H:\Diabetes In Pregnancy 1[1]


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  • Hand out Whites Classification
  • Prevalence can be 1-14 % depending on population studied. GDM represents 90% of pregnancies complicated by Diabetes.
  • 2009 practice guidelines has added testing for type2 diabetes should be done in babies small for gestational age birth weight added to list of conditions for association with insulin resistance. Testing should begin at age 10 or younger if puberty starts earlier. Babies with excess insulin become children who are at risk for obesity and adults at risk for type 2 diabetes. If mom has type 1 then baby risk is 1-2 % and if father has type 1 then 6% chance. Type 2 DM baby has 10-15% risk and 33% chance for glucose intolerance. (ADA Life with diabetes 2004 3 rd edition)
  • Especially multiple gestation pregnancies with increase hormone production that are insulin antagonist
  • According to ADA 2 values must exceed for positive diagnosis. Test should be done in morning 8-14 hr after a fast and after 3 days of unrestricted >150grams of CHOs and unlimited physical activity. Should remain seated and not smoke. 100 gms of glucola – need to check concentration of glucola. Various flavors have various concentrations of glucose. Sweet Success Update Spring 2009 Dr Lois Jovanovic is on Board of Directors. Based on literature search unclear why 2 values need to be elevated. No evidenced based studies. In 2007 large Italian study the women who had the 1 hr elevation was most severe condition. (OVA) This would indicate that more studies need to be done. Research indicates that even mild hyperglycemia (below diagnostic levels) should be addressed and is related to perinatal problems which can be reduced by treatment. If the cut off on 1 hr 50gm challenge the cutoff at <140 only 80% are caught but 90% are caught if <130 is used.
  • Address glyburide and metformin. 2003 The ADA and the American college of Obstetricians and Gynecologist are not currently recommending oral agent during pregnancy. It has been suggested that oral agent be reconsidered as a therapy in GDM. AACE does not recommend oral agents being used. They say insulin should be given to maintain BG control. According to ADA women with type 2 diabetes need to make transition from oral agents to insulin before conception. The safety of all currently available oral agents has not been established in pregnancy and may lead to prolonged hypoglycemia in the neonate and therefore not recommended. A study shows with gestational diabetes has found glyburide to be safe and clinically effective. Type 1 (defect in insulin production – thought to be autoimmune response. Need insulin to survive. Approx 5% all diabetes. Type 2 – obesity and sedentary lifestyle. Insulin resistance and deficiency. On rise in childhood now. Managed by diet and exercise and/or oral agents and or insulin – 95% diabetes. HGB A1c and fructosamine are proteins attached to glucose in blood. A1c = bld sugar control 3 months while fructosamine 2-3 wk control. Used more with preexisting diabetes and pregnancy. Better idea of control.
  • Insulin should be given at same time each day. Major side effects are hypoglycemia and weight gain. Optimal absorption occurs with abd site and site should be rotated.
  • Occasionally, NPH is given at bedtime if having a hard time with elevated FBS
  • Mimics the pattern of how insulin is released in a person with out diabetes. Inject once every 3 days instead of multiple daily injections. Usually only used with type 1 or type 2 patients not gestational diabetes because of cost.
  • Especially heart defects – often order fetal echo
  • H:\Diabetes In Pregnancy 1[1]

    1. 1. Diabetes in Pregnancy Jana McElroy RN, BSN, CDE Sandy Warner RNC- OB, MSN
    2. 2. “ All pregnant women want a successful outcome, a healthy baby.” Gestational Diabetes Caring for Yourself and Your Baby, International Diabetes Center, 2005.
    3. 3. Gestational Diabetes <ul><li>GDM occurs in 7% of pregnancies </li></ul><ul><li>The diabetes generally disappears after the baby is born. </li></ul><ul><li>The mom does have a 2 in 3 chance of developing diabetes later in life. </li></ul>
    4. 4. Gestational Diabetes continued <ul><li>The baby does not have diabetes, just the mom. </li></ul><ul><li>The hormones produced by the placenta cause the body to resist the action of insulin. </li></ul><ul><li>Insulin requirements may increase two or three times during pregnancy. </li></ul>
    5. 5. Gestational Diabetes continued <ul><li>Some women’s bodies are not able to produce sufficient insulin to keep the blood glucose in the acceptable range and this is gestational diabetes. </li></ul><ul><li>A1GDM – controlled with diet and exercise. </li></ul><ul><li>A2GDM – requires oral med &/or insulin also </li></ul>
    6. 6. Diagnosis of Gestational Diabetes <ul><li>Time of test </li></ul><ul><li>Fasting (before glucola) </li></ul><ul><li>1 hr after </li></ul><ul><li>2 hr after </li></ul><ul><li>3 hr after </li></ul><ul><li>Blood Glucose Level </li></ul><ul><li>>= 95 mg/dL </li></ul><ul><li>>= 180 mg/dL </li></ul><ul><li>>=155 mg/dL </li></ul><ul><li>>=140 mg/dL </li></ul>American Diabetes Association: Clinical Practice Recommendations 2009
    7. 7. Type 1 or Type 2 in Pregnancy <ul><li>Important for women with pre-existing diabetes to be in good blood glucose control for 3 months prior to planning a pregnancy. </li></ul><ul><li>A1c < = 7% * Fructosamine < 265 </li></ul><ul><li>Type 2 (Metformin and Acarbose are category B all other oral agents are category C. Insulin still the preferred. </li></ul>
    8. 8. Glycemic Targets <ul><li>Fasting <or= 90mg/dl </li></ul><ul><li>1 hr post meal <or= 130mg/dl </li></ul>
    9. 9. Carbohydrates <ul><li>Main source of fuel for our body. </li></ul><ul><li>Metabolized into glucose. </li></ul><ul><li>Most efficient source of energy for our body. </li></ul><ul><li>Provide important vitamins, minerals and fiber. </li></ul>
    10. 10. Medical Nutrition Therapy <ul><li>Dietitian assesses caloric needs for good growth and development for the baby and normal weight gain for the mother. </li></ul><ul><li>Carbohydrate counting is the preferred way to manage blood glucose control. </li></ul><ul><li>15 grams of carbohydrate equals one carbohydrate serving. </li></ul>
    11. 11. Carbohydrate Intake <ul><li>During pregnancy most women will receive </li></ul><ul><li>30 grams of carbohydrate at breakfast. </li></ul><ul><li>45-60 grams of carbohydrate at lunch and supper. </li></ul><ul><li>15-30 grams of carbohydrate at snack time. </li></ul>
    12. 12. Consistent Carbohydrate Intake <ul><li>It is important that patients taking insulin and/or medications that stimulate insulin production, eat most of the carbohydrate containing food from their meal. </li></ul><ul><li>Carbohydrate servings that are not eaten should be replaced with another carbohydrate food or drink. </li></ul>
    13. 13. Carbohydrate Foods <ul><li>Fruit </li></ul><ul><li>Milk </li></ul><ul><li>Starch </li></ul><ul><li>Sweets </li></ul>
    14. 14. Carbohydrate Serving (15 grams) 1 Tbsp sugar 4 oz regular pop 3 graham cracker squares ½ cup corn ½ cup oatmeal 1 cup vegetable soup ½ cup ice cream ½ cup unsweetened canned fruit ½ cup potatoes 1 container light yogurt 4 oz apple 7 saltine crackers 1 cup milk ½ cup fruit juice 1 slice of bread
    15. 15. Causes of Unstable Blood Glucose <ul><li>Lack of proper medication treatment for blood glucose. </li></ul><ul><li>Stress of the hospital admission. </li></ul><ul><li>Disease process (pregnancy, infection, steroids, brethine) </li></ul><ul><li>Poor dietary intake (incorrect portions of foods, incorrect selection of foods, poor oral intake) </li></ul><ul><li>Hormonal fluctuations </li></ul>
    16. 16. Insulin treatment <ul><li>Sliding scale insulin is reactive instead of proactive . </li></ul><ul><li>With sliding scale insulin, glycemic control is rarely assessed. </li></ul><ul><li>Sliding scale insulin involves a “one size-fits-all” approach. </li></ul>
    17. 17. Sliding Scale Insulin <ul><li>We test the patient’s blood glucose and it is 160 mg/dl before lunch. </li></ul><ul><li>Currently the patient would be covered with 2 units of insulin (Reacting to elevated blood glucose). </li></ul><ul><li>We do not take into consideration what the patient is going to eat that will raise the blood glucose. </li></ul>
    18. 18. Sliding Scale Insulin continued <ul><li>We often do not look at what the patient’s current treatment is: diet, oral agents and/or insulin and sliding scale insulin. (Be proactive. Is there a need to change the patient’s current diabetes medication regimen?) </li></ul><ul><li>The weight of the patient is not considered or how insulin resistant the patient is. (one-size-fits all) </li></ul>
    19. 19. Insulin Action Times Duration of Action NPH 10-24 hours NPH Ultralente 24-36 hours Ultralente Regular Regular 5-8 hours Lispro Humalog (Lispro) 3-5 hours 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Glargine (Lantus) 24 hours Lantus
    20. 20. Problem with Sliding Scale <ul><li>The previous slide showed the duration of the various insulins. </li></ul><ul><li>With sliding scale insulin there is the potential of overlapping of the insulin which creates the potential for low blood glucose. </li></ul><ul><li>Once again reacting to a high blood glucose reading, instead of being proactive and looking to adjust the patient’s current regimen. </li></ul>
    21. 21. Basal/Prandial Insulin <ul><li>Basal insulin (Lantus, Levemir, NPH) </li></ul><ul><li>Prandial insulin (Novolog, Humalog, Apidra) </li></ul>
    22. 22. Action Profiles of Insulin Analogues Plasma insulin levels Regular 6–8 hours NPH 12–20 hours Ultralente 18–24 hours Hours Glargine 24 hours Aspart, lispro 4–6 hours 0 1 2 5 3 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
    23. 23. Basal Insulin <ul><li>Basal insulin provides background insulin but does not cover the peaks in blood glucose at meal times. </li></ul><ul><li>NPH is used as the basal insulin in pregnancy. </li></ul><ul><li>If patient is mixing then the NPH and Novolog would be given at breakfast and supper. </li></ul>
    24. 24. Prandial Insulin <ul><li>Novolog, Humalog or Apidra are the rapid acting insulins that are designed to cover the peaks in blood glucose at meal times. </li></ul><ul><li>They have a rapid onset and last approximately 4 hours. </li></ul><ul><li>Rapid acting insulin is given within 5-15 minutes before the patient eats the meal. </li></ul>
    25. 25. Insulin Pumps
    26. 26. Why Consider an Insulin Pump <ul><li>Provides more precise insulin dosing-within 0.025 of a unit. </li></ul><ul><li>Offers improved insulin absorption with continuous delivery. </li></ul><ul><li>Helps you plan for and maintain tighter blood glucose control for a healthier pregnancy. </li></ul>
    27. 27. Maternal Effects of Diabetes <ul><li>Spontaneous abortion </li></ul><ul><li>Preeclampsia </li></ul><ul><li>PTL </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>Infection </li></ul><ul><li>DKA </li></ul><ul><li>C/Section, forceps or vacuum </li></ul><ul><li>hypoglycemia </li></ul>
    28. 28. Fetal Effect of diabetes <ul><li>Hypo or hyperglycemia </li></ul><ul><li>Congenital effects </li></ul><ul><li>Macrosomia </li></ul><ul><li>IUGR </li></ul><ul><li>Delayed lung maturity </li></ul><ul><li>IUFD </li></ul>
    29. 29. Neonatal Effects of Diabetes <ul><li>Hypoglycemia </li></ul><ul><li>Hyperbilirubinemia </li></ul><ul><li>Polycythemia </li></ul><ul><li>CHILDHOOD: learning disabilities </li></ul><ul><ul><ul><ul><ul><li>obesity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Type 2 diabetes </li></ul></ul></ul></ul></ul>
    30. 30. <ul><li>Better blood glucose control will improve patient outcomes. </li></ul><ul><li>Easier labor and delivery. </li></ul><ul><li>Healthy baby. </li></ul><ul><li>Decrease in infections. </li></ul><ul><li>Decrease in length of stay. </li></ul>
    31. 31. References “ American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control”, Endocrine Practice. Vol. 10, No. 1, 2004. American Diabetes Association Clinical Practice Recommendations 2009. Davidson, J., et al. Gestational Diabetes Caring for Yourself and Your Baby. International Diabetes Center, 3 rd edition, 2005.
    32. 32. References continued Diabetes Forecast. 2007 Resource Guide. Slocum, J. and Biastre, S. Gestational Diabetes, A Core Curriculum for Diabetes Education, Diabetes in the Life Cycle and Research. American Association of Diabetes Educators, 5 th edition, 2003. The Paradigm Platform of Insulin Pumps, Medtronic 2004.