Gestational Diabetes
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Transcript of Gestational Diabetes
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CLINICAL MANAGEMENT OF DIABETES DURING
PREGNANCYAntenatal, Intrapartum
and Postpartum Perspectives
Chukwuma I. Onyeije, M.D.Atlanta Perinatal Associates
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BACKGROUND: WHAT IS DIABETES?
• A defect in body energy regulation and utilization• Causes:
– Insulin deficiency – Insulin resistance
• End result: Elevated blood sugar• Impact of elevated blood sugar:
– Pregnancy complications– Multi-organ dysfunction– Excess mortality
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Epidemiology and Diagnosis
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Classification of Diabetes
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.
Genetic defects in b-cell function,
Pancreatic disease,
Endocrinopathies,
Drug- or chemical- induced, and other rare forms
Other types
Insulin resistance with b-cell dysfunction
Gestational
Insulin resistance and relative insulin deficiencyType 2
b-cell destruction with lack of insulinType 1
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INSULIN PHYSIOLOGY: REGULATION OF BLOOD SUGAR
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TYPE 1 DIABETES: INSULIN DEFICIENCY
-cell destruction with lack of insulin
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TYPE 2 DIABETES: INSULIN RESISTANCE
Insulin Resistance
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GESTATIONAL DIABETES: INSULIN DEFICIENCY AND INSULIN RESISTANCE
Insulin Resistance
Insulin Deficiency
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Gestational Diabetes Screening
•High risk•Marked obesity•Previous unexplained fetal demise•Personal history of GDM•Glucosuria•Strong family history of diabetes
•Low risk•Age <25 years•Normal weight before pregnancy•Ethnicity with low prevalence•No known first degree relatives with diabetes•No history of abnormal glucose tolerance•No history of poor obstetric outcome
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Gestational Diabetes Screening
Universal screening is advisable
•1 hour 50 gm glucose load (GCT)•Venous plasma glucose cut-offs
•140 mg/dl•135 mg/dl•130 mg/dl
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90%20-25%130
80%14-18%140
SENSITIVITYPATIENTS SCREENING
POSITIVE
THRESHOLD
SCREENING THRESHOLDS FOR GESTATIONAL DIABETES MELLITUS WITH THE 50-g ORALGLUCOSE-CHALLENGE TEST
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Diagnosis of Gestational Diabetes
Three Hour 100 gm glucose tolerance test (GTT)
Not necessary if GCT is >200mg/dl on screening
Two abnormal values required for the diagnosis of gestational diabetes
Currently two diagnostic criteria acceptable
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Competing Criteria
NDDG, 1979
•FBS 105•1 hour 190•2 hour 165•3 hour 145
Carpentar and Coustan, 1982
•FBS 95•1 hour 180•2 hour 155•3 hour 140
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1990
2000
1997-1998
No Data Less than 4% 4% to 6% Above 6%
Diabetes Trends Among Diabetes Trends Among Adults in the U.S.Adults in the U.S.
Source: CDC, Behavioral Risk Factor Surveillance System.
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Pathophysiology
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PRINCIPLE DANGERS
GESTATIONAL DIABETES:Fetal hyperinsulinemia
PREGESTATIONAL DIABETES:
Fetal Anomalies
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Normal Glucose Regulation in Pregnancy
•The pregnant patient has a tendency to develop HYPOGLYCEMIA between meals – Related to fetal demand
•Placental steroids cause increased tissue insulin resistance – They are “DIABETOGENIC”
• Insulin production INCREASES in normal pregnancy– By 30%
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RECALL:PATHOLOGIC CHANGES IN GDM
Insulin Resistance
Insulin Deficiency
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Effects of Hyperglycemia in GDM
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Fetal Hyperinsulinemia
• Promotes storage of excess nutrients – Net Effect: macrosomia
• Increased catabolism of excess nutrients and increased energy usage – Net Effect: Decreased fetal oxygen storage and
episodic fetal hypoxia
• Episodic fetal hypoxia leads to increased catecholamines causing: – Fetal hypertension– Cardiac remodelling and hypertrophy– Increased erythropoietin, RBC’s, hematocrit – Poor fetal circulation and hyperbilirubinemia– Stillbirth (?)
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The Impact of Fetal Macrosomnia
• Increased hyperbilirubinemia• Increased hypoglycemia• Increased acidosis• Increased birth trauma•Macrosomic children are more likely to
develop glucose intolerance in adulthood
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Congenital Anomalies and Diabetic Control
Risk for Congenital Anomalies at various levels of Hemoglobin A1C
Critical periods - 3-6 weeks post conception
Importance of pre-conceptional metabolic care
2.5%
14.0%
23.0%25.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
< 7.2
7.2 to 9.0
9.2 to 11.1
> 11.2
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Congenital Anomalies with Pregestational Diabetes
Cardiac defects x18 8.5%
• CNS defects x16 5.3%
- Anencephaly x 13
- Spina Bifida x 20
• All Anomalies x 8 18.4%
• Background major defects 3-4%
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Perinatal Risks for All Diabetic Pregnancies:
Mortality/Morbidity
MiscarriageIUGR
MacrosomiaBirth Injury
Stillbirth
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Neonatal Risks for All Diabetic Pregnancies:
Morbidity and Mortality
•Polycythemia and hyperviscosity•Neonatal hypoglycemia•Neonatal hypocalcemia•Hyperbilirubinemia•Hypertrophic and congestive
cardiomyopathy•RDS•Childhood impaired glucose tolerance
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Maternal Complications
•Chronic hypertension•Pre-eclampsia•Diabetic ketoacidosis•Maternal hypoglycemia•Maternal trauma•Higher C Section rate•Retinal disease/renal disease not affected
significantly by pregnancy
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CARE FOR THE PATIENTWITH DIABETES
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Pre-Pregnancy Management
•Preconceptional care– PRECONCEPTION CARE BEGINS AT THE END OF A
PREGNANCY WITH GDM– Tight glucose control (HbA1c)– Assessment and treatment of associated medical
problems- Hypertension, - Renal disease, - Retinal disease- Heart disease
– Folic acid– Assessment of family, financial and personal
resources to help achieve a successful pregnancy
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FIRST PERINATAL VISIT or UPON HOSPITALIZATION
•Review routine prenatal lab tests•Baseline 24 hour urinalysis for protein and
creatinine clearance•Baseline retinal exam - for Type 1 Diabetics•EKG - for Type 1 Diabetics•Thyroid function tests - for Type 1 Diabetics•Hemoglobin A1C•Fetal echocardiogram for pregestational
diabetics
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Antepartum Gestational Diabetes Care
•Dietary advice•Glucose monitoring (5 times per day)• Insulin therapy if necessary
– Oral Hypoglycemic agents•Frequent visits to monitor glucose control•Ultrasound monitoring of fetal growth•Mode of Delivery:
– Based on obstetric issues•Timing of Delivery:
– Based on glucose control
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What is an ADA diet?
• Avoidance of large meals with high percentage of simple carbohydrates
• Three small meals with three snacks are preferred• Low glycemic index foods release calories from the
gut slowly and improve metabolic control• Caloric content:
– 35 calories/Kg Ideal body weight (or 15 calories/pound IBW)
– No less than 1800 calories and no more than 2800 calories
– “Eyeball Technique”- Small patient 1800 calories- Medium patient 2200 calories- Large patient 2400 calorie
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What is a “Low” Glycemic Index•Glycemic Index (GI):
•Compares equal quantities of carbohydrate in foods
•Is a measure of the effect on blood glucose levels over a 2 hr period
•Provides a measure of carbohydrate quality.
•Expressed as a percentage
Time
GI = 30
GI = 100
BG
LB
GL
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‘Traditional’ starchy foods have a lower GI
• Barley
• Legumes/beans
• Multigrain ‘Specialty’ breads
• Mueslix
• Porridge oats
33
30’s
40’s
50’s
50’s
Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
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“Sugary” foods have a intermediate-low GI
• Soft drinks
• Flavoured milk (low fat)
• Yogurt (sweetened)
• Ice cream (low fat)
60’s
34
30-40
50’s
Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
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Modern starchy foods have a high GI
• Potatoes
• Cornflakes
• Rice crispies
• Wholegrain bread
• Crackers
• Rice (most types)
85
77
85
70
81
83
Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
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HOME GLUCOSE MONITORING
• Fasting and 2 hour post-prandial
• Pre-meal values only if sliding scale short acting insulin coverage is used
• Early AM value if hypoglycemia suspected
• Assure that glucose meter is calibrated
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INDICATIONS FOR HOSPITALIZATION
•Persistent nausea and vomiting•Significant maternal infection•DKA•Poor control/compliance •Preterm labor
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Intensive Inpatient Management:The APA Hybrid Protocol
• For poorly controlled diabetic patients admitted for rapid control.
• Empiric insulin with the patient’s current standing dose:
• Targets adequate glycemic control – Fasting values: Less than 100 mg/dl– 2 hour postparandial values: Less than
120 mg/dl – Avoidance of hypoglycemia, ketonuria,
and hyperglycemia
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Intensive Inpatient Management:The APA Hybrid Protocol
•Begin 2200 to 2400 calorie ADA diet.
•Obtain fingerstick every 2 hours for 12-24 hours
•Administer HUMALOG INSULIN for sliding scale
•Retake blood sugar at 2 hours after EACH sliding dose noted below and repeat sliding scale dose of insulin based on FSG.
•Adjust Insulin after 24 hours
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Intensive Inpatient Management:The APA Hybrid Protocol
2 hours14 Units220-260
2 hours16 Units>260
2 hours12 Units200-220
2 hours10 Units180-200
2 hours6 Units161-180
2 hours4 Units140-1600
4-6 hoursHold Humalog insulin
< 140
Recheck Blood sugarAdminister the following dosage of
humalog insulin
Blood sugar value
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FSG
0
100
200
300
11/19/2008 11/19/2008 11/19/2008 11/19/2008 11/20/2008 11/20/2008 11/20/2008
FSG
0
100
200
300
400
11/17/08 11/17/08 11/17/08 11/17/08 11/18/08
Series1
Patient CH – Before Hybrid Approach
Patient CH – After Hybrid Approach
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Intrapartum management
•ABSOLUTE REQUIREMENTS:– Dextrose containing intravenous fluids– Insulin
•Hourly glucose monitoring•Continuous fetal heart rate monitoring•Continuous tocodynametry•Manage labor as normal
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THE APA INSULIN DRIP PROTOCOL
INTRAVENOUS FLUID MAINLINE: D5W @ 125 cc/hr INSULIN DRIP:
Initially Check Fingerstick every hourMIX 100 Units Regular insulin in 500 cc NS (0.2 U/cc)TITRATE INFUSION AS FOLLOWS:
2.5 U/hr12.5 cc/hr*FS> 220
2.0 U/hr10 cc/hr*FS= 181-220
1.5 U/hr7.5 cc/hrFS= 141-180
1.0 U/hr5.0 cc/hrFS=101-140
0.5 U/hr2.5 cc/hrFS= 80-100
0 U/hrTurn off dripFS= <80
Units per hourDrip RateFingerstick Value
After Fingerstick has been between 80-140 x >2 hours, decrease frequency of fingersticks to every 2 hours then every 4 hours.
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HYPOGLYCEMIA DURING AN INSULIN DRIP
• For Glucose <60– Turn off Insulin drip for 30 minutes – Continue D5W (or D5LR) at 100 – 125 cc/hr– Recheck Glucose after 30 minutes– If blood glucose on recheck is still <60
- Give 25 ml of D50 IV (or 10-12 grams glucose)
– Recheck Blood Glucose every 30 minutes - Restart insulin when glucose >101 mg/dl
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INSULIN DRIP FOR THE INSULIN RESISTANT PATIENT• Method for poorly controlled, morbidly obese or
noncompliant patients with gestational diabetes• 50% of total daily insulin dosage divided by 24 hours
provides initial rate for insulin drip.• EXAMPLE:
– Ms. Jones current insulin regimen - AM: 80units NPH 45 units Regular insulin- PM: 60 units NPH, 55 units Regular insulin
– Total daily dosage= 240 units per day.– ½ of 240 units = 120 units
– 120 units / 24 hours = 5 units per hour as initial dosage.
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Management - Postpartum
•Use pre pregnancy insulin levels when on diet and monitor.
• If GDM monitor sugars only • Immediate postpartum goal is fingerstick <
200•GDM – Repeat GTT at 6 weeks postpartum•GDM - long term risk of NIDDM•Contraception
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THANK YOU !
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EXTRA SLIDES
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INSULIN SECRETION
• Rising blood glucose levels. • After the uptake of glucose by the
GLUT2 transporter there is • Glycolytic phosphorylation of glucose
causing• A rise in the ATP:ADP ratio, which
then• Inactivates the potassium channel that • Depolarizes the membrane, causing • Calcium channel to open up allowing
calcium ions to flow inward. The rise in levels of calcium leads to the
• Release of insulin from their storage
granule.
1 2
34
5
6
78
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INSULIN ACTION
Insulin-mediated glucose uptake begins when
• Insulin binds to the insulin receptor and
• Induces a signal transduction cascade which
• Allows the glucose transporter (GLUT4) to transport glucose into the cell.
1
23
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Diagnosed and Undiagnosed Diabetes in the US:Estimated Cases Among Adults, 1997
Data from Harris, et al. Diabetes Care. 1998;21:518-524.
0
2
4
6
8
10
12
UndiagnosedDiagnosed
10.2
5.4
Mill
ion
s of
Cas
es
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Glucose Tolerance Categories: NONPREGNANT Patients
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.
FPG
126 mg/dL
110 mg/dL
Impaired FastingGlucose
Normal
2-Hour PG on OGTT
200 mg/dL
140 mg/dL
Diabetes Mellitus
Impaired GlucoseTolerance
Normal
Diabetes Mellitus
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FOLIC ACID
• All women of reproductive age should consume at least 0.4 mg of folic acid
• High risk women should consume 4 mg/day
• This reduces the risk of neural tube defects
• Newer evidence suggests a lower risk of facial clefting and congenital heart disease as well