Diabetes in Pregnancy

Transcription

1 Diabetes in Pregnancy Resident School November

2 Goals Be able to screen for gestational and preexisting diabetes Be able to counsel women on the diagnosis of gestational diabetes Understand glucose monitoring in pregnancy and treatment goals Understand additional screening and monitoring needed by women with diabetes in pregnancy Understand basics of glucose control in labor Understand post partum issues for women with diabetes in pregnancy

3 Why we should care: Based on a recent CDC study Prevalence of GDM is somewhere between 4.6% and 9.2% in the United States In our own patient population 5% of all of our deliveries are in women affected by Gestational or preexisting diabetes DeSisto CL, Kim SY, Sharma AJ. Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), Prev Chronic Dis 2014;11: DOI:

4 Why else should we care? macrosomia or growth restriction cardiac defects (cardiomegaly, VSDs, transposition of the great vessels) CNS defects (like anencephaly or spina bifida renal anomalies miscarriage, preterm delivery, shoulder dystocia, IUFD polycythemia, hyperbilirubinemia, hypoglycemia, hypocalcemia, hypomagnesemia...

5 Maria Maria is a 26yo G1P0 who just learned she is pregnant and presents for her first prenatal visit. She is a healthy young woman with no previous medical history. Her BMI is 28. Her mother, and aunt and two uncles have diabetes. She is worried about gestational diabetes. She wants to know what screening she should have.

6 Screening options A1c this is for everyone to rule out pregestational DM 1hr 50g glucose tolerance test (if abnormal need 3hr test) 2hr 75g glucose tolerance test (1 abnormal is diagnostic)

7 Maria s first pregnancy 1st trimester you check an A1c. It s 5.1 Then when she is 27 weeks she does her 1 hr GTT Her result is 167. Now what?

8 Maria s 1st pregnancy continues Maria s 3hr GTT has the following results: fasting: 99 1hr: 187 2hr: 150 3hr: 145 Is this a positive or negative test result?

9 The 3hr GTT Fasting<95 1hr<180 2hr<155 3hr<140 at least 2 abnormal values = gestational diabetes 1 abnormal value = glucose intolerance, consider retesting later in pregnancy

10 Maria s 1st pregnancy continues You call Maria to tell her she has gestational diabetes. She has a lot of questions. What do I do now? Will I need a csection? Do I have to do shots like my mom does? Will my baby be ok?

11 A new diagnosis of GDM Explain the diagnosis Referral to diabetes education Start checking sugars Growth scans at 27, 33, 37 weeks Maria would like to know how low her sugar should be and how often to check.

12 Diabetic education Talk with an experienced attending at your site if you don t know who to refer to. IHS and First Choice may have their own educators Alere offers diabetic monitoring and teaching for pregnant women Diane Clokey is the educator for MFM you can call to set up teaching through her (just education not to transfer patient)

13 Goals for treatment Fasting<95 2hr post-prandial <120

14 Maria s course Maria does great for a while with dietary changes alone. You follow her weekly and she is under good control. You space her visits to every 2 weeks. After reaching 30 weeks you start to see her weekly again. Around 33 weeks you notice her sugars are creeping up. She has several sugars above goal now. When do you start medications?

15 When to start medications: Start medication if after diet education and concerted effort at diet modification there are still 2 or more values above goal in a 1 week period. Glyburide: Start at 2.5 mg BID OR 5MG Q AM depending on timing of elevated glucose. Maximum dose is 20 mg total per day. Metformin: Start at 500 mg po bid and increase to 1000 mg po bid or 850 mg po tid with meals Let the fellows know if starting meds so your patient can be added to co-follow

16 Starting insulin Insulin can be your first line agent or used when orals fail Starting dose: units/kg/day divided 25-30% as lispro which each meal 10-25% as NPH qhs Use post prandials to titrate lispro and fastings to titrate NPH

17 Anything else Maria needs now?

18 GDMA2 Fetal testing with twice weekly NST and once weekly AFI starting at 32 weeks (start at 40weeks if GDMA1) Serial growth scans every 4 weeks Also remember these patients are at higher risk for PIH! Talk about shoulder dystocia if you haven t already.

19 When to deliver: If well-controlled GDMA1: expectant management with IOL at no later than 41weeks (consider earlier if evidence of macrosomia) GDMA2: Consider IOL at 39 weeks if ripe cervix, do not allow to continue past 40 weeks

20 Indications for c-section? Consider primary c-section if estimated fetal weight >4500g

21 Maria s labor Maria presents to triage with painful contractions and 6cm dilated at 38+5.

22 What to think about in labor: How big is the baby? How well controlled is mom s diabetes? Is she on meds (and does she need them now)?

23 Glucose control in labor Most women with GDMA1 and those with well controlled GDMA2 will not require insulin in labor. Labor is a high glucose use/low resistance state (like exercise) Women requiring insulin in pregnancy and some women with preexisting DM may need insulin drip (or D5/insulin concurrently) Goal glucose is , check glucose every 1-2 hr in active labor. 6hr of good control before birth will decrease hypoglycemia in the newborn.

24 Maria s delivery While Maria is laboring you review shoulder dystocia with Maria with her nurse and the resident team present. You already talked to her about this earlier in the pregnancy, this is just a review.

25 Maria s delivery cont Maria has a beautiful delivery of a vigorous 3428g baby boy. She wants to know if her baby will be ok. She wonders if she s still going to have to check her sugar and take glyburide. And she wants to know if she s always going to have diabetes now. What happens to babies and what is PP management and counseling for mom?

26 Where do babies go? Babies born to moms with GDMA1 or GDMA2 well controlled on oral meds can got to MBU (within 1 hour of delivery). Babies born to moms on insulin or with poorly controlled DM on oral meds need to go to ICN3 or NICU within 45min of delivery.

27 Baby s glucose

28 Post partum Most women with GDM do not require medication after delivery. But they should have glucose screening at their post partum visit. Most women with pre-existing diabetes can return to their pregestational medication regimen if they were well controlled previously. Or ½ their pregnancy insulin level if not well controlled previously. Women who are affected by GDM have more than a 7-fold increased risk of developing type 2 diabetes 5 to 10 years after delivery.

29 Maria s second pregnancy Maria had her Mirena removed about 2 months ago and presents to you with her second pregnancy. She is now 32yo G2P1. Since her last baby she has gained some weight and her BMI is now 32. About 1 year ago she was screened for diabetes and was diagnosed with Type 2 diabetes. She has been on Metformin 1000mg BID

30 Pre-existing Diabetes HgbA1c 24hr urine EKG Eye exam if indicated by extent and duration of disease Schedule a dating ultrasound (even if LMP certain) Anatomy scan should include fetal echo Serial growth scans Antenatal testing at 32 weeks (28 weeks if poorly controlled)

31 Maria s second pregnancy Her A1c is 6.3% Ok to continue her metformin Counsel on risks associated with DM, and increased risk of PIH Counsel on possible need for insulin later in pregnancy

32 Screen everyone with A1c at first visit, 1hr or 2hr at weeks In new GDM: check fastings and postprandials and send to DM Ed Goal fasting<95, 2hr PP<120 Start meds if persistently >2 values over goal in a week. If on meds or preexisting DM get serial growth scans and ANT testing starting at 32 weeks. Delivery: if GDMA1 can go to 41weeks. If GDMA2 or preexisting consider at 39wk if cervix ripe and do not go past 40wks. Earlier if poor control Keep your fellows in the loop!

33 More information MFM protocol: MCH Clinical Guidelines: David H. Adamkin, MD and Committee on the Newborn Clinical Report Postnatal Glucose Homeostasis in Late-Preterm and Term Infants PEDIATRICS Volume 127, Number 3, March 2011 Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and metaanalysis. Lancet 2009;373(9677): Dabelea D, Mayer-Davis EJ, Lamichhane AP, D Agostino RB Jr, Liese AD, Vehik KS, et al. Association of intrauterine exposure to maternal diabetes and obesity with type 2 diabetes in youth: the SEARCH Case-Control Study. Diabetes Care 2008;31(7):