Gestational Diabetes

CLINICAL MANAGEMENT OF DIABETES DURING PREGNANCY Antenatal, Intrapartum and Postpartum Perspectives Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates

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

Epidemiology and Diagnosis

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 deficiency Type 2 b-cell destruction with lack of insulin Type 1

INSULIN PHYSIOLOGY: REGULATION OF BLOOD SUGAR

TYPE 1 DIABETES: INSULIN DEFICIENCY  - cell destruction with lack of insulin

TYPE 2 DIABETES: INSULIN RESISTANCE Insulin Resistance

GESTATIONAL DIABETES: INSULIN DEFICIENCY AND INSULIN RESISTANCE Insulin Resistance Insulin Deficiency

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

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

SCREENING THRESHOLDS FOR GESTATIONAL DIABETES MELLITUS WITH THE 50-g ORALGLUCOSE-CHALLENGE TEST 90% 20-25% 130 80% 14-18% 140 SENSITIVITY PATIENTS SCREENING POSITIVE THRESHOLD

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

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

Diabetes Trends Among Adults in the U.S. Source: CDC, Behavioral Risk Factor Surveillance System. 1990 2000 1997-1998 No Data Less than 4% 4% to 6% Above 6%

Pathophysiology

PRINCIPLE DANGERS
GESTATIONAL DIABETES:
Fetal hyperinsulinemia
PREGESTATIONAL DIABETES:
Fetal Anomalies

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%

RECALL: PATHOLOGIC CHANGES IN GDM Insulin Resistance Insulin Deficiency

Effects of Hyperglycemia in GDM Fetal hyperglycemia fetal hyperinsulinemia abnormal fetal growth impaired fetal well-being

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 (?)‏

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

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

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%

Perinatal Risks for All Diabetic Pregnancies: Mortality/Morbidity
Miscarriage
IUGR
Macrosomia
Birth Injury
Stillbirth

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

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

CARE FOR THE PATIENT WITH DIABETES

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

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

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

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

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 BGL BGL

‘ 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.

“ 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.

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.

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

INDICATIONS FOR HOSPITALIZATION
Persistent nausea and vomiting
Significant maternal infection
DKA
Poor control/compliance
Preterm labor

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

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

Intensive Inpatient Management: The APA Hybrid Protocol 2 hours 14 Units 220-260 2 hours 16 Units >260 2 hours 12 Units 200-220 2 hours 10 Units 180-200 2 hours 6 Units 161-180 2 hours 4 Units 140-1600 4-6 hours Hold Humalog insulin < 140 Recheck Blood sugar Administer the following dosage of humalog insulin Blood sugar value

Patient CH – Before Hybrid Approach Patient CH – After Hybrid Approach

Intrapartum management
ABSOLUTE REQUIREMENTS:
Dextrose containing intravenous fluids
Insulin
Hourly glucose monitoring
Continuous fetal heart rate monitoring
Continuous tocodynametry
Manage labor as normal

THE APA INSULIN DRIP PROTOCOL
INTRAVENOUS FLUID MAINLINE: D5W @ 125 cc/hr
INSULIN DRIP:
Initially Check Fingerstick every hour
MIX 100 Units Regular insulin in 500 cc NS (0.2 U/cc)‏
TITRATE INFUSION AS FOLLOWS:
After Fingerstick has been between 80-140 x >2 hours, decrease frequency of fingersticks to every 2 hours then every 4 hours.
2.5 U/hr 12.5 cc/hr* FS> 220 2.0 U/hr 10 cc/hr* FS= 181-220 1.5 U/hr 7.5 cc/hr FS= 141-180 1.0 U/hr 5.0 cc/hr FS=101-140 0.5 U/hr 2.5 cc/hr FS= 80-100 0 U/hr Turn off drip FS= <80 Units per hour Drip Rate Fingerstick Value

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

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.

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

THANK YOU !

EXTRA SLIDES

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 3 4 5 6 7 8

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 2 3

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 Undiagnosed Diagnosed 10.2 5.4 Millions of Cases

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 Fasting Glucose Normal 2-Hour PG on OGTT 200 mg/dL 140 mg/dL Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus

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

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Gestational Diabetes

by Chukwuma Onyeije on Oct 24, 2009

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