1. HOW SWEET IT IS: Managing Diabetes For A Healthy Pregnancy And Beyond
Ruth Ferrarotti, MSN, APRN-BC, CDE
Assoc. Clinical Prof., Univ. of Conn.

2. Discussion Topics Gestational Diabetes: Diagnosis and management
Postpartum recommendations
Established Diabetes:
Pre-pregnancy counseling
Management of diabetes
Diabetes After Pregnancy

3. Classification of Diabetes
Type 1 Diabetes – Beta cell destruction
Type 2 Diabetes – Progressive insulin secretory defect and insulin resistance
Other – genetic defects, diseases of exocrine pancreas and drug/chemical induced
Gestational Diabetes

4. Approximate Prevalence of Diabetes in Pregnancy in the United States
4.022 Million Births in 2002
More than 200,000 type 2 diabetes mellitus + 135,000 GDM type 1 diabetes mellitus = 341,000 pregnancies complicated by hyperglycemia annually
Diabetes 8%
Diabetes 8%
50% GDM
24% Diagnosed T2DM
Nondiabetes
92%
24% Undiagnosed T2DM
2% T1DM
GDM=gestational diabetes mellitus

5. Maternal hyperglycemia
The Impact of Maternal Hyperglycemia During Pregnancy Modified Pedersen Hypothesis
Fetal pancreas stimulated
Maternal hyperglycemia
Placenta
Fetal
hyperinsulinemia
Insulin
Insulin resistance syndrome
IgG-antibody-bound insulin
Fetus
Mother
IgG=immunoglobulin G

6. Diabetes and Pregnancy Type 1 and Type 2 Diabetes
Preexisting diabetes diagnosis
Preconception care is essential
Treat with insulin
If untreated during first few weeks’ gestation, associated with
Spontaneous abortion
Birth defects
If untreated during second or third trimester, associated with
Fetal macrosomia
Birth injury
Maternal hypertension
Maternal preeclampsia
Future diabetes and/or obesity in child
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

7. Preconception Care of Established Diabetes Medical Assessment
Duration and type of diabetes
Medical history and current medical management plan
Chronic diabetes-related complications
Retinopathy
Dilated eye exam by trained ophthalmologist
Nephropathy
24-hour urine for creatinine clearance, total protein excretion, and microalbuminuria
Neuropathy
Autonomic neuropathy, especially gastroparesis
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

8. Preconception Care of Established Diabetes Medical Assessment
Comorbid conditions (in addition to diabetic complications)
Hypertension
Measure blood pressure
Coronary artery disease
Stress test
Hyper- or hypothyroidism
Free T4 and TSH
Other autoimmune diseases
T4=thyroxine
TSH=thyroid-stimulating hormone
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

9. Preconception Care of Established Diabetes Blood Glucose Goals
SMBG
Fasting/premeal: 70 to100 mg/dL
1 hour postmeal: <140 mg/dL
A1C
In normal range (<6%, but ideally <5%)
Monitor until A1C is stable at <6%
SMBG=self-monitoring of blood glucose
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:1-19

10. 1-hour postmeal blood glucose (mg/dL)
Diabetes in Early Pregnancy (DIEP) Trial Postprandial Blood Glucose Levels Predict Macrosomia Risk
Risk for macrosomia (%) 60 50 40 30 20 10 80 90
100
110
120
130
140
150
160
170
180
1-hour postmeal blood glucose (mg/dL)
Adapted from Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1991;164(1 pt 1):

11. Management of Diabetes in Pregnancy
Type 1
Multiple daily injections
Insulin pump
Type 2
Change to insulin if on oral agents

12. Multiple Daily Injections
Combination of intermediate or longer acting insulin with rapid insulin
NPH
Lantus
Analog
Usually require 4-6 injections daily

13. Management of Diabetes in Pregnancy
Monitor BG pre and 2 hrs post meal
Calculate premeal rapid insulin based on carbohydrate intake
Calculate correction for premeal elevated glucose
Discourage postprandial correction

14. Insulin Pump Advantages:
More physiologic than MDI
Programmable bolus reduces risks for hypoglycemia, post-meal hyperglycemia and glucose excursions
Allows for greater flexibility with diet and lifestyle
Increased motivation promotes better control

15. Insulin Pump Disadvantages
Requires increased patient responsibility and motivation
Risk of rapid onset ketoacidosis if catheter becomes dislodged or site infection
Mechanical problems with pump
Infusion site limited in later pregnancy

16. Sensor Augmented Pumping Advantages
Decreased risk of glucose excursions and hypoglycemia
Provides instant information
Allows for greater flexibility to diet and lifestyle
Reduces number of self-monitored glucose tests

17. Sensor Augmented Pumping Disadvantages
Not as accurate as glucose results by fingerstick
“Too much data”
Expensive and not always covered by insurance
Requires another site
Alarms

18. Diabetes and Pregnancy Gestational Diabetes Mellitus
Glucose intolerance of variable degree with onset or first recognition during pregnancy
Mainstay of treatment is medical nutrition therapy (MNT)
Add insulin if MNT does not maintain normoglycemia
If untreated, associated with:
Late-term intrauterine fetal death
Fetal macrosomia
Neonatal hypoglycemia and/or jaundice
Maternal hypertension
Future diabetes and/or obesity in child
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S88-S90 Metzger BE, Coustan DR. Diabetes Care. 1998;21(suppl 2):B161-B167

19. Gestational Diabetes
Approximately 7% of all pregnancies are complicated by GDM
Translates to over 200,000 cases annually(1)
Approximately 42,000 births in Connecticut in 2008(2)
2980 complicated by GDM
(1) Diabetes Care, Vol.33, Supp. 1, Jan. 2010
(2) Connecticut Vital Statistics, 2008

20. Gestational Diabetes
Glucose intolerance of varying severity, with onset or first recognition during the current pregnancy.
Currently diagnosed using two step method
Diagnostic screening between weeks gestation

21. Diagnosis of GDM 1998 Guidelines 2010 Guidelines
1HR oral glucose challenge
≥ 186
3HR OGTT
FBS ≥ 95
1hr ≥ 180
2hr ≥ 155
3hr ≥ 140
Carpenter and Coustan
2010 Guidelines
2HR OGTT
FBG ≥ 92
1hr ≥ 180
2hr ≥ 153
IADPSG Consensus Panel

22. Managing GDM Lifestyle modifications: Self-monitoring blood glucose
Medical Nutrition Therapy
Exercise
Self-monitoring blood glucose
FBS < 90mg/dl 2 hr postprandial <120mg/dl
Medication
Oral agents
Insulin

23. Medications in GDM Insulin Oral agents NPH Analogs Lantus Glyburide
Metformin

24. Physical Activity in GDM
Can improve peripheral insulin resistance and glucose levels
Can obviate need for insulin
Encouraged for women with no obstetric contraindications
Avoid physical activity associated with maternal hypertension or fetal distress (eg, resistance training, lower-body weight-bearing exercise)
Upper-body cardiovascular training is a good option
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:
Jovanovic-Peterson L et al. Am J Obstet Gynecol. 1989;161:

25. Immediate Postpartum Insulin requirements disappear
Diabetes will disappear in 90% of GDM cases.
Continue monitoring hrs after delivery, as indicated

26. Postpartum Considerations Lactation and Nutrition
Breastfeeding is recommended
Decreased risk of type 1 diabetes and infection in infant
Promotes infant growth and development
Maintain pregnancy meal plan or develop postpartum plan to meet added caloric requirements of breastfeeding
Rapid weight loss is not advised; exercise is recommended
Insulin use must be continued if postpartum normoglycemia cannot be maintained with MNT
Blood glucose concentrations may be variable in women with type 1 diabetes
Test glucose frequently
Snack and/or adjust evening insulin to avoid nighttime hypoglycemia
Watch for hypoglycemia due to missed or delayed meals
Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes Association; 2000:67-86

27. Postpartum Recommendations
Self-monitoring
Fasting <100
2 hr post-prandial <140
Glucose testing 6-12 weeks post delivery
Reclassification of diabetes

28. Diabetes After Pregnancy
40-60% risk of developing Type 2 DM within 5-15 years
Approximately 20% continue with abnormal glucose after delivery
66% risk of developing GDM in subsequent pregnancy

29. Diagnosing Diabetes ADA 2010 Diagnostic Criteria A1C ≥ 6.5% or:
FPG ≥ 126mg/dl or:
Two-hour plasma glucose ≥ 200mg/dl or:
Classic symptoms of hyperglycemia or hyperglycemic crisis, a random glucose ≥200mg/dl

30. Diagnosing Diabetes New classifications Pre-diabetes
A1C 5.7% to 6.4%
2 hr OGTT
FPG
2 hr
Refer for nutrition counseling, weight loss and ongoing care