Gestational Diabetes Diagnosis and Blood Glucose Targets. Overview of Metabolism. Leona Dang-Kilduff, RN, MSN, CDE

Transcription

1 Gestational Diabetes Diagnosis and Blood Glucose Targets Leona Dang-Kilduff, RN, MSN, CDE Stanford University Mid-North Coastal and East Bay California, Regional Perinatal Program Director 2014 Overview of Metabolism Non-pregnant Non-diabetic Diet Fuels (oxid.) Storage of Excess Fuels Carbohydrates Glucose Glycogen Liver Gu ut Ins sulin Protein Amino Acids Protein Skeletal Muscle Skeletal Muscle Fats Fatty acids Triglycerides Fat Effects of on: Promotes Inhibits Liver: -Glycogen storage -Glycogenolysis -Triglyceride synthesis -Gluconeogenesis Muscle: -Glycogen storage -Glycogenolysis -Oxidation (glycolysis) -Proteolysis -Protein synthesis Adipose -Glycerol synthesis -Lipolysis -Triglyceride synthesis 1

2 Fat Skeletal muscle α cell Fed State Glucagon Glycogenolysis Gluconeogenesis Glucose β cell Arteriole Venule Fat Skeletal muscle Fasting State α cell Glucagon Glycogenolysis Gluconeogenesis Glucose β cell Arteriole Venule ADIPOSE TISSUE Lipolysis FFA LIVER Carnitine -Oxidation Ketogenesis Hyperketonemia MUSCLE Ketone Utilization Felig P. Science 1970;107:990 2

3 Fasting State in Normal Pregnancy 80 e (mg/100ml) Glucose P<.001 P<.001 Non-pregnant Pregnant P<.001 P< Duration of Fast (Hours) Felig P. Science 1970;107:990 Rate of Transfer Across Placenta (nmol/min/gm fetal weight) Palmitic acid (11) Glycerol (5) VLDL-TG (5) Alanine (25) Glucose (123) McNanley, T, Woods, J, Glob. libr. women's med.,(issn: ) 2008; DOI /GLOWM Estrogen, progesterone HPL, prolactin Hormonal Changes: Early Pregnancy Progesterone Growth hormone Hyperphagia Fat deposition HPL (human Placental Lactogen) secretion [accompanied by relatively normal hepatic and peripheral insulin sensitivity, prevents glycogenolysis, proteolysis, and lipolysis, leading to energy storage in early pregnancy] 3

4 Daily Glucose Excursions: Late Pregnancy vs Nonpregnant 140 Glucose (mg/dl) Nonpregnant Pregnant 60 8AM 12 Noon 6 PM 12 MN Parretti E, Mecacci F, Papini M, et al. Third-trimester maternal glucose levels from diurnal profiles in nondiabetetic pregnancies. Diabets Care. 2001;24(8) Chitayat L, Zisser H, Jovanovic L. Continuous glucose monitoring during pregnancy. Diabetes and Technology & Theraputics. 2009;11:S Basal Concentration in ( U/ml) Insul Nl Pregnant GDM P t = P g = P tg = Pre-Gravid Early Pregnancy Late Pregnancy Catalano PM, Huston L, Amini SB, et al. Longitudinal changes in glucose metabolism during pregnancy in obease women with normal glucose tolerance and gestational diabetes mellitus. AJOG 1999;180(4):180:903 Catalano PM, Kirwan JP, Haugel-de Mouzon S, et al. Gestational Diabetes and insulin resisitance: Role in short- and long-term implications for mother and fetus. J. Nutr. 2003;133:1674S-1683S. 1 st Phase Response U-ml -1, Pre-Gravid Early Pregnancy Late Pregnancy Control GDM P t = Catalano PM, Huston L, Amini SB, et al. Longitudinal changes in glucose metabolism during pregnancy in obease women with normal glucose tolerance and gestational diabetes mellitus. AJOG 1999;180(4):180:903 Catalano PM, Kirwan JP, Haugel-de Mouzon S, et al. Gestational Diabetes and insulin resisitance: Role in short- and long-term implications for mother and fetus. J. Nutr. 2003;133:1674S-1683S. 4

5 Sensitivity ensitivity Index Se 0.3 Control GDM P t = P g = Pre-Gravid Early Pregnancy Late Pregnancy Catalano PM, Huston L, Amini SB, et al. Longitudinal changes in glucose metabolism during pregnancy in obease women with normal glucose tolerance and gestational diabetes mellitus. AJOG 1999;180(4):180:903 Catalano PM, Kirwan JP, Haugel-de Mouzon S, et al. Gestational Diabetes and insulin resisitance: Role in short- and long-term implications for mother and fetus. J. Nutr. 2003;133:1674S-1683S. CDAPP: Guidelines for Care, 2012 (7) Requirement During Pregnancy Triple Double Normal Breast feeding Weeks Conception Delivery What Happens with High Glucoses and Levels? High Glucose levels Resistance Before 8 wks = Birth Defects Poor Placental Implantation Stimulates fetal insulin secretion Delayed Excess = Fetal Growth Organ Maturation Requirement of O2 increase Resets genes and response and function - reprogramming -obesity and diabetes, etc Stimulates Glycogen deposits in placenta Poor placental transfer of O2 and nutrients Stimulates RBC production Hypoxia -intolerance of labor -? Demise Stimulates Lumen of blood Vessels HTN, PIH Poor fetal growth Hyperbilirubinemia Polycythemia 5

6 Two GDM Screening Options Early A1c One step--75gram OGTT Or *Above are the Sweet Success Guidelines for Care 2012 Recommendations (7) Two Step 50 gram Load if gram OGTT Gestational Diabetes Screening and Diagnosis Early Screen if: Previous History of: Gestational diabetes Macrosomia history Unexplained still birth Malformed infant History of overt DM in parents, siblings, children (1 st ) Body weight with BMI > 25 Age > 25 Heavy glucoseuria (>2+) Medications that increase glucose intolerance Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older (this includes GDM) Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at 6

7 Gestational Diabetes Screening and Diagnosis Early screen if: High risk ethnic group: African American American Indian Hispanic/Latina Asian Pacific Islander Southeast Asian Indigenous Australian All women at weeks gestation Diagnosis by A1c A1c Diagnostic Category < 5.7 No diabetes Pre-diabetes Diabetes A1c drops approximately 0.5% in pregnancy ADA. Diagnosis and classification of diabetes Mellitus. Diabetes Care 2010;33(Suppl 1):S62- S69. Critical Periods of Development Weeks gestation from LMP Most susceptible time for major malformation Central Nervous System Heart Arms Eyes Legs Teeth Palate External genitalia Ear Missed Period Mean Entry into Prenatal Ca California Diabetes and Pregnancy Program Guidelines for Care

8 Screening in Unusual Cases Bariatric surgery clients- Most will not tolerate a glucose load Hyperemesis SO Fasting and 1 hour postprandial blood glucose level checked at 22-24, 28-32, and 34 weeks gestation Obtain fasting and 1 hour post-meal blood glucose for 1 week with a blood glucose meter while she continues her usual diet. Fasting test 75 Gram OGTT ONE STEP TEST FBS 1h hour 2h hour > 92 > 180 > value = positive screen ADA. Diagnosis and classification of diabetes Mellitus. Diabetes Care 2010;33(Suppl 1):S62- S69. 8

9 What do we TEACH? What is GDM? What does it do to a pregnancy? What can be done? Self Blood Glucose Testing Medical Nutrition Therapy (MNT) Monitoring - Maternal and Fetal Antepartum/Intrapartum/Postpartum care Newborn care Long-term prevention Diabetes is: Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting in defects in insulin secretion, insulin action or both. ADA. Diagnosis and classification of diabetes Mellitus. Diabetes Care 2010;33(Suppl 1):S62- S69. Either don t make enough insulin or Can t effectively use what is made Diabetes is: Overt or pre-existing: ( % all pregnancies) Type 1- dependent, Ketone prone Type 2-Non-insulin dependent Accounts for 90% of all Diabetics 80% are obese IGT or Pre-Diabetes Polycystic Ovary Syndrome/Metabolic Syndrome GDM: (~90%) Diagnosed during pregnancy (1-14% of all pregnancies) 9

10 Why Treat => To have a healthy baby S S I S I SI S I I S S S I Blood Glucose Testing All clients start with a minimum testing schedule of FBS and 1 (or 2) hours after meals Premeal blood glucoses if suspected elevations between meals or if utilizing algorithm HS and overnight blood sugars are used if suspected over night hypoglycemia Blood Glucose Monitoring Additional testing as needed for suspected hypo or hyperglycemia Decrease testing if well controlled with diet only clients Recommend testing meter accuracy once a trimester Recommend using memory meters *Clients with meters that do not match record should have blood glucoses done during office visits 10

11 What is Normal? Pregnancy and CGMS Ben-Haroush et al. in 2004 and Yogev et al. in 2007 (12) looked at non-diabetic pregnancies with the CGMS---> Average was Fasting Pre-meal hour Post meal was hour Peak post meal time was minutes The mean over night Glucose was Blood Glucose Targets Time Plasma Glucose mg/dl California (7) Plasma Glucose mg/dl ACE (9) Plasma Glucose mg/dl ACOG(10,11) Fasting and 65 - < < 95 pre-meal <100 Post-meal 1 hour Post-meal 2 hour <130 < 120 < 130 to 140 < 120 < AM Interpartum <100 Time Blood Glucose Targets Plasma Glucose mg/dl CDAPP (7) ADA 2010 (8) GDM DM1 or 2 Plasma Glucose mg/dl ACOG (10,11) Fasting and <95 <90 < 95 pre-meal Post-meal < 130 < 140 < 130 < 130 to 140 hour Post-meal 2 < 120 <120 < 120 hour 2-6AM Interpartum <100 <100 11

12 Blood Glucose Monitors I counted 32 different home blood glucose meters at just one pharmacy Of these 25 had the capacity to download Memory varied from none to 1000 Hematocrit ranges were from 0-70% Time for testing ran from 5 to 50 seconds Blood glucose range from mg/dl Temperature readings Sizes, colors, and cases varied significantly SO What should we be looking for? So what do we want in a Meter? Accuracy Hematocrit range Ease of use Blood glucose range Temperature ranges Memory Ability to download Ability to reapply more blood Alternate testing capacity Size of displays Battery required Alarms Computer Downloading Every company has their own programs All require some data port and computer access All have print outs All have the ability to program desired ranges All the companies I have encountered will give free software and often the data cables too 12

13 Log Sheet One Touch Web site. Accessed 6/2009 Pie Charts One Touch Web site. Accessed 6/2009 What Affects Blood Glucose Pregnancy Food choices Exercise and Activity Stress Medications Timing Other 13

14 References 1. Felig P, Pozefsky T, Marliss E, Cahill GF Jr. Alanine: key role in gluconeogenesis. Science Feb 13;167(3920): McNanley, T, Woods, J, Glob. ed. Women's Med., (ISSN: ) 2008; DOI /GLOWM Parretti E, Mecacci F, Papini M, et al. Third-trimester maternal glucose levels from diurnal profiles in nondiabetetic pregnancies. Diabetes Care. 2001;24(8) Chitayat L, Zisser H, Jovanovic L. Continuous glucose monitoring during pregnancy. Diabetes and Technology & Theraputics. 2009;11:S Catalano PM, Huston L, Amini SB, et al. Longitudinal changes in glucose metabolism during pregnancy in obese women with normal glucose tolerance and gestational diabetes mellitus. AJOG 1999;180(4):180: Catalano PM, Kirwan JP, Haugel-de Mouzon S, et al. Gestational Diabetes and insulin resistance: Role in short- and long-term implications for mother and fetus. J. Nutr. 2003;133:1674S-1683S. References Page 2 7. California Diabetes and Pregnancy Program. Sweet Success Guidelines for Care, ADA. Diagnosis and classification of diabetes Mellitus. Diabetes Care 2010;33(Suppl 1):S62- S AACE. American Association of Clinical endocrinologist medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1) ACOG task force. ACOG Practice Bulletin: Gestational diabetes. ACOG 2001;30(3): ACOG task force. ACOG Practice Bulletin: Pregestational diabetes mellitus. ACOG 2005;60(3): Yogev Y, Ben-Haroush A, Chen R, Rosenn B, et al. Diurnal glycemic profile in obese and normal weight nondiabetic pregnant women. Am J Obstet Gynecol. 2004;191: Contact Information Leona Dang-Kilduff, RN, MSN, CDE or leonad@stanford.edu Questions??? 14