Diabetes in Pregnancy. Grand Rounds. Jessi Goldstein, MD MCH Fellow August 1, 2012

Transcription

1 Diabetes in Pregnancy Grand Rounds Jessi Goldstein, MD MCH Fellow August 1, 2012

2 Why is Diabetes in Pregnancy Important? Gestational Diabetes (GDM) increases the risk of : 1) Preeclampsia 2) Preterm Birth 3) Cesarean Section Diabetes: Type 1 and Type 2, increased risk of: 1) High blood pressure 2) Preeclampsia 3) Kidney disease 4) Nerve damage 5) Heart disease 6) Blindness With preexisting

3 For infant, uncontrolled blood sugar can lead to: 1) Birth defects in pre-existing diabetics, especially of brain, spine and heart 2) Increased birth weight 3) Brachial plexus palsy if shoulder dystocia 4) Low blood sugar at birth 5) Increase chance of obesity and later-life Diabetes 6) Miscarriage, stillbirth, preterm birth, increased risk of cesarean section.

4 The Public Health concern The obesity epidemic being what it is, and the obvious link between DM and obesity, DM education for moms and you, and me, seems like a good idea!

5

6 County-level Estimates of Obesity among Adults aged 20 years: States 2004 United Age-adjusted percent > 30.8

7 County-level Estimates of Obesity among Adults aged 20 years: States 2009 United Age-adjusted percent > 30.8

8 County-level Estimates of Diagnosed Diabetes among Adults aged 20 years: United States 2004 Age-adjusted percent >

9 County-level Estimates of Diagnosed Diabetes among Adults aged 20 years: United States 2009 Age-adjusted percent >

10 Classification of Diabetes 1. Gestational Diabetes A1. Euglycemia achieved with diet and exercise. 2. Gestational Diabetes A2. Requires medication to achieve euglycemia. 3. Type 1. No endogenous insulin. Ketosis prone. 4. Type 2. Associated with obesity. Insulin resistant.

11 Screening controversial? USPSTF in 2008 concluded that based on available evidence, screening and treatment can t be justified, but still looking at it. Recent trials have showed improved neonatal outcomes with control, and also a dose-response relationship. ACOG recommends screening with either history or 1 hour, followed by 3 hour OGTT (oral glucose tolerance test) according to 2011 Committee Opinion.

12 Per ACOG, No glucose tolerance test needed if meet all of these criteria : 1)less than 25 years old 2)not a member of a racial or ethnic group with a high prevalence of diabetes (eg, Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry) 3) BMI < or =25 4) no history of abnormal glucose tolerance 5) no previous history of adverse pregnancy outcomes usually associated with GDM 6) no known diabetes in first-degree relative Practicing at UNM we screen everybody!!!

13 Hyperglycemia and Adverse Pregnancy Outcome trial (HAPO) Primary results were positive relationship between glucose concentrations and adverse pregnancy outcomes 2-h 75 g oral glucose tolerance test (OGTT) used. 28,562 women participated between 7/2000 and 4/ ,505 completed OGTT. After exclusions 23,316 participated.

14 HAPO Trial There was a strong continuous relationship noted between maternal hyperglycemia and increasing rates of: Large for gestational age infants (LGA). Cord blood c-peptide (fetal marker for hyerinsulinemia). Neonatal hypoglycemia. Cesarean delivery.

15 ACOG being conservative ACOG is not recommending instituting 2 hr OGTT as recommendation, according to Sept 2011 Committee opinion because there is not yet evidence this will lead to significant clinical improvements and the effect of increase diagnosis will lead to more health care costs.

16 Who cares? What do we do? At our institution according to MCH Guidelines there are choices

17 Initial prenatal screening All pregnant women without known pre-gestational diabetes should be screened by lab as our population is high risk. Options are random glucose, fasting plasma glucose, HBA1C. HbA1C is recommended.

18 What is the cutoff for normal random glucose? What is the cut off for normal fasting? What is the cutoff for normal HbA1C?

19 <200 If above, then diagnose as Type 2 DM <126 <6.5

20 In between If fasting glucose > 92 but <126 GDM If HbA1C or initial random glucose , check fasting glucose next visit and treat accordingly. If normal follow up at wks with OGTT.

21 High Risk patients Hx GDM Habitual abortion Hx unexplained IUFD Hx macrosomia without GDM Polyhydramnios without GDM hx glucosuria Hx congenital anomalies Hx glucose intolerance Morbid obesity Strong fhx DM If pt high risk do HBA1C and fasting blood sugar at presentation or random glucose if fasting not feasible.

22 At weeks screening option 1: 50 gram OGTT. If > at 1 hour abnormal. If abnormal do 3 hr OGTT. IF> 200, consider to be GDM. If FBS> 92 pt has gestational DM and may treat as such without 3hr OGTT. If one abnormal, glucose intolerant, 2 or more abnormal GDM. 3hr OGTT is fasting test. Blood sugar measured fasting, then hourly for 3 hours after 100 gram oral glucose load. Normals are: FBS< 95, 1 hr < 180, 2 hr <155, 3 hr <140.

23 3 hour OGTT with 1 abnormal Diagnosed as glucose intolerant. Repeat in 4 weeks if > 24 weeks. If any values abnormal GDM. If not, no need to repeat again.

24 At weeks screening option 2: 75 gram fasting 2 hr OGTT. One abnormal value for diagnosis of GDM. Normals FBS< 92, 1hr <180, 2 hr <153. This test is more sensitive and picks up more people.

25 Management Send everyone, including glucose intolerant to DM management (either in house or off site depending on clinic capability). If GDM order glucometer, lancets and test strips. If GDM visits once weekly until control achieved.

26 What is a diabetic diet?

27 Carbohydrates and Calories The average pregnant woman needs an additional 300 calories during the second and third trimesters of her pregnancy. The American Diabetes Association recommends that even obese pregnant women eat at least 12 calories per pound of body weight to ensure adequate nutritional intake. No more than 40 percent of these calories should come from carbohydrates. For example, a pregnant woman weighing 175 pounds should eat at least 2,100 calories daily, and 840 of those calories should come from carbs. Each gram of carbs has 4 calories, so that's 210 g of carbs each day.

28 Example A pregnant woman weighing 160 pounds. Basal metabolic rate (which you can find on internet, med calc) as Assuming low activity level x 1.2= 1800 calories. Add 300 calories a day for being pregnant. should eat at least 2,100 calories daily based on. 2100x 0.40=840 of those calories should come from carbs. Each gram of carbs has 4 calories. 4x210=840. So 210 grams of carbs

29 210 grams of carbs. Carb counting approach 55 carbs per meal, then 45 grams as snacks ( 3 x 15 gram snack). Carbs drive glucose levels so focusing on them and not total calories simplifies things for patients. This is just one approach, there are different ones.

30 In general, GDM meal plan will follow these principles: 3 small meals and 2-3 small snacks (smaller meals cause lower blood sugars) avoidance of concentrated sweets and sugars, including fruit juice plenty of non-starchy vegetables lower-fat food choices in general, to keep weight gain at a healthy level low-fat or non-fat milk, yogurt or cheese for adequate calcium. Include a good source of protein at every meal and snack. Highprotein foods are low-fat meat, chicken, fish, low-fat cheese, nuts, peanut butter, cottage cheese, eggs, turkey

31 Breakfast with 55 carbs and 15 carb snack. Breakfast Omelet with 2 eggs, 5 oz ham, ½ cup shredded cheese. 2 slices whole wheat toast. ½ grapefruit. Mid-Morning Snack 1 small apple and tsp peanut butter.

32 Lunch Lunch with 55 carbs and 15 carb snack Turkey burger (with Jennie-O ground turkey) on a whole wheat bun, garnished with lettuce, tomato and onion and a slice american cheese. 5 ounces fruit salad. Mid-Afternoon Snack 7 carrot sticks with 4 tsp of regular ranch dressing for dipping.

33 Dinner 55 carb dinner with 15 carb snack. Five ounces grilled chicken breast with ½ cup rice, 1 cup steamed vegetables, 1 wheat dinner roll, ½ avocado. Evening Snack 4 ounces plain yogurt with 2 graham cracker squares.

34 Prenatal Management of Preexisting Diabetes (Type 1,2) First Visit Consult with MCH Fellow/FP-OB faculty Hgb A1C, then every trimester. collect 24 hr urine (protein, creatinine clearance, creatinine), PIH labs for baseline. schedule EKG. Schedule eye exam. Schedule ultrasound appointment (dating), genetics counseling.

35 Prenatal Management of Preexisting Diabetes (Type 1,2) Convert from oral sulfonylurea at time of pregnancy diagnosis (not studied adequately in first trimester). Weekly visits at 20 weeks, sooner if poor control Level II/genetics US including fetal echo at weeks Growth scan at 26 weeks and every 4 weeks thereafter NST twice weekly, AFI once weekly starting at 32 weeks; start at weeks if poorly controlled.

36 Prenatal Management of Preexisting Diabetes (Type 1,2) Plan for IOL (induction of labor) at weeks. Decision for timing based on if macrosomia, level control, parity and cervical exam. Consider primary c-section if EFW (estimated fetal weight) > 4500 grams. Or if will be >4500 at term weeks. Average DM growth 200 grams per week. IF EFW > 90% consult FP- OB.

37 Management of GDMA1 Refer for diabetic teaching/ diet. Dating US if not obtained already. Visits weekly once control achieved, then may go to q2 weeks until 30 weeks, then weekly again after 30 weeks. Check blood sugars QID. FBS, 2 hour postprandial after each meal.

38 Management GDMA1 Goals are FBS <95, 2 hr pp <120. HbA1C values are unreliable in pregnancy and a low value can often give false reassurance of good glycemic control. A reliable patient s report of their sugars is a more valuable source of information.

39 Management of GDMA1 Ultrasound at weeks for estimated fetal weight, rule out macrosomia. If > 4000 gm or > 90 percentile for estimated gestational age consider induction at 39 weeks. Twice a week NSTs starting at 40 weeks with weekly AFI. If poor control, treat as GDMA2. Recommend induction at 41 weeks if good dates.

40 Poor control. Management of GDMA1 Consider starting insulin. If start meds GDMA2. Metformin or Glyburide (if after 14 weeks) for FBS >95; 2 hour >120 in two or more values in a week. May continue additional week of dietary management if issue was noncompliance with diet.

41 Management GDMA2 Follow fasting and 2 hr postprandial plasma glucose Growth scan every 4 weeks (but no earlier than 26 weeks). Twice weekly NSTs with AFI once a week starting at 32 weeks. Induction at weeks depending on control. Do not allow pregnancy to continue beyond due date. Consider primary c-section if estimated fetal weight > 4500 gm. Remember, at higher risk to develop PIH.

42 Glyburide for GDMA2 Risk of hypoglycemia, watch for signs and symptoms. Not studied in 1 st trimester so don t start prior to 14 weeks. Usual starting dose is 2.5mg BID or 5 mg q am, depending on when sugars high. If plasma glucose not controlled increase dose in increments of 2.5mg to 5mg each week to achieve control Maximum 20mg/day Patients not controlled at maximum dose will require insulin

43 Management GDMA2 with Metformin No hypoglycemia Not as effective as glyburide, 1/3-2/3 women will need insulin as well. Start 500 mg bid and increase to 1000 mg bid. Diarrhea big side effect so start slowly. Consider starting insulin.

44 Starting Insulin Insulin QID at units/kg/day with Lispro (30% of total) with each meal and 10% as NPH qhs for 4x/day dosing. Self-monitoring QID. Should be adjusted PRN to control blood glucose. Use Lispro to cover meals, NPH to cover overnight and fasting. NPH dose must be adjusted based on fasting blood sugars. Lispro should be taken 15 minutes before or immediately after each meal.

45 Type 1 DM More complicated. Blood sugars should be followed with MFM.

46 GDMA1 When to Deliver Labor spontaneously or induce 41 weeks, not at increased risk if well controlled. Start antenatal testing at 40 weeks. GDMA2, Type 2 with good control with nl antepartum testing. induce at weeks Poor control dating scan 20 weeks deliver at weeks dating scan > 20 weeks tap and deliver weeks

47 Management of GDMA2, Type 2 DM in active labor Key is excellent intrapartum control for at least 6 hrs prior to delivery with glucose in range. Rare to need insulin drip in gestational diabetics but some type 2 may need insulin drip. Check fingerstick glucose q1-2 hrs with goal being less than 100. ***If think they require insulin drip get MCH fellow consult to evaluate prior to starting***

48 Why do we care about glucose control in labor? Babies have a good strong working pancreas and in utero crank up insulin to meet mom s hyperglycemia LGA, hypoglycemia after birth. 6 hours prior to delivery are crucial. After birth ICN 3 must be called by 30 minutes and baby down in ICN 3 after 45 minutes. Encourage mom to breastfeed prior to transport, 1 st blood sugar checked half hour after 1 st feed, feed must occur within 1 hour. Babies transition in ICN3 for 6 hours for q 1 hour glucose monitoring and s/sx hypoglycemia monitoring.

49 Neonatal hypoglycemia Encourage mom to breastfeed prior to transport, 1 st blood sugar checked half hour after 1 st feed, feed must occur within 1 hour. Babies transition in ICN3 for 6 hours for q 1 hour glucose monitoring and s/sx hypoglycemia monitoring. Depending on blood glucose, will either supplement with formula, or start IV glucose drip. Usually if blood glucose < or = 45 interventions are considered.

50 Induction Patient should take usual medication (insulin or glyburide) at bedtime. Eat small breakfast and take meds. If npo after midnight, or not take morning medication. On arrival, check blood glucose and start insulin drip if needed. Ask when they last ate. If last ate recently and blood sugar elevated, may down trend in next few hours and can hold off on drip.

51 Spontaneous labor On Arrival check blood glucose. Ask when last took insulin or oral medication. Ask when they last ate. Consider starting insulin drip.

52 Scheduled Cesarean Patient should take usual medication (insulin or glyburide) at bedtime. Eat nothing after midnight. Do not take morning medication. On arrival check blood glucose (patient should be fasting so should be normal if sugars have been well controlled). Perform cesarean section within 2 hours. If unable to perform surgery immediately or patient in poor control, start insulin drip if needed. Perform cesarean section after 4-6 hrs euglycemia.

53 GDMA1 : Postpartum Management Regular diet. No need to check blood glucose. GDMA2: Regular diet. Check fasting glucose in am. If <150 no need for medication.

54 Postpartum Management Type II DM, GDMA2 on insulin if fasting > 150: Consult Fellow Vaginal delivery: ADA diet and ½ of total insulin dose used in pregnancy Cesarean delivery: D5NS at 125 cc/hr. Check blood glucose every 4 hrs. Use regular insulin sliding scale to control blood glucose. When tolerating PO, ADA diet and ½ total pregnancy insulin.

55 Postpartum Management Type II DM not on insulin, but previously on oral glycemic agents: ADA diet. Check fasting glucose. If > 150 place on pre-pregnancy meds if compatible with breastfeeding or glyburide or metformin.

56 Postpartum Management According to ACOG and ADA, all gestational diabetic patients should have a 2hour OGTT 6-12 weeks postpartum. HbA1c, or fastinq blood sugar at 6-12 weeks may be acceptable alternatives. Patients should be screened every 1-3 years (depending on what you read) for DM. Pre-gestational diabetics normally return to their prepregnant insulin and /or oral med needs. Patients should be followed closely in the postpartum period to adjust their insulin as needed.

57 Postpartum Management: Family Planning All methods of birth control are appropriate for postpartum patients who do not have any other risk factors for a particular method. Caution with Depo Provera has been associated with weight gain, and earlier development of DM in patients with prior GDM. It is essential that patients with type 2 DM be in excellent control (HbA1c under 7.0) prior to conception to minimize the risk of congenital anomalies.

58 Questions?

59 References tational_diabetes Center for prenatal development : Handout: Daily meal and snack ideas. medical-management and follow-up of gestational diabetes. UNM MCH Clinical Guidelines MFM Diabetes protocol HAPO trial