Management of diabetes in pregnancy

Management of gestational diabetes mellitus

1. MANAGEMENT OF DIABETES IN PREGNANCY Sharon Treesa Antony 2 nd M.Sc Nursing Govt. College of Nursing, Kottayam

2. definition Diabetes mellitus is a metabolic disorder consequent to decrease in insulin secretion or increase in insulin resistance or both resulting in abnormalities of carbohydrate , protein and lipid metabolism.

3. Carbohydrate metabolism in pregnancy Diabetogenic state Insulin resistance HPL Cortisol , estriol , progesterone Insulin destruction by kidney and placental insulinases Increased lipolysis Changes in gluconeogenesis

4. Classification of pregnant patients with diabetes mellitus Pregestational Type 1 Type 2 Secondary Gestational Impaired glucose tolerance ( OGTT at 2 hour 140-199 mg/dl )

5. Modified white’s classification ( ACOG) CLASS Onset FBS 2 HOUR PPBS THERAPY A1 Gestational < 105 mg/dl <120 mg/dl Diet A2 > 105 >120 Insulin CLASS AGE OF ONSET DURAATION ( YEAR) VASCULAR DISEASE THERAPY B >20 YEARS <10 None Insulin C 10-19 10-19 None “ D <10 >20 Benign retinopathy “ F Any Any Nephropathy “ R Any Any Proliferative retinopathy “ H Any Any Heart “ T Any any Prior renal transplant t “

6. causes Type 1 – autoimmune, chromosome 6 and 11 Type 2 – insulin resistance, islet dysfunction

7. Risk factors for GDM Family history Previous overweight baby Previous IUD with pancreatic islet cell hyperplasia Unexplained perinatal loss Presence of polyhydramnios or recurrent vaginal candidiasis Persistent glycosuria

8. Age > 30 years Obesity Ethnic group ( East Asian, Pacific island)

9. Signs and symptoms Signs of GDM in previous pregnancy Infant > 4 kg IUD/Congenital anomalies Poly hydarmnios Recurrent monilial vaginitis

10. Signs of GDM in current pregnancy Glycosuria on 2 successive visits Recurrent monilial vaginitis Macrosomic baby Poly hydramnios

11. Pregestational diabetes mellitus Acanthosis nigricans T1 : hypogycemia , starvation leads to ketosis T2: hyperglycemia leading to ketonemia , aminoacidemia T3 : hypoglycemia , ketosis

12. Labour: hypoglycemia , acidemia from starvation ketosis Postpartum: hypoglycemia

13. ketoacidosis Hyperventilation Mental lethargy Dehydration Hypotension Abdominal pain, nausea, vomiting Fruity odour to breath Ketonuria

14. Screening and diagnosis Criteria for diagnosis of DM( expert committee 2001) Fasting plasma glucose >/=126 mg/dl 2 hour PPPG: >200mg/dl after a75g glucose load Symptoms of diabetes such as polyuria , polydypsia , unexplained weight loss + casual plasma glucose > 200 mg/dl

15. Gestational DM Low risk group <25 years Normal body weight prior to pregnancy Negative family history No h/o impaired glucose tolerance No h/o poor obstetric outcome Not a member of high risk ethnic group

16. High risk group + ve family history h/o poor obstetric outcome Prior infant> 4kg Obesity Multiple pregnancy PCOS

17. Glycosuria on 2 consecutive visits High risk ethnic group Hypertensive disorder Recurrent monilial vaginitis Poly hydramnios

18. All the high risk group should be screened at First visit Between 24-28 weeks

19. Two step approach 50g oral glucose 1 hour PPBS >130mg /dl OGTT

20. One step approach TIME CARPENTER AND COUSTAN ( mg/dl) NDDG FASTING 95 105 1 HOUR 180 190 2 HOURS 155 165 3 HOURS 140 145

21. PLASMA ( mg%) Time Normal tolerance Impaired glucose tolerance Diabetes Fasting < 100 >/= 100 and< 126 >/= 126 2 hour post glucose < 140 >/=140 and < 200 >/ = 200

22. IADPSG 2 PHASE STRATEGY FOR SCREENING OF DIABETES MELLITUS ( international association of diabetes & pregnancy study group) First antenatal visit :all women FBS/RBS/HbA1c FBS: >/= 126 mg% RBS: >/= 200mg% HbA1c:>/=6.5% OVERT DM

23. FBS: < 92mg% - normal >/= 92 mg% - GDM

24. 24-28 WEEKS : OGTT All women not previously found to have GDM FBS: >/= 92mg% 1hour: >/= 180 mg% 2 hour: >/= 153mg% FBS: >/=126 mg%- overt DM All values< threshold is normal One or more values more than threshold: GDM

25. Effects of pregnancy on diabetes More insulin demand Hyperglycemia , ketoacidosis Hypoglycemia Progression of diabetic retinopathy Worsening of diabetic retinopathy Diabetic neuropathy Atherosclerosis More metabolic demands Insulin resistance

26. Effects of diabetes on pregnancy Spontaneous abortion Pre eclampsia Pre term labour Polyhydramnios Infection

27. Diabetic ketoacidosis Increased operative delivery PPH Pelvic floor trauma Retinopathy Hypoglycemia Prolongation of labour Shoulder dystocia

28. FETAL AND NEONATAL EFFECTS Hypoglycemia Hyperglycemia Congenital defects Macrosomia Growth restriction Fetal death

29. Neonatal complications Hypoglycemia Respiratory distress syndrome Hyperbilirubinemia Polycythemia Hypocalcemia Hypomagnesimia Cardiomyopathy

30. Long term effects Childhood obesity Neuropsychological effects Diabetes

31. management PRECONCEPTIONAL COUNSELLING

32. High risk case Regular follow up Evaluation of end organ damage at first visit

33. Diabetic nephropathy 24 hour urine protein Creatinine clearance BUN Urine culture

34. Retinopathy : fundus examination Cardiovascular system BP ECG Echocardiography Stress test Autonomic dysfunction

35. Good glycemic control ( HbA1c 4-6%) Start insulin for those on OHA Weight management, Exercise No smoking and alcohol Folic acid: 5mg/day

36. MANAGEMENT DURING PREGNANCY

37. Early registration Regular antenatal checkup At first visit: Evaluation for endorgan dysfunction Macrovascular disease Treat CAD TFT Advise SMBG 4-6 times/day

38. Metabolic goal during pregnancy Premeal plasma blood glucose : 70 – 105 mg/dl PPBS: no higher than 130mg/dl Monitor HbA1c every 4-6 weeks

39. Dietary therapy Consultation with dietician 30-35kcal/kg/day in the form of 3 major meals and 2-3 minor meals

40. CHO: 50-60% Fat :<30% Adequate fiber Protein: 12-20%

41. According to apa daily calorie intake <80% of ideal body weight: 36-40 kcal/kg 80-120%: 30 120-150: 24 >150: 12-18

42. Ideal body weight 100lb for first 5 feet height + 5 pounds/ inch for each inch over 5 feet (+ 10% for large frame)( - 10% for small frame)

43. Formula for calculating caloric needs Baseline calories= IBW* 10 Activity calories Sedentary: IBW* 3 Moderate: IBW* 5 Strenuous:(IBW*7)-10 Obesity: - 500 calories Pregnancy:+300 calories

44. Total calories= baseline calories+activity calories- obesity+ pregnancy

45. Calorie distribution( ACOG) 10-20% at breakfast 5-10% at midmorning 20-30% at lunch 5-10% at mid after noon snack 30-40% at dinner 5-10% at bed time snack

46. Low glycemic index foods and soluble fibres Lipids from monounsaturated fats: avacadoes , olive, peanut PUFA Limit sugary and concentrated sweets Plenty of cabbage, cucumber, green onions, mushrooms, spinach

47. One glass water/ hour Soluble and insoluble fiber Sodium: 3000mg/day

48. Meal plan Exchange system Carbohydrate counting Food pyramid

49. Lifestyle modifications Regular exercise Water intake Exercising site of injection Aerobic exercise with resistance training 2 times a week

50. Oral hypoglycemic agents Sulphonylureas Eg : Glyburide Increase insulin secretion 2.5mg PO daily

51. Biguanides Eg : metformin Cross placenta Transferred in breast milk

52. Thiazoledinediones Crosses placenta

53. Insulin therapy Short acting( regular) Rapid acting( lispro , aspart , glulisine ) Long acting ( NPH, lente , ultralente ) Mixtard (30/70)

54. Types of insulin Types Onset of action Peak of action ( hour) Duration of action (hour) RAPID ACTING Lispro <0.25 0.5-1.5 3-4 Insulin aspart <0.25 0.5-1.5 3-4 SHORT ACTING Regular 0.5-1.0 2-3 3-6 INTERMEDIATE ACTING NPH 2-4 6-10 10-16 Lente 3-4 6-12 12-18 COMBINATIONS 70/30 0.5-1 Dual 10-16 50/50 0.5-1 Dual 10-16

55. Calculation guidelines foor insulin during pregnancy Trimester Insulin dosage(unit/kg body weight Pre pregnant 0.5-0.6 T1 0.7-0.8 T2 0.8-1.0 T3 UNTIL 36 WEEKS 0.9-1.2 Post partum 0.6

56. Early morning Hyperglycemia causes Somogyi effect Dawn phenomenon Waning insulin

57. Insulin therapy for gDM When to initiate When MNT with exercise doesnot keep FPG< 95mg/dl 2 hour post prandial < 120 mg/dl

58. Fetal surveillance Detection of embryopathy 8-10 weeks: USG 10-12 weeks: HbA1c 16-20 weeks: maternal serum AFP genetic testing 18-20 weeks: anomaly scan 24-26 weeks:fetal echo

59. Growth monitoring SFH USG Q4weeks from 20 weeks

60. Assessment of fetal distress Twice weekly NST or weekly BPP from 28- 34 weeks Uterine artery doppler Amniocentesis for L/S ratio

61. Maternal surveillance with pre existing diabetes HbA1c every 4-6 weeks GRBS every visit urinalysis RFT with total protein, 24 hour urine protein, creatinine clearance Retinal examination TFT

62. Management of DKA Hydration:1L NS in 1 st hr, then 200-500ml/hr Insulin:10-20u PI IV bolus,5-10u/hr ( 50u in 500ml NS) Monitor blood glucose Q1-2 hours Glucose < 250 mg/dl: 5% D 5-10g/hr Potassium correction: after initial litre of fluid, KCL added in each pint Sodium bicarbonate:pH <7.1: 44mEq Q2H Monitoring

63. Management of preterm labour Nifedipine Steroid

64. Obstetric management Timing of delivery Mode Indications for CS Weight>/= 4500g Proliferative retinopathy Other associated indications Unstable IDDM

65. INTRAPARTUM MANAGEMENT Monitoring blood glucose, urine ketones To mainain RBS 72-144 mg/dl Planned CS Early morning, take night dose of insulin NPO& skip morning dose of insulin 5% neutralised with insulin( 6u / 500ml)

66. Infusion rate Blood sugar value Infusion rate 70-130 1u/hr 130-160 2u/hr 160-200 3u/hr

67. Postpartum care and advice Hydration GRBS Q2H Target FES:100mg/dl PPBS: 150mg/dl Diet control for type 2 DM OHA v/s insulin Metformin : hypoglycemia

68. OGTT at 6 weeks Recurrence in 50% Weight management Diet modification

69. contraception no OCP for those with vascular disease

70. Neonatal management Monitor for hypo glycemia , hypocalcemia , hypomagnesimia , hyperbilirubinemia and birth injury Early breast feeding Monitoring Hypoglycemia : 10% D IV 2ml/kg over 2-3 minutes

71. Nursing management Prevention Preconception Euglycemia History Physical examination Psychosocial Lab evaluation Educate about interaction between pregnancy, DM, family planning

72. 7. Education in self management Diet Exercise SMBG Stress control Insulin administration GRBS Q1-2H after meals and at bed time HbA1c Q4-6 weeks Record keeping

73. During pregnancy Early confirmation of pregnancy HbA1c Q2-3 mon Dietary advices Consistent CHO intake No saturated fat and sugary foods Eat at same time each day Healthy snacks Water :8-10 glass /day

74. Sleep and rest Exercise Regular exercise Hydration Check blood glucose before and after exercise Carry a snack Aerobic exercise 30 minutes twice weekly Proper shoes ID bracelet

75. Coping Stress and fear More frequent prenatal visits Periodic USG, DFMC

76. Insulin administration Need for refrigeration reuse of syringes Rotation of injection sites

77. smbg After each meal Fasting Immediately after meals 1-2 hours after meals At bed time Between 2am and 3am

78. hypoglycemia Teach 15: 15 rule Have 15 g fast sugar Wait for 15 minutes Check again 15g CHO: glucose tablets, ½ cup orange juice, 1 cup skim milk, 5-6 hard candies

79. Sick day rules If unable to eat, continue insulin and GRBS and ketone monitoring Indications for calling doctor Insulin is usually doubled when urine ketones are present CHO food choices: lemon soda, orange juice Sodium and pottasium replacement Small amounts of fluids every hour Report vomiting

80. Intrapartum Preterm labor Insulin requirement falls Glucse requirement: 2.5mg/kg GRBS Q1-2 H IV infusion of D5 LR unless urine ketone present or blood glucose< 70mg/dl Insulin solution 25 units PI in 250ml NS

81. Insulin dosage PLASMA CAPILLARY BLOOD GLUCOSE ( mg/dl) INSULIN DOSAGE (units/hour) < 80 0.0 80-100 0.5 101-140 1.0 141-180 1.5 181-220 2.0 Greater than 220 2.5

82. Keep 50%D at bedside No breakfast and morning dose NPO

83. Continuous fetal monitoring Monitor labour progress V/S, input and output Urine ketones Complications

84. Caesarean delivery Timing no breakfast NPO GRBS Q1H Short acting insulin + glucose After delivery IV D5W 100-125ml/hour No insulin may be needed after delivery of placenta

85. Post partum ( type 1 and 2) Insulin If PPBS> 150 mg/dl, dosage of insulin 0.6 units/kg/hour Education to maintain euglycemia Encourage breast feeding +CHO snacks Dietary needs increases by 500-800 calories Fluctuations in blood glucose level Insulin does not cross the breast milk Monitor for breast infections

86. Postpartum ( GDm ) Monitor blood sugar 50% chance for type 2 DM OGTT at 6weeks and RBS / FBS annually Continue lifestyle modifications Family planning

87. Nursing diagnoses

88. THANK YOU