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Diabetes in Pregnancy: Care Principles

Diabetes in Pregnancy: Care Principles. Elizabeth Guevara, FNP-BC Maternal Fetal Medicine - DM. Why Do We Care?. Insulin Requirements. Blood Glucose Ranges. GDM Background & Incidence.

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Diabetes in Pregnancy: Care Principles

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  1. Diabetes in Pregnancy: Care Principles Elizabeth Guevara, FNP-BC Maternal Fetal Medicine - DM

  2. Why Do We Care?

  3. Insulin Requirements

  4. Blood Glucose Ranges

  5. GDM Background & Incidence 1964: Formal diagnostic criteria established for gestational diabetes based on mother’s increased risk of future development of diabetes  lifetime risk of diabetes exceeded 70% GDM incidence in U.S. formerly ~2-10%, now estimated ~18% with the ADA-endorsed IADPSG 2011 criteria Change from 2-step diagnosis (50 gm screen with 100 gm 3-hr GTT confirmation) to 75 gm 2-hr GTT

  6. GDM: Recurrence Risk • 35-80% risk of GDM recurrence • Higher risk of recurrence if: • Parity: >1 in 1st GDM pregnancy • Greater infant birth weight in 1st GDM pregnancy • Maternal obesity (BMI > 30) • Early GDM (<24 wks) in 1st GDM pregnancy • Insulin requirement in 1st GDM pregnancy • Weight gain > 7 kg in 1st GDM pregnancy • Interval between pregnancies < 24 months

  7. GDM: Future T2DM Risk “The closer you are to diabetes in pregnancy, the sooner you will become diabetic.” • Variable quoted rates of conversion to T2DM • 22% some degree of glucose intolerance in immediate postpartum period (2-hr GTT @ 6-8 wks PP) • 3.2% impaired fasting glucose (IFG) • 11% impaired glucose tolerance (IGT) • 2.1% both IFG and IGT • 5.8% (~5-10%) overt T2DM • 20-50% risk over the 10 years following pregnancy: marked increased risk in first 5 years then plateaus after 10 years • 35-60% chance of developing T2DM in the following 10-20 years

  8. GDM: PP T2DM Risk Factors Impaired glucose tolerance postpartum Elevated fasting glucose during pregnancy: FPG > 121 in pregnancy  risk 21-fold Obesity, especially abdominal obesity Postpartum weight gain Early GDM diagnosis (<20-24 wks gestation) Insulin use/requirement during pregnancy Physical Inactivity Diet higher in fat content (38-40% of total calories) High glycemic index / low fiber diet

  9. GDM: Modifiable Risk Factors • Breastfeeding for at least 6 months • Postpartum Weight loss • Return to pre-pregnancy weight by 3 months PP • Lose 5-10% of body weight • Lose at least 10 pounds prior to next pregnancy • Regular physical activity

  10. Basic New Patient Teaching Medical Nutrition Therapy (MNT) Exercise Blood Glucose Meter Use & Testing Schedules

  11. Medical Nutrition Therapy • Food Groups • “Carbohydrates” (starches) • Dairy • Fruits • Vegetables • Protein • Fats • Portion Amounts • Measuring Cups • Hand Jive

  12. Carbohydrates/Starches • Portion = 15 grams total carbohydrates • Examples • Bread: 1 slice whole grain • Tortilla: 1 corn or wheat (6”) • Rice & Pasta: 1/3 cup • Beans: ½ cup • Hot Cereal: ½ cup • Potato: 1 small or ½ medium (or ½ cup total) • Winter Squash, Corn, Peas, Sweet Potato: ½ cup • Crackers: 6 saltines • English Muffin: ½

  13. Milk / Calcium-Rich Foods • Portion = 15 grams total carbohydrates • Examples • Milk (~1%): 8 oz. • Yogurt: 6 oz. plain or light yogurt (no fructose in ingredients)

  14. Fruits • Portion = 15 grams total carbohydrates • Examples: highly variable amounts • Apple, Nectarine, Orange: 1 small • Banana: 1 small…in reality ½ normal banana • Blueberries: ¾ cup • Grapefruit: ½ large • Grapes: 17 small • Mango: ½ cup • Papaya & Melon: 1 cup • Pineapple: ¾ cup • Strawberries & Watermelon: 1 ¼ cups

  15. Vegetables • Portion = 5 grams total carbohydrates • Amounts: 1 cup raw or ½ cup cooked • Exceptions: • Jicama: ½ cup • Vegetable Juice: ½ cup • “Starchy” vegetables: corn, peas, potato, sweet potato / yam, winter squash (acorn, butternut, kabocha, pumpkin, etc.) – count as Carbohydrate

  16. Protein • Portion ~ 7 grams protein • Examples • Canned Meats: ¼ cup • Cheese: 1 oz. • Cottage Cheese: ¼ cup • Eggs: 1 whole or 2 egg whites • Meats/Fish/Fowl: 1 oz. • Peanut Butter: 1 tbsp natural • Tofu: ½ cup

  17. Fats • Portion ~ 4.5 grams unsaturated fat • Examples • Avocado: 2 tbsp • Olives: 8 black, 10 green • Nuts • Almonds: 6 whole • Peanuts: 10 whole • Pecans: 2 whole • Walnuts: 2 whole • Vegetable Oil: olive, canola 1 tsp • Avoid All Animal (Saturated) Fats

  18. Free Foods • Portion = less than 5 grams total carbohydrates (<20 calories) • Examples • Artificial Sweetener (no saccharin: crosses the placenta) • Broth (low sodium) • Decaffeinated Coffee & Tea • Drink Mix (sugar free) • Gelatin (sugar free) • Herbs (dried & fresh) • Lemon • Lettuce • Mushroom • Radish

  19. Foods to Eliminate • Avoid during pregnancy to prevent inducing hyperglycemia • Examples • Bagel / Muffin • Coffee Creamer / Flavored Milk • Condiments / Sauces: BBQ Sauce, Ketchup, Teriyaki Sauces • Fruit Juices / Flavored Drinks / Sodas • Ice Cream / Frozen Yogurt • Instant Cereals* • Jam / Jelly • Sugars: Honey, Sugar, Syrup • Sweets: Cake, Candy, Cookies, Custard, Donuts, Pies, Pudding

  20. Basic Tenets of MNT in Pregnancy • 3 Meals & 3 Snacks Daily • Meals • Breakfast: 1-2 carbs, 1 protein, 1+ vegetables, ?1 fat • 1 egg, 1 whole wheat toast, spinach, ?oil • No milk or fruit • Lunch: 3 carbs, 4 proteins, 2+ vegetables, ?1 fat • 3 chicken tacos with salsa, side salad, ?avocado • No milk or fruit • Dinner: 3 carbs, 4 proteins, 2+ vegetable, ?1 fat • 1 medium baked potato, grilled fish, ½ cup corn, broccoli, ?oil • No milk or fruit

  21. MNT for Diabetes in Pregnancy • 3 Meals & 3 Snacks Daily • Snacks: between each meal and ~30-60 minutes before bed • 1st 2 snacks: 1 milk, 1 fruit, 1 protein, ?1 fat • 8 oz. milk or 6 oz. yogurt, ½ banana, 1 cheese stick (mozzarella), ?walnuts • No “carbohydrate” foods • Last snack: 1 dairy, 1 carb, 1 protein, ?1 fat • 8 oz. milk, ½ sandwich: 1 whole wheat bread, turkey, lettuce, tomato ?mayo • No fruit

  22. MNT Timing • Goal: no more than 10 hours between last snack & breakfast • Avoid elevated fasting blood glucose • Avoid ketone production • Meals are usually ~3 hours apart • 0800 Breakfast • 1000 Snack • 1300 Lunch • 1600 Snack • 1900 Dinner • 2200 Snack • 2230 Go to sleep • Nothing to eat until breakfast

  23. Exercise • Minimum goal = 30 minutes daily • Standard recommendation: 10 minutes after each meal • Exercise after eating increases glucose uptake by muscles • Decreases postprandial blood glucose level • Type of exercise • Baseline level of exercise prior to pregnancy • Avoid exercise that might cause trauma • Exercise class: let instructor know to tailor routine for pregnancy

  24. SMBG Testing • The minimum 4: all types of diabetes in pregnancy • Fasting • 1 Hour PC (time from first bite of food) • The extra 2: for patients on MDI insulin (3-4x daily) • AC Dinner • AC Last Snack • Type 1 Diabetes: often 2-4 am test & AC lunch • Additional tests • Hypoglycemia symptoms • When blood glucose result is radically different than anticipated

  25. Putting it Together Patient Log Brought To Each Visit!

  26. Labs, Diagnostics, Delivery • Hemoglobin A1C • Ultrasounds for Growth • 30 weeks: on medication • 36-37 weeks: intended vaginal delivery • Fetal Monitoring / Nonstress Test • 32-36 weeks: weekly testing if on meds • 40-41 weeks: no medication • Vaginal Delivery Timing • 39-40 weeks: on medication • 40-41 week: no medication & good control

  27. It Goes Beyond Pregnancy ++ + + + + =Healthier Outcomes for Individual, Familial & Societal Health

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