diabetes in pregnancy - moodle.phcn.vic.gov.au · general information and national estimates on...
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Diabetes in
pregnancy
Fiona McKeeman-Credentialled Diabetes Educator
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Diabetes In Pregnancy
Gestational Diabetes
Pre-Existing Diabetes- Type 1 Diabetes
Type 2 Diabetes
The Endocrine Unit
The advanced trainee/ Reg
Pager 464 or through switch during working hours
The consultants - Drs Renouf, Matthiesson & Dutta
After hours -Contact the endocrinologist on call through switch
The DNEs (Diabetes Nurse Educators) Sue, Fiona, Kylie, Debbie, Fadwa
Page 506 or ext 7625 (working hrs Mon-Fri)
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Carbohydrate
glucose
g
g g g
Insulin
Pancreas
g
Muscle cell
g
g
2-3
times
g g g g g
g
Placenta
Hormones
Gestational Diabetes
What is GDM?
Gestational Diabetes Melitis is glucose intolerance with onset or first recognition in pregnancy
Usually a temporary form of diabetes that occurs during pregnancy.
Rising levels of placental hormones (HPL and progesterone) have opposite action to insulin causing release of glucose from cells into the bloodstream. These Hormones also cause insulin resistance.
Insulin production from the pancreas needs to increase (2-3 times more) to match the effect of these placental hormones.
Women who develop GDM have deficient insulin production and/or significant insulin resistance.
Foetal and maternal risks of GDM
Risks to Baby Macrosomia
Neonatal Hypoglycaemia
Birth Trauma
Shoulder dystocia
Respiratory Distress
Hypocalcaemia
Polycythemia
Jaundice
Obesity, abnormal glucose tolerance, GDM &Type 2 diabetes in adolescence and adulthood.
Risks to Mother Pre-eclampsia
Polyhydramnios
Caesarean Birth
Future risk of GDM 50% next pregnancy 70% if you have had it in first two pregnancies.
Future risk of Type 2- 50%
Testing for GDMNew recommendations ADIPS 2014 (nov) (RANZCOG Endorsed)
All women not known to have pre pregnancy diabetes or hyperglycemia
in pregnancy should undergo 75gm OGTT at 24-28 weeks (Glucose
Challenge Test (GCT) screening no longer recommended)
Those Identified as HIGHER RISK should undergo a 75gm OGTT early
in pregnancy or at the fist opportunity after conception.
Women in the HIGHER RISK group who have a normal result on early
pregnancy testing should have a repeat 75gm OGTT at usual time of 24-
28wks. However a OGTT should be performed at any earlier time if
clinically indicated.
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GDM Risk Factors
Higher risk groups- (any of below)
Previous hyperglycaemia in pregnancy
Previously elevated BGL
Maternal age ≥40 yrs.
Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African.
Family History of Diabetes (1st degree relative or a sister with GDM)
Pre pregnancy BMI >30kg/m2
Previous macrosomia (baby birth wt >4500gm or >90th centile)
Polycystic ovarian syndrome
Medications: Corticosteroids, antipsychotics
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Diagnostic Criteria RANCOG Endorsed – recommended adoption Jan 1st 2015
Old Criteria: Fasting ≥5.5, 1hr- not considered, 2hr ≥ 8.0
GDM occurs in approx. 5-8% of Australian pregnancies (may increase to 12-14% with new diagnostic criteria)
Carbohydrate
glucose
g
g g g
Insulin
Pancreas
Muscle cell
g
g
g gg g g
g
Placenta
Hormones
Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm
Pre-Existing - Type 2 Diabetes
g
g
g
g
Carbohydrate
glucose
g
g g
g
Insulin
Pancreas
Muscle cell
g
g
g
gg g g
g
Placenta
Hormones
Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm
Pre-Existing - Type 1 Diabetes
g
g
g
g
Fat
cellFA
ketones
Foetal and maternal risks of Pre-existing Diabetes
Risks to Baby
Congenital abnormalities 2-3 higher risk than gen pop
Miscarriage/ foetal death
Intra uterine growth retardation- small for gestational age
Type 1 diabetes (greater if father has Type 1 diabetes) 2% mother vs 5% father
Macrosomia
Birth Trauma
Shoulder dystocia
Neonatal Hypoglycaemia
Respiratory Distress
Polycythemia
Jaundice
Hypocalcaemia
Obesity, abnormal glucose tolerance &Type 2 diabetes in adolescence and adulthood.
Risks to Mother
Some complications of diabetes accelerated by pregnancy eg renal damage and retinopathy.
UTI’s
Hypoglycaemia
Ketoacidosis- Type 1 diabetes
Pre-eclampsia
Polyhydramnios
Caesarean Birth
Normal BGLs are the aim pre pregnancy and throughout
pregnancy12
Type 1 & Type 2 Diabetes
Congenital Abnormalities
Congenital abnormalities (heart, CNS, neural tube, kidneys, GI ) 2-3 times higher risk than general population.
Malformation rates are related to the degree of hyperglycaemia
Most congenital abnormalities occur 3-6 weeks after conception -often before pregnancy is diagnosed.
Can result in miscarriage, Foetal death in utero
Women conceiving with HbA1c less than 7% have malformation rates comparable to non –diabetic women.
Pre pregnancy counselling vital
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GDM (no DM before pregnancy)
Pre-existing diabetes
Type 1
Type 2
Diet and Exercise Rx
Insulin Rx
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?? Metformin Rx
Treatment targets for self BG monitoring Varies between centres around Australia.
The Following are suggested by ADIPS Based on “best
available” data but need further research for RANZCOG
endorsement.
Fasting ≤ 5.0 mmol/l
(1 hour BG after commencing meal ≤ 7.4 mmol/l)- if can’t
wait to 2hrs
2 hour BG after commencing meal ≤ 6.7 mmol/l
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Medtronic Paradigm pump
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On admission
Check DMR for any admission instructions from GDM clinic
Check for Diabetes Labour management plan in DMR
Refer to Clinical Practice Guideline- Diabetes in pregnancy (on intranet)
Ring to inform endocrine unit during working hours if not urgent
at any time, if required urgently
In labour- GDM and Type 2 Diabetes
Withhold insulin when in labour
Aim is to keep the BGLs 4-7 mmol
This reduces the risk of neonatal hypoglycaemia
Check BGLs Hourly in labour
Contact Endocrinology unit If BGLs >7.0 an insulin infusion may be required (stop after delivery of placenta)
GDM -NO insulin after delivery
Type 2- Endocrinology review to assess if oral agents or insulin is required.
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Type 1 DM in labour
Hourly BGLs
Require an insulin infusion
Insulin pump patients – routinely cease pump and commence infusion when in labour
Type 1 After delivery
Reduce insulin infusion to 1/5th at delivery of placenta (do not stop infusion until restarting insulin injections)
Ongoing Insulin doses will NEED TO BE REDUCED to 1/5th of previous pregnancy doses
Do NOT withhold insulin or glucose even if not eating
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Elective Caesarean Section – On insulin
Clarify plan of management for pre, peri and post operation with endocrinology and anaesthetist.
Ideally caesarean sections for patients with insulin requiring diabetes should be scheduled early on the morning list to minimise disturbance of glucose metabolism.
Normal insulin night prior to Caesarean. Withhold morning insulin
Type 2 and GDM monitor BGL early morning and pre-op – if >7.0 insulin infusion may be required (cease infusion after delivery)
Patients with Type 1 diabetes switch to insulin and dextrose infusion in morning. Reduce rate One Fifth rate after delivery of the placenta.
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Insulin Infusion 50units Actrapid
in 50ml Normal saline
10% dextrose 12hrly rate
Insulin dextrose Intravenous Infusion
Extra 10units Actrapid in
10ml Normal saline to
prime through tubing
Preparing insulin infusionFollow MR18B insulin infusion order -contact endocrinologist for or.
Prepare Insulin Syringe Driver:
Make up 10 units (Actrapid) in 10mls normal saline (ie 1 unit per ml) prime infusion line with all of this solution before connecting – coats the tubing as insulin is sticky protein and will stick to plastic coating until fully coated.
Make up 50ml syringe with 50 units regular insulin (Actrapid) in 50mls normal saline (ie 1 unit per ml)
Connect to same cannula as dextrose infusion using Y lumen connector
Starting rate ordered by endocrinologist
Prepare Dextrose Infusion
10% Dextrose to commence at 12hrly rate when BGL less than 15mmol
Aim is to keep BGL’s 4-7mmol during labour- specific instructions need to be handwritten by Dr in lower section of infusion protocol.
Hourly BGL’s
Follow hypo treatment as per insulin infusion protocol MR 18B
Hypoglycaemia Treatment
Routine hypo treatment (when not on insulin infusion)
If BGL<3.9mmol
100ml lucozade (if able to swallow and conscious)
Repeat BGL 10mim
If still < 3.9 repeat lucozade 100ml
Give longer acting carb snack once >4.0mmol
If altered conscious state- 25ml IV Dextrose 50% slow push-retest in 5min- commence 8/24 10% dextrose.
(If no IV access Glucagon IM 1mg)
(Refer to hypoglycaemia treatment CPG)
Care post delivery
GDM
Diabetes educator review- advise risk of subsequent
risk of diabetes and GDM.
Check QID BGL 24 hrs (diet controlled) 48hrs (insulin)
notify endo if above 10
75 gm OGTT 6wks post partum
Review appointment GDM clinic or GP 8-10wks
postpartum
1-2 yearly OGTT if not pregnant
Early OGTT in next pregnancy – first visit or 12-14
wks gestation
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Care Post Delivery
Pre-Existing Diabetes
Continue QID BGL’s – Notify endocrinology if
BGL>10mmol or <3.5mmol
Diabetes Educator review- advise risk of
hypoglycaemia post delivery and after
breastfeeding
GDM clinic review 2-4wks
Ongoing follow-up at DIAB clinic or private
endocrinologist
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QUESTIONS?
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(HAPO) Hyperglycemia and Adverse Pregnancy
Outcomes Study
HAPO Study
5 year international study 23,000 women
AT ≈ 28wks subject had a 75g OGTT with fasting, 1 and 2 hour samples . Subjects and healthcare providers blinded to results unless FBG >5.8mmol/l or 2 hour value >11.1 then out of study and treated.
Conclusions:
BGL’s that are elevated but under diagnostic level of GDM have increased risks usually associated with GDM.
Data showed a continuous increase in risk as blood glucose levels rise of:
Large birth weight
High blood insulin levels in the newborn
Primary Caesarean birth
Pre-eclampsia and shoulder dystocia/birth injury
Was not significantly associated with hypoglycaemia in the newborn requiring treatment
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The HAPO Study Cooperative Research Group. N Engl J Med 2008;358:1991-2002
Frequency of Primary Outcomes across the Glucose Categories
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References
RANZCOG July 2014 Diagnosis of Gestational Diabetes Mellitus (GDM) and Diabetes Mellitus in Pregnancy
ADIPS Consensus Guidelines for the Testing and Diagnosis of Gestational Diabetes Mellitus in Australia- Nov
2014
The HAPO Study Co-Operative Research Group 2008 “Hyperglycemia and Adverse Pregnancy Outcomes” NEJM May 2008 Vol358 no19
Nankervis A. 2001 “Diabetes and Pregnancy: Women’s Experiences and Medical Guidelines” Miravana Publishers Australia
Nankervis A 2007 “Gestational Diabetes” Diabetes Management Vol19 June
Siri et al NEJM vol 341 no 23 December 1999 “Current concepts: Gestational Diabetes Mellitus”
Diabetes-genetics.org 2009 “Genetics of Diabetes Mellitus”
MacNeil et al 2001 “rates and Risk Factors for Recurrence of Gestational Diabets” Diabetes Care Vol24 no4 April.
2007 National Institute of Diabetes and Digestive and Kidney Diseases: National diabetes statistics fact sheet: general information and national estimates on diabetes in the United States, 2007.
Hoffman et al, The Australian Diabetes in Pregnancy Society “Gestational diabetes mellitus- management guidelines” MJA1999 169:93-97
Gabbe SG et al Obstet Gynecol 2003:102 856-888. As cited in Pumps in Pregnancy Presentation Dr Alan O Marcus 2007
The Australian Diabetes in Pregnancy Society 2005 “Consensus Guidelines for the management of patients with Type1 and Type 2 diabetes in relation to Pregnancy guide” http://www.adips.org/content/ADIPS_PreGDM_Guidelines.pdf
Nankervis A Conn,J 2013 Gestational diabetes mellitus: Negotiating the confusion. Australian Family Physician Vol.42 No.8 August p528-531
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