Pregnancy workshop. 25 th April 2014 Caroline Byrne

Transcription

1 Pregnancy workshop 25 th April 2014 Caroline Byrne

2 Topics for Discussion Need for good control, pre pregnancy counselling How good control changes outcomes Using CSII in routine care Practical aspects of CSII during pregnancy

3 Glycaemic control and pregnancy outcome <5% <20% OR 1.38, 95% CI ; p< Holman N Diab Med 2011, Bell R Diabetologia 2012

4 EASIPOD Patient Information Leaflet

5 Effects of PPC on pregnancy preparation PPC No PPC P (n=181) (n=499) Planned 91% 37.5% < Precon counselling 83% 32% < EASIPOD leaflet 43% 15% < Folic acid 88% 27% < ACE 2 (1%) 23 (5%) 0.05 Statin 0 38 (7.6%) Booking gestation 6.7 (4.4-10) 7.7 (5.1-15) < Murphy HR et al, Diab Care 2010

6 Effects of PPC on glycaemic control PPC (n=181) No PPC (n=499) P Pre-pregnancy 7.2 ( ) 8.1 ( ) < HbA1c (1 st trimester) 6.9 ( ) 7.4 ( ) < HbA1c (2 nd trimester) 6.4 ( ) 6.5 ( ) HbA1c (3 rd trimester) 6.4 ( ) 6.5 ( ) 0.05 Booking HbA1c 7% 53% 38% < HbA1c <6.1%* 17.8% 10.4% < *17.8% PPC (10.9%T1D, 32% T2D) vs. 10.4% (5.1% T1D, 16.5% T2D) (p=0.05)

7 Pre pregnancy care Joint mutlidisciplinary appointments See 1 year before planning pregnancy Strongly encourage DAFNE asap Ideally then transfer to CSII See every 2-4 months Encourage telephone/ contact in between for optimisation Smoother transition to pregnancy clinic

8 How many pregnant pumpers have we had? T1, 13 on pumps with 3 emergency starts T1, 14 on pumps 4 emergency starts T1, 22 on pumps with 5 emergency starts T 1 26 on pumps with 7 emergency start T1, 24on pumps with 5 emergency starts

9 Pregnancy Best time to initiate 1 st trimester issues 2 nd trimester issues 3 rd trimester issues Perinatal support Postnatal support

10 Best time to initiate Ideally 6-12 months prior to conception If required during pregnancy 8-12 weeks gestation or Late 2 nd trimester, but may be too late already to influence growth! Weigh up benefit and risk Requires +++ input for duration of pregnancy as requirements change so rapidly and pt not given time to learn self management skills to same degree (no luxury of learning by trial and error!) Very short saline trial Intensive support regular s, weekly/fortnightly clinic appts, etc.

11 1 st trimester issues Hypos, hypos and more hypos Driving and work safety Target setting and temporary basal rates Ever changing hormonal levels Nausea and vomiting Organogenesis Miscarriage 4-8 weeks

12 Transition to pump RH T1DM 1983 DAFNE 2010 HbA1c 7.6% Humalog 2:1 1.5:1 1.5:1 Levemir 7/12.5 8/40 reduced levemir and ratio s due to hypo s And start injecting pre meal CHO suggested 30/30/50/50 Dawn phenomenon, injecting at 3am Decision for transition to pump

13 Settings Total daily dose on MDI Reduce by 30% 50% as basal over 24hrs Bolus worked out on 500 rule for ratio s (usually then increased depending on individuals) Correction factor on 100 rule Targets 7-8 for first 24 hours

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17 2 nd trimester issues Severe hypo risk still issue up to 16-18weeks More stability Less morning sickness Endogenous fetal insulin production from 14 weeks Index for 3 rd trimester fetal growth acceleration Post-prandial readings most significant? Metformin Increasing insulin requirements from 20 weeks

18 3 rd trimester issues Ever increasing insulin requirements CHO resistance causing post-prandial highs requiring large bolus of insulin Length of time taken to deliver bolus Timing of when to bolus Optimal wave options Hypos as a result of overlap with basal 2 4 hours after meals Max bolus / ratio on pump settings Active insulin / insulin on board

19 3 rd trimester issues Management techniques! Bolus given 15-30mins prior to meal Use of square/extended wave option Use bolus ratio setting and then add additional units Limiting CHO intake <30g Breakfast, <60g?<50g other meals Corrections plus temp basal rate 125% for 2 hours Snacking and or 0% basal to prevent overlap with basal 2 4 hours after meals

20 Good Breakfasts 1 small pot natural / diet / Greek yoghurt (12-15g) with a chopped fruit or cup of berries (5-10g) 25g high fibre cereal / 1 Weetabix with semi skimmed or skimmed milk 25g jumbo porridge oats (15g) with crème fraiche (0g) and 1 cup berries (5-10g) 1 Slice Whole wheat bread (15-20g) with 2 poached or scrambles eggs / mushroom / tomato

21 Good Mid Meal Snacks 10-15g Carbohydrate 1-2 pieces fruit. 2 whole-wheat crispbreads or oatcakes with low fat cream cheese. Small pot low fat yoghurt. 1 slice wholemeal bread sandwich or toast. 1 Weetabix or Shredded Wheat. Wholemeal mini pitta bread. 1-2 Wheatmeal Digestives or Hobnobs.

22 Carbohydrate Free Snacks can be eaten any time Olives Vegetable pieces with humous, low fat cream cheese or salsa dips. Avocado Cherry tomatoes Cubes of low fat cheese (try with cocktail onion or gherkin) Natural nuts or mixed seeds Sun blushed or sun dried tomatoes Cooked meats Sugar free jelly Corn on the cob Boiled egg 1 cup cherries or berry fruits

23 3 rd pregnancy 35 weeks

24 CGM in dealing with hypoglyceamia overnight

25 36 weeks HbA1c 42 Scan AC normal

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27 What to change?

28 Decrease carb ratio by ½ g Decrease senstivity up to 3.5 mmol/l Reduce overnight basal by 10-15% Close checking of FM Use temp basal for any activity Cautious corrections Aim for IOL end of 38 th week

29 3 rd trimester issues Dropping insulin requirements and hypos late in pregnancy? Placental insufficiency Requires close obstetric monitoring Consider admission and early delivery options

30 Perinatal support Pump management during delivery Infusion set positioning Restarting pump following sliding scale Insulin requirements Discussion regarding risk of severe hypoglycaemia post natally Set alternative pattern on pump pre-delivery (32-34wks):- at least 50% less basal, ratio 1:12-15g 0-3mths: Snacking (10-15g) when breastfeeding and /or temp basal 80% for 1 hour Remind to reset bolus, sensitivity (3mmol/l), targets (5-8mmol/l) and active insulin (4hrs) on pump Expect unstable glucose post delivery hours due to hormones, etc. Targets 5 10mmol/l SBGM

31 During clinics Collect data from Daily Totals TDD Basal % Totals carbs Av. BG

32 Postnatal support Consider impact from high intensity support for 9 months to nothing post delivery, esp if pump started in pregnancy! Prepare patient and discuss/agree follow-up pre-delivery Seen on ward for stabilisation Contact as appropriate post discharge Seen at 8-10 weeks postnatal in clinic Seen at 3-6 months in pump clinic

33 Postnatal support Things to consider:? Group support for pregnant or new mother pumpers Contraception Mirena or Implanon recommended Re-introduction into routine diabetes medical clinic system (3-6mths post)

34 Questions?