gestationaldiabetesupdate2.ppt

8/11/2019 gestationaldiabetesupdate2.ppt

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Gestational Diabetes

Update

Leigh Caplan RN CDEMarsha Feldt RD CDE

SUNDEC - Diabetes Education Centre

May 22, 2009


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Learning Objectives

Review physiology of pregnancy and gestational

diabetes

Review CDA clinical practice guidelines for

diagnosis and management of gestational diabetes

Highlight nutrition therapy approaches

Discuss role of hospital based gestational diabetes

programs

Discuss post partum considerations for diabetes

risk and prevention


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Case study:

Sue comes to see you for nutritioncounselling

32 years old, BMI 25

family history of type 2

G1P0 26 wks gestation

Informs you she just received the diagnosis ofgestational diabetes

GTT results - 5.1, 10.7, 9.1

What do you do?


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Definition:

Hyperglycemia with onset or first

recognition during Pregnancy

Prevalence

3.7% in non-aboriginal8-18% in aboriginal populations

CDA CPG 2008



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Physiology in Late Pregnancy

Characterized by accelerated growth of thefetus

A rise in blood levels of severaldiabetogenic hormones

Food ingestion results in higher

and more prolonged plasma glucoseconcentration
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Physiology in Late Pregnancy

Maternal insulin and glucagon do notcross the placenta

During late pregnancy a womens basalinsulin levels are higher than non-gravidlevels

Food ingestion results in a twofold tothreefold increase in insulin secretion

(Franz, M.J., 2001)


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Physiology of GDM

Gestational hormones

induce insulin

resistance

Inadequate insulin

reserve andhyperglycemia ensues


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Fetal Risks

Macrosomia - shoulder dystocia and related complications

Jaundice

Hypoglycemia

No increasein congenital anomalies

Exposure to GDM in utero

LGA children or those born to obese mother have a 7% risk ofdeveloping IGT at 7-11 yrs age

Breastfeeding may lower riskCDA CPG 2008



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Maternal Risks

C-section

Pre-eclampsia

Recurrence risk of GDM is 30-50%

30-60% lifetime risk in developing IFG,IGT or type 2 diabetesCDA CPG 2008



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GDM Screening

All women should be screened for GDM

between 24-28 weeks

vs. risk factor based approach which canmiss up to the cases of GDM

Women with multiple risk factors shouldbe screened in the first trimester


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Risk Factors:

for first trimester screening > 35 yrs

BMI > 30

Previous diagnosis of GDM

Delivery of a mascrosomic baby

Member of a high-risk population (Aboriginal, Hispanic, South Asian, Asian, African)

Acanthosis nigricans Corticosteroid use

PCOS


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Diagnosis of Gestational

DiabetesGestational Diabetes

Screen (GDS)

1 hr after 50g load of

glucose

Value 75 g OGTT

indicated

10.3 mmol/L No - GDM


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Diagnosis of Gestational

Diabetes75 g OGTT

GDM= 2 or more

values greater than

or equal to

IGT= singleabnormal value

Fasting > 5.3

mmol/L

1 hr > 10.6

mmol/L

2 hr > 8.9

mmol/L


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Management of Gestational

Diabetes Strive to achieve glycemic targets

Receive nutrition counselling from an

Registered Dietitian Encourage physical activity

Avoid ketosis

If BG targets are not reached within 2weeks then insulin therapy should bestarted


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Target Blood Glucose Values

for GDM

Fasting/Pre-prandial: 3.85.2 mmol/L

1 hour 5.5 - 7.7 mmol/L

2 hour 5.0 - 6.6 mmol/L
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Nutrition Therapy as treatment

for GDM

A tool to achieve appropriate nutrition

and glycemic goals of pregnancy

to normalize fetal growth and birth

weight


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Medical Nutrition Therapy

for GDM

Definition:

A carbohydrate controlled meal plan

with adequate nutrition for appropriate

weight gain, normoglycemia, and the

absence of ketones


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Clinical Outcomes

Achieve and maintain normoglycemia

Promote adequate calories for wt gain

in absence of ketones

Consume food providing adequate

nutrients for maternal and fetal health


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GDM Nutrition Controversies

What is a healthy weight gain for an obese

woman with GDM?

How far to manipulate energy intake?

Does the balance of carbohydrate and fatmatter?


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Excess Weight Gain

May increase incidence of GDM infuture pregnancy

Obese women have larger babies

More likely to develop macrosomia if

gain >25lb More likely to develop macrosomia with

high post prandial BG levels


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Calorie Restricted Diets

Avoid severe restriction -


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Role of Carbohydrate

Carbohydrate can be modified to controlpostprandial glucose elevations

High fiber not associated with lowerglucose levels in GDM

Lower carb intake (


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Emphasis for GDM

Healthy Eating following CFG appropriate foradequate weight gain

DRI= minimum 175 g CHO/day Spacing of CHO into 3 meals & 2 to 4 snacks

Smaller amounts of CHO at breakfast*

Evening snack is important to prevent ketosisovernight

Encourage activity as tolerated


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Carbohydrate Counting with

Beyond the Basics Canadian Diabetes Association meal

planning guide

Based on Canadas food guidegroups

Each food group outlines portion sizes ofvarious foods

Each carbohydrate choice (grains/starch,fruit, milk) = 15 grams carbohydrate


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Grains8-10 choicesFruit2-3 choices

Milk3-4 choices


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Dietary Fat in GDM

up to 40% of total energy intake during

pregnancy

choose food source which are lower insaturated and transfats


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Artificial Sweeteners

When used within ADI

Aspartamedoes not cross placenta; no adverse

effects

Sucralose (splenda)acceptable

Acesulfame potassiumacceptable

Saccharincrosses placenta; not acceptable

Cyclamatesnot acceptable


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Back to Sue

3 weeks later Trying to work with meal plan

Weight has been stable for 3 weeks

Blood glucose readings: Fasting 5.0 to 5.7

2 hours pc breakfast 4.6 to 5.3

2 hours pc lunch 5.7 to 6.5 2 hours pc dinner 7.2 to 7.9

What do you discuss with Sue?


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Purpose of Insulin

To achieve plasma glucose control nearly

identical to those observed in women without

diabetes Must be individualized

Insulin requirements will

change with various

stages of gestation

(ADA. Medical Management of Pregnancy

Complicated by Diabetes., 2000)


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Types of Insulin

Approved in pregnancy

Fast acting: Humalog , NovoRapid

Short acting: Regular/R

Intermediate acting: NPH/N

Detemir can be used if woman unable to tolerate

NPH ( Ongoing study to evaluate use in

pregnancy)

Glargineavoid use


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Devices for Insulin Delivery
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Considerations for Adjusting

Insulin

Look for patterns in blood glucose readings

Adjust for hypoglycemia first

Then adjust for high blood glucose


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Can oral hypoglycemia agents be

used to treat GDM? Glyburide

Does not cross the placenta

Controlled BG in 80% of women

Women with high FBG less likely to respond toGlyburide

More adverse perinatal outcomes compared toinsulin

Not approved in Canada use is considered off-label and requires

appropriate discussions of risks with patient

CDA CPG 2008


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Metformin

alone or with insulin was not associated with

increased perinatal complications compared with

insulin

Less severe hypoglycemia in neonates

Does cross the placentalong term study MiG

TOFU ongoing

Not approved in Canada use is considered off-label and requiresappropriate discussions of risks with patient

NEJM, 2008


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Postpartum Physiology:

Once the placenta is delivered:

Hormones clear from circulation

They will be monitored in hospital if

blood glucose remains elevated may

require medications


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Postpartum Focus:

Encourage follow up with health careprovider to have

OGTT (6 weeks to 6 months 75 g OGTT) weight management,

postpartum visit with a registered dietitian

Encourage breastfeeding

Monitoring occasionally with meter

Future pregnancy


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Breastfeeding and DM meds

Both metformin and glyburide/glipizide

are found at low concentrations (or not

at all) in breast milk Hale et al, Diabetologia 2002

Feig et al, Diabetes Care 2005

Can be considered however, more long-term studies needed


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SUNDECDiabetes Education

Centre

(416) 480-4805

Multidisciplinary team of health

professionals ( RN, RD) Self referral

Individual counselling

Group education classes

Type 2, Pre-diabetes, Diabetes

Prevention and Seniors programs


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Case 2

JustineJustine was diagnosed with gestational diabetes at 20

weeks, pre-preg BMI = 28.7, GTT results were: 6.2, 10.2, 9.8

She is now at 25 weeks

FBS 6.17.4

3 meals and 1 -2 snacks.

Diet history: Oatmeal at breakfast, lunch and dinner consistof aprox. cup rice, lots of vegetables and meat, in theafternoon a piece of fruit, 2 cups of milk at bed

What would you do?


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www.diabetes.ca


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Resources and References

Canadian Diabetes Association: www.diabetes.ca

-Recommendations for Nutrition Best Practice in theManagement of GDM

-2003 Canadian Diabetes Association Clinical Practice

Guidelines for the Prevention and Management ofDiabetes in Canada

Nutrition for a Healthy Pregnancy: National Guidelinesfor the Child Bearing Years

Healthy Eating is in Store for you:

www.healthyeatingisinstore.ca
http://www.diabetes.ca/http://www.healthyeatingisinstore.ca/http://www.healthyeatingisinstore.ca/http://www.diabetes.ca/

gestationaldiabetesupdate2.ppt

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