Diabetes in Pregnancy Susan Drummond RN MSN C-EFM Objectives 1. Describe types of diabetes and diagnosis of gestational diabetes 2. Identify a management plan for diabetes during pregnancy 3. Describe risks of hyperglycemia to the fetus. Classification Type I Diabetes: insulin dependent Type II Diabetes: non-insulin dependent Gestational Diabetes: diabetes during pregnancy 1
Type I Diabetes Inadequate insulin production related to a loss of pancreatic beta cell function. No known etiology Classic symptoms: polydipsia, polyuria, polyphagia, weight loss and blurred vision. Management: dietary manipulation, exercise and exogenous insulin Type II Diabetes Inappropriate release of insulin from adequate number of Beta cells or abnormal uptake of insulin at the tissue level. May have a genetic predisposition Seen frequently in obese population. Management may include dietary manipulation, exercise and weight loss. Gestational Diabetes Glucose intolerance with onset or first recognition during pregnancy. Management may include dietary manipulation, oral agents or insulin. 2
Consequences of GDM LGA infant/macrosomia Preeclampsia Insulin resistance is the cause of GDM and also appears to be associated with development of preeclampsia Polyhydramnios Stillbirth Primarily related to poor glycemic control Neonatal Morbidity Screening US Preventive Services Task Force recommends screening all pregnant women for GDM at or beyond 24 weeks gestation. 50 gm oral glucose challenge test. 100 gm oral glucose tolerance tests. Should earlier screening be considered? What about the 2- hour OGTT criteria to diagnose GDM? Ann Intern Med 2014;160: 414-20. Management of Gestational Diabetic Nutrition consult Caloric allotment Carbohydrate Intake Caloric Distribution Exercise program Monitor blood glucose- fasting and 2 h. PP Give one week trial for diet and exercise Medication 3
Prenatal Care Issues Encourage euglycemia Antepartum testing Timing of Delivery Pharmocologic Treatment Glyburide- stimulates insulin release from the pancreas and increases insulin sensitivity in the tissues. Usual dosage is 2.5-20 mg/daily in divided doses Metformin- Inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissues Primarily used in women with pregestational diabetes and in women with polycystic ovary syndrome and infertility. Insulin therapy Typical starting dosage is 0.7-1.0 units/kg daily in divided doses Patient management if existing Type I or Type II Diabetes Blood glucose monitoring NIDDM: fasting blood sugar and 2 h PP IDDM: fasting, AC and HS Diet Oral agents Insulin Humalog Regular NPH or Lente Insulin aspart Ultralente Insulin glargine Insulin lispro 4
Hypoglycemia Signs/Symptoms (BG <40-50 mg/gl) Hunger - Blurred vision Nausea - Numbness (lips/tongue) Headache - Disorientation Sweating - Irritability Weakness - Coma Fatigue -Tremulousness- Loss of consciousness Hypoglycemia Causes exercise Skipping meals or snacks taking too much insulin Treatment Check blood glucose Eat snack Glucose tablets Glucagon emergency kit Hyperglycemia Signs and Symptoms Polydipsia Polyuria Polyphagia Hunger Fatigue Blurred vision 5
Hyperglycemia Causes Missed insulin doses caloric intake Illness lack of exercise Stress Treatment BG >200 mg/dl- check ketones, may need IVF May need extra insulin Antepartum Testing Generally recommended for women who are on insulin or an oral antihyperglycemic agent. vweekly or twice-weekly beginning at 32 weeks vacog recommends for women with GDM and poor glycemic control- no concensus about management of patient with well-controlled GDM. vnst or BPP v ACOG Practice Bulletin #137: Gestational Diabetes Mellitus; Obstet Gynecol 2013; 122:406. vfetal Movement Counting Timing of Delivery Optimal timing of delivery has not been established. Ø GDM (diet/exercise controlled) Ø Recommend induction by 41 weeks. Do not electively deliver before 39 weeks Ø GDM ( Insulin/oral agents) Ø Recommend delivery from 39 0/7 39 6/7 weeks. Ø Scheduled C/S Ø Should be an option if EFM >4500 gms Obstet Gynecol 2011; 118:323. AJOG 2012: 206:309 e.1 Obstet Gynecol 2013: 122:465. 6
Nursing Care during Labor Vital Signs Fetal Monitoring - high risk protocol IV fluids Monitoring for metabolic changes- assess for signs of hypo- or hyperglycemia, or DKA Latent phase- monitor glucose levels every 2-4 hours Active phase- monitor glucose levels every 1-2 hours If insulin is infusing- monitor glucose levels every hour Target range: >70 and <126 mg/dl Delivery When you see the placenta, turn off the insulin! Discontinue IV insulin infusion. Anticipate a in SQ insulin requirements postpartum compared to prenatal dosages. Type 1 Diabetes: Markedly reduced insulin requirements for first 24-48 hours after delivery; check glucose levels every 4-6 hours. Between 24-48 hours after delivery- resume standard diabetes management with daily dose about 50% of the insulin dose before delivery. Type 2 Diabetes: Tend to be normal or modestly elevated; measure fasting pre- and postprandial glucose levels. After 24-48 hours, standard management with diet and pharmacologic therapy as needed Early followup contact at 2 weeks postpartum to assess glucose control Gestational Diabetes Monitor fasting glucose levels for 24-72 hours Overt diabetes: fasting glucose >126mg/dl Screen at 6-12 weeks postpartum Postpartum Screening Up to 1/3 of GDM will have diabetes or impaired glucose metabolism at postpartum screening 15-70% will develop Type 2 Diabetes later in life 7 times greater risk than women without a history of GDM 75 gram, 2-hour OGTT is recommended Obstet Gynecol 2013: 122:465. ACOG Practice Bulletin #180, July 2017 7
Breastfeeding Strongly encouraged for women with Type 1, Type 2, and Gestational Diabetes Improves maternal glucose metabolism Decreases the incidence of diabetes two years after a diagnosis of GDM compared with not breastfeeding. Ann Intern Med 2015; 163:889. 8