Managing Gestational Diabetes Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes.
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Transcript of Managing Gestational Diabetes Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes.
![Page 1: Managing Gestational Diabetes Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649dc55503460f94ab91af/html5/thumbnails/1.jpg)
Managing Gestational Diabetes
Cynthia V. Brown, RN, MN, ANP, CDESoutheastern Endocrine & Diabetes
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Managing Gestational Diabetes• The management of gestational
diabetes is necessary for a healthy baby and mom.
• Managing this disorder well is a….
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Richard Shafer:Richard Shafer:
…CHALLENGE!!!
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Definitions
Gestational DiabetesPre-gestational Diabetes
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Gestational diabetes...
• May have its’ onset or be first recognized during pregnancy
• Diabetes may have previously existed but not diagnosed
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Pre-gestational diabetes...
• May be present and undiagnosed
• Evolving
• Already present and under treatment
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Why is this important?
• Pre-existing diabetes at conception can lead to congenital anomalies
• Gestational diabetes leads to macrosomia and premature delivery
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Congenital Malformations
• Cardiovascular: transposition, vsd, asd, hypoplastic left ventricle, anomalies of the aorta
• CNS: anencephaly, encephalocele, meningomyelocele, microcephaly
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Malformations...
• Skeletal: caudal regression, spina bifida
• GU: Potter syndrome, polycystic kidneys
• GI: tracheoesophageal fistula, bowel atresia, imperforate anus
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First Trimester Miscarriages
0
5
10
15
20
25
30
35
40
<6.05 6.05-7.2 7.2-8.3 8.3-9.5 >9.5
HbgA1c
Per
cent
of
wom
en
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Complications by Trimester• First
– Still births– Miscarriages– Congenital defects
• Second and Third– Hyperinsulinism– Macrosomia– Delayed lung development
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Complications...
• Delivery– Injuries– RD– Pregnancy loss– Neonatal hypoglycemia
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Hormonal Influences
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Decreased glucose levels
• Due to passive diffusion to fetus
• Causes hypoglycemia, even in non-diabetic patients
• Greatly decreases insulin need in first trimester
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Accelerated starvation...
• Due to glucose diffusion
• Leads to elevated ketone production
• Unsure if this hurts baby or not
• Use as guide for increased calories
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Decreased maternal alanine• Gluconeogenic amino acid
• Results in further lowering of FBS
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Counterregulatory hormones• Suppressed responses to hypoglycemia• Study found BS as low as 44 did not
elicit a response• Level at which glucose & GH released
5-10 mg/dl lower in pregnant women with Type 1 DM
• Hypoglycemia aggravated by lower intake due to AM sickness
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Prolonged hyperglycemia
• Enhances transplacental delivery of glucose to fetus
• Resistance to insulin x 5-6 hours PC
• Resistance related to several anti-insulin hormones
• Results in hyperglycemia
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Hormones affecting blood sugar• Insulin • Glucagon• Epinephrine• Steroids• Growth hormone• Progesterone• Human placental lactogen
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Peak Times of Hormonal Activity• Hormone Onset Peak
Potency• Estradiol 32 d 26 wk 1• Prolactin36 d 10 wk 2• HCS 45 d 26 wk 3• Cortisol 50 d 26 wk 5• Progesterone65 d 32 wk 4
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Risk Factors
• Over 25 years of age• Family history of Type 2 diabetes• Obesity• Prior unexplained miscarriages or
stillbirths• History GDM or baby >10 pounds• PCOS
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Dietary Modifications
• Decrease carbohydrate content• Frequent small feedings• Small breakfast meals• Bedtime snacks• No > 10 hours overnight fast• NO JUICE• Adequate calorie intake
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Blood Sugar Goals
• Fasting: < 90 mg/dl• Premeal: 60-90 mg/dl• One-hour post-prandial: <120
mg/dl• Two-hour post-prandial: <120
mg/dl• 2AM-6AM: 60-90 mg/dl
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Estimated insulin needs
• Prepregnancy 0.6 U/kg• Weeks 2-16 0.7 U/kg• Weeks 16-26 0.8 U/kg• Weeks 26-36 0.9 U/kg• Weeks 36-40 1.0 U/kg• Postpartum <0.6 U/kg
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When to Start Medications
• Allow 1 week of dietary changes• Continue with diet if BS in target• First week with 2 elevated sugars,
insulin starts• Frequent testing so as not to miss
elevation• Anticipate need increasing• Do not be afraid!
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Medications
• Sulfonylureas:– Glyburide typically used– Anecdotal evidence – Not very effective– Unable to achieve higher insulin
levels for meals– No long-term studies for safety
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Medications
• Insulin:– NPH:
• BID dosing• Can start only at HS if FBS elevated• Long history of safety• Inconsistent absorption
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Medications
• Lantus:– 24 hour coverage– Sometimes hard to affect dawn rise
without nocturnal low BS– Does not rise to meet meal-time rise
of BS
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Medications
• Insulin analogs:– Humalog, Novolog, Apidra– Very rapid acting– Very effective pre- and post prandial– Less risk of hypoglycemia
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Medications
• Regular insulin:– Slower onset– Longer duration– May be necessary in those who do not
want to take as many injections
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Insulin Dosing During Labor• Need decreases dramatically• BS must be perfect in 72 hours
prior to delivery• May not need insulin during labor• Type 1 needs only basal insulin
with PRN supplementation
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Postpartum
• Continue periodic testing • Aim to lose weight• Glucose challenge @ 6 wk check• Breast-feeding lowers BS, leads to
hypoglycemia
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Managing Gestational Diabetes
THANK YOU!
Cynthia V. Brown, RN, MN, ANP, CDE
Southeastern Endocrine & Diabetes