pregnancy Fiona McKeeman-Credentialled Diabetes Educator 1 - - PowerPoint PPT Presentation

Diabetes in pregnancy

Fiona McKeeman-Credentialled Diabetes Educator

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Diabetes In Pregnancy

 Gestational Diabetes  Pre-Existing Diabetes-

 Type 1 Diabetes  Type 2 Diabetes

The Endocrine Unit

 The advanced trainee/ Reg  Pager 464 or through switch during working hours  The consultants -

 Drs Renouf, Matthiesson & Dutta  After hours -Contact the endocrinologist on call through switch

 The DNEs (Diabetes Nurse Educators)

 Sue, Fiona, Kylie, Debbie, Fadwa  Page 506 or ext 7625 (working hrs Mon-Fri)

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Carbohydrate glucose g g g g Insulin Pancreas g Muscle cell g g

2-3 times

g g

g g g

g

Placenta

Hormones

Gestational Diabetes

What is GDM?

 Gestational Diabetes Melitis is glucose intolerance with onset

• r first recognition in pregnancy

 Usually a temporary form of diabetes that occurs during

pregnancy.

 Rising levels of placental hormones (HPL and progesterone)

have opposite action to insulin causing release of glucose from cells into the bloodstream. These Hormones also cause insulin resistance.

 Insulin production from the pancreas needs to increase (2-3

times more) to match the effect of these placental hormones.

 Women who develop GDM have deficient insulin production

and/or significant insulin resistance.

Foetal and maternal risks of GDM

 Risks to Baby

 Macrosomia  Neonatal Hypoglycaemia  Birth Trauma  Shoulder dystocia  Respiratory Distress  Hypocalcaemia  Polycythemia  Jaundice  Obesity, abnormal glucose

tolerance, GDM &Type 2 diabetes in adolescence and adulthood.

 Risks to Mother

 Pre-eclampsia  Polyhydramnios  Caesarean Birth  Future risk of GDM 50%

next pregnancy 70% if you have had it in first two pregnancies.

 Future risk of Type 2- 50%

Testing for GDM

New recommendations ADIPS 2014 (nov) (RANZCOG Endorsed)  All women not known to have pre pregnancy diabetes or hyperglycemia in pregnancy should undergo 75gm OGTT at 24-28 weeks (Glucose Challenge Test (GCT) screening no longer recommended)  Those Identified as HIGHER RISK should undergo a 75gm OGTT early in pregnancy or at the fist opportunity after conception.  Women in the HIGHER RISK group who have a normal result on early pregnancy testing should have a repeat 75gm OGTT at usual time of 24-

• 28wks. However a OGTT should be performed at any earlier time if

clinically indicated.

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GDM Risk Factors

 Higher risk groups- (any of below)

 Previous hyperglycaemia in pregnancy  Previously elevated BGL  Maternal age ≥40 yrs.  Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait

Islander, Pacific Islander, Maori, Middle Eastern, non-white African.

 Family History of Diabetes (1st degree relative or a sister with GDM)  Pre pregnancy BMI >30kg/m2  Previous macrosomia (baby birth wt >4500gm or >90th centile)  Polycystic ovarian syndrome  Medications: Corticosteroids, antipsychotics

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Diagnostic Criteria RANCOG Endorsed – recommended adoption Jan 1st 2015

Old Criteria: Fasting ≥5.5, 1hr- not considered, 2hr ≥ 8.0

GDM occurs in approx. 5-8% of Australian pregnancies (may increase to 12-14% with new diagnostic criteria)

Carbohydrate glucose g g g g Insulin Pancreas Muscle cell g g g g

g g g

g

Placenta

Hormones

Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

Pre-Existing - Type 2 Diabetes g g g g

Carbohydrate glucose g g g g Insulin Pancreas Muscle cell g g g g

g g g

g

Placenta

Hormones

Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

Pre-Existing - Type 1 Diabetes g g g g

Fat cell

FA

ketones

Foetal and maternal risks of Pre-existing Diabetes



Risks to Baby

 Congenital abnormalities 2-3 higher risk

than gen pop

 Miscarriage/ foetal death  Intra uterine growth retardation- small for

gestational age

 Type 1 diabetes (greater if father has Type 1

diabetes) 2% mother vs 5% father

 Macrosomia  Birth Trauma  Shoulder dystocia  Neonatal Hypoglycaemia  Respiratory Distress  Polycythemia  Jaundice  Hypocalcaemia  Obesity, abnormal glucose tolerance &Type

2 diabetes in adolescence and adulthood.



Risks to Mother



Some complications of diabetes accelerated by pregnancy eg renal damage and retinopathy.



UTI’s



Hypoglycaemia



Ketoacidosis- Type 1 diabetes



Pre-eclampsia



Polyhydramnios

 Caesarean Birth

Normal BGLs are the aim pre pregnancy and throughout pregnancy

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Type 1 & Type 2 Diabetes Congenital Abnormalities

 Congenital abnormalities (heart, CNS, neural tube, kidneys,

GI ) 2-3 times higher risk than general population.

 Malformation rates are related to the degree of

hyperglycaemia

 Most congenital abnormalities occur 3-6 weeks after

conception -often before pregnancy is diagnosed.

 Can result in miscarriage, Foetal death in utero  Women conceiving with HbA1c less than 7% have

malformation rates comparable to non –diabetic women.

 Pre pregnancy counselling vital

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GDM (no DM before pregnancy)

Pre-existing diabetes

Type 1 Type 2

Diet and Exercise Rx Insulin Rx

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?? Metformin Rx

 Treatment targets for self BG monitoring

 Varies between centres around Australia.  The Following are suggested by ADIPS Based on “best

available” data but need further research for RANZCOG endorsement.

 Fasting ≤ 5.0 mmol/l  (1 hour BG after commencing meal ≤ 7.4 mmol/l)- if can’t

wait to 2hrs

 2 hour BG after commencing meal ≤ 6.7 mmol/l

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Medtronic Paradigm pump

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On admission

 Check DMR for any admission instructions from

GDM clinic

 Check for Diabetes Labour management plan in

DMR

 Refer to Clinical Practice Guideline- Diabetes in

pregnancy (on intranet)

 Ring to inform endocrine unit

 during working hours if not urgent  at any time, if required urgently

In labour- GDM and Type 2 Diabetes

 Withhold insulin when in labour  Aim is to keep the BGLs 4-7 mmol  This reduces the risk of neonatal hypoglycaemia  Check BGLs Hourly in labour  Contact Endocrinology unit If BGLs >7.0 an insulin

infusion may be required (stop after delivery of placenta)

 GDM -NO insulin after delivery  Type 2- Endocrinology review to assess if oral agents or

insulin is required.

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Type 1 DM in labour

 Hourly BGLs  Require an insulin infusion  Insulin pump patients – routinely cease pump and

commence infusion when in labour Type 1 After delivery

 Reduce insulin infusion to 1/5th at delivery of placenta

(do not stop infusion until restarting insulin injections)

 Ongoing Insulin doses will NEED TO BE REDUCED to

1/5th of previous pregnancy doses

 Do NOT withhold insulin or glucose even if not eating

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Elective Caesarean Section – On insulin



Clarify plan of management for pre, peri and post

• peration with endocrinology and anaesthetist.



Ideally caesarean sections for patients with insulin requiring diabetes should be scheduled early on the morning list to minimise disturbance of glucose metabolism.



Normal insulin night prior to Caesarean. Withhold morning insulin



Type 2 and GDM monitor BGL early morning and pre-

• p – if >7.0 insulin infusion may be required (cease

infusion after delivery)



Patients with Type 1 diabetes switch to insulin and dextrose infusion in morning. Reduce rate One Fifth rate after delivery of the placenta.

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Insulin Infusion 50units Actrapid in 50ml Normal saline 10% dextrose 12hrly rate

Insulin dextrose Intravenous Infusion

Extra 10units Actrapid in 10ml Normal saline to prime through tubing

Preparing insulin infusion

Follow MR18B insulin infusion order -contact endocrinologist for or. Prepare Insulin Syringe Driver:



Make up 10 units (Actrapid) in 10mls normal saline (ie 1 unit per ml) prime infusion line with all of this solution before connecting – coats the tubing as insulin is sticky protein and will stick to plastic coating until fully coated.



Make up 50ml syringe with 50 units regular insulin (Actrapid) in 50mls normal saline (ie 1 unit per ml)



Connect to same cannula as dextrose infusion using Y lumen connector



Starting rate ordered by endocrinologist Prepare Dextrose Infusion



10% Dextrose to commence at 12hrly rate when BGL less than 15mmol



Aim is to keep BGL’s 4-7mmol during labour- specific instructions need to be handwritten by Dr in lower section of infusion protocol.



Hourly BGL’s



Follow hypo treatment as per insulin infusion protocol MR 18B

Hypoglycaemia Treatment

 Routine hypo treatment (when not on insulin infusion)  If BGL<3.9mmol  100ml lucozade (if able to swallow and conscious)  Repeat BGL 10mim  If still < 3.9 repeat lucozade 100ml  Give longer acting carb snack once >4.0mmol  If altered conscious state- 25ml IV Dextrose 50% slow

push-retest in 5min- commence 8/24 10% dextrose.

 (If no IV access Glucagon IM 1mg)  (Refer to hypoglycaemia treatment CPG)

Care post delivery

 GDM

 Diabetes educator review- advise risk of subsequent

risk of diabetes and GDM.

 Check QID BGL 24 hrs (diet controlled) 48hrs (insulin)

notify endo if above 10

 75 gm OGTT 6wks post partum  Review appointment GDM clinic or GP 8-10wks

postpartum

 1-2 yearly OGTT if not pregnant  Early OGTT in next pregnancy – first visit or 12-14

wks gestation

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Care Post Delivery

 Pre-Existing Diabetes

Continue QID BGL’s – Notify endocrinology if

BGL>10mmol or <3.5mmol

Diabetes Educator review- advise risk of

hypoglycaemia post delivery and after breastfeeding

GDM clinic review 2-4wks Ongoing follow-up at DIAB clinic or private

endocrinologist

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QUESTIONS?

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(HAPO) Hyperglycemia and Adverse Pregnancy Outcomes Study

 HAPO Study  5 year international study 23,000 women  AT ≈ 28wks subject had a 75g OGTT with fasting, 1 and 2 hour

samples . Subjects and healthcare providers blinded to results unless FBG >5.8mmol/l or 2 hour value >11.1 then out of study and treated.

 Conclusions:  BGL’s that are elevated but under diagnostic level of GDM have

increased risks usually associated with GDM.

 Data showed a continuous increase in risk as blood glucose levels

rise of:

 Large birth weight  High blood insulin levels in the newborn  Primary Caesarean birth  Pre-eclampsia and shoulder dystocia/birth injury  Was not significantly associated with hypoglycaemia in the newborn

requiring treatment

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The HAPO Study Cooperative Research Group. N Engl J Med 2008;358:1991-2002

Frequency of Primary Outcomes across the Glucose Categories

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References



RANZCOG July 2014 Diagnosis of Gestational Diabetes Mellitus (GDM) and Diabetes Mellitus in Pregnancy



ADIPS Consensus Guidelines for the Testing and Diagnosis of Gestational Diabetes Mellitus in Australia- Nov 2014



The HAPO Study Co-Operative Research Group 2008 “Hyperglycemia and Adverse Pregnancy Outcomes” NEJM May 2008 Vol358 no19



Nankervis A. 2001 “Diabetes and Pregnancy: Women’s Experiences and Medical Guidelines” Miravana Publishers Australia



Nankervis A 2007 “Gestational Diabetes” Diabetes Management Vol19 June



Siri et al NEJM vol 341 no 23 December 1999 “Current concepts: Gestational Diabetes Mellitus”



Diabetes-genetics.org 2009 “Genetics of Diabetes Mellitus”



MacNeil et al 2001 “rates and Risk Factors for Recurrence of Gestational Diabets” Diabetes Care Vol24 no4 April.



2007 National Institute of Diabetes and Digestive and Kidney Diseases: National diabetes statistics fact sheet: general information and national estimates on diabetes in the United States, 2007.



Hoffman et al, The Australian Diabetes in Pregnancy Society “Gestational diabetes mellitus- management guidelines” MJA1999 169:93-97

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Gabbe SG et al Obstet Gynecol 2003:102 856-888. As cited in Pumps in Pregnancy Presentation Dr Alan O Marcus 2007

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The Australian Diabetes in Pregnancy Society 2005 “Consensus Guidelines for the management of patients with Type1 and Type 2 diabetes in relation to Pregnancy guide” http://www.adips.org/content/ADIPS_PreGDM_Guidelines.pdf



Nankervis A Conn,J 2013 Gestational diabetes mellitus: Negotiating the confusion. Australian Family Physician Vol.42 No.8 August p528-531 30