pregnancy Fiona McKeeman-Credentialled Diabetes Educator 1 - PowerPoint PPT Presentation

Diabetes in pregnancy Fiona McKeeman-Credentialled Diabetes Educator 1

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) 3

Gestational Diabetes 2-3 times Pancreas Carbohydrate Insulin glucose Muscle cell g g g g g g g g g g g g g Hormones Placenta

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  Risks to Mother  Macrosomia  Pre-eclampsia  Neonatal Hypoglycaemia  Polyhydramnios  Birth Trauma  Caesarean Birth  Shoulder dystocia  Future risk of GDM 50% next pregnancy 70% if you  Respiratory Distress have had it in first two  Hypocalcaemia pregnancies.  Polycythemia  Future risk of Type 2- 50%  Jaundice  Obesity, abnormal glucose tolerance, GDM &Type 2 diabetes in adolescence and adulthood.

Testing for GDM New 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. 7

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 (1 st degree relative or a sister with GDM)  Pre pregnancy BMI >30kg/m 2  Previous macrosomia (baby birth wt >4500gm or >90 th centile)  Polycystic ovarian syndrome  Medications: Corticosteroids, antipsychotics 8

Diagnostic Criteria RANCOG Endorsed – recommended adoption Jan 1 st 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) 9

Pre-Existing - Type 2 Diabetes Pancreas Carbohydrate Insulin glucose Muscle cell g g g g g g g g g g g g g g g g Hormones Placenta Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

Pre-Existing - Type 1 Diabetes Pancreas Carbohydrate Insulin g glucose Muscle cell g g g g ketones Fat g g g cell FA g g g g g g g g Hormones Placenta Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

Foetal and maternal risks of Pre-existing Diabetes Risks to Baby  Risks to Mother   Congenital abnormalities 2-3 higher risk than gen pop Some complications of   Miscarriage/ foetal death diabetes accelerated by pregnancy eg renal damage  Intra uterine growth retardation- small for gestational age and retinopathy.  Type 1 diabetes (greater if father has Type 1 UTI’s  diabetes) 2% mother vs 5% father Hypoglycaemia   Macrosomia Ketoacidosis- Type 1 diabetes   Birth Trauma Pre-eclampsia   Shoulder dystocia Polyhydramnios  Neonatal Hypoglycaemia   Respiratory Distress  Caesarean Birth  Polycythemia  Jaundice  Hypocalcaemia  Obesity, abnormal glucose tolerance &Type 2 diabetes in adolescence and adulthood. Normal BGLs are the aim pre pregnancy and throughout pregnancy 12

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 13

GDM (no DM before pregnancy) Diet and Exercise Rx Insulin Rx Pre-existing diabetes ?? Metformin Rx Type 1 Type 2 14

 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 15

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Medtronic Paradigm pump 17

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. 19

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 1/5 th at delivery of placenta (do not stop infusion until restarting insulin injections)  Ongoing Insulin doses will NEED TO BE REDUCED to 1/5 th of previous pregnancy doses  Do NOT withhold insulin or glucose even if not eating 20

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. 21

Insulin dextrose Intravenous Infusion 10% dextrose 12hrly rate Insulin Infusion 50units Actrapid in 50ml Normal saline Extra 10units Actrapid in 10ml Normal saline to prime through tubing

Preparing insulin infusion Follow 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 25