HOW SWEET IT IS:HOW SWEET IT IS:

Managing Diabetes For A Healthy Managing Diabetes For A Healthy Pregnancy And BeyondPregnancy And Beyond Ruth Ferrarotti, MSN, APRN-BC, Ruth Ferrarotti, MSN, APRN-BC, CDECDE Assoc. Clinical Prof., Univ. of Conn.Assoc. Clinical Prof., Univ. of Conn.

Discussion TopicsDiscussion Topics

Gestational Diabetes:Gestational Diabetes:Diagnosis and management Diagnosis and management

Postpartum recommendationsPostpartum recommendations

Established Diabetes:Established Diabetes:Pre-pregnancy counselingPre-pregnancy counseling

Management of diabetesManagement of diabetes

Postpartum recommendationsPostpartum recommendations

Diabetes After PregnancyDiabetes After Pregnancy

Classification of Classification of DiabetesDiabetes Type 1 DiabetesType 1 Diabetes – Beta cell – Beta cell

destruction destruction Type 2 DiabetesType 2 Diabetes – Progressive insulin – Progressive insulin

secretory defect and insulin resistancesecretory defect and insulin resistance OtherOther – genetic defects, diseases of – genetic defects, diseases of

exocrine pancreas and drug/chemical exocrine pancreas and drug/chemical inducedinduced

Gestational DiabetesGestational Diabetes

Approximate Prevalence of Approximate Prevalence of Diabetes Diabetes in Pregnancy in the United Statesin Pregnancy in the United States

GDM=gestational diabetes mellitus

Nondiabetes 92%

More than 200,000 type 2 diabetes mellitus + 135,000 GDM + 6000 More than 200,000 type 2 diabetes mellitus + 135,000 GDM + 6000 type 1 diabetes mellitus = 341,000 pregnancies complicated by type 1 diabetes mellitus = 341,000 pregnancies complicated by

hyperglycemia annually hyperglycemia annually

Diabetes 8%

4.022 Million Births in 2002

50% GDM

Diabetes 8%

2% T1DM

24% Diagnosed T2DM

24% Undiagnosed T2DM

Fetalhyperinsulinemia

The Impact of Maternal The Impact of Maternal Hyperglycemia Hyperglycemia During PregnancyDuring PregnancyModified Pedersen HypothesisModified Pedersen Hypothesis

Fetus

Fetal pancreas stimulated

IgG=immunoglobulin GMother

Plac

enta

IgG-antibody-bound insulin

Insulin

Maternal hyperglycemia

Insulin resistance syndrome

Diabetes and PregnancyDiabetes and Pregnancy Type 1 and Type 2 DiabetesType 1 and Type 2 Diabetes

Preexisting diabetes diagnosisPreexisting diabetes diagnosis Preconception care is essentialPreconception care is essential Treat with insulinTreat with insulin If untreated during first few weeks’ gestation, If untreated during first few weeks’ gestation,

associated withassociated with– Spontaneous abortionSpontaneous abortion– Birth defectsBirth defects

If untreated during second or third trimester, associated If untreated during second or third trimester, associated withwith– Fetal macrosomiaFetal macrosomia– Birth injuryBirth injury– Maternal hypertensionMaternal hypertension– Maternal preeclampsiaMaternal preeclampsia– Future diabetes and/or obesity in childFuture diabetes and/or obesity in child

American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

Preconception Care of Established Preconception Care of Established DiabetesDiabetesMedical AssessmentMedical Assessment

Duration and type of diabetesDuration and type of diabetes Medical history and current medical Medical history and current medical

management planmanagement plan Chronic diabetes-related complicationsChronic diabetes-related complications

– RetinopathyRetinopathy Dilated eye exam by trained ophthalmologistDilated eye exam by trained ophthalmologist

– NephropathyNephropathy 24-hour urine for creatinine clearance, total protein 24-hour urine for creatinine clearance, total protein

excretion, and microalbuminuriaexcretion, and microalbuminuria

– NeuropathyNeuropathy Autonomic neuropathy, especially gastroparesisAutonomic neuropathy, especially gastroparesis

American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

Preconception Care of Established Preconception Care of Established DiabetesDiabetesMedical AssessmentMedical Assessment

Comorbid conditions (in addition to Comorbid conditions (in addition to diabetic complications)diabetic complications)– HypertensionHypertension

Measure blood pressureMeasure blood pressure

– Coronary artery diseaseCoronary artery disease Stress testStress test

– Hyper- or hypothyroidismHyper- or hypothyroidism Free TFree T44 and TSH and TSH

– Other autoimmune diseasesOther autoimmune diseasesT4=thyroxineTSH=thyroid-stimulating hormone

American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

SMBGSMBG– Fasting/premeal: 70 to100 mg/dLFasting/premeal: 70 to100 mg/dL– 1 hour postmeal: <140 mg/dL1 hour postmeal: <140 mg/dL

A1CA1C– In normal range (<6%, but ideally <5%)In normal range (<6%, but ideally <5%)– Monitor until A1C is stable at <6%Monitor until A1C is stable at <6%

Preconception Care of Established Preconception Care of Established DiabetesDiabetesBlood Glucose GoalsBlood Glucose Goals

SMBG=self-monitoring of blood glucose

Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:1-19

Diabetes in Early Pregnancy (DIEP) Diabetes in Early Pregnancy (DIEP) Trial Trial Postprandial Blood Glucose Postprandial Blood Glucose Levels Levels Predict Macrosomia RiskPredict Macrosomia Risk

Adapted from Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1991;164(1 pt 1):103-111

1-hour postmeal blood glucose (mg/dL)1-hour postmeal blood glucose (mg/dL)

Risk for Risk for macrosomia macrosomia (%)(%)

8080

6060

9090 100100 110110 120120 130130 140140 150150 160160 170170 180180

5050

4040

3030

2020

1010

00

Management of Management of Diabetes in PregnancyDiabetes in Pregnancy Type 1 Type 1

– Multiple daily injectionsMultiple daily injections– Insulin pumpInsulin pump

Type 2 Type 2 – Change to insulin if on oral agentsChange to insulin if on oral agents– Insulin pumpInsulin pump

Multiple Daily Multiple Daily InjectionsInjections Combination of intermediate or Combination of intermediate or

longer acting insulin with rapid longer acting insulin with rapid insulininsulin– NPHNPH– LantusLantus– AnalogAnalog

Usually require 4-6 injections Usually require 4-6 injections dailydaily

Management of Management of Diabetes in PregnancyDiabetes in Pregnancy Monitor BG pre and 2 hrs post Monitor BG pre and 2 hrs post

mealmeal Calculate premeal rapid insulin Calculate premeal rapid insulin

based on carbohydrate intakebased on carbohydrate intake Calculate correction for premeal Calculate correction for premeal

elevated glucose elevated glucose Discourage postprandial correctionDiscourage postprandial correction

Insulin PumpInsulin Pump Advantages: Advantages: More physiologic than MDIMore physiologic than MDI

– Programmable bolus reduces risks for Programmable bolus reduces risks for hypoglycemia, post-meal hypoglycemia, post-meal hyperglycemia and glucose excursionshyperglycemia and glucose excursions

Allows for greater flexibility with Allows for greater flexibility with diet and lifestylediet and lifestyle

Increased motivation promotes Increased motivation promotes better controlbetter control

Insulin PumpInsulin Pump Disadvantages Disadvantages Requires increased patient Requires increased patient

responsibility and motivationresponsibility and motivation Risk of rapid onset ketoacidosis if Risk of rapid onset ketoacidosis if

catheter becomes dislodged or catheter becomes dislodged or site infectionsite infection

Mechanical problems with pumpMechanical problems with pump Infusion site limited in later Infusion site limited in later

pregnancypregnancy

Sensor Augmented Sensor Augmented PumpingPumping Advantages Advantages Decreased risk of glucose Decreased risk of glucose

excursions and hypoglycemiaexcursions and hypoglycemia Provides instant informationProvides instant information Allows for greater flexibility to Allows for greater flexibility to

diet and lifestylediet and lifestyle Reduces number of self-Reduces number of self-

monitored glucose testsmonitored glucose tests

Sensor Augmented Sensor Augmented PumpingPumping Disadvantages Disadvantages Not as accurate as glucose results Not as accurate as glucose results

by fingerstickby fingerstick ““Too much data”Too much data” Expensive and not always Expensive and not always

covered by insurancecovered by insurance Requires another siteRequires another site AlarmsAlarms

American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S88-S90Metzger BE, Coustan DR. Diabetes Care. 1998;21(suppl 2):B161-B167

Mainstay of treatment is medical nutrition therapy Mainstay of treatment is medical nutrition therapy (MNT)(MNT)

Add insulin if MNT does not maintain normoglycemiaAdd insulin if MNT does not maintain normoglycemia If untreated, associated with:If untreated, associated with:

– Late-term intrauterine fetal deathLate-term intrauterine fetal death– Fetal macrosomia Fetal macrosomia – Neonatal hypoglycemia and/or jaundiceNeonatal hypoglycemia and/or jaundice– Maternal hypertensionMaternal hypertension– Future diabetes and/or obesity in childFuture diabetes and/or obesity in child

Diabetes and PregnancyDiabetes and Pregnancy Gestational Diabetes Gestational Diabetes MellitusMellitus

Glucose intolerance of variable degree with onset or first recognition during pregnancy

Gestational DiabetesGestational Diabetes Approximately 7% of all Approximately 7% of all

pregnancies are complicated by pregnancies are complicated by GDMGDM

Translates to over 200,000 cases Translates to over 200,000 cases annually(1)annually(1)

Approximately 42,000 births in Approximately 42,000 births in Connecticut in 2008(2)Connecticut in 2008(2)

2980 complicated by GDM2980 complicated by GDM (1)(1) Diabetes Care, Vol.33, Supp. 1, Jan. Diabetes Care, Vol.33, Supp. 1, Jan.

20102010 (2) Connecticut Vital Statistics, 2008 (2) Connecticut Vital Statistics, 2008

Gestational Diabetes Gestational Diabetes

Glucose intolerance of varying Glucose intolerance of varying severity, with onset or first severity, with onset or first recognition during the current recognition during the current pregnancy.pregnancy.

Currently diagnosed using two Currently diagnosed using two step methodstep method

Diagnostic screening between 24-Diagnostic screening between 24-28 weeks gestation28 weeks gestation

Diagnosis of GDMDiagnosis of GDM

1998 Guidelines1998 Guidelines– 1HR oral glucose 1HR oral glucose

challengechallenge 135-185135-185 ≥ ≥ 186186

– 3HR OGTT3HR OGTT FBS FBS ≥ 95≥ 95 1hr ≥ 1801hr ≥ 180 2hr ≥ 1552hr ≥ 155 3hr ≥ 1403hr ≥ 140

Carpenter and CoustanCarpenter and Coustan

2010 Guidelines2010 Guidelines– 2HR OGTT 2HR OGTT

FBG FBG ≥ 92≥ 92 1hr ≥ 1801hr ≥ 180 2hr ≥ 1532hr ≥ 153

IADPSG Consensus IADPSG Consensus Panel Panel

Managing GDMManaging GDM

Lifestyle modifications:Lifestyle modifications:– Medical Nutrition TherapyMedical Nutrition Therapy– ExerciseExercise

Self-monitoring blood glucoseSelf-monitoring blood glucoseFBS < 90mg/dl 2 hr postprandial <120mg/dlFBS < 90mg/dl 2 hr postprandial <120mg/dl

MedicationMedication– Oral agentsOral agents– InsulinInsulin

Medications in GDMMedications in GDM

InsulinInsulin– NPHNPH– AnalogsAnalogs– LantusLantus

Oral agentsOral agents– GlyburideGlyburide– MetforminMetformin

Physical Activity in GDMPhysical Activity in GDM• Can improve peripheral insulin resistance Can improve peripheral insulin resistance

and glucose levelsand glucose levels• Can obviate need for insulin Can obviate need for insulin • Encouraged for women with no obstetric Encouraged for women with no obstetric

contraindicationscontraindications• Avoid physical activity associated with Avoid physical activity associated with

maternal hypertension or fetal distress (eg, maternal hypertension or fetal distress (eg, resistance training, lower-body weight-resistance training, lower-body weight-bearing exercise) bearing exercise)

• Upper-body cardiovascular training is a good Upper-body cardiovascular training is a good optionoption

Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed.Alexandria, Va: American Diabetes Association; 2000:111-132Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1989;161:415-419

Immediate Postpartum Immediate Postpartum

Insulin requirements disappearInsulin requirements disappear

Diabetes will disappear in 90% of Diabetes will disappear in 90% of

GDM cases.GDM cases.

Continue monitoring 24-48 hrs after Continue monitoring 24-48 hrs after delivery, as indicateddelivery, as indicated

Postpartum ConsiderationsPostpartum ConsiderationsLactation and NutritionLactation and Nutrition

Breastfeeding is recommendedBreastfeeding is recommended – Decreased risk of type 1 diabetes and infection in infantDecreased risk of type 1 diabetes and infection in infant– Promotes infant growth and developmentPromotes infant growth and development

Maintain pregnancy meal plan or develop postpartum plan to Maintain pregnancy meal plan or develop postpartum plan to meet added caloric requirements of breastfeedingmeet added caloric requirements of breastfeeding

Rapid weight loss is not advised; exercise is recommended Rapid weight loss is not advised; exercise is recommended

Insulin use must be continued if postpartum normoglycemia Insulin use must be continued if postpartum normoglycemia cannot be maintained with MNTcannot be maintained with MNT

Blood glucose concentrations may be variable in women with Blood glucose concentrations may be variable in women with type 1 diabetestype 1 diabetes– Test glucose frequentlyTest glucose frequently– Snack and/or adjust evening insulin to avoid nighttime Snack and/or adjust evening insulin to avoid nighttime

hypoglycemiahypoglycemia– Watch for hypoglycemia due to missed or delayed mealsWatch for hypoglycemia due to missed or delayed meals

Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:67-86

Postpartum Postpartum RecommendationsRecommendations Self-monitoring Self-monitoring

– Fasting <100Fasting <100– 2 hr post-prandial <1402 hr post-prandial <140

Glucose testing 6-12 weeks post Glucose testing 6-12 weeks post deliverydelivery

Reclassification of diabetesReclassification of diabetes

Diabetes After Diabetes After PregnancyPregnancy 40-60% risk of developing Type 2 40-60% risk of developing Type 2

DM within 5-15 yearsDM within 5-15 years Approximately 20% continue with Approximately 20% continue with

abnormal glucose after deliveryabnormal glucose after delivery 66% risk of developing GDM in 66% risk of developing GDM in

subsequent pregnancysubsequent pregnancy

Diagnosing DiabetesDiagnosing Diabetes

ADA 2010 Diagnostic CriteriaADA 2010 Diagnostic Criteria– A1C A1C ≥ 6.5% or:≥ 6.5% or:– FPG ≥ 126mg/dl or:FPG ≥ 126mg/dl or:– Two-hour plasma glucose ≥ Two-hour plasma glucose ≥

200mg/dl or:200mg/dl or:– Classic symptoms of hyperglycemia Classic symptoms of hyperglycemia

or hyperglycemic crisis, a random or hyperglycemic crisis, a random glucose ≥200mg/dlglucose ≥200mg/dl

Diagnosing DiabetesDiagnosing Diabetes

New classificationsNew classifications Pre-diabetesPre-diabetes

– A1C 5.7% to 6.4%A1C 5.7% to 6.4%– 2 hr OGTT2 hr OGTT

FPG 100-126FPG 100-126 2 hr 140-1992 hr 140-199

Refer for nutrition counseling, Refer for nutrition counseling, weight loss and ongoing careweight loss and ongoing care