowers Hemoglobin A1c levels

Lower risk of nighttime hypoglycemia vs. NPH insulin

Can be given in the morning or evening

Available in vials and pens

Insulin Treatment in Pregnancy

Insulin Pumps

https://www.youtube.com/watch?v=Crkyl9bqfC0

Insulin Pumps

Advantages Disadvantages

Convince of changing basal and bolus rates Pump malfunctions/battery failure

No medication vials/pens unless emergency Abscess formation

Worn discreetly Poor uptake from infusion site

No need for needles Need to have compliant and motivated patient!

Cn preset for after delivery

Continuous Glucose Monitors

A CGM works through a tiny sensor inserted under your skin, usually on your belly or arm.

The sensor measures your interstitial glucose level, which is the glucose found in the fluid between the cells.

The sensor tests glucose every few minutes.

A transmitter wirelessly sends the information to a monitor.

Continuous Glucose Monitors

Intrapartum Management

Intrapartum Management:GDM

Diet Controlled BG on admission and every 2 hours

Carb controlled diets

IV: LR with D5 piggyback prn BG <100 mg/dl

Insulin-requiring BG on admission and every 2 hours

Insulin not usually needed in active labor

Insulin drip if BG >110 mg/dl

Intrapartum Management: Type 1 or Type 2 DM

Target BG 60-110 mg/dl (best 110)

Insulin infusion or insulin pump (if allowed)

IV fluids (maintain LR, Kcal needed or BG <100 mg/dl: dextrose IV)

Check BG on admission and every hour

NPO or carb free liquids

Intrapartum Management: Insulin Drip Protocol

Intrapartum Management: Elective Cesarean Section

Take usual intermediate acting insulin on the evening prior to delivery Take half of dose of long acting insulin

Ideally first case in the morning

Measure blood glucose level in OR prior to anesthesia

Postoperatively use sliding scale

Check BS q2-4h until oral intake established

fasting and 2h postprandial once eating

Intrapartum Management: Timing of Delivery

Depends on fetal size and glucose control Usually 37-39 weeks gestation

Diet controlled, AGA fetus – may be able to deliver at 39-40 weeks

Intrapartum Management:Betamethasone Use in Preterm

Labor

Glucocorticoids (Corticosteroids)

Increase hepatic glucose production

Inhibit glucose uptake into muscle

Affect beta-cell function Day 1: double all insulin (IV or subQ) within 4 hours of

injection

Day 2: continue increased doses, modify prn

Day 3: decrease by 50%, add to original dose

Day 4: revert to pre-Betamethosone dose

Intrapartum Management: BG Control During Admission

Follow Hospital Policy and Procedure

Use hospital monitor, not patient’s

Factor’s affecting accuracy: Hematocrit, fluid status, temperature, meds, hypotension, pH, oxygenation, user error

Frequency Before meal, HS (if correcting pre-meal)

Before meals, 1-2 hours post-meal, HS

Type 1 or 2 may include 3 AM

Postpartum Care: Type 1 and Type 2 Diabetes

Insulin requirements decline sharply after delivery (honeymoon period after placental delivery)

Glycemic goals less stringent: FBG <100, 1 hour PP <150,

2 hour PP <140 mg/dl

Type 2: D/C insulin @ placental delivery, may need SC insulin

Type 1: convert IV insulin to SC insulin Usually require 40-50% of pregnancy dose

Re-initiate pre-pregnancy regimen after delivery

Sliding Scale insulin for additional coverage

Breastfeeding: Type 1 and Type 2 Diabetes

Type 2: assess oral agents

Insulin safe, Metformin safe in breastfeeding

Hypoglycemia precautions important, especially with Type 1 (frequent monitoring, may be able to snack with no insulin)

Good control necessary for milk production

Postpartum Care: GDM

Discontinue insulin (or oral agent) after delivery Blood glucose monitoring for 48 hours If fasting blood glucose levels are persistently elevated (>126)

after 48 hours, consider restarting insulin or oral hypoglycemic

TESTING ACOG recommends a 2 hour (75 g) GTT at 6-12 weeks

postpartum for all women with gestational DM

Up to 60% of women with insulin requiring gestational DM will develop Type II diabetes later in life

Breastfeeding GDM

May reduce risk of diabetes in child

Promotes weight loss (burns 500 kcal/day) while exclusively breastfeeding)

Lowers BG, may delay need for medication

Diabetes Technology Use During Delivery

Can be ideal for Type 1 DM management Common guidelines

Alert, oriented, Demonstrate Knowledge Discontinue for decreased cognition Physician orders Non-suicidal Furnish own supplies Remove for surgery, MRI/CT scans/Xrays Possible release form Must not be off pump for >1 hr, risk of DKA

Continuous glucose monitor: not approved for hospital use, helpful with Type 1/pregnancy, measures glucose in interstitial fluid

Conclusions

Early, aggressive treatment of diabetes during pregnancy is important to improve outcomes (maternal, fetal, neonatal, and possibly lifelong)

All people caring for the patient with diabetes are responsible for teaching, and altering treatment plan as necessary

Long term follow up of women who had gestational diabetes is recommended

Questions?