HOW SWEET IT IS: Managing Diabetes For A Healthy Pregnancy And Beyond Ruth Ferrarotti, MSN, APRN-BC, CDE Assoc. Clinical Prof., Univ. of Conn.

Discussion Topics Gestational Diabetes: Diagnosis and management Postpartum recommendations Established Diabetes: Pre-pregnancy counseling Management of diabetes Diabetes After Pregnancy

Classification of Diabetes Type 1 Diabetes – Beta cell destruction Type 2 Diabetes – Progressive insulin secretory defect and insulin resistance Other – genetic defects, diseases of exocrine pancreas and drug/chemical induced Gestational Diabetes

Approximate Prevalence of Diabetes in Pregnancy in the United States 4.022 Million Births in 2002 More than 200,000 type 2 diabetes mellitus + 135,000 GDM + 6000 type 1 diabetes mellitus = 341,000 pregnancies complicated by hyperglycemia annually Diabetes 8% Diabetes 8% 50% GDM 24% Diagnosed T2DM Nondiabetes 92% 24% Undiagnosed T2DM 2% T1DM GDM=gestational diabetes mellitus

Maternal hyperglycemia The Impact of Maternal Hyperglycemia During Pregnancy Modified Pedersen Hypothesis Fetal pancreas stimulated Maternal hyperglycemia Placenta Fetal hyperinsulinemia Insulin Insulin resistance syndrome IgG-antibody-bound insulin Fetus Mother IgG=immunoglobulin G

Diabetes and Pregnancy Type 1 and Type 2 Diabetes Preexisting diabetes diagnosis Preconception care is essential Treat with insulin If untreated during first few weeks’ gestation, associated with Spontaneous abortion Birth defects If untreated during second or third trimester, associated with Fetal macrosomia Birth injury Maternal hypertension Maternal preeclampsia Future diabetes and/or obesity in child American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

Preconception Care of Established Diabetes Medical Assessment Duration and type of diabetes Medical history and current medical management plan Chronic diabetes-related complications Retinopathy Dilated eye exam by trained ophthalmologist Nephropathy 24-hour urine for creatinine clearance, total protein excretion, and microalbuminuria Neuropathy Autonomic neuropathy, especially gastroparesis American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

Preconception Care of Established Diabetes Medical Assessment Comorbid conditions (in addition to diabetic complications) Hypertension Measure blood pressure Coronary artery disease Stress test Hyper- or hypothyroidism Free T4 and TSH Other autoimmune diseases T4=thyroxine TSH=thyroid-stimulating hormone American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

Preconception Care of Established Diabetes Blood Glucose Goals SMBG Fasting/premeal: 70 to100 mg/dL 1 hour postmeal: <140 mg/dL A1C In normal range (<6%, but ideally <5%) Monitor until A1C is stable at <6% 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

1-hour postmeal blood glucose (mg/dL) Diabetes in Early Pregnancy (DIEP) Trial Postprandial Blood Glucose Levels Predict Macrosomia Risk Risk for macrosomia (%) 60 50 40 30 20 10 80 90 100 110 120 130 140 150 160 170 180 1-hour postmeal blood glucose (mg/dL) Adapted from Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1991;164(1 pt 1):103-111

Management of Diabetes in Pregnancy Type 1 Multiple daily injections Insulin pump Type 2 Change to insulin if on oral agents

Multiple Daily Injections Combination of intermediate or longer acting insulin with rapid insulin NPH Lantus Analog Usually require 4-6 injections daily

Management of Diabetes in Pregnancy Monitor BG pre and 2 hrs post meal Calculate premeal rapid insulin based on carbohydrate intake Calculate correction for premeal elevated glucose Discourage postprandial correction

Insulin Pump Advantages: More physiologic than MDI Programmable bolus reduces risks for hypoglycemia, post-meal hyperglycemia and glucose excursions Allows for greater flexibility with diet and lifestyle Increased motivation promotes better control

Insulin Pump Disadvantages Requires increased patient responsibility and motivation Risk of rapid onset ketoacidosis if catheter becomes dislodged or site infection Mechanical problems with pump Infusion site limited in later pregnancy

Sensor Augmented Pumping Advantages Decreased risk of glucose excursions and hypoglycemia Provides instant information Allows for greater flexibility to diet and lifestyle Reduces number of self-monitored glucose tests

Sensor Augmented Pumping Disadvantages Not as accurate as glucose results by fingerstick “Too much data” Expensive and not always covered by insurance Requires another site Alarms

Diabetes and Pregnancy Gestational Diabetes Mellitus Glucose intolerance of variable degree with onset or first recognition during pregnancy Mainstay of treatment is medical nutrition therapy (MNT) Add insulin if MNT does not maintain normoglycemia If untreated, associated with: Late-term intrauterine fetal death Fetal macrosomia Neonatal hypoglycemia and/or jaundice Maternal hypertension Future diabetes and/or obesity in child American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S88-S90 Metzger BE, Coustan DR. Diabetes Care. 1998;21(suppl 2):B161-B167

Gestational Diabetes Approximately 7% of all pregnancies are complicated by GDM Translates to over 200,000 cases annually(1) Approximately 42,000 births in Connecticut in 2008(2) 2980 complicated by GDM (1) Diabetes Care, Vol.33, Supp. 1, Jan. 2010 (2) Connecticut Vital Statistics, 2008

Gestational Diabetes Glucose intolerance of varying severity, with onset or first recognition during the current pregnancy. Currently diagnosed using two step method Diagnostic screening between 24-28 weeks gestation

Diagnosis of GDM 1998 Guidelines 2010 Guidelines 1HR oral glucose challenge 135-185 ≥ 186 3HR OGTT FBS ≥ 95 1hr ≥ 180 2hr ≥ 155 3hr ≥ 140 Carpenter and Coustan 2010 Guidelines 2HR OGTT FBG ≥ 92 1hr ≥ 180 2hr ≥ 153 IADPSG Consensus Panel

Managing GDM Lifestyle modifications: Self-monitoring blood glucose Medical Nutrition Therapy Exercise Self-monitoring blood glucose FBS < 90mg/dl 2 hr postprandial <120mg/dl Medication Oral agents Insulin

Medications in GDM Insulin Oral agents NPH Analogs Lantus Glyburide Metformin

Physical Activity in GDM Can improve peripheral insulin resistance and glucose levels Can obviate need for insulin Encouraged for women with no obstetric contraindications Avoid physical activity associated with maternal hypertension or fetal distress (eg, resistance training, lower-body weight-bearing exercise) Upper-body cardiovascular training is a good option Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:111-132 Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1989;161:415-419

Immediate Postpartum Insulin requirements disappear Diabetes will disappear in 90% of GDM cases. Continue monitoring 24-48 hrs after delivery, as indicated

Postpartum Considerations Lactation and Nutrition Breastfeeding is recommended Decreased risk of type 1 diabetes and infection in infant Promotes infant growth and development Maintain pregnancy meal plan or develop postpartum plan to meet added caloric requirements of breastfeeding Rapid weight loss is not advised; exercise is recommended Insulin use must be continued if postpartum normoglycemia cannot be maintained with MNT Blood glucose concentrations may be variable in women with type 1 diabetes Test glucose frequently Snack and/or adjust evening insulin to avoid nighttime hypoglycemia Watch 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 Recommendations Self-monitoring Fasting <100 2 hr post-prandial <140 Glucose testing 6-12 weeks post delivery Reclassification of diabetes

Diabetes After Pregnancy 40-60% risk of developing Type 2 DM within 5-15 years Approximately 20% continue with abnormal glucose after delivery 66% risk of developing GDM in subsequent pregnancy

Diagnosing Diabetes ADA 2010 Diagnostic Criteria A1C ≥ 6.5% or: FPG ≥ 126mg/dl or: Two-hour plasma glucose ≥ 200mg/dl or: Classic symptoms of hyperglycemia or hyperglycemic crisis, a random glucose ≥200mg/dl

Diagnosing Diabetes New classifications Pre-diabetes A1C 5.7% to 6.4% 2 hr OGTT FPG 100-126 2 hr 140-199 Refer for nutrition counseling, weight loss and ongoing care