Managing Gestational Diabetes. Definition of GDM

Transcription

1 Managing Gestational Diabetes Definition of GDM Gestational diabetes is defined as glucose intolerance of variable severity with onset or first recognition during pregnancy that excludes those with overt diabetes First through Fifth International GDM Conference 2014 ADA Clinical Practice Guidelines

2 The Incidence of GDM is Rising Incidence is increasing as population becomes more sedentary and obese Incidence of GDM reflects the increase in type Getahun et al. Trends in gestational diabetes. Am J Obstet Gynecol; Prevalence of GDM by Race/Ethnicity Northern California Kaiser Permanente GDM % Asian Hispanic African Amer Non Hispanic White Ferrara A. et al. An Increase in GDM: Northern CA. ACOG March 2004

3 Pathophysiology of GDM Insulin Resistance Relative Insulin Deficiency Gestational Diabetes BASICS 2011 International Diabetes Center at Park Nicollet Maternal hyperglycemia Fetal hyperglycemia Pedersen Hypothesis Fetal hyperinsulinemia (ß-cell hypertrophy and hyperplasia) Excessive fetal growth -macrosomia/ large for gestational age -post-partum hypoglycemia -increase rate of c-section; difficult deliveries -maternal hypertension -other problems Reece, Coustan, Gabbe. Diabetes in Women. 3 rd edition. Page 165

4 Maternal-Fetal Complications of GDM Fetal Macrosomia Neonatal hypoglycemia Respiratory distress syndrome Neonatal hypocalcemia Neonatal hyperbilirubinemia Polycythemia Maternal Hypertension Preterm delivery Cesarean section Difficult deliveries Polyhydramnios Hyperglycemia Adverse Pregnancy Outcomes Trial- HAPO Strong continuous association of maternal glucose levels with: Increased birth weight Cord-blood C-peptide Primary C-section Post-partum hypoglycemia Birth Weight > 90th Percentile Cord C-Peptide >90th Percentile Frequency (%) Glucose Categories Fasting One Hour Two Hour Frequency (%) Glucose Categories Fasting One Hour Two Hour Metzger B et al. NEJM. 2008;358:

5 When to screen for GDM? Risk Assessment High risk: At first prenatal visit GDM or DM Family Hx Obese; Older High risk ethnic group Normal risk: Between wk Low risk: May not screen No know relatives with DM Low risk ethnic group- Caucasian Non-obese: BMI < 25 <25 years old No hx of GDM, glucosuria or adverse perinatal outcomes GDM Screening & Diagnosis First prenatal visit If at high risk (hx GDM, LGA, fam hx, pre-pregnancy BMI >30) do an A1C test - A1C > 6.5% = type 2 DM - A1C < 6.5% - test weeks All women between weeks - 1 hour, 50 gm random GCT If > 200 = GDM If only one elevation, repeat OGTT in 2-4 weeks? Weeks Gestation Diagnostic Criteria 100 gm OGTT Fasting > 95 1 hour > hour > hour > 140 Meet or exceed 2 or more values Or, fasting > 105 If mg/dl then schedule 100 gm OGTT within one week

6 Diagnostic Criteria and Glucose Thresholds for GDM Organization (year) OGT Test Used -- # of Abnormal Values Threshold (equal to or greater than) WHO (1999) 75 gm 1 abnormal 110 mg/dl ACOG (2001) ADA ( ) ADA (2014) ADA ( ) 100 gm* 2 abnormal 95 mg/dl 75 gm 1 abnormal 92 mg/dl * 50 gm OGCT > 130 or 140 mg/dl Fasting 1-hr 2-hr 3-hr 180 mg/dl 180 mg/dl 140 mg/dl 155 mg/dl 153 mg/dl 140 mg/dl Key: WHO-World Health Organization ACOG-American College of Obstetricians and Gynecologists ADA- American Diabetes Association Not enough evidence of benefits over risks to switch to 1 step method which would increase GDM 2-3 fold A single standard for GDM screening and Dx should be agreed upon by professional organizations in US and Internationally

7 Referral for Diabetes Self- Management of GDM Refer within one week Self Management Training Blood glucose monitoring Food plan Ketone testing Record Keeping and follow up Additional therapy: if needed- glyburide or insulin Self-Monitoring Blood Glucose Test 4 times a day Fasting mg/dl 1 hr after meals- < 130 mg/dl Glucose levels are about 10 points lower than nonpregnant levels No research data to support testing frequency A1C testing Glucose Value Mean glucose Fasting Pre-prandial Post-prandial peak Post-prandial peak time Mean nighttime glucose Normal in pregnancy 83.7 mg/dl 75 mg/dl 78.2 mg/dl 110 mg/dl 70.5 minutes 68.3 mg/dl No usually done ~ 1% point lower Ben-Haroush A, et al. AJObGyn (2004)p 576 Yogev et al. AJObGyn (2004) p 949

8 Glucose Targets for GDM Pregnancy Time of Test GDM ADA GDM - ACOG IDC Fasting Before mg/dl mg/dl mg/dl breakfast Before meals or snack mg/dl 1 hour post meal <140 mg/dl <130 mg/dl 2 hour post meal <120 mg/dl < 120 mg/dl 2 AM to 6 AM Above 60 mg/dl ACOG Practice Bulletin. Obstet-Gynecol, December Clinical Recommendations, Diabetes Care January 2014 Gestational Diabetes BASICS 2011 and Gestational Diabetes: Caring for Yourself and Your Baby 2013; International Diabetes Center Ketone Testing Test is to identify starvation ketosis, not DKA Very little research to support testing IDC recommends ketone testing during the first 2 wks after diagnosis Goal is negative or trace ketones May indicate under eating or fear of taking insulin May indicate too many hours without food/carb add or increase evening snack

9 Medical Nutrition Therapy for GDM A carbohydrate controlled meal plan that promotes adequate nutrition with appropriate weight gain, normoglycemia and the absence of ketones. * Individualized food plan 3 meals and 2-4 snacks Avoid foods very high in carbohydrate Avoid sweetened beverages *American Dietetic Assoc. Nutrition Practice Guidelines, 1997, 2002, 2009

10 My Food Plan for GDM Sample distribution of carbohydrate 1 Choice = 15 grams carbohydrate Breakfast limit of 2 (30 grm) Noon meal 3 4 (45-60 grm) Evening meal 3 4 (45-60 grm) 3-4 Snacks 1 2 (15-30 grm) Less Carbohydrate for Breakfast Higher hormone levels in AM Usually 30 gm carb Test one hour after eating; target glucose <130 mg/dl Avoid highly processed foods, like cereals at breakfast

11 Healthy Eating Consume adequate calories and nutrients Minimum carbs = 175 gm 130 gm non-pregnant Eleven carb choices Test glucose post-meal Consider glycemic index Avoid alcohol Safe eating The Glycemic Index Strengths Encourages use of unprocessed, whole, high fiber foods May explain post-meal glucose variability May help fine-tune glucose control Fiber Fat Fructose Challenges Person to person variability Not easily accessible Impacted by food preparation, ripeness and country of origin Methodology not standardized Does not address portion control Refined Processed white Fernandes et al. JADA 2005:105,557 Brand-Miller, J et al. Am J Clin Nutr 2002:765 Low GI High GI

12 Use of Artificial Sweeteners FDA approved artificial sweeteners are approved for the general public including pregnant women In place of sweetened products, use will help control postmeal glucose levels Limited data to support use in pregnancy If pregnant woman chooses to consume, use moderation Journal of Academy of Nutrition and Dietetics, Position Statement: Use of Nutritive and Non-nutritive Sweeteners. May 2012 Institute of Medicine 2009 Weight gain guidelines based on prepregnant weight Category BMI Total Gain in Pounds Total Gain in Kilograms Underweight < Normal Overweight Obese > Institute of Medicine. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academy Press; 2009.

13 What Percentage Meet IOM Guidelines? 30% gain within the IOM guidelines 20% gain less than IOM guidelines 50% gain more than the IOM guidelines Avoid excessive weight gain Interventions can prevent excessive weight gain Monitor weight gain on chart Self-monitoring of food and activity with accountability 33% calorie restriction Avoid ketonuria and ketonemia Knopp RH et al. J Am Col Nutr, 1991 Rizzo T, et al. NEJM, 1991 Rae A. Aust N Z J, 2000 Olson CM. Am J Obstet Gyncel, 2004 Relationship of Maternal Wt Gain to Infant Birth Wt Very Overweight Moderately Overweight Ideal weight Underweight Institute of Medicine. Nutrition and Pregnancy 1990

14 One Week Follow-up Important to review records Assess understanding Monitoring and Evaluation Post-meal glucose levels Large portion sizes Inaccurate/ misunderstanding carb counting Intake of sweetened beverages, soda/ juices Inactivity; bed rest; tocolytic drugs; illness Certain foods raise BG more than others Need for insulin/glyburide or dose increase Weight changes Wt. loss due to lower carbohydrate intake Excessive gain due to high fat choices and/or inactivity Starvation ketosis Under-eating due to fear of high BG/insulin Many hours without eating; no evening snack Understanding and ability to follow the food plan

15 Review of Food Record Lunch 6 sub sandwich = 3 carb 1 cup milk = 1 carb Total carb = 4 carb (60 g) Post-meal glucose = 180 Is the patient counting carbohydrates correctly? Is the meal/snack within the food plan? Are the food choices healthy? What is glucose level after eating within target? Less than 130 mg/dl Food and BG Record- Example

16 Initial Therapy Based on OGTT OGTT fasting <95 mg/dl OGTT fasting mg/dl OGTT fasting >125 mg/dl When to add pharmacologic therapy? When glucose targets have not been achieved 2 or more values out of target within a week, without explanation Rate of fetal growth is excessive Unable to consume adequate calories/nutrients to maintain weight and glucose control Complaint of being hungry Pharmacologic therapy is added to nutrition therapy

17 Use of Glyburide in Pregnancy Landmark study published in 2000 by Langer showed that glyburide was safe and effective compared to insulin Since that study, numerous other studies reported that glyburide therapy is effective in maintaining glycemic control in conjunction with nutrition therapy If fasting > 115 mg/dl, glyburide unlikely to be adequate Pregnancy category B Teach hypoglycemic protocol Conway et al. J Mat Fetal Neonat Med. 24;15:51-55, Landon M, Gabbe S. Obstetrics and Gynecology. 118 (6), Dec 2011, Use of Metformin in GDM Metformin versus Insulin for the Treatment of Gestational Diabetes showed similar outcomes; women preferred metformin to insulin Metformin lowers BG by reducing hepatic glucose output and increasing insulin sensitivity There is sufficient evidence that it is safe to use; it is not considered teratogenic Comparing metformin to glyburide: more likely to need insulin with metformin Rowan, NEJM, 2008;358:

18 Insulins Used in Pregnancy Regular and NPH: Pregnancy category B Used for twice daily injection regimens to cover food plan Longer duration of action may lead to more hypoglycemia Lispro and Aspart :Pregnancy category B Lower incidence of hypoglycemia May cover post meals more appropriately; adjust food plan Levemir (Detemir): Pregnancy category B as of April 2012 Glargine (Lantus): Pregnancy category C Has been used now for many years Package Insert MICROMEDEX Insulin Initiation Starting dose calculation: U/kg Conventional Split/Mixed: Reg/NPH twice a day Multiple Daily Injections: Rapid-acting and longacting analogs taken 3-4 times per day Gestational Diabetes BASICS Curriculum Guide. 2011International Diabetes Center Staged Diabetes Management Quick Guide, 5 th Edition, 2009

19 Healthy Coping Labor and Delivery Keep blood glucose levels between mg/dl Continue medication if taken and eating normally Once in active labor NPO and hold medication Check blood glucose every 2 hours If >100 mg/dl sliding scale insulin If < 60 mg/dl treat for hypoglycemia

20 Hospitalization Costs (2008) Prexisting DM GDM Normal Pregnancy Mean length of stay Mean hospital costs $5,900 $4,500 $3,800 Healthcare Cost and Utilization Project. Statistical Brief #102; Neonatal Hypoglycemia Plasma glucose < 40 mg/dl in term infant Reagent strips inaccurate at low levels, but will overestimate incidence Does not correlate well with macrosomia Blood glucose should be checked at 1 and 2 hours after birth - nadir typically at 2 hours

21 Postpartum Breastfeeding is encouraged Assess glycemic status at 6-12 weeks postpartum visit Home glucose records: check fasting and 2 hour BG- once a week 75 gm OGT; fasting glucose alone not sensitive to pick up IGT Screen at one year post-delivery Screen at least every 3 years after that 5 th International Conference on GDM, Diabetes Care. July 2007 Predictors of Diabetes in Women with Previous GDM 8 year risk of postpartum diabetes = 52.7% Increase risk with: Women who required insulin Women with BMI >30 Women with more than 2 prior pregnancies Auto-antibodies to GAD (glutamic acid decarboxylase) autoimmunity test Lobner K. DIABETES, March 2006

22 Prevention of Type 2 Diabetes Diabetes Prevention Trial showed 58% reduction in diabetes 5-7% weight loss Regular activity of 150 min/week Advise women with GDM to lose weight after delivery which includes a combination of diet modification and physical activity IDC Patient Education Materials

23 Questions? References AADE Desk Reference, Chapter 23 Pregnancy in Diabetes ACOG Clinical Expert Series: GDM; Obstetrics & Gynecology, Dec 2011 Evidence-based Nutrition Practice Guidelines for Gestational Diabetes, the Academy of Nutrition and Dietetic EAL. Fifth International Conference-Workshop on Gestational Diabetes, Diabetes Care supplement, July 2007 Hyperglycemia and Adverse Pregnancy Outcomes, NEJM, May 8, 2008 IDC Publishing: My Food Plan for GDM and GDM BASICS IADPSG Recommendations. Diabetes Care, March 2010