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Managing Gestational Diabetes

Managing Gestational Diabetes. Cynthia V. Brown, RN, MN, ANP, CDE Southeastern Endocrine & Diabetes. Managing Gestational Diabetes. The management of gestational diabetes is necessary for a healthy baby and mom. Managing this disorder well is a…. Richard Shafer:. … CHALLENGE!!!.

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Managing Gestational Diabetes

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

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

  3. Richard Shafer: …CHALLENGE!!!

  4. Definitions Gestational Diabetes Pre-gestational Diabetes

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

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

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

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

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

  10. First Trimester Miscarriages Percent of women HbgA1c

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

  12. Complications... • Delivery • Injuries • RD • Pregnancy loss • Neonatal hypoglycemia

  13. Hormonal Influences

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

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

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

  17. 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

  18. 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

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

  20. Peak Times of Hormonal Activity • Hormone Onset Peak Potency • Estradiol 32 d 26 wk 1 • Prolactin 36 d 10 wk 2 • HCS 45 d 26 wk 3 • Cortisol 50 d 26 wk 5 • Progesterone 65 d 32 wk 4

  21. 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

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

  23. 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

  24. Estimated insulin needs • Prepregnancy 0.6 U/kg • Weeks 2-16 0.7 U/kg • Weeks 16-26 0.8 U/kg • Weeks 26-36 0.9 U/kg • Weeks 36-40 1.0 U/kg • Postpartum <0.6 U/kg

  25. 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!

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

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

  28. 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

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

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

  31. 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

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

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

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