Diabetic and Pregnant: Guidelines for Inpatient Care. Outreach OB CNY Regional Perinatal Program

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Lindsay Elliott
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1 Diabetic and Pregnant: Guidelines for Inpatient Care Outreach OB CNY Regional Perinatal Program

2 No Financial Disclosures

3 Objectives Women we treat Treatment regimens Intrapartum Postpartum Diabetic Emergencies Centering

4 WHO WE TREAT

5 Type 1 Diabetes Autoimmune disease of the β-cells of the pancreas leading to insulin deficiency Acute onset, life-threatening Familial risk based on HLA genes 40-50% risk in monozygotic twins 5% of adult diabetics

6 Increase in insulin resistance and progressive insulin deficiency Insidious onset Polygenic disease with strong genetic component % monozygotic twins Type 2 Diabetes

7 Gestational Diabetes Any diabetes with onset or first recognition in pregnancy (ADA) Incidence 5-10% (CDC 2011)

8 HOW WE TREAT

9 GDM : A1 turns into A2 Goals: fasting <95, 2hr <120 or 1hr <140 Lowers risk of macrosomia (deveciana NEJM 1995, ADA 2003, ACOG 2013) Initiate therapy when >20% are abnormal (Coustan 2004) 25% of GDM patients require insulin (Landon 2011)

10 Insulin Gold Standard Does not cross the placenta Weight-based regimen or start low 0.7/0.8/0.9(maternal weight in kg) by trimester 2/3 of total in am (2/3 long-acting, 1/3 short) 1/3 of total in pm (1/2 long-acting, 1/2 short) Inject into abdomen = best absorption

11 Insulin Neutral Protamine Hagedorn (NPH) Humulin N/Novolin N Onset hr Peak 5-8 hr Duration hr Only cloudy insulin Can be mixed with others Bedtime dosing may prevent early am hypoglycemia and better control am fasting

12 Other Basal Insulins Glargine (Lantus) Category C Less hypoglycemia compared to NPH Devlin Diabetes Care 2002 Detemir (Levemir) Category B Both with slow onset, minimal peak and up to 24 hours of duration

13 Meal Coverage - Short Acting Onset (hr) Peak (hr) Duration (hr) Pros Regular Lower cost Safe Aspart (NovoLog) Most physiologic Lowers pp better Take with meals Cons PP hypoglycemia Inconvenient timing before meals? More costly Less effective with grazers? Immunogenic? Lispro (Humalog) <5

14 Oral Agents Studied in Pregnancy Glyburide (DiaBeta) 2.5mg to 20mg in QD to BID Insulin stimulator Minimal transplacental passage 20-40% failure with BMI >40 Nicholson Obstet Gynecol 2009 Metformin (Glucophage) 500mg 1000mg BID Insulin sensitizer Less effective than glyburide in GDM, failure 50% Moore Obstet Gynecol 2010 QuickTime and a decompressor are needed to see this picture. QuickTime and a d ecomp re ssor are n eeded to see this picture.

15 Insulin Pump Lispro or Aspart Improved HbA1C without more hypoglycemic episodes or DKA Kallas-Koeman et al Diabetol 2014

16 Pump Settings Basal rate X units / hour Bolus with food = Carbohydrate (CHO) ratio 1 unit for X grams CHO Correction or sensitivity 1 unit lowers glucose by X mg/dl

17 Type 1: not on a pump Best control is CHO counting with correction Sliding scale for premeal (AC) coverage, for example AC FSBG < 70 none Insulin (Lispro or Aspart)

18 Commonly Used Insulin Regimens QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture.

19 Sliding Scales Hospital SS usually created for non-pregnant patients Insulins not studied in pregnancy (Apidra) Often a correction for hyperglycemia not preventing the spike Must specify premeal (AC) or postprandial (PC) for use Watch out for hypoglycemia!

20 L&D: INTRAPARTUM CARE

21 Goal: Euglycemia in Labor Maintain FSBG <110 mg/dl Decrease neonatal morbidity: Hypoglycemia Respiratory distress Metabolic acidosis

22 Gestational A1 Check it on admission Then q 4-6 hours SS coverage starting >110 mg/dl

23 Type 2 or A2DM q 2-4 hours in latent labor q1-2 hours in active labor SS coverage starting >110 mg/dl vs. insulin gtt May use current regimen when taking po

24 Type 1 Every 2 hours in latent labor, every hour in active May use patient s pump or insulin drip Need insulin to function IV glucose = D5LR IV insulin (Regular only insulin in gtt form) Typical rate units Regular/hour then titrate

25 Insulin SS Labor Protocol For example FSBG (mg/dl) Lispro (Units) SQ < >300 14

26 Insulin GTT Protocol Protocol 1: Recommended by American College of Obstetricians and Gynecologists * Start of Labor Hold Start normal saline infusion <70 mg/dl or active labor Hold >100 mg/dl Regular insulin at 1.25 units/hour 5 percent dextrose normal saline (D5NS) at ml/hour to achieve FSBG of about 100 mg/dl. Increase by 0.5 units/hour if >110 mg/dl Protocol 2: Recommended for women with type 1 diabetes <70 mg/dl mg/dl mg/dl mg/dl mg/dl 3.0 FSBG < 130 mg/dl 5 percent Dextrose Lactated Ringers at 125 ml/hour mg/dl mg/dl 5.0 >190 Check Ketones

27 Planned Cesarean Delivery Patient takes evening insulin Type 1 ½ am basal Type 2/A2 nothing in am Treat with Lispro in am as needed Try to schedule early in day

28 L&D: POSTPARTUM CARE

29 Postpartum Recommendations Pregestational A2 Decrease regimen by 50% Or return to prepregnancy dosing Follow-up with Endocrinologist/PCP No monitoring vs surveillance off medications if large doses 2 hour 75 gm GTT 6-12 weeks postpartum

30 Postpartum: Breastfeeding Improved insulin sensitivity during lactation Increased duration decreases risk of T2DM >6 months improve weight loss, decrease in metabolic syndrome and cardiac death Decrease infant overweight and childhood obesity

31 DIABETIC EMERGENCIES

32 Hypoglycemia Protocol FSBG < 70 mg/dl or mg/dl with sx If mg/dl may give po, if <50 mg/dl ½ amp 50% dextrose IV OR IM glucagon if no IV acess Repeat FSBG in 15 minutes

33 Diabetic Ketoacidosis: Recognizing Signs in Pregnancy Elevated FSBG (usually higher than 200 mg/dl), signs/symptoms of dehydration, polyuria, change in mental status, Kussmaul s respiration (rapid, deep, sighing), fruity breath, uterine activity, abnormal fetal heart rate patterns Continuous monitoring for viable fetus Check electrolytes for anion gap ( >12), high serum osmolality, urinalysis for ketones, serum acetone, arterial blood gas (ph <7.3), and CBC Investigate potential causes such as urinary tract infection, pneumonia, non-compliance with insulin, medication error, pump failure, alcohol or illicit drug use Care with betamethasone in diabetic patients

34 DKA: The Fetal Compartment Avoid stat delivery for fetal tracing abnormalities as often improves with maternal resuscitation

35 Diabetic Ketoacidosis: Treatment Rapid volume replacement with normal saline if Na is normal range or 1/2 NS if high Na, 500cc-1L/hour x 4 hours, then cc/hr. Add 5% dextrose when FSBG <250 mg/dl Insulin gtt (Regular) started with fluids at 0.14 units/kg/hr (goal to lower FSBG by >60 mg/dl/hour) Hourly FSBG, q1-2 electrolytes and strict I&Os Potassium will need to be supplemented. If <5.3 meq/l start 40 meq/l in 1/2NS Consider ICU management for patients with underlying renal or cardiac disease Maternal Fetal Medicine Consultation recommended

36 In SUMMARY Know who you treat Medication errors easy, but are less with knowledge of medications No monitoring = no chance to optimize maternal/fetal outcomes Prompt treatment of emergencies Seek help for complicated patients

37 CENTERING CNY Regional Perinatal Center since Aug 2013 March of Dimes-funded grant Kathleen Dermady, CNM PI Opt-out program for diabetic patients Other centers use this model for low-risk care St. Regis Mohawk Health Auburn Rome NYS: 19 centers

40 Collaborative Model: The Evidence Higher satisfaction with physician interaction associated with improved control (Van Hoff Ann Int Med 1997) Shared-decision making associated with improved outcomes (Parchman Ann Fam Med 2010) Peer support works male veterans with DM (Heisler Ann Int Med 2010) Recommended by Institute of Medicine

41 Centering Group prenatal care (7-10 women) 10 sessions of facilitated discussions Replaces regular care

46 Why Centering with Diabetes? High degree of education/counseling Emphasizes patient values Peer collaboration Need to gather evidence on different, hopefully improved models of care for region s patients Need to demonstrate this can be costeffective

47 Thank You!

INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco

INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco CLINICAL RECOGNITION Background: Appropriate inpatient glycemic