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EASY TO FOLLOW POWERPOINT PRESENTATION ON GDM USEFUL FOR HEALTH CARE PROVIDERS AND ALL WOMEN OF REPRODUCTIVE AGE GROUP
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GESTATIONAL GESTATIONAL DIABETESDIABETES
DR.RISHIKESAN K.VDR.RISHIKESAN K.V
VENNIYIL MEDICAL CENTREVENNIYIL MEDICAL CENTRE
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Gestational DiabetesGestational Diabetes
This diagnosis is given when a woman, who This diagnosis is given when a woman, who has never had diabetes before, gets diabetes has never had diabetes before, gets diabetes or has high blood sugar, when she is or has high blood sugar, when she is pregnant. pregnant. Its medical name is Its medical name is gestational diabetes gestational diabetes mellitusmellitus or GDM. or GDM.It is one of the most common health problems It is one of the most common health problems for pregnant women.for pregnant women.The word “gestational” actually refers to The word “gestational” actually refers to “during pregnancy.”“during pregnancy.”
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Gestational DiabetesGestational Diabetes
It occurs in about 5% of It occurs in about 5% of all pregnancies. all pregnancies.
If not treated, gestational If not treated, gestational diabetes can cause diabetes can cause health problems for the health problems for the mother and the fetus.mother and the fetus.
Glucose MetabolismGlucose Metabolism
Normal pregnancy Normal pregnancy : Diabetogenic state: Diabetogenic state*increase in pc BG*increase in pc BG
*insulin resistance*insulin resistance
Early Pregnancy : Early Pregnancy : Anabolic stateAnabolic state
*increase in maternal fat store*increase in maternal fat store qsqs
*decreased FFA concentration*decreased FFA concentration
*decrease in insulin requirements*decrease in insulin requirements
CHO MetabolismCHO MetabolismEffects of Pregnancy Effects of Pregnancy **Mild fasting hypoglycemia;Mild fasting hypoglycemia; *Post prandial hyperglycemia *Post prandial hyperglycemia Due to increase in plasma volume in early Due to increase in plasma volume in early
gestation and increase in fetal glucose gestation and increase in fetal glucose utilization.utilization.
As pregnancy advances As pregnancy advances -Progressive increase -Progressive increase in tissue resistance to insulinin tissue resistance to insulin– Increase insulin secretion to maintain Increase insulin secretion to maintain
euglycemiaeuglycemia– Suppressed glucagon responseSuppressed glucagon response– Inc. prolactin, cortisolInc. prolactin, cortisol– HPL has GH like effectsHPL has GH like effects
CHO MetabolismCHO Metabolism
Gestational DiabetesGestational Diabetes
Risk FactorsRisk Factorsmaternal age >25maternal age >25
Family historyFamily history
glucosuriaglucosuria
prior macrosomiaprior macrosomia
previous unexplained stillbirthprevious unexplained stillbirth
ethnic group: Hispanic, Black, ethnic group: Hispanic, Black, AsiansAsians
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Insulin from the Insulin from the pancreaspancreas
Vad happens to the carbohydrates from the Vad happens to the carbohydrates from the food? food?
- -- -
- -- -- -
Fat/muscle cellFat/muscle cell
Stored sugar in the Stored sugar in the liver (glycogen)liver (glycogen)
Carbohydrates Carbohydrates from foodfrom food
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Why didn’t I have diabetes before?Why didn’t I have diabetes before?
During pregnancy, many During pregnancy, many physiological changes take place. physiological changes take place. Changes in metabolism can be Changes in metabolism can be seen. Insulin may not be as effective seen. Insulin may not be as effective in moving sugar into the cells during in moving sugar into the cells during pregnancy. Therefore, the cells can’t pregnancy. Therefore, the cells can’t get the sugar they need for energy. get the sugar they need for energy. Increased sugar levels in the blood Increased sugar levels in the blood can lead to many problems.can lead to many problems.
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Why isn’t insulin doing its job?Why isn’t insulin doing its job?
The placenta is a system of vessels that The placenta is a system of vessels that passes nutrients, blood, and water from passes nutrients, blood, and water from mother to fetus.mother to fetus. The placenta makes certain hormones The placenta makes certain hormones that may prevent insulin from working the that may prevent insulin from working the way that it should.way that it should. When this condition happens, it is referred When this condition happens, it is referred to as to as insulin resistanceinsulin resistance.. In order to keep metabolism normal during pregnancy, In order to keep metabolism normal during pregnancy, the the
body has to make three times more insulin than normal body has to make three times more insulin than normal to to offset the hormones made by the placenta.offset the hormones made by the placenta.
Placenta
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Why isn’t insulin doing its job?Why isn’t insulin doing its job?
For most women, the body’s extra For most women, the body’s extra insulin is enough to keep their blood insulin is enough to keep their blood sugar levels in the healthy range.sugar levels in the healthy range.But, for about 5% of pregnant women, But, for about 5% of pregnant women, even the extra insulin is not enough to even the extra insulin is not enough to keep blood sugar levels normal.keep blood sugar levels normal.These women end up with high blood These women end up with high blood sugar or gestational diabetes at around sugar or gestational diabetes at around the 20the 20thth to 24 to 24thth week of pregnancy. week of pregnancy.
Gestational DiabetesGestational Diabetes
ScreeningScreening
– 24-28 weeks routine24-28 weeks routine– no need to fastno need to fast– screen at 1st prenatal visit if hx of screen at 1st prenatal visit if hx of
previous GDMprevious GDM– screen earlier (12-24 weeks ) if risk screen earlier (12-24 weeks ) if risk
factorsfactors
MATERNAL RISKMATERNAL RISK Birth traumaBirth trauma
Preterm LaborPreterm Labor
PIHPIH
Operative deliveryOperative delivery
50% lifetime risk in developing Type 50% lifetime risk in developing Type II DMII DM
Recurrence risk of GDM is 30-50%Recurrence risk of GDM is 30-50%
Gestational DiabetesGestational Diabetes
Will GDM hurt my baby?Will GDM hurt my baby?Most women with gestational diabetes give birthMost women with gestational diabetes give birthto healthy babies; this is especially true forto healthy babies; this is especially true forwomen who have kept their blood sugar underwomen who have kept their blood sugar undercontrol, maintained a healthy diet, engaged incontrol, maintained a healthy diet, engaged inregular, moderate physical activity, and regular, moderate physical activity, and had a healthy weight throughout thehad a healthy weight throughout thepregnancy.In some cases, however, pregnancy.In some cases, however, the condition can affect the pregnancy.the condition can affect the pregnancy.
GDM GDM Associated ConditionsAssociated Conditions MacrosomiaMacrosomia
In this condition, the baby’s body is larger than normal. Large-In this condition, the baby’s body is larger than normal. Large-bodied babies may be injured during natural delivery bodied babies may be injured during natural delivery through the vagina, so the baby may need to be delivered through the vagina, so the baby may need to be delivered through cesarean section. through cesarean section.
HypoglycemiaHypoglycemia
In this condition, the baby’s blood glucose is too low. In this condition, the baby’s blood glucose is too low. Breastfeeding may need to be started right away to get Breastfeeding may need to be started right away to get more glucose into the baby’s system. If breastfeeding is not more glucose into the baby’s system. If breastfeeding is not possible, then the baby may need to get glucose put possible, then the baby may need to get glucose put directly into the blood through a thin, plastic tube in his or directly into the blood through a thin, plastic tube in his or her arm.her arm.
JaundiceJaundice
In this condition ,the baby’s skin turns yellowish. The white In this condition ,the baby’s skin turns yellowish. The white parts of the eye may also change color slightly. If treated, parts of the eye may also change color slightly. If treated, this is not a serious problem.this is not a serious problem.
GDM GDM ASSOCIATED CONDITIONS….ASSOCIATED CONDITIONS….
Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS)
In this condition, the baby has trouble breathing. In this condition, the baby has trouble breathing. The baby may need oxygen or other help The baby may need oxygen or other help breathing if he or she has this condition.breathing if he or she has this condition.
Low Calcium and Magnesium Levels in Baby’s Low Calcium and Magnesium Levels in Baby’s BloodBlood
In this condition, spasms in the hands and feet, or In this condition, spasms in the hands and feet, or twitching and cramping of muscles can occur. twitching and cramping of muscles can occur. The condition can be treated through The condition can be treated through supplementation with magnesium and calcium supplementation with magnesium and calcium supplements.supplements.
Keep in mind that just because you have GDM it does not mean that these problems will occur
Could GDM hurt my baby in other ways?Could GDM hurt my baby in other ways?
Gestational diabetes usually does Gestational diabetes usually does notnot cause birth cause birth defects or deformities.defects or deformities.
Most developmental or physical defects happened Most developmental or physical defects happened during the first trimester of pregnancy, between the during the first trimester of pregnancy, between the 11stst and 8 and 8thth week, and gestational diabetes typically week, and gestational diabetes typically develops around the 24develops around the 24 thth week of pregnancy. week of pregnancy.
Women with gestational diabetes typically have normal blood sugar levels during the first trimester, allowing the body and body Systems of the fetus to develop normally.
The fact that you have gestational diabetes will not cause diabetes in your baby.However, your child will be at a higher risk for developingtype 2 diabetes in adulthood and may get it at a youngerage (younger than 30).
As your child grows, taking steps such as: eating a healthy diet, maintaining a healthy weight, and getting regular, moderate physical activity can help to reduce his or her risk.Macrosomic, or large-bodied babies are at higher risk for childhood and adult obesity.
Magnetic Resonance Image of Pregnancy Complicated by Diabetes
Normoglycmia Hyperglycmia
Jovanovic L et al. Am J Perinatol. 1993;10:432-437
Macrosomia
Gestational Diabetes
Fetal RisksFetal Risks
no increaseno increase in congenital anomalies in congenital anomaliesincreased risk of stillbirth if fasting+ increased risk of stillbirth if fasting+
pc hyperglycemiapc hyperglycemiamacrosomiamacrosomiabirth trauma-shoulderbirth trauma-shoulder dystocia and related dystocia and related complications complications
Gestational DiabetesGestational Diabetes
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A Treatment Plan for GDMA Treatment Plan for GDMMay include these items:May include these items:
Knowing your blood sugar (glucose) level and keeping it Knowing your blood sugar (glucose) level and keeping it under controlunder control
Eating a healthy diet, as outlined by your health care Eating a healthy diet, as outlined by your health care providerprovider
Getting regular, moderate physical activityGetting regular, moderate physical activity Maintaining a healthy weight gainMaintaining a healthy weight gain Keeping daily records of your diet, physical activity, and Keeping daily records of your diet, physical activity, and
glucose levelsglucose levelsTaking insulin and/or other medications as prescribedTaking insulin and/or other medications as prescribed
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Know your blood sugar level Know your blood sugar level & keep it under control: & keep it under control: OverviewOverview
There are two parts:There are two parts:– Knowing your blood sugar levelKnowing your blood sugar level
Test to see how much glucose is in your bloodTest to see how much glucose is in your blood– Keeping your blood sugar level under controlKeeping your blood sugar level under control
Keep the amount within a healthy range at all timesKeep the amount within a healthy range at all timesThis is important to do because your blood sugar level change This is important to do because your blood sugar level change
throughout the day based on what foods you eat, when you throughout the day based on what foods you eat, when you eat them, and how much you eat. Your level of physical activity eat them, and how much you eat. Your level of physical activity and when you do physical activity also influences blood sugar and when you do physical activity also influences blood sugar levels.levels.
Management Management
Goal is to optimize BG Goal is to optimize BG
levels to minimize risk levels to minimize risk
of adverse perinatal of adverse perinatal
outcomesoutcomes Diet Diet
ExerciseExercise
Insulin therapyInsulin therapy
Gestational DiabetesGestational Diabetes
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Know your blood sugar level Know your blood sugar level & keep it under control & keep it under control
Although your glucose Although your glucose levels change during the levels change during the day, there is a healthy day, there is a healthy range that is normal. If range that is normal. If your glucose level is your glucose level is outside of the healthy outside of the healthy target range, speak with target range, speak with your health care your health care provider.provider.
Time of Blood Sugar
Test
Healthy Target Levels (in
mg/dl)
Fasting glucose
level
No higher than 95
One hour after eating
No higher than 140
Two hours after eating
No higher than 120
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Know your blood sugar level Know your blood sugar level & keep it under control & keep it under control
Knowing your glucose Knowing your glucose levels at specific times of levels at specific times of the day may become very the day may become very important if insulin important if insulin therapy becomes therapy becomes necessary.necessary.Insulin resistance can Insulin resistance can increase as a pregnancy increase as a pregnancy progresses indicating a progresses indicating a need for additional insulin need for additional insulin to control glucose levelsto control glucose levels. .
Measuring your blood sugar will
give you information
about…
For example
The amount of food you can eat
Can you have that extra ½ bagel for breakfast?
Foods that affect your glucose
level
Does your body process different foods differently?
Times when your glucose level is
high or low
You might have high blood sugar in the morning after breakfast; other women may have high blood sugar after dinner.
Times that physical activity is more likely to
keep your glucose level in
target
Does walking for 20 minutes after breakfast or dinner help to keep your glucose level within the healthy range?
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Know your blood sugar level Know your blood sugar level & keep it under control & keep it under control
You may have to test four times a day:You may have to test four times a day:
1.1. In the morning before eating breakfast, In the morning before eating breakfast, referred to as the referred to as the FastingFasting glucose level glucose level
2.2. 1 or 2 hours 1 or 2 hours after breakfastafter breakfast
3.3. 1 or 2 hours 1 or 2 hours after lunchafter lunch
4.4. 1 or 2 hours 1 or 2 hours after dinnerafter dinner
You may also have to test your glucose level before you You may also have to test your glucose level before you go to bed at night. This is referred to as your go to bed at night. This is referred to as your nighttime nighttime oror nocturnal nocturnal glucose test. glucose test.
Management : DietManagement : Diet
patients without fasting patients without fasting hyperglycemiahyperglycemia
average 8000-9000 kj/day.average 8000-9000 kj/day.BMI >27 25 kcal/kg/IBW /dBMI >27 25 kcal/kg/IBW /d
BMI 20-26 30 ; BMI 20-26 30 ;
BMI <20 38 ; BMI <20 38 ;
Gestational DiabetesGestational Diabetes
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Eating a healthy dietEating a healthy dietOverviewOverview
A healthy diet is one that includes A healthy diet is one that includes a balance of foods from all the a balance of foods from all the food groups, giving the nutrients, food groups, giving the nutrients, vitamins, and minerals necessary vitamins, and minerals necessary for a healthy pregnancy. for a healthy pregnancy. For women with gestational For women with gestational diabetes, a healthy diet can help to diabetes, a healthy diet can help to keep blood sugar levels in the keep blood sugar levels in the healthy target range.healthy target range.Carbohydrates are often the center Carbohydrates are often the center of a healthy diet for a woman with of a healthy diet for a woman with gestational diabetes.gestational diabetes.
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Eating a healthy dietEating a healthy diet CarbohydratesCarbohydratesCarbohydrates are nutrients which come Carbohydrates are nutrients which come
from foods like grain products, fruits, and from foods like grain products, fruits, and vegetables. vegetables. During digestion, the body is able to break During digestion, the body is able to break down most carbohydrates into simple down most carbohydrates into simple sugars, like glucose.sugars, like glucose.Eating carbohydrates affects blood sugar Eating carbohydrates affects blood sugar levels. Eating a large amount of levels. Eating a large amount of carbohydrates at a meal will have a larger carbohydrates at a meal will have a larger effect on blood glucose levels than eating a effect on blood glucose levels than eating a small amount of carbohydrates.small amount of carbohydrates.It is important to balance between eating It is important to balance between eating enough carbohydrates to receive the enough carbohydrates to receive the necessary amounts of energy and resultant necessary amounts of energy and resultant glucose, and not consuming too much to glucose, and not consuming too much to where blood sugar levels are out of where blood sugar levels are out of controlcontrol..
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Eating a healthy dietEating a healthy dietMeal PlansMeal Plans
CHO counting
With this meal plan, the number of grams of carbohydrates that is eaten at each meal or snack is counted to make sure that they are within a certain range. A meal plan may be very specific, allowing a specified amount at each meal or snack, or it may be more general, with a daily carbohydrate total.
The exchange
system
The exchange system groups each food consumed into one of the following food groups: bread/starches, fruits, vegetables, proteins, milk, and fats. Each food within a group has very similar amounts of carbohydrate, fat, protein and calories, but the amounts of vitamins and minerals may vary. In this plan, the number of items from a food group that is eaten at each meal is counted. There is a designated amount for each group every day.
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Eating a healthy dietEating a healthy dietto keep blood sugar in check:to keep blood sugar in check:
Eat meals and snacks on a regular
schedule throughout the day
Researchers recommend that women with gestational diabetes should eat at least three small-to-medium sized meals and two to four snacks every day.
Eat smaller amounts of carbohydrates at
each meal
It is preferable to eat several small meals every day rather than one large meal. Carbohydrates will increase blood glucose level directly, therefore, eating a small amount of carbohydrates all through the day will help keep blood sugar from rising too high.
Add a nighttime snack to your meal
plan
A snack of one or two servings of carbohydrates before bedtime will keep blood sugar at a healthy level during sleep. Some healthy examples could include: a piece of fruit, a handful of pretzels, or crackers.
Diet : general principlesDiet : general principles
55% CHO / 25% Protein / 55% CHO / 25% Protein / 20% fat20% fat
Normal weight gain 10-12 kgNormal weight gain 10-12 kg
Avoid ketosisAvoid ketosis
Liberal exercise program to Liberal exercise program to optimize BG controloptimize BG control
Gestational DiabetesGestational Diabetes
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Role of physical activityRole of physical activityWomen with gestational diabetes often Women with gestational diabetes often need regular, moderate physical activity need regular, moderate physical activity to help control their blood sugar levels to help control their blood sugar levels by allowing insulin to work better.by allowing insulin to work better.
Examples include:Examples include:– WalkingWalking– Prenatal aerobics classesPrenatal aerobics classes– SwimmingSwimming
However, a consultation and approval However, a consultation and approval by a health care provider is needed by a health care provider is needed before beginning any physical activity before beginning any physical activity during pregnancy.during pregnancy.
Caution
Keep in mind that it may take 2 to 4
weeks before physical
activity has an effect on blood sugar levels.
If persistent hyperglycemiaIf persistent hyperglycemia
after one week of dietafter one week of diet
control proceed to insulincontrol proceed to insulin
6-14 weeks 6-14 weeks 0.5u/kg/d 0.5u/kg/d
14-26 weeks14-26 weeks 0.7u/kg/d 0.7u/kg/d
26-36 weeks 0.9u/kg/d26-36 weeks 0.9u/kg/d
36-40weeks 36-40weeks 1 u /kg/d 1 u /kg/d
Gestational DiabetesGestational DiabetesINSULININSULIN
If fasting hyperglycemia start with If fasting hyperglycemia start with NPHNPHhs hs
initial dose initial dose 6-8 U 6-8 U
if only pc hyperglycemia use if only pc hyperglycemia use HHumalogumalog 2-4u ac the specific meal 2-4u ac the specific meal
adjust adjust 2u/time2u/time ; 1 formula /time ; 1 formula /time
BG target BG target ac <5.3 (90mg.)ac <5.3 (90mg.)
2 h pc <6.7 ( 120 mg)2 h pc <6.7 ( 120 mg)
Gestational DiabetesGestational DiabetesINSULININSULIN
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Role of moderate physical activityRole of moderate physical activityResearchers are uncertain about the Researchers are uncertain about the exact amount of physical activity required exact amount of physical activity required to control blood sugar during gestational to control blood sugar during gestational diabetes.diabetes.The amount that is usually recommended The amount that is usually recommended is based on how active an individual was is based on how active an individual was before the pregnancy and whether or not before the pregnancy and whether or not there are any other health concerns.there are any other health concerns.For some women with GDM, regular For some women with GDM, regular physical activity can include walking, physical activity can include walking, swimming, or light running; whereas, for swimming, or light running; whereas, for other women only slow walking may be other women only slow walking may be recommended. recommended. A health care provider can offer advice on A health care provider can offer advice on appropriate activities, and their duration appropriate activities, and their duration and frequency to assure a healthy and frequency to assure a healthy pregnancy. pregnancy.
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Role of moderate physical activityRole of moderate physical activityGeneral Guidelines For Physical ActivityGeneral Guidelines For Physical Activity
Do Don’t
Participate in moderate and regular physical activity unless prohibited by a health care
provider
Get too tired while working out or doing physical
activity
Choose activities like swimming, that
don’t require a lot of standing or balance
Do any activity while lying on your back when you are in your 2nd or
3rd trimester of pregnancy
Wear loose, light clothing that won’t cause excessive sweating or
increased body temperature
Perform activities in very hot weather
Drink a lot of water before, during, and after your activity
Perform activities that may bump or hurt your belly, or that may cause you to lose your balance
Eat a healthy diet and gain the right amount of
weight
Fast (skip meals) or do physical activity when you are hungry
Watch your level of exertion (Can you talk easily?)
Over-exert yourself
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Maintain a healthy weightMaintain a healthy weightOverviewOverview
Healthy weight gain can refer to Healthy weight gain can refer to your your overall weight gainoverall weight gain or your or your weekly rate of weight gainweekly rate of weight gain..
Some health care providers Some health care providers focus only on overall gain or focus only on overall gain or only on weekly gain, but some only on weekly gain, but some keep track of both types of keep track of both types of weight gain.weight gain.
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Maintain a healthy weightMaintain a healthy weightWeekly Rate Of Weight GainWeekly Rate Of Weight Gain
Time Frame Expected Weight Gain
In the first trimester of pregnancy
(the first 3 months)
Three to six pounds for the entire three
months
During the second and third trimester
(the last 6 months)
Between ½ and 1 pound each week
If you gained too much weight early in the
pregnancy
Limit weight gain to ¾ of a pound each week (3 pounds
each month) to help get your blood sugar level
under control
A weight gain of two pounds or more each week is
considered high.
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Maintain a healthy weightMaintain a healthy weightThings to Keep in MindThings to Keep in Mind
1.1. A weekly rate of weight gain may go up and down A weekly rate of weight gain may go up and down throughout the pregnancy.throughout the pregnancy.
2.2. A physician can assess whether weight gain is A physician can assess whether weight gain is appropriate or not.appropriate or not.
3.3. A A weight lossweight loss can be can be dangerousdangerous during any part of during any part of the pregnancy, therefore any weight loss needs to the pregnancy, therefore any weight loss needs to be reported to a health care provider right away.be reported to a health care provider right away.
4.4. If weight gain slows or stop, and does not increase If weight gain slows or stop, and does not increase again after one-to-two weeks, it should be reported again after one-to-two weeks, it should be reported to a health care provider immediately. Adjustments to a health care provider immediately. Adjustments in your treatment plan may be necessary.in your treatment plan may be necessary.
Maintain a healthy weightMaintain a healthy weightAdditional tipsAdditional tips
Try to get more light or moderate physical Try to get more light or moderate physical activity, if your health care provider says activity, if your health care provider says that it is safe.that it is safe.
Use the Use the Nutrition FactsNutrition Facts labels on food packages labels on food packages to make lower-calorie food choices that fit to make lower-calorie food choices that fit into a healthy meal plan.into a healthy meal plan.
Eat fewer fried foods and “fast” foodsEat fewer fried foods and “fast” foods..
Eat healthy foods that fit into your meal plan, Eat healthy foods that fit into your meal plan, such as salads with low-fat dressings and such as salads with low-fat dressings and broiled or grilled chicken.broiled or grilled chicken.
Use less butter and margarine on food, or don’t Use less butter and margarine on food, or don’t use them at alluse them at all..
Additional tipsAdditional tips
Use spices and herbs (such as curry, garlic, Use spices and herbs (such as curry, garlic, and parsley) and low-fat or lower calorie and parsley) and low-fat or lower calorie sauces to flavor rice and pasta.sauces to flavor rice and pasta.
Eat smaller meals and have low-calorie snacks more Eat smaller meals and have low-calorie snacks more often, to ensure that your body has a constant often, to ensure that your body has a constant glucose supply, and to prevent yourself from getting glucose supply, and to prevent yourself from getting very hungry.very hungry.
Avoid skipping meals or cutting back too much on Avoid skipping meals or cutting back too much on breakfast or lunch. Eating less food or skipping breakfast or lunch. Eating less food or skipping meals could make you overly hungry at the next meals could make you overly hungry at the next meal, causing you to overeat.meal, causing you to overeat.
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GDMGDM
Keep daily records of your diet, physicalKeep daily records of your diet, physicalactivity, and glucose levelsactivity, and glucose levels
Keeping records refers to writing down your blood sugar numbers, Keeping records refers to writing down your blood sugar numbers, physical activities, and everything that you eat and drink in a physical activities, and everything that you eat and drink in a daily record bookdaily record book..
Recording everything that you eat and drink really means Recording everything that you eat and drink really means everything everything that you eat and drink. This refers to bites, nibbles, that you eat and drink. This refers to bites, nibbles, snacks, second helpings and all liquids.snacks, second helpings and all liquids.
It’s easy to forget or underestimate how much snacking you really It’s easy to forget or underestimate how much snacking you really do.do.
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Keep daily records of your diet, Keep daily records of your diet, physical activity, and glucose physical activity, and glucose
levelslevels
Keep track of the followingKeep track of the following
Blood sugar levelBlood sugar levelFoodFoodPhysical wellnessPhysical wellnessPhysical activityPhysical activityWeight gainWeight gain
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Keep daily records of your diet, physical Keep daily records of your diet, physical activity, and glucose levelsactivity, and glucose levels
It’s a good idea to follow a schedule for It’s a good idea to follow a schedule for writing in the record book.writing in the record book.
This lets you get used to writing in it and This lets you get used to writing in it and helps you to remember to do it.helps you to remember to do it.
Daily records help to keep track of how well your Daily records help to keep track of how well your treatment plan is working and what, if anything, treatment plan is working and what, if anything, should be changed.should be changed.
The information also reveals whether or not The information also reveals whether or not you will need insulin, and if so, how much you will need insulin, and if so, how much will be needed.will be needed.
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Take insulin and/or Take insulin and/or other medications as prescribedother medications as prescribed
Even if you do everything your health Even if you do everything your health care provider recommends to manage care provider recommends to manage your gestational diabetes, you may still your gestational diabetes, you may still need to take insulin during your need to take insulin during your pregnancy to keep it under control.pregnancy to keep it under control.
The only way to get extra insulin into The only way to get extra insulin into your body is to inject it under your skin your body is to inject it under your skin with a needle.with a needle.
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Take insulin and/or Take insulin and/or other medications as prescribedother medications as prescribed
You may have to include small amounts of insulin in You may have to include small amounts of insulin in your treatment plan if:your treatment plan if:Your blood sugar level is too high.Your blood sugar level is too high. You blood sugar level is frequently too highYou blood sugar level is frequently too highYour blood sugar level remains high, and you are not Your blood sugar level remains high, and you are not gaining much weight even with proper eating habit.gaining much weight even with proper eating habit.You cannot safely add physical activity to your You cannot safely add physical activity to your treatment plantreatment plan
Take insulin and/or Take insulin and/or other medications as other medications as
prescribedprescribed
Things to know about insulin:
1. If you need to take insulin, it does not mean that you didn’t try hard enough or that you failed at taking care of yourself.
2. Taking insulin does not mean that you have Type 1 diabetes.
Things to know about insulinThings to know about insulin3. An increase in the amount or dosage of 3. An increase in the amount or dosage of
insulin needed does not mean that your insulin needed does not mean that your pregnancy is in danger.pregnancy is in danger.
4. You may need more insulin if you are 4. You may need more insulin if you are under high amounts of stress or if you are under high amounts of stress or if you are sick because your blood sugar level gets sick because your blood sugar level gets higher on its own in these cases.higher on its own in these cases.
Neonatal Malformations Are Not Related Neonatal Malformations Are Not Related to Type of Insulinto Type of Insulin
0
2
4
6
8
10
12
14
16
GDM Preexisting diabetes
Regular human insulin
Insulin lisproCongenital malformation rate (%)
Bhattacharyya A et al. Q J Med. 2001;94:255-260
7.9%
6.6%
15.8%
3.8%
N=213 N=97
P=0.79
P=0.16
Malformations Are Related to Malformations Are Related to Glucose Not Type of InsulinGlucose Not Type of Insulin
Wyatt JW, Frias JL, Hoyme HE, Jovanovic L, et al. Congenital anomaly rate in offspring of pre-gestational diabetic women treated with insulin lispro during pregnancy. Diabetic Medicine 21:2001-2007, 2004.
Take insulin and/or Take insulin and/or other medications as other medications as
prescribedprescribedSpecial instructions for women taking insulin are to:Special instructions for women taking insulin are to:
Follow a regular eating scheduleFollow a regular eating schedule The timing of insulin shots and of eatingThe timing of insulin shots and of eating meals needs to be correct. Yourmeals needs to be correct. Your healthcare provider can tell you whenhealthcare provider can tell you when to do both. It is very important not toto do both. It is very important not to skip or delay meals and snacks when skip or delay meals and snacks when taking insulin because this can affect your glucose taking insulin because this can affect your glucose
insulin balance.insulin balance.
Know the symptoms of hypoglycemiaIf your blood sugar level drops below 60 at any time, you have hypoglycemia. This can be very dangerous. Hypoglycemia is already common in all women with gestational diabetes, but for women taking insulin for this condition, they are at greater risk.
Before any physical activity is begun, you should test your blood sugar. If it is low, do not begin the activity. Eat something and test again to make sure it is higher before beginning
Why does low blood sugar occur?
Too much exerciseSkipping meals or snacksDelaying meals or snacksNot eating enoughToo much insulin
How might I feel if I have How might I feel if I have low blood sugar?low blood sugar?
Very hungryVery hungryVery tiredVery tiredShaky or tremblingShaky or tremblingSweating or clamminessSweating or clamminessNervousNervousConfusedConfusedLike you’re going to pass out or faintLike you’re going to pass out or faintBlurred visionBlurred vision
* Report any abnormal blood sugar level to your health care provider right away, in case a change in your treatment plan is needed.
Hypoglycemia Hypoglycemia Prevention StrategiesPrevention Strategies
Consistent MonitoringConsistent Monitoring
Before All Meals & Snacks
Pre/Post Exercise
Bedtime
3 a.m. (occasionally)
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Things to keep in mind about deliveryThings to keep in mind about deliveryBlood Sugar and Insulin Balance
Keeping blood sugar levels under control during labor and delivery is vital for both you and your baby’s health. If you did not have to take insulin during the pregnancy, then you won’t need it during labor or delivery; however, if you did have to take insulin during pregnancy, then you may receive an insulin shot when labor begins or during labor.
Early Delivery
Gestational diabetes puts women at higher risk for a condition known as preeclampsia late in pregnancy. Preeclampsia is a condition associated with sudden blood pressure increases, which can be quite serious. Unfortunately, the only cure to preeclampsia is delivery of the baby, but delivery may not be the best option for your health or for the health of your baby. Your health care provider will keep you under close watch if this condition develops, determining whether early delivery is safe and needed.
Cesarean Delivery
This is a type of delivery used to deliver the baby, as opposed to natural delivery through the vagina. Cesarean delivery is also referred to as a cesarean section, or “C” section. Simply having gestational diabetes is not reason alone to have a C section, but your health care provider may have other reasons for choosing this option, such as changes in your health or your baby’s health during delivery.
PostpartumPostpartumoften will not require insulinoften will not require insulin
if fasting hyperglycemia – if fasting hyperglycemia –
more likely to develop persistent Diabetesmore likely to develop persistent Diabetes
6 weeks post partum 75g OGTT6 weeks post partum 75g OGTT
yearly fasting BGyearly fasting BG
emphasize importance of maintaining N emphasize importance of maintaining N weight, exerciseweight, exercise
Gestational DiabetesGestational Diabetes
Will I develop Type 2 diabetes in the Will I develop Type 2 diabetes in the futurefuture? There are ? There are CERTAIN TRAITS CERTAIN TRAITS ::
1.1. You developed gestational diabetes before your You developed gestational diabetes before your 2424thth week of pregnancy. week of pregnancy.
2.2. Your blood sugar level during pregnancy was Your blood sugar level during pregnancy was consistently on the high end of the healthy range.consistently on the high end of the healthy range.
3.3. Your blood sugar levels after the baby was born Your blood sugar levels after the baby was born were higher-than-average, according to your health were higher-than-average, according to your health care provider.care provider.
4.4. You are in the impaired glucose tolerance category.You are in the impaired glucose tolerance category.5.5. You are obese, according to your health care You are obese, according to your health care
provider.provider.
……....CERTAIN TRAITS CERTAIN TRAITS which increase which increase the chancesthe chances
66.You have diabetes in your family..You have diabetes in your family.77.You belong to a high-risk ethnic group (Hispanic, .You belong to a high-risk ethnic group (Hispanic,
African American, Native American, South or East African American, Native American, South or East Asian, Pacific Islander, Indigenous Australian).Asian, Pacific Islander, Indigenous Australian).
88.You have had gestational diabetes with other .You have had gestational diabetes with other pregnancies.pregnancies.
With one or more of these traits, you should talk to your doctor about Type 2 diabetes.
Should I breastfeed having gestational Should I breastfeed having gestational diabetes?diabetes?
Yes, women with gestational diabetes should Yes, women with gestational diabetes should breastfeed their babies, if possible.breastfeed their babies, if possible.Breastfeeding is not only beneficial to the baby, Breastfeeding is not only beneficial to the baby, but it is also beneficial to the mother. but it is also beneficial to the mother.Breastfeeding allows the body to use extra calories Breastfeeding allows the body to use extra calories stored during pregnancy, allowing for weight loss.stored during pregnancy, allowing for weight loss.A weight loss after having the baby not only A weight loss after having the baby not only enhances overall health, but also helps to reduce enhances overall health, but also helps to reduce the risk of developing type 2 diabetes later in life.the risk of developing type 2 diabetes later in life.
Breastfeeding is also believed to help lower fasting blood glucose levels in mothers.
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Will I have diabetes after Will I have diabetes after having my baby?having my baby?
Shortly after the baby is born, the placentaShortly after the baby is born, the placenta is “delivered.”is “delivered.”
Since the placenta is what was causing the insulin resistance, Since the placenta is what was causing the insulin resistance, when it is gone, gestational diabetes usually resolves as well.when it is gone, gestational diabetes usually resolves as well.But, just by having had gestational diabetes, you have a 40% But, just by having had gestational diabetes, you have a 40% higher chance of developing type 2 diabetes later in life than higher chance of developing type 2 diabetes later in life than women who did not have the condition during pregnancy.women who did not have the condition during pregnancy.Keeping your weight within a healthy range and keeping up Keeping your weight within a healthy range and keeping up regular, moderate physical activity after your baby is born can regular, moderate physical activity after your baby is born can help lower your risk for developing type 2 diabetes.help lower your risk for developing type 2 diabetes.
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What should I do after delivery?What should I do after delivery?
Six weeks after your baby Six weeks after your baby is born, you should have a is born, you should have a blood test to find out blood test to find out whether your blood sugar whether your blood sugar level is back to normal. level is back to normal.
Based on the results you Based on the results you will fall into one of the will fall into one of the three categories:three categories:
If your category is…
You should…
NormalGet checked for diabetes every 3 years
Impaired Glucose
Tolerance
Get checked for diabetes every year and talk with your health care provider to learn about ways to lower your risk for developing diabetes.
DiabeticWork with your health care provider in setting up a treatment plan for your diabetes.
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Importance of checking oftenImportance of checking often
Getting checked for diabetes is important Getting checked for diabetes is important because Type 2 diabetes shows few because Type 2 diabetes shows few symptoms.symptoms.The only way to know for sure is to have a The only way to know for sure is to have a blood test that reveals a higher-than-normal blood test that reveals a higher-than-normal blood sugar level.blood sugar level.If you notice any of these things, you should If you notice any of these things, you should tell your health care provider right away:tell your health care provider right away:– Being very thirstyBeing very thirsty– Urinating oftenUrinating often– Feeling constantly or overly tiredFeeling constantly or overly tired– Losing weight quickly and/or without Losing weight quickly and/or without
reasonreason
Gestational DiabetesGestational DiabetesIntra partum managementIntra partum management
Check bloodCheck blood
Glucose hourly Glucose hourly
Maintain BG Maintain BG
4-6mmol/L ( 70-4-6mmol/L ( 70-110mg /dl )110mg /dl )
PostpartumPostpartumoften will not require insulinoften will not require insulin
if fasting hyperglycemia –if fasting hyperglycemia –
more likely to develop more likely to develop
persistent Diabetespersistent Diabetes
6 weeks post partum 75g 6 weeks post partum 75g
OGTTOGTT
yearly fasting BGyearly fasting BG
emphasize importance of maintaining emphasize importance of maintaining Normal weight, exerciseNormal weight, exercise
Gestational DiabetesGestational Diabetes
Preexisting Preexisting DiabetesDiabetes
Preconception CounsellingPreconception Counselling
risk of NTD ~1-2%risk of NTD ~1-2%
Folic Acid 1-4 mg /dayFolic Acid 1-4 mg /day
BG 3.5-5.3 (65-95 mg/dL)prior to mealsBG 3.5-5.3 (65-95 mg/dL)prior to meals
switch to MDI regimen (insulin ac meals switch to MDI regimen (insulin ac meals and HS)and HS)
keep track of cycles keep track of cycles
Normoglycemia prior to conception Normoglycemia prior to conception Ideally Ideally HBA1C 6% or lessHBA1C 6% or lessTeam approachTeam approachGlucose monitoring qidGlucose monitoring qidACE contraindicated : should be D/C at ACE contraindicated : should be D/C at conception or use Diltiazem insteadconception or use Diltiazem insteadBaseline HBA1C, 24h urine for protein Baseline HBA1C, 24h urine for protein Creatinine Clearance , opthalmology Creatinine Clearance , opthalmology reviewreviewSwitch from OHA to insulinSwitch from OHA to insulin
Preexisting DiabetesPreexisting Diabetes
AdviceDiet : Maintaining a healthy diet and preventing or reducing overweight willhelp you control your diabetes
Exercise : Regular exercise will help to maintain an optimum weight and will benefit all members of the family
Smoking : It is widely accepted that smoking causes heart and lung disease. Most diabetic complications are worsened by smoking
Weight control : There is a greater risk of Developing diabetes and heart disease with increasing waist circumference
Finnish Diabetes StudyThis study was conducted to determine the
effects of a programme of changes in lifestyle in patients with ‘Pre’ diabetes
Lifestyle changes included
•Weight reduction greater than 5% (if needed)•Fat intake less than 30% of calorie intake•Saturated fat less than 10% of calorie intake•Fibre intake greater than 15grams/ 1000 calories•Exercise greater than 4 hours per week (brisk walking)
Carrying out this programme resulted in less diabetes by 58%
Are you eating healthy foods?How often do you exercise?
Do you smoke?Do you know your target weight?
Blood Pressure140 / 80
Very good control of blood pressure is required!
Raised blood pressure can increase all complications of diabetes
It is important that it is checked regularly
Tablets maybe taken to control blood pressure
You may need to change what you eat and exercise more
UK Prospective Diabetes StudyUK Prospective Diabetes StudyBlood Pressure Control Study
Aggressive blood pressurecontrol reduces the risk of
most complications inDiabetes
It’s as simple as that!
Remember your target is 140/80 Have you hit the bulls-eye?
Target :
Ret
ino
path
y p
rog
ress
ion
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
any
dia
bete
s re
late
den
dpoi
nts
Dia
bete
s re
late
dde
ath
Hea
rtfa
ilur
e
stro
ke
Mic
rova
scul
ar
dis
ease
Los
s of
vis
ion
24%
32%
56%44%
37%34%
47%
P=0.004
P=0.019
P=0.004
P=0.013
P=0.009P=0.004
P=0.004
Ret
ino
path
y p
rog
ress
ion
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
any
dia
bete
s re
late
den
dpoi
nts
Dia
bete
s re
late
dde
ath
Hea
rtfa
ilur
e
stro
ke
Mic
rova
scul
ar
dis
ease
Los
s of
vis
ion
24%
32%
56%44%
37%34%
47%
P=0.004
P=0.019
P=0.004
P=0.013
P=0.009P=0.004
P=0.004
Any diabetes 0
10
20
30
40
50
60
problemHeartFailure
Stroke
CholesterolThis is the amount of fat in blood
Some blood fats are necessary to provide important energy sources
Too much fat can cause you to beoverweight, making it much more difficult to control your diabetes
It can also cause heart problems
How much fat does your blood contain?
The optimal target for blood cholesterol level is
LESS THAN 5
1 2 3 4 5 600
20
40
60
80
100
Riskreduction
55%
Simvastatin
Number of years on
Pro
port
ion
wit
hout
maj
or
Hea
rt p
rob
lem
s (%
)
1 2 3 4 5 600
20
40
60
80
100
Riskreduction
55%
Placebo
Number of years on simvastatin
Pro
port
ion
wit
hout
maj
or
Hea
rt p
rob
lem
s (%
)
SCANDINAVIAN SIMVASTATINSURVIVAL STUDY
This study showed that long-term simvastatin (cholesterol lowering drug) therapy reduces chances of dying and heart problemsin patients with diabetes
Do you know what your level is?Are you on target?
FAT
BLOOD
SERUM
D i a b e t e s C o n t r o lB l o o d g l u c o s e n e e d s t o b e k e p t w i t h i n
a c o n t r o l l e d r a n g e
4 – 7T h i s c a n b e h e l p e d b y r e g u l a r b l o o d g l u c o s e m o n i t o r i n g a t h o m e a n d k e e p i n g a n a c c u r a t e w r i t t e n r e c o r d . B r i n g i t t o c l i n i c !
W h a t i s H b A 1 c % ?
T h i s v a l u e t e l l s y o u t h e a m o u n t o f g l u c o s e s t i c k i n g t o y o u r b l o o d o v e r t h e l a s t 6 0 d a y sI t r e f l e c t s h o w w e l l y o u r d i a b e t e s h a s b e e n c o n t r o l l e d
T h e a i m i s t o h a v e a v a l u e o f l e s s t h a n 7 . 0 %W h a t d r u g s h e l p t o c o n t r o l d i a b e t e s ?
M e t f o r m i n , G l i c l a z i d e , G l i m e p i r i d e , P i o g l i t a z o n e , R o s i g l i t a z o n e , I n s u l i n a n d
m a n y o t h e r d r u g s
U K P r o s p e c t i v e D i a b e t e s G l u c o s e C o n t r o l S t u d y
T h e U K P D s t u d y s h o w s t h a t g o o dT h e U K P D s t u d y s h o w s t h a t g o o dg l u c o s e c o n t r o l c a n d e c r e a s e t h e g l u c o s e c o n t r o l c a n d e c r e a s e t h e
r i s k s o f :r i s k s o f :
H e a r t a t t a c k b y 1 6 %C a t a r a c t b y 2 4 %K i d n e y p r o b l e m s b y 3 3 %
-
-
-
-
-
-
-
-
-
-
A r e y o u i n c o n t r o l o f y o u r d i a b e t e s ?W h a t i s y o u r H b A 1 c % ?
0
1
2
3
4
5
6
7
8
9
1 0
H b A 1 c %> 1 6 0 1 4 0 t o 1 5 0 1 3 0 - 1 4 0 < 1 3 0
< 6
6 t o 7
7 t o 8
> 8
B l o o d P r e s s u r e
R i s k o f D i a b e t e s C o m p l i c a t i o n s
I n c r e a s i n g
E y e sH o w y o u r e y e s w o r k
Y o u r e y e h a s a l e n s a n d a n o p e n i n g a t t h e f r o n t , w h i c h a d j u s t t o b r i n g o b j e c t s i n t o f o c u s o n t h e r e t i n a a t t h e b a c k o f t h e e y e .
T h e r e t i n a i s m a d e u p o f d e l i c a t e t i s s u e t h a t i s s e n s i t i v e t o l i g h t r a t h e r l i k e t h e f i l m i n a c a m e r a .
A t t h e c e n t r e o f t h e r e t i n a i s t h e m a c u l a , w h i c h i s a s m a l l a r e a a b o u t t h e s i z e o f a p i n h e a d . I t i s v i t a l b e c a u s e i t e n a b l e s y o u t o s e e f i n e d e t a i l .
W h e n w a s t h e l a s t t i m e y o u h a d y o u r e y e s c h e c k e d ?
I s D i a b e t e s s l o w l y s t e a l i n g y o u r v i s i o n ?
• A p e r s o n w i t h d i a b e t e s c a n h a v e e y e d i s e a s e a n d n o t e v e n k n o w i t u n t i l s e r i o u s , i r r e v e r s i b l e v i s i o n l o s s h a s o c c u r r e d
• T h e o n l y w a y t o d i a g n o s e e a r l y s i g n s o f d i a b e t i c e y e d i s e a s e i s t h r o u g h a d i l a t e d e y e e x a m a t l e a s t o n c e a y e a r
D I A B E T I C E Y E D I S E A S ED i a b e t i c E y e D i s e a s e ( D i a b e t i c r e t i n o p a t h y ) i s t h e c o m m o n e s t c a u s e o f b l i n d n e s s u n d e r t h e a g e o f 6 5 i n t h e W e s t e r n W o r l d3 7 % o f d i a b e t e s p a t i e n t s h a v e r e t i n o p a t h y a t d i a g n o s i s o f d i a b e t e s1 5 0 0 n e w c a s e s o f b l i n d n e s s c o u l d b e p r e v e n t e d b y y e a r l y s c r e e n i n g i n U K 2 0 y e a r s a f t e r d i a g n o s i s 9 5 % w i t h T y p e 1 d i a b e t e s h a v e r e t i n o p a t h y2 0 y e a r s a f t e r d i a g n o s i s 6 0 % o f p a t i e n t s w i t h T y p e 2 d i a b e t e s h a v e r e t i n o p a t h y L a s e r t r e a t m e n t c a n s a v e e y e s i g h t g e t t i n g w o r s e i n 9 0 % o f p a t i e n t s
N o r m a l r e t i n a D i a b e t i c R e t i n o p a t h y
M a c u l a O p t i c D i s c F a t t y H a e m o r r h a g eD e p o s i t s
F e e t• D u r i n g a l i f e t i m e , y o u r f e e t m a y w a l k t h e e q u i v a l e n t o f f o u r
t i m e s a r o u n d t h e w o r l d ! • T o e n s u r e t h a t t h e y c o n t i n u e t h e i r t r i p t h r o u g h l i f e w i t h o u t
c o m p l a i n t , i t p a y s t o l o o k a f t e r y o u r f e e t !
I t i s i m p o r t a n t t h a t y o u e x a m i n e y o u r f e e t r e g u l a r l y . Y o u s h o u l da l s o f e e l i n s i d e a l l s h o e s f o r a n y s e a m s o r s t i t c h i n g w h i c h c o u l d r u b t h e f o o t a n d l e a d t o p r o b l e m s . I t i s i m p o r t a n t t h a t y o u r e c e i v e r e g u l a r f o o t a d v i c e o r t r e a t m e n t .
P e o p l e s u f f e r i n g f r o m d i a b e t e s c a n o f t e n e x p e r i e n c e l o s s o f s e n s a t i o n i n t h e i r f e e t . E v e n t h e s m a l l e s t i n j u r y c a n l e a d t o i n f e c t i o n , w h i c h i f
n o t t r e a t e d p r o m p t l y , m a y l e a d t o s e r i o u s c o m p l i c a t i o n s .
F o o t P r o b l e m s
1 5 % o f p a t i e n t s w i t h d i a b e t e s w i l l d e v e l o p f o o t u l c e r s d u e t o n e r v e d a m a g e a n d r e d u c e d b l o o d f l o w
F o o t u l c e r s c o m e b e f o r e 8 5 % o f a m p u t a t i o n s i n p e o p l e w i t h d i a b e t e s . F o o t u l c e r s a r e t h e c o m m o n e s t c a u s e o f a m p u t a t i o n i n t h e U K
L i v e r p o o l D i a b e t e s C l i n i c : F o o t P r o t e c t i o n P r o g r a m m e
W h e n p a t i e n t s w i t h d i a b e t e s a n d f o o t d e f o r m i t i e s a t t e n d e d r e g u l a r c l i n i c s w i t h a t r a i n e d p o d i a t r i s t a n d f o o t e d u c a t i o n , i t w a s f o u n d t h a t
A t 2 y e a r s u l c e r a t i o n w a s r e d u c e d t o 2 . 4 % c o m p a r e d w i t h 3 . 5 % A m p u t a t i o n w a s r e d u c e d b y 3 t i m e s
W h e n w a s t h e l a s t t i m e y o u h a d y o u r f e e t c h e c k e d ?
Guardian Drugs
30
25
20
15
10
5
0Any cardiovascular Heart Attack
problem
- 14%
-29%
ASPIRIN
Diabetes UK recommends taking aspirin to prevent against heart problems in all diabetes patients (greater than 30yrs) with any of the following:
Heart attack, angina, high blood pressure, eye problems, blood vessel diseases and kidney problems
Also if: Indo - Asian, overweight, high cholesterol, Heart Disease risk greater than 15%, family history, history of heart disease, smokers
ACE -inhibitors are drugs that have a special role in preventing diabetic complications.The HOPE study showed that one ace inhibitor, ‘Ramipril’ reduced:
The names of these drugs end in ‘PRIL’
Do you know if you are taking any of the guardian drugs?
ACE INHIBITORS
% D
ecre
ase
in E
vent
s
Heart Disease Stroke Kidney Eye disease
What are Guardian Drugs?Guardian drugs are given to protect you from further diabetes
complications
D i a b e t e s C a r e 4 U !W e l c o m e t o D i a b e t e s C a r e 4 U ! H e r e y o u w i l l f i n d p o s t e r s p a c k e d f u l l o f i n f o r m a t i o n a n d i n n o v a t i v e i d e a s t o e n s u r e y o u h a v e g r e a t D i a b e t e s
C a r e ! B e f o r e y o u e n t e r i n t o t h e u n i q u e e x p e r i e n c e l e t u s g o o v e r t h e p r o b l e m s o f d i a b e t e s .
D I A B E T I C E Y E D I S E A S EM o s t c o m m o n c a u s e o f
b l i n d n e s s i n p e o p l e o fw o r k i n g a g e
H E A R T a n d B L O O D V E S S E L S2 t o 4 f o l d i n c r e a s e d r i s k o f
h e a r t d i s e a s e a n d s t r o k e7 5 % h a v e h y p e r t e n s i o n
D I A B E T I C K I D N E Y D I S E A S E
2 0 % o f a l l n e w p a t i e n t s n e e d i n g r e n a l d i a l y s i s t h e r a p y h a v e d i a b e t e s
F O O T P R O B L E M S1 5 % o f p e o p l e w i t h d i a b e t e s d e v e l o p f o o t
u l c e r ; 5 - 1 5 % o f t h e s e n e e d a m p u t a t i o n
I f y o u t h i n k a n y a r e a o f y o u r c a r e n e e d s t o b e a d d r e s s e d p l e a s e m a k e a n o t e a n d d i s c u s s t h i s w i t h y o u r D i a b e t e s C a r e T e a m .
E n j o y t h e P o s t e r s !
S t r o k e
E y e D i s e a s e
H e a r t D i s e a s e
H i g h B l o o d P r e s s u r e
K i d n e y D i s e a s e
R e m e m b e r w i t h g o o d c a r e a l l
c o m p l i c a t i o n s c a n b e r e d u c e d
o r e v e n p r e v e n t e d !
P a i n o r l o s s o f t h e l o w e r l e g s d u e t o i m p a i r e d b l o o d f l o w
P e r i p h e r a l N e u r o p a t h y( n e r v e d i s e a s e )
Assess for end organ diseaseAssess for end organ disease
Assess for nephropathy – Assess for nephropathy –
inc risk of PIH. inc risk of PIH.
Assess & Rx.retinopathy :Assess & Rx.retinopathy :
may may PROGRESS.PROGRESS.
Assess for neuropathy :Assess for neuropathy :generallygenerally
remains stable during pregnancyremains stable during pregnancy
Assess and treat Assess and treat
Vasculopathy.Vasculopathy.CAD is a relative CAD is a relative
C/I for pregnancyC/I for pregnancy
Pre existing DiabetesPre existing Diabetes
Maternal RisksMaternal Risks– PIH /PETPIH /PET– polyhydramniospolyhydramnios– preterm labourpreterm labour– operative delivery ~50%operative delivery ~50%– birth traumabirth trauma– infectioninfection– increase in insulin requirementsincrease in insulin requirements– DKADKA
Preexisting DiabetesPreexisting Diabetes
Fetal RisksFetal Risks
congenital anomalies 3X inc. riskcongenital anomalies 3X inc. risk
unexplained stillbirth unexplained stillbirth
shoulder dystociashoulder dystocia
macrosomiamacrosomia
IUGRIUGR
Preexisting DiabetesPreexisting Diabetes
Neonatal Risks Neonatal Risks hypoglycemiahypoglycemiahypocalcemiahypocalcemiahyperbilirubinemia/polycythemiahyperbilirubinemia/polycythemiaidiopathic RDSidiopathic RDSdelayed lung maturitydelayed lung maturityprematurityprematuritypredisposition to diabetespredisposition to diabetes
Preexisting DiabetesPreexisting Diabetes
Congenital anomaliesCongenital anomalies
3x the general population risk 3x the general population risk
approaches the gen. pop.risk (2-3%) approaches the gen. pop.risk (2-3%) if optimal control in periconception if optimal control in periconception periodperiod
related to glycemic control during related to glycemic control during embryogenesis embryogenesis
Preexisting DiabetesPreexisting Diabetes
CVSCVS :ASD/VSD, :ASD/VSD,
CoA :Transposition, :CoA :Transposition, :CardiomegalyCardiomegaly
CNSCNS
:Anencephaly,:Anencephaly,
:NTD,:NTD,
:Microcephaly:Microcephaly
GI GI ::duodenal atresia, duodenal atresia, anorectal atresia, situs anorectal atresia, situs inversusinversus
GUGU : :renal agenesis renal agenesis
:Polycystic kidneys:Polycystic kidneys
MSKMSK
:caudal regression:caudal regression
:siren:siren
Congenital anomalies
Preexisting Preexisting DiabetesDiabetes
Maternal SurveillanceMaternal Surveillance
Blood pressureBlood pressure
Renal function *Renal function *
Urine culture **Urine culture **
Thyroid functionThyroid function
BG control HB A1C*BG control HB A1C*
* q trimester * q trimester • ** monthly** monthly
Preexisting DiabetesPreexisting Diabetes
Fetal SurveillanceFetal Surveillance
U/S for dating/viability ~ 8 weeksU/S for dating/viability ~ 8 weeks
Fetal anomaly detectionFetal anomaly detection
nuchal translucency 11-14wnuchal translucency 11-14w
maternal serum screenmaternal serum screen
anatomy survey 18-20 wanatomy survey 18-20 w
Fetal echo 22 w Fetal echo 22 w
Preexisting Preexisting DiabetesDiabetes
Preexisting Diabetes
Multidose InsulinMultidose Insulin
breakfastbreakfast 25% H 25% H
lunch lunch 15% H 15% H
suppersupper 25% H 25% H
hs hs 35% NPH 35% NPH
Indicates insulin as aIndicates insulin as a% of total daily dose% of total daily dose
Gabbe Obstet Gynecol 2003
Insulin TherapyInsulin Therapy
onset (h) peak(h) duration onset (h) peak(h) duration (h)(h)
insulin analogs insulin analogs .25 .25 0.5-1.50.5-1.5 6-86-8rapid acting rapid acting 0.5 0.5 2-42-4 8-8-
1212intermediate intermediate 1-1.51-1.5 4-84-8 12-12-
1818
Insulin PumpInsulin Pump– Allows insulin release close to Allows insulin release close to
physiologic physiologic – Use short acting insulinUse short acting insulin– 50-60% of total dose is basal rate50-60% of total dose is basal rate– 40-50% given as boluses40-50% given as bolusesPotential complicationsPotential complicationsPump failure, Infection , Pump failure, Infection , Increased risk of DKA if aboveIncreased risk of DKA if abovehappenshappens
Insulin Insulin TherapyTherapy
Peripartum ManagementPeripartum Management
Withhold subcutaneous insulin from Withhold subcutaneous insulin from onset of labour or inductiononset of labour or induction
IV D10 @50cc/hIV D10 @50cc/h
IV short acting insulin inIV short acting insulin in
NS usually starting atNS usually starting at
0.5-1u/h*0.5-1u/h**10u insulin in 100 cc NS(1U=10cc)*10u insulin in 100 cc NS(1U=10cc)
Timing of Delivery Timing of Delivery GDM Diet controlledGDM Diet controlledSame as non diabetic Same as non diabetic
Offer induction at 41 weeks Offer induction at 41 weeks
if undelivered if undelivered
GDM on Insulin/Type II/Type IGDM on Insulin/Type II/Type IIf suboptimal control deliver followingIf suboptimal control deliver following
confirmation of lung maturity if <39confirmation of lung maturity if <39
weeksweeks
Otherwise deliver by 40 weeksOtherwise deliver by 40 weeks
Generally do not allow to go posttermGenerally do not allow to go postterm
Mode of DeliveryMode of Delivery
*Macrosomic infants of diabetic*Macrosomic infants of diabetic
mothers have higher rates mothers have higher rates
of shoulder dystocia than non of shoulder dystocia than non
diabetic mothers diabetic mothers
*Ultrasound estimates of fetal*Ultrasound estimates of fetal
weight become significantlyweight become significantly
inaccurate after 4000ginaccurate after 4000g
*Reasonable to recommend C/S *Reasonable to recommend C/S delivery if EFW is >4500gdelivery if EFW is >4500g
insulin rate usually based on BG and pre-insulin rate usually based on BG and pre-delivery insulin requirementdelivery insulin requirement
eg. For each 75-100 total units /24h of pre-eg. For each 75-100 total units /24h of pre-delivery insulin, 1 unit per hour neededdelivery insulin, 1 unit per hour needed
measure capillary BG hourly / VPG q2-3hmeasure capillary BG hourly / VPG q2-3h
target: 4-6mmol/Ltarget: 4-6mmol/L
Peripartum Peripartum ManagementManagement
Following deliveryFollowing delivery
stop insulin infusionstop insulin infusion
Begin sub Q insulinBegin sub Q insulin
Resume previous MDIResume previous MDI
schedule at 1/2 -2/3 theschedule at 1/2 -2/3 the
pre pregnancypre pregnancy dose dose
Maintain IV D5W @50cc/h Maintain IV D5W @50cc/h
until oral feeds tolerateduntil oral feeds tolerated
Peripartum Peripartum Management Management
Oral HypoglycemicOral Hypoglycemic agents agents
Traditionally not Traditionally not
recommended in pregnancyrecommended in pregnancy
Recent RCT of Recent RCT of oral oral glyburide vs insulin glyburide vs insulin for GDMfor GDM
440 patients440 patients
BG measured 7x dailyBG measured 7x daily
Treatment started after 11 weeks Treatment started after 11 weeks gestationgestation
Glyburide Glyburide InsulinInsulin
Achieved N BGAchieved N BG 82%82% 88%88%LGA infantsLGA infants 12%12% 13%13%MacrosomiaMacrosomia 77 44C SectionC Section 2323 2424HypoglycemiaHypoglycemia 99 66PreeclampsiaPreeclampsia 66 66Anomalies Anomalies 22 22
Oral Hypoglycemic agents Oral Hypoglycemic agents
Langer NEJM 2000
THE END