Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Diabetes in Pregnancy: Care Principles Elizabeth Guevara, FNP-BC Maternal Fetal Medicine - DM."— Presentation transcript:

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 1 st GDM pregnancy  Greater infant birth weight in 1 st GDM pregnancy  Maternal obesity (BMI > 30)  Early GDM (<24 wks) in 1 st GDM pregnancy  Insulin requirement in 1 st GDM pregnancy  Weight gain > 7 kg in 1 st 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 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 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  1 st 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  weeks: intended vaginal delivery  Fetal Monitoring / Nonstress Test  weeks: weekly testing if on meds  weeks: no medication  Vaginal Delivery Timing  weeks: on medication  week: no medication & good control

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


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

Similar presentations


Ads by Google