Diabetes and Pregnancy Pregestational and Gestational Diabetes throughout

Diabetes and Pregnancy Pregestational and Gestational Diabetes throughout the pregnancy

Pregestational vs Gestational Diabetes Pregestational diabetes is diabetes that pre exists the pregnancy Gestational diabetes develops or is first discovered during the pregnancy.

Changes in glucose metabolism during pregnancy Early in pregnancy there is an increased insulin secretion At the end of the first trimester most women have an increased glucose utilization and increased insulin secretion In the second and third trimesters there is a progressive increase in insulin resistance due to pregnancy hormones from the placenta.

How do these changes effect preexisting diabetes? Insulin needs may be decreased in the first trimester due to these changes as well as the nausea and vomiting pregnant women experience. There will be an progressive increased need for insulin during the second and third trimester. Post partum needs will be decreased dramatically

Preconception health and diabetes This is a concept in which a mother receives care before she becomes pregnant in order to achieve optimal results for her and her baby. Primary goal in diabetes is a Hb. A 1 c of less than 7% at pre conception. To continue on birth control until it is at that level. However, remember that it is recommended that ALL women receive preconception care.

Additional preconception testing Pap CBC Serum creatinine Thyroid 24 hour urine Lipid panel Retinal exam Neurological exam Medication usage Insulin regimen Referral to diabetes educator Referral to dietician

Maternal Consequences of preexisting diabetes Preeclampsia Bacterial infections Polyhydraminos Birth trauma from macrosomic infants Preterm labor Cesarean delivery Postpartum hemorrhage DKA

A word about DKA and pregnancies DKA is seen in 5 -10% of pregnancies complicated by diabetes DKA develops more rapidly and at less severe levels of hyperglycemia Pregnancy lowers this level to around 200! One resource that I read proposed that nearly 50% of fetuses of moms that develop DKA will die.

Ketone testing No clear standard of care in my research. In practice: If ketones are present but blood glucose is normal, it may mean that mom needs more carbohydrate in her diet If ketones are present but blood glucose is elevated, it means that mom needs more insulin in her regime.

Fetal Consequence of preexisting diabetes Congenital anomalies Spontaneous abortion Macrosomia Intrauterine fetal death Delayed pulmonary maturity (39 weeks) Hypoglycemia at birth Hyperbilirubinemia Polycythemia Hypocalcemia Decreased magnesium Intrauterine growth restriction Learning disabilities Childhood obesity and type 2 diabetes later in life

Poor gylcemic control and organogenesis in the first trimester If the glycosylated hemoglobin levels (Hb. A 1 c) are less than 7% at preconception, the risk of fetal anomalies is close to the general population 2 -3% If the level is close to 10% the risk of fetal anomalies rises to 20 -25%

Poor glycemic control and the third trimester Consequences are metabolic in nature Fetal hyperinsulinism results in accelerated growth. Large fetuses have an increased need for oxygen resulting in fetal distress and even demise Other consequences are increased risk for preterm labor and pulmonary immaturity of the infant.

Components of Prenatal care of the diabetic woman Self management of glucose Lab tests listed in preconceptual care Eye exam in first trimester with close follow up Maternal serum alpha fetoprotein Hb. A 1 c every 4 -6 weeks Initial ultrasound and one at 18 -20 weeks Fetal kick counts Nonstress and Contraction stress testing Delivery plan

Fetal kick counts and stress testing. Fetal kick counts should begin daily at 28 weeks gestation (page 214) Nonstress testing at 32 -34 weeks; twice weekly (page 230) If a nonstress test is nonreactive, must have a biophysical profile (page 223) Contraction stress testing may be utilized shortly before labor. (page 231)

Insulin Requirements First Trimester. 8 U/Kg per day Second Trimester 1. U/kg per day Third trimester 1. 2 U/kg per day 2/3 of dose is given in the morning at a 2: 1 ratio of NPH to regular or Lispro The balance is given at dinner or separately with the short acting before dinner and the longer before bedtime. (1: 1 ratio) More info page 336

More about Insulin does not cross the placental barrier. The fetus makes it’s own insulin Oral antidiabetics do cross the placental barrier. (exception Glyberide) Women who are on oral anti diabetics are switched to insulin before pregnancy to prevent possible birth defects.

Delivery Planning: time and route If delivery is planned electively before 39 weeks fetal lung maturity must be assessed Macrosomia is a indication for cesarean section Early Inductions may be indicated for: non reassuring fetal status; decline in fetal growth, severe preeclampsia, nephropathy, poor glucose control, history of still birth Inductions after 40 weeks of gestation are typical because of danger of fetal compromise

Glycemic control during labor D 5 W 100 -150/hr once active labor begins or if glucose levels are less than 70 Insulin by IV infusion at 1. 25 U/hr if glucose levels exceed 100 Goal is to maintain blood glucose level at 100 mg/hr (your text says 70 -90 is best) See order sheet.

Post partum glycemic control The insulin needs will dramatically drop Typically insulin dose is recalculated based on one half of the pre delivery dose.

GESTATIONAL DIABETES Gestation diabetes is defined as carbohydrate intolerance and consists of both insulin resistance and diminished insulin secretion during pregnancy.

Maternal complications of gestational diabetes Preeclampsia and hypertensive disorders Polyhydramnios Cesarean section because of fetal macrosomia Excessive weight gain. Increased risk to develop type 2 diabetes later on

Fetal Complications in gestational diabetes Macrosomia Birth trauma Sholder dystocia Hypoglycemia hypocalcemia Hyperbilirubinemia Respiratory distress syndrome Polycythemia Increased risk for obesity and impaired glucose tolerance or diabetes later in life

Risk Factors for GDM Obesity Hispanic, African, American Indian, South or East Asian, Pacific Island ancestry Over 25 Previous birth outcome associated with GDM Glycosuria GDM in previous pregnancy History of abnormal glucose tolerance test History of diabetes in first degree relative

More risk factors Multiple gestation Polycystic ovary syndrome Hypertensive disorder Recurrent monilial vaginitis Polyhydramnios without fetal anomalies Glycosuria on two consecutive visits

Screening in the first trimester for high risk patients If a woman presents with enough high risk factors a physician or midwife may screen the patient in the first trimester in addition to a second trimester (24 -28 week) screening.

One hour glucose challenge test screening Patient drinks a 50 G solution of glucose >140 requires a 3 hour GTT Some sources suggest >135 or 130 as the target > 200 treat for gestational diabetes; 3 hour GTT is not necessary Screening at 24 -28 weeks of gestation High risk patients may be screened at initial visit and then repeated at 24 -28 weeks gestation

3 Hour Glucose Tolerance Test Fast for at least 8 hours Drink 100 G of glucose solution Blood draw at 1, 2, and 3 hours Cut off values: Fasting 105 (95) 1 hour 190 (180) 2 hour 165 (155) 3 hour 145 (140) (if two or more values are met or exceed the patient is diagnosed as gestational diabetes)

Glucose Tolerance Test Prep 3 days of unrestricted carbohydrates with a minimum of 150 grams of carbohydrates in each day Unrestricted activity before test Fasting for 8 -14 hours No smoking 12 hours before and during test Avoid caffeine; it raises the blood sugar Sitting during the testing.

Antepartum management of GD Nutrition: 35 kcal/kg if underweight 30 kcal/kg if normal 25 kcal/kg if obese 50% of calories in carbohydrate 4 calories =1 gram of carbohydrate Insulin therapy which may need adjustments every 7 -14 days through the pregnancy Glyburide is being used at 2. 5 mg BID but has not yet been approved by the USFDA Fetal kick counts, NST, CST and ultrasound

Glucose goal during pregnancy Preprandial plasma glucose <95 1 Hour postprandial < 130 -140 2 Hour postprandial <120

Delivery timing, labor, etc The criteria for delivery timing, induction etc are the same as for pre existing diabetes. In addition the standards of glycemic control during labor are the same.

Post partum management of GD With delivery the diabetogenic effects of placental hormones are diminished. Women with gestational diabetes usually regain glycemic control Blood glucose values should be assessed in the immediate postpartum period Maternal glycemic status should be re evaluated at 6 weeks with a 2 H GTT

Concerns of infants of diabetic mothers Congenital anomalies Macrosomia Birth trauma Shoulder dystocia Perinatal asphyxia Respiratory distress syndrome Hypoglycemia Hypocalcemia and hypomagnesemia Cardiomyopathy Hyperbilirubinemia and polycythemia Page 822 -23

On your own. Know the signs and symptoms of hyperglycemia Know the signs and symptoms of hypoglycemia Know the treatment of hypoglycemia page 355

Glucagon the hormone that stimulates hepatic glucose production Administer 1 mg IM Repeat in fifteen minutes When awake and alert give 15 g of carbohydrates