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Gestational Diabetes


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Gestational Diabetes

  1. 1. CLINICAL MANAGEMENT OF DIABETES DURING PREGNANCY Antenatal, Intrapartum and Postpartum Perspectives Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates
  2. 2. BACKGROUND: WHAT IS DIABETES? <ul><li>A defect in body energy regulation and utilization </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Insulin deficiency </li></ul></ul><ul><ul><li>Insulin resistance </li></ul></ul><ul><li>End result: Elevated blood sugar </li></ul><ul><li>Impact of elevated blood sugar: </li></ul><ul><ul><li>Pregnancy complications </li></ul></ul><ul><ul><li>Multi-organ dysfunction </li></ul></ul><ul><ul><li>Excess mortality </li></ul></ul>
  3. 3. Epidemiology and Diagnosis
  4. 4. 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
  6. 6. TYPE 1 DIABETES: INSULIN DEFICIENCY  - cell destruction with lack of insulin
  7. 7. TYPE 2 DIABETES: INSULIN RESISTANCE Insulin Resistance
  9. 9. Gestational Diabetes Screening <ul><li>High risk </li></ul><ul><ul><li>Marked obesity </li></ul></ul><ul><ul><li>Previous unexplained fetal demise </li></ul></ul><ul><ul><li>Personal history of GDM </li></ul></ul><ul><ul><li>Glucosuria </li></ul></ul><ul><ul><li>Strong family history of diabetes </li></ul></ul><ul><li>Low risk </li></ul><ul><ul><li>Age <25 years </li></ul></ul><ul><ul><li>Normal weight before pregnancy </li></ul></ul><ul><ul><li>Ethnicity with low prevalence </li></ul></ul><ul><ul><li>No known first degree relatives with diabetes </li></ul></ul><ul><ul><li>No history of abnormal glucose tolerance </li></ul></ul><ul><ul><li>No history of poor obstetric outcome </li></ul></ul>
  10. 10. Gestational Diabetes Screening <ul><li>Universal screening is advisable </li></ul><ul><li>1 hour 50 gm glucose load (GCT)‏ </li></ul><ul><ul><li>Venous plasma glucose cut-offs </li></ul></ul><ul><ul><ul><li>140 mg/dl </li></ul></ul></ul><ul><ul><ul><li>135 mg/dl </li></ul></ul></ul><ul><ul><ul><li>130 mg/dl </li></ul></ul></ul>
  12. 12. Diagnosis of Gestational Diabetes <ul><li>Three Hour 100 gm glucose tolerance test (GTT)‏ </li></ul><ul><li>Not necessary if GCT is >200mg/dl on screening </li></ul><ul><li>Two abnormal values required for the diagnosis of gestational diabetes </li></ul><ul><li>Currently two diagnostic criteria acceptable </li></ul>
  13. 13. Competing Criteria <ul><li>NDDG, 1979 </li></ul><ul><li>FBS 105 </li></ul><ul><li>1 hour 190 </li></ul><ul><li>2 hour 165 </li></ul><ul><li>3 hour 145 </li></ul><ul><li>Carpentar and Coustan, 1982 </li></ul><ul><li>FBS 95 </li></ul><ul><li>1 hour 180 </li></ul><ul><li>2 hour 155 </li></ul><ul><li>3 hour 140 </li></ul>
  14. 14. 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%
  15. 16. Pathophysiology
  16. 17. PRINCIPLE DANGERS <ul><li>GESTATIONAL DIABETES: </li></ul><ul><ul><li>Fetal hyperinsulinemia </li></ul></ul><ul><li>PREGESTATIONAL DIABETES: </li></ul><ul><ul><li>Fetal Anomalies </li></ul></ul>
  17. 18. Normal Glucose Regulation in Pregnancy <ul><li>The pregnant patient has a tendency to develop HYPOGLYCEMIA between meals </li></ul><ul><ul><li>Related to fetal demand </li></ul></ul><ul><li>Placental steroids cause increased tissue insulin resistance </li></ul><ul><ul><li>They are “DIABETOGENIC” </li></ul></ul><ul><li>Insulin production INCREASES in normal pregnancy </li></ul><ul><ul><li>By 30% </li></ul></ul>
  18. 19. RECALL: PATHOLOGIC CHANGES IN GDM Insulin Resistance Insulin Deficiency
  19. 20. Effects of Hyperglycemia in GDM Fetal hyperglycemia fetal hyperinsulinemia abnormal fetal growth impaired fetal well-being
  20. 21. Fetal Hyperinsulinemia <ul><li>Promotes storage of excess nutrients </li></ul><ul><ul><li>Net Effect: macrosomia </li></ul></ul><ul><li>Increased catabolism of excess nutrients and increased energy usage </li></ul><ul><ul><li>Net Effect: Decreased fetal oxygen storage and episodic fetal hypoxia </li></ul></ul><ul><li>Episodic fetal hypoxia leads to increased catecholamines causing: </li></ul><ul><ul><li>Fetal hypertension </li></ul></ul><ul><ul><li>Cardiac remodelling and hypertrophy </li></ul></ul><ul><ul><li>Increased erythropoietin, RBC’s, hematocrit </li></ul></ul><ul><ul><li>Poor fetal circulation and hyperbilirubinemia </li></ul></ul><ul><ul><li>Stillbirth (?)‏ </li></ul></ul>
  21. 22. The Impact of Fetal Macrosomnia <ul><li>Increased hyperbilirubinemia </li></ul><ul><li>Increased hypoglycemia </li></ul><ul><li>Increased acidosis </li></ul><ul><li>Increased birth trauma </li></ul><ul><li>Macrosomic children are more likely to develop glucose intolerance in adulthood </li></ul>
  22. 23. Congenital Anomalies and Diabetic Control <ul><li>Risk for Congenital Anomalies at various levels of Hemoglobin A1C </li></ul><ul><li>Critical periods - 3-6 weeks post conception </li></ul><ul><li>Importance of pre-conceptional metabolic care </li></ul>
  23. 24. Congenital Anomalies with Pregestational Diabetes <ul><li>Cardiac defects x18 8.5% </li></ul><ul><li>CNS defects x16 5.3% </li></ul><ul><ul><ul><li>Anencephaly x 13 </li></ul></ul></ul><ul><ul><ul><li>Spina Bifida x 20 </li></ul></ul></ul><ul><li>All Anomalies x 8 18.4% </li></ul><ul><li>Background major defects 3-4% </li></ul>
  24. 25. Perinatal Risks for All Diabetic Pregnancies: Mortality/Morbidity <ul><li>Miscarriage </li></ul><ul><li>IUGR </li></ul><ul><li>Macrosomia </li></ul><ul><li>Birth Injury </li></ul><ul><li>Stillbirth </li></ul>
  25. 26. Neonatal Risks for All Diabetic Pregnancies: Morbidity and Mortality <ul><li>Polycythemia and hyperviscosity </li></ul><ul><li>Neonatal hypoglycemia </li></ul><ul><li>Neonatal hypocalcemia </li></ul><ul><li>Hyperbilirubinemia </li></ul><ul><li>Hypertrophic and congestive cardiomyopathy </li></ul><ul><li>RDS </li></ul><ul><li>Childhood impaired glucose tolerance </li></ul>
  26. 27. Maternal Complications <ul><li>Chronic hypertension </li></ul><ul><li>Pre-eclampsia </li></ul><ul><li>Diabetic ketoacidosis </li></ul><ul><li>Maternal hypoglycemia </li></ul><ul><li>Maternal trauma </li></ul><ul><li>Higher C Section rate </li></ul><ul><li>Retinal disease/renal disease not affected significantly by pregnancy </li></ul>
  28. 29. Pre-Pregnancy Management <ul><li>Preconceptional care </li></ul><ul><ul><li>PRECONCEPTION CARE BEGINS AT THE END OF A PREGNANCY WITH GDM </li></ul></ul><ul><ul><li>Tight glucose control (HbA1c)‏ </li></ul></ul><ul><ul><li>Assessment and treatment of associated medical problems </li></ul></ul><ul><ul><ul><li>Hypertension, </li></ul></ul></ul><ul><ul><ul><li>Renal disease, </li></ul></ul></ul><ul><ul><ul><li>Retinal disease </li></ul></ul></ul><ul><ul><ul><li>Heart disease </li></ul></ul></ul><ul><ul><li>Folic acid </li></ul></ul><ul><ul><li>Assessment of family, financial and personal resources to help achieve a successful pregnancy </li></ul></ul>
  29. 30. FIRST PERINATAL VISIT or UPON HOSPITALIZATION <ul><li>Review routine prenatal lab tests </li></ul><ul><li>Baseline 24 hour urinalysis for protein and creatinine clearance </li></ul><ul><li>Baseline retinal exam - for Type 1 Diabetics </li></ul><ul><li>EKG - for Type 1 Diabetics </li></ul><ul><li>Thyroid function tests - for Type 1 Diabetics </li></ul><ul><li>Hemoglobin A1C </li></ul><ul><li>Fetal echocardiogram for pregestational diabetics </li></ul>
  30. 31. Antepartum Gestational Diabetes Care <ul><li>Dietary advice </li></ul><ul><li>Glucose monitoring (5 times per day)‏ </li></ul><ul><li>Insulin therapy if necessary </li></ul><ul><ul><li>Oral Hypoglycemic agents </li></ul></ul><ul><li>Frequent visits to monitor glucose control </li></ul><ul><li>Ultrasound monitoring of fetal growth </li></ul><ul><li>Mode of Delivery: </li></ul><ul><ul><li>Based on obstetric issues </li></ul></ul><ul><li>Timing of Delivery: </li></ul><ul><ul><li>Based on glucose control </li></ul></ul>
  31. 32. What is an ADA diet? <ul><li>Avoidance of large meals with high percentage of simple carbohydrates </li></ul><ul><li>Three small meals with three snacks are preferred </li></ul><ul><li>Low glycemic index foods release calories from the gut slowly and improve metabolic control </li></ul><ul><li>Caloric content: </li></ul><ul><ul><li>35 calories/Kg Ideal body weight (or 15 calories/pound IBW)‏ </li></ul></ul><ul><ul><li>No less than 1800 calories and no more than 2800 calories </li></ul></ul><ul><ul><li>“ Eyeball Technique” </li></ul></ul><ul><ul><ul><li>Small patient 1800 calories </li></ul></ul></ul><ul><ul><ul><li>Medium patient 2200 calories </li></ul></ul></ul><ul><ul><ul><li>Large patient 2400 calorie </li></ul></ul></ul>
  32. 33. What is a “Low” Glycemic Index <ul><li>Glycemic Index (GI): </li></ul><ul><li>Compares equal quantities of carbohydrate in foods </li></ul><ul><li>Is a measure of the effect on blood glucose levels over a 2 hr period </li></ul><ul><li>Provides a measure of carbohydrate quality . </li></ul><ul><li>Expressed as a percentage </li></ul>Time GI = 30 GI = 100 BGL BGL
  33. 34. ‘ Traditional’ starchy foods have a lower GI <ul><li>Barley </li></ul><ul><li>Legumes/beans </li></ul><ul><li>Multigrain ‘Specialty’ breads </li></ul><ul><li>Mueslix </li></ul><ul><li>Porridge oats </li></ul>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.
  34. 35. “ Sugary” foods have a intermediate-low GI <ul><li>Soft drinks </li></ul><ul><li>Flavoured milk (low fat) </li></ul><ul><li>Yogurt (sweetened) </li></ul><ul><li>Ice cream (low fat) </li></ul>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.
  35. 36. Modern starchy foods have a high GI <ul><li>Potatoes </li></ul><ul><li>Cornflakes </li></ul><ul><li>Rice crispies </li></ul><ul><li>Wholegrain bread </li></ul><ul><li>Crackers </li></ul><ul><li>Rice (most types)‏ </li></ul>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.
  36. 37. HOME GLUCOSE MONITORING <ul><li>Fasting and 2 hour post-prandial </li></ul><ul><li>Pre-meal values only if sliding scale short acting insulin coverage is used </li></ul><ul><li>Early AM value if hypoglycemia suspected </li></ul><ul><li>Assure that glucose meter is calibrated </li></ul>
  37. 38. INDICATIONS FOR HOSPITALIZATION <ul><li>Persistent nausea and vomiting </li></ul><ul><li>Significant maternal infection </li></ul><ul><li>DKA </li></ul><ul><li>Poor control/compliance </li></ul><ul><li>Preterm labor </li></ul>
  38. 39. Intensive Inpatient Management: The APA Hybrid Protocol <ul><li>For poorly controlled diabetic patients admitted for rapid control. </li></ul><ul><li>Empiric insulin with the patient’s current standing dose: </li></ul><ul><li>Targets adequate glycemic control </li></ul><ul><ul><li>Fasting values: Less than 100 mg/dl </li></ul></ul><ul><ul><li>2 hour postparandial values: Less than 120 mg/dl </li></ul></ul><ul><ul><li>Avoidance of hypoglycemia, ketonuria, and hyperglycemia </li></ul></ul>
  39. 40. Intensive Inpatient Management: The APA Hybrid Protocol <ul><li>Begin 2200 to 2400 calorie ADA diet. </li></ul><ul><li>Obtain fingerstick every 2 hours for 12-24 hours </li></ul><ul><li>Administer HUMALOG INSULIN for sliding scale </li></ul><ul><li>Retake blood sugar at 2 hours after EACH sliding dose noted below and repeat sliding scale dose of insulin based on FSG. </li></ul><ul><li>Adjust Insulin after 24 hours </li></ul>
  40. 41. 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
  41. 42. Patient CH – Before Hybrid Approach Patient CH – After Hybrid Approach
  42. 43. Intrapartum management <ul><li>ABSOLUTE REQUIREMENTS: </li></ul><ul><ul><li>Dextrose containing intravenous fluids </li></ul></ul><ul><ul><li>Insulin </li></ul></ul><ul><li>Hourly glucose monitoring </li></ul><ul><li>Continuous fetal heart rate monitoring </li></ul><ul><li>Continuous tocodynametry </li></ul><ul><li>Manage labor as normal </li></ul>
  43. 44. THE APA INSULIN DRIP PROTOCOL <ul><li>INTRAVENOUS FLUID MAINLINE: D5W @ 125 cc/hr </li></ul><ul><li>INSULIN DRIP: </li></ul><ul><ul><li>Initially Check Fingerstick every hour </li></ul></ul><ul><ul><li>MIX 100 Units Regular insulin in 500 cc NS (0.2 U/cc)‏ </li></ul></ul><ul><ul><li>TITRATE INFUSION AS FOLLOWS: </li></ul></ul><ul><li>After Fingerstick has been between 80-140 x >2 hours, decrease frequency of fingersticks to every 2 hours then every 4 hours. </li></ul>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
  44. 45. HYPOGLYCEMIA DURING AN INSULIN DRIP <ul><li>For Glucose <60 </li></ul><ul><ul><li>Turn off Insulin drip for 30 minutes </li></ul></ul><ul><ul><li>Continue D5W (or D5LR) at 100 – 125 cc/hr </li></ul></ul><ul><ul><li>Recheck Glucose after 30 minutes </li></ul></ul><ul><ul><li>If blood glucose on recheck is still <60 </li></ul></ul><ul><ul><ul><li>Give 25 ml of D50 IV (or 10-12 grams glucose) </li></ul></ul></ul><ul><ul><li>Recheck Blood Glucose every 30 minutes </li></ul></ul><ul><ul><ul><li>Restart insulin when glucose >101 mg/dl </li></ul></ul></ul>
  45. 46. INSULIN DRIP FOR THE INSULIN RESISTANT PATIENT <ul><li>Method for poorly controlled, morbidly obese or noncompliant patients with gestational diabetes </li></ul><ul><li>50% of total daily insulin dosage divided by 24 hours provides initial rate for insulin drip. </li></ul><ul><li>EXAMPLE: </li></ul><ul><ul><li>Ms. Jones current insulin regimen </li></ul></ul><ul><ul><ul><li>AM: 80units NPH 45 units Regular insulin </li></ul></ul></ul><ul><ul><ul><li>PM: 60 units NPH, 55 units Regular insulin </li></ul></ul></ul><ul><ul><li>Total daily dosage= 240 units per day. </li></ul></ul><ul><ul><li>½ of 240 units = 120 units </li></ul></ul><ul><ul><li>120 units / 24 hours = 5 units per hour as initial dosage. </li></ul></ul>
  46. 47. Management - Postpartum <ul><li>Use pre pregnancy insulin levels when on diet and monitor. </li></ul><ul><li>If GDM monitor sugars only </li></ul><ul><li>Immediate postpartum goal is fingerstick < 200 </li></ul><ul><li>GDM – Repeat GTT at 6 weeks postpartum </li></ul><ul><li>GDM - long term risk of NIDDM </li></ul><ul><li>Contraception </li></ul>
  47. 48. THANK YOU !
  48. 49. EXTRA SLIDES
  49. 51. INSULIN SECRETION <ul><li>Rising blood glucose levels. </li></ul><ul><li>After the uptake of glucose by the GLUT2 transporter there is </li></ul><ul><li>Glycolytic phosphorylation of glucose causing </li></ul><ul><li>A rise in the ATP:ADP ratio, which then </li></ul><ul><li>Inactivates the potassium channel that </li></ul><ul><li>Depolarizes the membrane, causing </li></ul><ul><li>Calcium channel to open up allowing calcium ions to flow inward. The rise in levels of calcium leads to the </li></ul><ul><li>Release of insulin from their storage granule. </li></ul>1 2 3 4 5 6 7 8
  50. 52. INSULIN ACTION <ul><li>Insulin-mediated glucose uptake begins when </li></ul><ul><li>Insulin binds to the insulin receptor and </li></ul><ul><li>Induces a signal transduction cascade which </li></ul><ul><li>Allows the glucose transporter (GLUT4) to transport glucose into the cell. </li></ul>1 2 3
  51. 53. 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
  52. 54. 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
  53. 55. FOLIC ACID <ul><li>All women of reproductive age should consume at least 0.4 mg of folic acid </li></ul><ul><li>High risk women should consume 4 mg/day </li></ul><ul><li>This reduces the risk of neural tube defects </li></ul><ul><li>Newer evidence suggests a lower risk of facial clefting and congenital heart disease as well </li></ul>