2. Managing Gestational Diabetes Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes

3. Managing Gestational Diabetes The management of gestational diabetes is necessary for a healthy baby and mom. Managing this disorder well is a….

4. Richard Shafer: … CHALLENGE!!!

5. Definitions Gestational Diabetes Pre-gestational Diabetes

6. Gestational diabetes... May have its’ onset or be first recognized during pregnancy Diabetes may have previously existed but not diagnosed

7. Pre-gestational diabetes... May be present and undiagnosed Evolving Already present and under treatment

8. Why is this important? Pre-existing diabetes at conception can lead to congenital anomalies Gestational diabetes leads to macrosomia and premature delivery

9. Congenital Malformations Cardiovascular: transposition, vsd, asd, hypoplastic left ventricle, anomalies of the aorta CNS: anencephaly, encephalocele, meningomyelocele, microcephaly

10. Malformations... Skeletal: caudal regression, spina bifida GU: Potter syndrome, polycystic kidneys GI: tracheoesophageal fistula, bowel atresia, imperforate anus

11. First Trimester Miscarriages HbgA1c Percent of women

12. Complications by Trimester First –Still births –Miscarriages –Congenital defects Second and Third –Hyperinsulinism –Macrosomia –Delayed lung development

13. Complications... Delivery –Injuries –RD –Pregnancy loss –Neonatal hypoglycemia

14. Hormonal Influences

15. Decreased glucose levels Due to passive diffusion to fetus Causes hypoglycemia, even in non-diabetic patients Greatly decreases insulin need in first trimester

16. Accelerated starvation... Due to glucose diffusion Leads to elevated ketone production Unsure if this hurts baby or not Use as guide for increased calories

17. Decreased maternal alanine Gluconeogenic amino acid Results in further lowering of FBS

18. 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

19. 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

20. Hormones affecting blood sugar Insulin Glucagon Epinephrine Steroids Growth hormone Progesterone Human placental lactogen

21. Peak Times of Hormonal Activity HormoneOnsetPeak Potency Estradiol32 d26 wk1 Prolactin36 d10 wk2 HCS45 d26 wk3 Cortisol50 d26 wk5 Progesterone65 d32 wk4

22. 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

23. Dietary Modifications Decrease carbohydrate content Frequent small feedings Small breakfast meals Bedtime snacks No > 10 hours overnight fast NO JUICE Adequate calorie intake

24. 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

25. Estimated insulin needs Prepregnancy0.6 U/kg Weeks 2-160.7 U/kg Weeks 16-260.8 U/kg Weeks 26-360.9 U/kg Weeks 36-401.0 U/kg Postpartum<0.6 U/kg

26. 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!

27. Medications Sulfonylureas: –Glyburide typically used –Anecdotal evidence –Not very effective –Unable to achieve higher insulin levels for meals –No long-term studies for safety

28. Medications Insulin: –NPH: BID dosing Can start only at HS if FBS elevated Long history of safety Inconsistent absorption

29. 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

30. Medications Insulin analogs: –Humalog, Novolog, Apidra –Very rapid acting –Very effective pre- and post prandial –Less risk of hypoglycemia

31. Medications Regular insulin: –Slower onset –Longer duration –May be necessary in those who do not want to take as many injections

32. 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

33. Postpartum Continue periodic testing Aim to lose weight Glucose challenge @ 6 wk check Breast-feeding lowers BS, leads to hypoglycemia

34. Managing Gestational Diabetes THANK YOU! Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes