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    2. 5. Gestational Diabetes <ul><li>This diagnosis is given when a woman, who has never had diabetes before, gets diabetes or has high blood sugar, when she is pregnant. </li></ul><ul><li>Its medical name is gestational diabetes mellitus or GDM. </li></ul><ul><li>It is one of the most common health problems for pregnant women. </li></ul><ul><li>The word “gestational” actually refers to “during pregnancy.” </li></ul> of 42 gdm
    3. 6. Gestational Diabetes <ul><li>It occurs in about 5% of all pregnancies. </li></ul><ul><li>If not treated, gestational diabetes can cause health problems for the mother and the fetus. </li></ul>kvr gdm
    4. 7. Glucose Metabolism <ul><li>Normal pregnancy : Diabetogenic state </li></ul><ul><ul><li>*increase in pc BG </li></ul></ul><ul><ul><li>*insulin resistance </li></ul></ul><ul><ul><li>Early Pregnancy : </li></ul></ul><ul><ul><li>Anabolic state </li></ul></ul><ul><ul><li>*increase in maternal fat store qs </li></ul></ul><ul><ul><li>*decreased FFA concentration </li></ul></ul><ul><ul><li>*decrease in insulin requirements </li></ul></ul>
    5. 8. CHO Metabolism <ul><li>Effects of Pregnancy </li></ul><ul><li>* Mild fasting hypoglycemia; </li></ul><ul><li>*Post prandial hyperglycemia </li></ul><ul><li>Due to increase in plasma volume in early gestation and increase in fetal glucose utilization. </li></ul><ul><li>As pregnancy advances -Progressive increase in tissue resistance to insulin </li></ul><ul><ul><li>Increase insulin secretion to maintain euglycemia </li></ul></ul><ul><ul><li>Suppressed glucagon response </li></ul></ul><ul><ul><li>Inc. prolactin, cortisol </li></ul></ul><ul><ul><li>HPL has GH like effects </li></ul></ul>
    6. 9. CHO Metabolism
    7. 10. Gestational Diabetes <ul><li>Risk Factors </li></ul><ul><ul><ul><li>maternal age >25 </li></ul></ul></ul><ul><ul><ul><li>Family history </li></ul></ul></ul><ul><ul><ul><li>glucosuria </li></ul></ul></ul><ul><ul><ul><li>prior macrosomia </li></ul></ul></ul><ul><ul><ul><li>previous unexplained stillbirth </li></ul></ul></ul><ul><ul><ul><li>ethnic group: Hispanic, Black, Asians </li></ul></ul></ul>
    8. 17. Vad happens to the carbohydrates from the food? gdm Insulin from the pancreas - - - - - Fat/muscle cell Stored sugar in the liver (glycogen) Carbohydrates from food
    9. 18. Why didn’t I have diabetes before? <ul><li>During pregnancy, many physiological changes take place. Changes in metabolism can be seen. Insulin may not be as effective in moving sugar into the cells during pregnancy. Therefore, the cells can’t get the sugar they need for energy. Increased sugar levels in the blood can lead to many problems. </li></ul>gdm 17
    10. 20. Why isn’t insulin doing its job? <ul><li>The placenta is a system of vessels that </li></ul><ul><li>passes nutrients, blood, and water from </li></ul><ul><li>mother to fetus. </li></ul><ul><li>The placenta makes certain hormones </li></ul><ul><li>that may prevent insulin from working the </li></ul><ul><li>way that it should. </li></ul><ul><li>When this condition happens, it is referred </li></ul><ul><li>to as insulin resistance . </li></ul><ul><li>In order to keep metabolism normal during pregnancy, the body has to make three times more insulin than normal to offset the hormones made by the placenta. </li></ul> gdm Placenta
    11. 21. Why isn’t insulin doing its job? <ul><li>For most women, the body’s extra insulin is enough to keep their blood sugar levels in the healthy range. </li></ul><ul><li>But, for about 5% of pregnant women, even the extra insulin is not enough to keep blood sugar levels normal. </li></ul><ul><li>These women end up with high blood sugar or gestational diabetes at around the 20 th to 24 th week of pregnancy. </li></ul> gdm
    12. 28. Gestational Diabetes <ul><li>Screening </li></ul><ul><ul><li>24-28 weeks routine </li></ul></ul><ul><ul><li>no need to fast </li></ul></ul><ul><ul><li>screen at 1st prenatal visit if hx of previous GDM </li></ul></ul><ul><ul><li>screen earlier (12-24 weeks ) if risk factors </li></ul></ul>
    13. 37. <ul><li>MATERNAL RISK </li></ul><ul><li>Birth trauma </li></ul><ul><li>Preterm Labor </li></ul><ul><li>PIH </li></ul><ul><li>Operative delivery </li></ul><ul><li>50% lifetime risk in developing Type II DM </li></ul><ul><li>Recurrence risk of GDM is 30-50% </li></ul>Gestational Diabetes
    14. 38. Will GDM hurt my baby? <ul><li>Most women with gestational diabetes give birth </li></ul><ul><li>to healthy babies; this is especially true for </li></ul><ul><li>women who have kept their blood sugar under </li></ul><ul><li>control, maintained a healthy diet, engaged in </li></ul><ul><li>regular, moderate physical activity, and </li></ul><ul><li>had a healthy weight throughout the </li></ul><ul><li>pregnancy.In some cases, however, </li></ul><ul><li>the condition can affect the pregnancy. </li></ul>
    15. 40. GDM Associated Conditions <ul><li>Macrosomia </li></ul><ul><li>In this condition, the baby’s body is larger than normal. Large-bodied babies may be injured during natural delivery through the vagina, so the baby may need to be delivered through cesarean section. </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>In this condition, the baby’s blood glucose is too low. Breastfeeding may need to be started right away to get more glucose into the baby’s system. If breastfeeding is not possible, then the baby may need to get glucose put directly into the blood through a thin, plastic tube in his or her arm. </li></ul><ul><li>Jaundice </li></ul><ul><li>In this condition ,the baby’s skin turns yellowish. The white parts of the eye may also change color slightly. If treated, this is not a serious problem. </li></ul>
    16. 41. GDM ASSOCIATED CONDITIONS…. <ul><li>Respiratory Distress Syndrome (RDS) </li></ul><ul><li>In this condition, the baby has trouble breathing. The baby may need oxygen or other help breathing if he or she has this condition. </li></ul><ul><li>Low Calcium and Magnesium Levels in Baby’s Blood </li></ul><ul><li>In this condition, spasms in the hands and feet, or twitching and cramping of muscles can occur. The condition can be treated through supplementation with magnesium and calcium supplements. </li></ul>Keep in mind that just because you have GDM it does not mean that these problems will occur
    17. 42. Could GDM hurt my baby in other ways? <ul><li>Gestational diabetes usually does not cause birth defects or deformities. </li></ul><ul><li>Most developmental or physical defects happened during the first trimester of pregnancy, between the 1 st and 8 th week, and gestational diabetes typically develops around the 24 th week of pregnancy. </li></ul>
    18. 43. Women with gestational diabetes typically have normal blood sugar levels during the first trimester, allowing the body and body Systems of the fetus to develop normally.
    19. 44. The fact that you have gestational diabetes will not cause diabetes in your baby. However, your child will be at a higher risk for developing type 2 diabetes in adulthood and may get it at a younger age (younger than 30).
    20. 45. As your child grows, taking steps such as: eating a healthy diet, maintaining a healthy weight, and getting regular, moderate physical activity can help to reduce his or her risk. Macrosomic, or large-bodied babies are at higher risk for childhood and adult obesity.
    21. 46. Magnetic Resonance Image of Pregnancy Complicated by Diabetes Normoglycmia Hyperglycmia Jovanovic L et al. Am J Perinatol . 1993;10:432-437
    22. 47. Macrosomia
    23. 48. Gestational Diabetes
    24. 49. <ul><li>Fetal Risks </li></ul><ul><li>no increase in congenital anomalies </li></ul><ul><li>increased risk of stillbirth if fasting+ pc hyperglycemia </li></ul><ul><li>macrosomia </li></ul><ul><li>birth trauma-shoulder </li></ul><ul><li>dystocia and related </li></ul><ul><li>complications </li></ul>Gestational Diabetes
    25. 52. A Treatment Plan for GDM May include these items: <ul><li>Knowing your blood sugar (glucose) level and keeping it under control </li></ul><ul><li>Eating a healthy diet, as outlined by your health care provider </li></ul><ul><li>Getting regular, moderate physical activity </li></ul><ul><li>Maintaining a healthy weight gain </li></ul><ul><li>Keeping daily records of your diet, physical activity, and glucose levels </li></ul><ul><li>Taking insulin and/or other medications as prescribed </li></ul> gdm PBRC 2006
    26. 55. Know your blood sugar level & keep it under control: Overview <ul><li>There are two parts: </li></ul><ul><ul><li>Knowing your blood sugar level </li></ul></ul><ul><ul><ul><li>Test to see how much glucose is in your blood </li></ul></ul></ul><ul><ul><li>Keeping your blood sugar level under control </li></ul></ul><ul><ul><ul><li>Keep the amount within a healthy range at all times </li></ul></ul></ul><ul><li>This is important to do because your blood sugar level change throughout the day based on what foods you eat, when you eat them, and how much you eat. Your level of physical activity and when you do physical activity also influences blood sugar levels. </li></ul> gdm
    27. 56. <ul><li>Management </li></ul><ul><li>Goal is to optimize BG </li></ul><ul><li>levels to minimize risk </li></ul><ul><li>of adverse perinatal </li></ul><ul><li>outcomes Diet </li></ul><ul><li>Exercise </li></ul><ul><li>Insulin therapy </li></ul>Gestational Diabetes
    28. 57. Know your blood sugar level & keep it under control <ul><li>Although your glucose levels change during the day, there is a healthy range that is normal. If your glucose level is outside of the healthy target range, speak with your health care provider. </li></ul> of 42 PBRC 2006 Time of Blood Sugar Test Healthy Target Levels (in mg/dl) Fasting glucose level No higher than 95 One hour after eating No higher than 140 Two hours after eating No higher than 120
    29. 58. Know your blood sugar level & keep it under control <ul><li>Knowing your glucose levels at specific times of the day may become very important if insulin therapy becomes necessary. </li></ul><ul><li>Insulin resistance can increase as a pregnancy progresses indicating a need for additional insulin to control glucose levels . </li></ul> gdm Measuring your blood sugar will give you information about… For example The amount of food you can eat Can you have that extra ½ bagel for breakfast? Foods that affect your glucose level Does your body process different foods differently? Times when your glucose level is high or low You might have high blood sugar in the morning after breakfast; other women may have high blood sugar after dinner. Times that physical activity is more likely to keep your glucose level in target Does walking for 20 minutes after breakfast or dinner help to keep your glucose level within the healthy range?
    30. 59. Know your blood sugar level & keep it under control <ul><li>You may have to test four times a day: </li></ul><ul><ul><li>In the morning before eating breakfast, referred to as the Fasting glucose level </li></ul></ul><ul><ul><li>1 or 2 hours after breakfast </li></ul></ul><ul><ul><li>1 or 2 hours after lunch </li></ul></ul><ul><ul><li>1 or 2 hours after dinner </li></ul></ul><ul><li>You may also have to test your glucose level before you go to bed at night. This is referred to as your nighttime or nocturnal glucose test. </li></ul> gdm
    31. 60. <ul><li>Management : Diet </li></ul><ul><li>patients without fasting hyperglycemia </li></ul><ul><li>average 8000-9000 kj/day. </li></ul><ul><li>BMI >27 25 kcal/kg/IBW /d </li></ul><ul><li>BMI 20-26 30 ; </li></ul><ul><li>BMI <20 38 ; </li></ul>Gestational Diabetes
    32. 61. Eating a healthy diet Overview <ul><li>A healthy diet is one that includes a balance of foods from all the food groups, giving the nutrients, vitamins, and minerals necessary for a healthy pregnancy. </li></ul><ul><li>For women with gestational diabetes, a healthy diet can help to keep blood sugar levels in the healthy target range. </li></ul><ul><li>Carbohydrates are often the center of a healthy diet for a woman with gestational diabetes. </li></ul>63 gdm
    33. 62. Eating a healthy diet Carbohydrates <ul><li>Carbohydrates are nutrients which come from foods like grain products, fruits, and vegetables. </li></ul><ul><li>During digestion, the body is able to break down most carbohydrates into simple sugars, like glucose. </li></ul><ul><li>Eating carbohydrates affects blood sugar levels. Eating a large amount of carbohydrates at a meal will have a larger effect on blood glucose levels than eating a small amount of carbohydrates. </li></ul><ul><li>It is important to balance between eating enough carbohydrates to receive the necessary amounts of energy and resultant glucose, and not consuming too much to where blood sugar levels are out of control . </li></ul> of 42 gdm
    34. 63. Eating a healthy diet Meal Plans of 42 PBRC 2006 CHO counting With this meal plan, the number of grams of carbohydrates that is eaten at each meal or snack is counted to make sure that they are within a certain range. A meal plan may be very specific, allowing a specified amount at each meal or snack, or it may be more general, with a daily carbohydrate total. The exchange system The exchange system groups each food consumed into one of the following food groups: bread/starches, fruits, vegetables, proteins, milk, and fats. Each food within a group has very similar amounts of carbohydrate, fat, protein and calories, but the amounts of vitamins and minerals may vary. In this plan, the number of items from a food group that is eaten at each meal is counted. There is a designated amount for each group every day.
    35. 64. Eating a healthy diet to keep blood sugar in check: of 42 PBRC 2006 Eat meals and snacks on a regular schedule throughout the day Researchers recommend that women with gestational diabetes should eat at least three small-to-medium sized meals and two to four snacks every day. Eat smaller amounts of carbohydrates at each meal It is preferable to eat several small meals every day rather than one large meal. Carbohydrates will increase blood glucose level directly, therefore, eating a small amount of carbohydrates all through the day will help keep blood sugar from rising too high. Add a nighttime snack to your meal plan A snack of one or two servings of carbohydrates before bedtime will keep blood sugar at a healthy level during sleep. Some healthy examples could include: a piece of fruit, a handful of pretzels, or crackers.
    36. 65. <ul><li>Diet : general principles </li></ul><ul><li>55% CHO / 25% Protein / 20% fat </li></ul><ul><li>Normal weight gain 10-12 kg </li></ul><ul><li>Avoid ketosis </li></ul><ul><li>Liberal exercise program to optimize BG control </li></ul>Gestational Diabetes
    37. 66. Role of physical activity <ul><li>Women with gestational diabetes often need regular, moderate physical activity to help control their blood sugar levels by allowing insulin to work better. </li></ul><ul><li>Examples include: </li></ul><ul><ul><li>Walking </li></ul></ul><ul><ul><li>Prenatal aerobics classes </li></ul></ul><ul><ul><li>Swimming </li></ul></ul><ul><li>However, a consultation and approval by a health care provider is needed before beginning any physical activity during pregnancy. </li></ul> PBRC 2006 Caution Keep in mind that it may take 2 to 4 weeks before physical activity has an effect on blood sugar levels.
    38. 67. <ul><li>If persistent hyperglycemia </li></ul><ul><li>after one week of diet </li></ul><ul><li>control proceed to insulin </li></ul><ul><li>6-14 weeks 0.5u/kg/d </li></ul><ul><li>14-26 weeks 0.7u/kg/d </li></ul><ul><li>26-36 weeks 0.9u/kg/d </li></ul><ul><li>36-40weeks 1 u /kg/d </li></ul>Gestational Diabetes INSULIN
    39. 68. <ul><li>If fasting hyperglycemia start with NPH hs </li></ul><ul><li>initial dose 6-8 U </li></ul><ul><li>if only pc hyperglycemia use H umalog </li></ul><ul><li>2-4u ac the specific meal </li></ul><ul><li>adjust 2u/time ; 1 formula /time </li></ul><ul><li>BG target ac <5.3 (90mg.) </li></ul><ul><li>2 h pc <6.7 ( 120 mg) </li></ul>Gestational Diabetes INSULIN
    40. 69. Role of moderate physical activity <ul><li>Researchers are uncertain about the exact amount of physical activity required to control blood sugar during gestational diabetes. </li></ul><ul><li>The amount that is usually recommended is based on how active an individual was before the pregnancy and whether or not there are any other health concerns. </li></ul><ul><li>For some women with GDM, regular physical activity can include walking, swimming, or light running; whereas, for other women only slow walking may be recommended. </li></ul><ul><li>A health care provider can offer advice on appropriate activities, and their duration and frequency to assure a healthy pregnancy. </li></ul> gdm
    41. 70. Role of moderate physical activity General Guidelines For Physical Activity gdm Do Don’t Participate in moderate and regular physical activity unless prohibited by a health care provider Get too tired while working out or doing physical activity Choose activities like swimming, that don’t require a lot of standing or balance Do any activity while lying on your back when you are in your 2 nd or 3 rd trimester of pregnancy Wear loose, light clothing that won’t cause excessive sweating or increased body temperature Perform activities in very hot weather Drink a lot of water before, during, and after your activity Perform activities that may bump or hurt your belly, or that may cause you to lose your balance Eat a healthy diet and gain the right amount of weight Fast (skip meals) or do physical activity when you are hungry Watch your level of exertion (Can you talk easily?) Over-exert yourself
    42. 72. Maintain a healthy weight Overview <ul><li>Healthy weight gain can refer to your overall weight gain or your weekly rate of weight gain . </li></ul><ul><li>Some health care providers focus only on overall gain or only on weekly gain, but some keep track of both types of weight gain. </li></ul> gdm
    43. 73. Maintain a healthy weight Weekly Rate Of Weight Gain gdm A weight gain of two pounds or more each week is considered high . Time Frame Expected Weight Gain In the first trimester of pregnancy (the first 3 months) Three to six pounds for the entire three months During the second and third trimester (the last 6 months) Between ½ and 1 pound each week If you gained too much weight early in the pregnancy Limit weight gain to ¾ of a pound each week (3 pounds each month) to help get your blood sugar level under control
    44. 74. Maintain a healthy weight Things to Keep in Mind <ul><li>A weekly rate of weight gain may go up and down throughout the pregnancy. </li></ul><ul><li>A physician can assess whether weight gain is appropriate or not. </li></ul><ul><li>A weight loss can be dangerous during any part of the pregnancy, therefore any weight loss needs to be reported to a health care provider right away. </li></ul><ul><li>If weight gain slows or stop, and does not increase again after one-to-two weeks, it should be reported to a health care provider immediately. Adjustments in your treatment plan may be necessary. </li></ul> gdm
    45. 75. Maintain a healthy weight Additional tips <ul><li>Try to get more light or moderate physical activity, if your health care provider says that it is safe. </li></ul><ul><li>Use the Nutrition Facts labels on food packages to make lower-calorie food choices that fit into a healthy meal plan. </li></ul><ul><li>Eat fewer fried foods and “fast” foods . </li></ul><ul><li>Eat healthy foods that fit into your meal plan, such as salads with low-fat dressings and broiled or grilled chicken. </li></ul><ul><li>Use less butter and margarine on food, or don’t use them at all . </li></ul>
    46. 76. Additional tips <ul><li>Use spices and herbs (such as curry, garlic, and parsley) and low-fat or lower calorie sauces to flavor rice and pasta. </li></ul><ul><li>Eat smaller meals and have low-calorie snacks more often, to ensure that your body has a constant glucose supply, and to prevent yourself from getting very hungry. </li></ul><ul><li>Avoid skipping meals or cutting back too much on breakfast or lunch. Eating less food or skipping meals could make you overly hungry at the next meal, causing you to overeat. </li></ul>
    47. 77. Keep daily records of your diet, physical activity, and glucose levels <ul><li>Keeping records refers to writing down your blood sugar numbers, physical activities, and everything that you eat and drink in a daily record book . </li></ul><ul><li>Recording everything that you eat and drink really means everything that you eat and drink. This refers to bites, nibbles, snacks, second helpings and all liquids. </li></ul><ul><li>It’s easy to forget or underestimate how much snacking you really do. </li></ul> of 42 GDM
    48. 78. Keep daily records of your diet, physical activity, and glucose levels <ul><li>Keep track of the following </li></ul><ul><li>Blood sugar level </li></ul><ul><li>Food </li></ul><ul><li>Physical wellness </li></ul><ul><li>Physical activity </li></ul><ul><li>Weight gain </li></ul> GDM
    49. 79. Keep daily records of your diet, physical activity, and glucose levels <ul><li>It’s a good idea to follow a schedule for writing in the record book. </li></ul><ul><li>This lets you get used to writing in it and helps you to remember to do it. </li></ul><ul><li>Daily records help to keep track of how well your treatment plan is working and what, if anything, should be changed. </li></ul><ul><li>The information also reveals whether or not you will need insulin, and if so, how much will be needed. </li></ul> gdm
    50. 80. Take insulin and/or other medications as prescribed <ul><li>Even if you do everything your health care provider recommends to manage your gestational diabetes, you may still need to take insulin during your pregnancy to keep it under control. </li></ul><ul><li>The only way to get extra insulin into your body is to inject it under your skin with a needle. </li></ul> gdm
    51. 82. Take insulin and/or other medications as prescribed <ul><li>You may have to include small amounts of insulin in your treatment plan if: </li></ul><ul><li>Your blood sugar level is too high. </li></ul><ul><li>You blood sugar level is frequently too high </li></ul><ul><li>Your blood sugar level remains high, and you are not gaining much weight even with proper eating habit. </li></ul><ul><li>You cannot safely add physical activity to your treatment plan </li></ul> gdm
    52. 83. Take insulin and/or other medications as prescribed <ul><li>Things to know about insulin : </li></ul><ul><ul><li>If you need to take insulin, it does not mean that you didn’t try hard enough or that you failed at taking care of yourself. </li></ul></ul><ul><ul><li>Taking insulin does not mean that you have Type 1 diabetes. </li></ul></ul>
    53. 84. Things to know about insulin <ul><ul><li>3. An increase in the amount or dosage of insulin needed does not mean that your pregnancy is in danger. </li></ul></ul><ul><ul><li>4. You may need more insulin if you are under high amounts of stress or if you are sick because your blood sugar level gets higher on its own in these cases. </li></ul></ul>
    54. 85. Neonatal Malformations Are Not Related to Type of Insulin 0 2 4 6 8 10 12 14 16 GDM Preexisting diabetes Regular human insulin Insulin lispro Congenital malformation rate (%) Bhattacharyya A et al. Q J Med. 2001;94:255-260 7.9% 6.6% 15.8% 3.8% N=213 N=97 P =0.79 P =0.16
    55. 86. Malformations Are Related to Glucose Not Type of Insulin Wyatt JW, Frias JL, Hoyme HE, Jovanovic L, et al. Congenital anomaly rate in offspring of pre-gestational diabetic women treated with insulin lispro during pregnancy. Diabetic Medicine 21:2001-2007, 2004.
    56. 87. Take insulin and/or other medications as prescribed <ul><li>Special instructions for women taking insulin are to: </li></ul><ul><li>Follow a regular eating schedule </li></ul><ul><li>The timing of insulin shots and of eating </li></ul><ul><li>meals needs to be correct. Your </li></ul><ul><li>healthcare provider can tell you when </li></ul><ul><li>to do both. It is very important not to </li></ul><ul><li>skip or delay meals and snacks when </li></ul><ul><li>taking insulin because this can affect your glucose insulin balance. </li></ul>
    57. 88. <ul><ul><li>Know the symptoms of hypoglycemia </li></ul></ul><ul><ul><li>If your blood sugar level drops below 60 at any time, you have hypoglycemia. This can be very dangerous. Hypoglycemia is already common in all women with gestational diabetes, but for women taking insulin for this condition, they are at greater risk. </li></ul></ul>
    58. 89. Before any physical activity is begun, you should test your blood sugar. If it is low, do not begin the activity. Eat something and test again to make sure it is higher before beginning
    59. 90. Why does low blood sugar occur? Too much exercise Skipping meals or snacks Delaying meals or snacks Not eating enough Too much insulin
    60. 91. How might I feel if I have low blood sugar? <ul><li>Very hungry </li></ul><ul><li>Very tired </li></ul><ul><li>Shaky or trembling </li></ul><ul><li>Sweating or clamminess </li></ul><ul><li>Nervous </li></ul><ul><li>Confused </li></ul><ul><li>Like you’re going to pass out or faint </li></ul><ul><li>Blurred vision </li></ul>* Report any abnormal blood sugar level to your health care provider right away, in case a change in your treatment plan is needed.
    61. 92. Hypoglycemia Prevention Strategies <ul><li>Consistent Monitoring </li></ul><ul><li>Before All Meals & Snacks </li></ul><ul><li>Pre/Post Exercise </li></ul><ul><li>Bedtime </li></ul><ul><li>3 a.m. (occasionally) </li></ul>
    62. 93. Things to keep in mind about delivery gdm Blood Sugar and Insulin Balance Keeping blood sugar levels under control during labor and delivery is vital for both you and your baby’s health. If you did not have to take insulin during the pregnancy, then you won’t need it during labor or delivery; however, if you did have to take insulin during pregnancy, then you may receive an insulin shot when labor begins or during labor. Early Delivery Gestational diabetes puts women at higher risk for a condition known as preeclampsia late in pregnancy. Preeclampsia is a condition associated with sudden blood pressure increases, which can be quite serious. Unfortunately, the only cure to preeclampsia is delivery of the baby, but delivery may not be the best option for your health or for the health of your baby. Your health care provider will keep you under close watch if this condition develops, determining whether early delivery is safe and needed. Cesarean Delivery This is a type of delivery used to deliver the baby, as opposed to natural delivery through the vagina. Cesarean delivery is also referred to as a cesarean section, or “C” section. Simply having gestational diabetes is not reason alone to have a C section, but your health care provider may have other reasons for choosing this option, such as changes in your health or your baby’s health during delivery.
    63. 94. <ul><li>Postpartum </li></ul><ul><li>often will not require insulin </li></ul><ul><li>if fasting hyperglycemia – </li></ul><ul><li>more likely to develop persistent Diabetes </li></ul><ul><li>6 weeks post partum 75g OGTT </li></ul><ul><li>yearly fasting BG </li></ul><ul><li>emphasize importance of maintaining N weight, exercise </li></ul>Gestational Diabetes
    64. 95. Will I develop Type 2 diabetes in the future ? There are CERTAIN TRAITS : <ul><li>You developed gestational diabetes before your 24 th week of pregnancy. </li></ul><ul><li>Your blood sugar level during pregnancy was consistently on the high end of the healthy range. </li></ul><ul><li>Your blood sugar levels after the baby was born were higher-than-average, according to your health care provider. </li></ul><ul><li>You are in the impaired glucose tolerance category. </li></ul><ul><li>You are obese, according to your health care provider. </li></ul>
    65. 96. … .. CERTAIN TRAITS which increase the chances <ul><li>6 .You have diabetes in your family. </li></ul><ul><li>7 .You belong to a high-risk ethnic group (Hispanic, African American, Native American, South or East Asian, Pacific Islander, Indigenous Australian). </li></ul><ul><li>8 .You have had gestational diabetes with other pregnancies. </li></ul>With one or more of these traits, you should talk to your doctor about Type 2 diabetes .
    66. 97. Should I breastfeed having gestational diabetes? <ul><li>Yes, women with gestational diabetes should breastfeed their babies, if possible. </li></ul><ul><li>Breastfeeding is not only beneficial to the baby, but it is also beneficial to the mother. </li></ul><ul><li>Breastfeeding allows the body to use extra calories stored during pregnancy, allowing for weight loss. </li></ul><ul><li>A weight loss after having the baby not only enhances overall health, but also helps to reduce the risk of developing type 2 diabetes later in life. </li></ul>
    67. 98. Breastfeeding is also believed to help lower fasting blood glucose levels in mothers.
    68. 99. Will I have diabetes after having my baby? <ul><li>Shortly after the baby is born, the placenta </li></ul><ul><li>is “delivered.” </li></ul><ul><li>Since the placenta is what was causing the insulin resistance, when it is gone, gestational diabetes usually resolves as well. </li></ul><ul><li>But, just by having had gestational diabetes, you have a 40% higher chance of developing type 2 diabetes later in life than women who did not have the condition during pregnancy. </li></ul><ul><li>Keeping your weight within a healthy range and keeping up regular, moderate physical activity after your baby is born can help lower your risk for developing type 2 diabetes. </li></ul> gdm
    69. 101. What should I do after delivery? <ul><li>Six weeks after your baby is born, you should have a blood test to find out whether your blood sugar level is back to normal. </li></ul><ul><li>Based on the results you will fall into one of the three categories: </li></ul> gdm If your category is… You should… Normal Get checked for diabetes every 3 years Impaired Glucose Tolerance Get checked for diabetes every year and talk with your health care provider to learn about ways to lower your risk for developing diabetes. Diabetic Work with your health care provider in setting up a treatment plan for your diabetes.
    70. 102. Importance of checking often <ul><li>Getting checked for diabetes is important because Type 2 diabetes shows few symptoms. </li></ul><ul><li>The only way to know for sure is to have a blood test that reveals a higher-than-normal blood sugar level. </li></ul><ul><li>If you notice any of these things, you should tell your health care provider right away: </li></ul><ul><ul><li>Being very thirsty </li></ul></ul><ul><ul><li>Urinating often </li></ul></ul><ul><ul><li>Feeling constantly or overly tired </li></ul></ul><ul><ul><li>Losing weight quickly and/or without reason </li></ul></ul> gdm
    71. 103. Gestational Diabetes Intra partum management <ul><li>Check blood </li></ul><ul><li>Glucose hourly </li></ul><ul><li>Maintain BG </li></ul><ul><li>4-6mmol/L ( 70-110mg /dl ) </li></ul>
    72. 104. <ul><li>Postpartum </li></ul><ul><li>often will not require insulin </li></ul><ul><li>if fasting hyperglycemia – </li></ul><ul><li>more likely to develop </li></ul><ul><li>persistent Diabetes </li></ul><ul><li>6 weeks post partum 75g </li></ul><ul><li>OGTT </li></ul><ul><li>yearly fasting BG </li></ul><ul><li>emphasize importance of maintaining Normal weight, exercise </li></ul>Gestational Diabetes
    73. 105. Preexisting Diabetes <ul><li>Preconception Counselling </li></ul><ul><li>risk of NTD ~1-2% </li></ul><ul><li>Folic Acid 1-4 mg /day </li></ul><ul><li>BG 3.5-5.3 (65-95 mg/dL)prior to meals </li></ul><ul><li>switch to MDI regimen (insulin ac meals and HS) </li></ul><ul><li>keep track of cycles </li></ul>
    74. 106. <ul><li>Normoglycemia prior to conception </li></ul><ul><li>Ideally HBA1C 6% or less </li></ul><ul><li>Team approach </li></ul><ul><li>Glucose monitoring qid </li></ul><ul><li>ACE contraindicated : should be D/C at conception or use Diltiazem instead </li></ul><ul><li>Baseline HBA1C, 24h urine for protein Creatinine Clearance , opthalmology review </li></ul><ul><li>Switch from OHA to insulin </li></ul>Preexisting Diabetes
    75. 108. <ul><li>Assess for end organ disease </li></ul><ul><ul><li>Assess for nephropathy – </li></ul></ul><ul><ul><li>inc risk of PIH. </li></ul></ul><ul><ul><li>Assess & Rx.retinopathy : </li></ul></ul><ul><ul><li>may PROGRESS. </li></ul></ul><ul><ul><li>Assess for neuropathy : generally </li></ul></ul><ul><ul><li>remains stable during pregnancy </li></ul></ul><ul><ul><li>Assess and treat </li></ul></ul><ul><ul><li>Vasculopathy. CAD is a relative </li></ul></ul><ul><ul><li>C/I for pregnancy </li></ul></ul>Pre existing Diabetes
    76. 109. <ul><li>Maternal Risks </li></ul><ul><ul><li>PIH /PET </li></ul></ul><ul><ul><li>polyhydramnios </li></ul></ul><ul><ul><li>preterm labour </li></ul></ul><ul><ul><li>operative delivery ~50% </li></ul></ul><ul><ul><li>birth trauma </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>increase in insulin requirements </li></ul></ul><ul><ul><li>DKA </li></ul></ul>Preexisting Diabetes
    77. 110. <ul><li>Fetal Risks </li></ul><ul><li>congenital anomalies 3X inc. risk </li></ul><ul><li>unexplained stillbirth </li></ul><ul><li>shoulder dystocia </li></ul><ul><li>macrosomia </li></ul><ul><li>IUGR </li></ul>Preexisting Diabetes
    78. 111. <ul><li>Neonatal Risks </li></ul><ul><li>hypoglycemia </li></ul><ul><li>hypocalcemia </li></ul><ul><li>hyperbilirubinemia/polycythemia </li></ul><ul><li>idiopathic RDS </li></ul><ul><li>delayed lung maturity </li></ul><ul><li>prematurity </li></ul><ul><li>predisposition to diabetes </li></ul>Preexisting Diabetes
    79. 112. <ul><li>Congenital anomalies </li></ul><ul><li>3x the general population risk </li></ul><ul><li>approaches the gen. pop.risk (2-3%) if optimal control in periconception period </li></ul><ul><li>related to glycemic control during embryogenesis </li></ul>Preexisting Diabetes
    80. 113. <ul><li>CVS </li></ul><ul><li>:ASD/VSD, CoA :Transposition, :Cardiomegaly </li></ul><ul><li>CNS </li></ul><ul><ul><li>:Anencephaly, </li></ul></ul><ul><ul><li>:NTD, </li></ul></ul><ul><ul><li>:Microcephaly </li></ul></ul><ul><li>GI : duodenal atresia, anorectal atresia, situs inversus </li></ul><ul><li>GU : renal agenesis </li></ul><ul><ul><ul><li>:Polycystic kidneys </li></ul></ul></ul><ul><li>MSK </li></ul><ul><li>:caudal regression </li></ul><ul><ul><ul><li>:siren </li></ul></ul></ul>Preexisting Diabetes Congenital anomalies
    81. 114. <ul><li>Maternal Surveillance </li></ul><ul><li>Blood pressure </li></ul><ul><li>Renal function * </li></ul><ul><li>Urine culture ** </li></ul><ul><li>Thyroid function </li></ul><ul><li>BG control HB A1C* </li></ul><ul><li> * q trimester </li></ul><ul><li>** monthly </li></ul>Preexisting Diabetes
    82. 115. <ul><li>Fetal Surveillance </li></ul><ul><li>U/S for dating/viability ~ 8 weeks </li></ul><ul><li>Fetal anomaly detection </li></ul><ul><li>nuchal translucency 11-14w </li></ul><ul><li>maternal serum screen </li></ul><ul><li>anatomy survey 18-20 w </li></ul><ul><li>Fetal echo 22 w </li></ul>Preexisting Diabetes
    83. 116. <ul><li>Multidose Insulin </li></ul><ul><li>breakfast 25% H </li></ul><ul><li>lunch 15% H </li></ul><ul><li>supper 25% H </li></ul><ul><li>hs 35% NPH </li></ul><ul><li>Indicates insulin as a </li></ul><ul><li>% of total daily dose </li></ul>Gabbe Obstet Gynecol 2003
    84. 117. Insulin Therapy <ul><li>onset (h) peak(h) duration (h) </li></ul><ul><li>insulin analogs .25 0.5-1.5 6-8 </li></ul><ul><li>rapid acting 0.5 2-4 8-12 </li></ul><ul><li>intermediate 1-1.5 4-8 12-18 </li></ul>
    85. 118. <ul><li>Insulin Pump </li></ul><ul><ul><li>Allows insulin release close to physiologic </li></ul></ul><ul><ul><li>Use short acting insulin </li></ul></ul><ul><ul><li>50-60% of total dose is basal rate </li></ul></ul><ul><ul><li>40-50% given as boluses </li></ul></ul><ul><ul><li>Potential complications </li></ul></ul><ul><ul><li>Pump failure, Infection , </li></ul></ul><ul><ul><li>Increased risk of DKA if above </li></ul></ul><ul><ul><li>happens </li></ul></ul>Insulin Therapy
    86. 119. Peripartum Management <ul><li>Withhold subcutaneous insulin from onset of labour or induction </li></ul><ul><li>IV D10 @50cc/h </li></ul><ul><li>IV short acting insulin in </li></ul><ul><li>NS usually starting at </li></ul><ul><li>0.5-1u/h* </li></ul><ul><li>*10u insulin in 100 cc NS(1U=10cc) </li></ul>
    87. 120. Timing of Delivery <ul><li>GDM Diet controlled </li></ul><ul><li>Same as non diabetic </li></ul><ul><li>Offer induction at 41 weeks </li></ul><ul><li>if undelivered </li></ul><ul><li>GDM on Insulin/Type II/Type I </li></ul><ul><li>If suboptimal control deliver following </li></ul><ul><li>confirmation of lung maturity if <39 </li></ul><ul><li>weeks </li></ul><ul><li>Otherwise deliver by 40 weeks </li></ul><ul><li>Generally do not allow to go postterm </li></ul>
    88. 121. Mode of Delivery <ul><li>*Macrosomic infants of diabetic </li></ul><ul><li>mothers have higher rates </li></ul><ul><li>of shoulder dystocia than non </li></ul><ul><li>diabetic mothers </li></ul><ul><li>*Ultrasound estimates of fetal </li></ul><ul><li>weight become significantly </li></ul><ul><li>inaccurate after 4000g </li></ul><ul><li>*Reasonable to recommend C/S delivery if EFW is >4500g </li></ul>
    89. 122. <ul><li>insulin rate usually based on BG and pre-delivery insulin requirement </li></ul><ul><li>eg. For each 75-100 total units /24h of pre-delivery insulin, 1 unit per hour needed </li></ul><ul><li>measure capillary BG hourly / VPG q2-3h </li></ul><ul><li>target: 4-6mmol/L </li></ul>Peripartum Management
    90. 123. <ul><li>Following delivery </li></ul><ul><li>stop insulin infusion </li></ul><ul><li>Begin sub Q insulin </li></ul><ul><li>Resume previous MDI </li></ul><ul><li>schedule at 1/2 -2/3 the </li></ul><ul><li>pre pregnancy dose </li></ul><ul><li>Maintain IV D5W @50cc/h </li></ul><ul><li>until oral feeds tolerated </li></ul>Peripartum Management
    91. 124. Oral Hypoglycemic agents <ul><li>Traditionally not </li></ul><ul><li>recommended in pregnancy </li></ul><ul><li>Recent RCT of oral </li></ul><ul><li>glyburide vs insulin for GDM </li></ul><ul><li>440 patients </li></ul><ul><li>BG measured 7x daily </li></ul><ul><li>Treatment started after 11 weeks gestation </li></ul>
    92. 125. <ul><li>Glyburide Insulin </li></ul><ul><li>Achieved N BG 82% 88% </li></ul><ul><li>LGA infants 12% 13% </li></ul><ul><li>Macrosomia 7 4 </li></ul><ul><li>C Section 23 24 </li></ul><ul><li>Hypoglycemia 9 6 </li></ul><ul><li>Preeclampsia 6 6 </li></ul><ul><li>Anomalies 2 2 </li></ul>Oral Hypoglycemic agents Langer NEJM 2000
    93. 126. THE END