IMM Diabetes in Pregnancy
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When is period of organogenesis? (Infant most negatively affected by unstable blood sugars)
17-56 days after conception
What is target HbA1c in woman with diabetes?
Less than 1% above the normal range (4% to 6%).
What lab tests to expect in woman with diabetes?
- Pap smear
- serum creatinine
- thryroid studies
- 24hr urine eval for total protein
- creatine clearance
Diabetic meds NOT recommended during pregnancy
Statins (Category X)---discontinue before conception
ARB's (angiotensin receptor blockers)
Possible preconception recommendation for diabetic medications
"If oral diabetic agents are being used, the woman should be switched to insulin therapy." (Glyburide and Metformin not FDA approved)
What do you need to remember about diabetes and eyes?
- woman should get dilated retinal examination done before pregnancy
Recommended heart screenings before pregnancy
- Lipid panel
- blood pressure
- goal: evaluate if pt can tolerate increased cardiac demands of pregnancy
Diabetes and nervous system
assess for peripheral and autonomic neuropathy
Contraception and diabetes
Diabetic woman can take contraception if she is non smoker and if she doesn't have vasculopathy.
Even with euglycemia, congenital anomalies are 2-3% (in general population)
Three ways to diagnose diabetes
- 1. Acute symptoms plus random plasma glucose of 200 mg/dL or higher.
- 2. Fasting (no calorie intake for 8hrs) plasma glucose 126 mg/dL or higher.
- 3. 2 Hr plasma glucose 200 mg/dL or higher during OGTT. (Must use 75g anhydrous glucose dissolved in water)
Diagnostic criteria for impaired glucose--- "prediabetes"
1. Impaired fasting glucose is diagnosed when fasting glucose level are 100 to 125 mg/dL
2. Impaired glucose tolerance (IGT) is diagnosed when 2hr oral glucose tolerance values are 140 mg/dL to 199 mg/dL
Gestational diabetes characteristics:
glucose intolerance develops or is first discovered during pregnancy (may have underlying diabetes that is undiagnosed)
after pregnancy, diabetes classification may be changed to type 1, 2, IFG, IGT, or normoglycemic
occurrence of gestational diabetes increases future risk for progression to type 2 diabetes
Normal glucose metabolism
- 1. Carbs broken down into glucose
- 2. Glucose to bloodstream
- 3. Blood glucose stimulates pancreas to release insulin
- 4. Insulin released from beta cells in islets of Langerhans. Insulin is released in two phases: 1)bolus release owing to high sugar in blood and 2) basal release is gradual release of insulin, under feedback control of blood glucose.
- 5. Insulin causes the following actions:
- *) stimulates entry of glucose into cells for utilization as energy, *) promotes the storage of glucose as glycogen in muscles and liver cells, *) inhibits release of glucose from liver or muscle glygogen, *) stimulates entry of amino acids into cells, *) enhances fat storage and prevents the mobilization of fat for energy, *) inhibits the formation of glucose from non-carbohydrates (ie amino acids).
5 characteristics of type 1 diabetes
- 1. Develops at any age, but two thirds of all cases are diagnosed before age 18.
- 2. Symptoms include significant weight loss, polyuria, and polydipsia with hyperglycemia.
- 3. DKA is possible.
- 4. The pt is dependent on exogenous insulin.
- 5. Coma and death can result if diagnosis and/or treatment are delayed.
8 characteristics of type 2 diabetes
- 1. Accounts for 90-95% of all diabetes in the United States.
- 2. It is usually diagnosed after the age of 30, but can occur at any age.
- 3. Often, patients are asymptomatic at the time of diagnosis. Because type 2 frequently goes undiagnosed for years, many patients have end-organ complications such as retinopathy, neuropathy, or nephropathy at the time of diagnosis.
- 4. Endogenous insulin levels may be increased, normal or decreased. The need for exogenous insulin is variable.
- 5. Insulin resistance with impaired glucose tolerance is usually seen in the first stages.
- 6. Risks of developing type 2 diabetesincreases with age, obesity, and lack of physical activity.
- 7. HHNS may develop.
- 8. Most patients are obese or have an increased percentage of body fat distributed mainly in the abdominal region.
Definition of gestational diabetes
Glucose intolerance develops or is first discovered during pregnancy: insulin resistance and diminished insulin secretion is usually seen.
At what gestational age should laboratory screening for gestational diabetes be performed?
24-28 weeks gestation
What are premeal blood glucose goals during pregnancy?
What are 1-hr postprandial blood glucose goals during pregnancy?
Less than 130 to 140 mg/dL
What does the HbA1c measure?
It reflects the weighted mean of blood glucose over the past 4-6 weeks.
What is hypoglycemia? (Adult)
Blood glucose level of 70 mg/dL or lower.
What are the caloric requirements for a type 2 diabetic pregnant woman who is 5' 2" and 258lbs.
258 lbs =117 kg
117 x 25 kcal/kg per day = 2925 kcal per day
What are general guidelines that should be followed during exercise in pregnancy?
1. Medical evaluation before initiating program. Be educated on risks/benefits
2. Obtain metabolic control before exercising (glucose between 90 and 140). If blood glucose is above 250, check urine for ketones. If ketones are negative but blood glucose is over 300, be cautious with exercise.
3. Exercise programs should last less than 45 minutes.
4. Meals should be consumed 1-3 hrs before the exercise program.
5. Insulin should be given in the abdomen and not injected into active muscles. Decrease the bolus insulin if its peak coincides with the exercise period.
6. Monitor blood glucose before and after exercise. Identify when changes in the insulin regimen or diet are necessary. Learn the way the body responds to different types of exercise.
7. Monitor necessary food intake. Eat extra carbs as needed to prevent hypoglycemia and always have carbs available during and after exercise.
8. Include a warm up and cool down period with each exercise session.
9. Avoid exercising in the supine position after the first trimester to prevent aortocaval compression and hypotension.
What is the major complication of insulin therapy?
Should oral diabetic medications be used during pregnancy in type 2 diabetic women?
According to IMM, no. Use has not been approved by FDA.
What changes in insulin requirements occurr during the first, second, and third trimesters?
1st trimester: insulin requirements are slightly decreased
2nd and 3rd: insulin requirements increase
decrease during the immediate postpartum
What conditions of diabetes are affected by pregnancy?
coronary artery disease
When does the fetal pancreas begin to function?
When and how often should NST's begin in pregestational diabetes?
NST's at 32 weeks on a weekly basis and increase to twice a week at 36 weeks gestation.
Can oral diabetic medications be used while breastfeeding?
No. They are secreted through the breastmilk and may affect the infant.
How is gestational diabetes diagnosed?
Elevated 1 hour screening glucose challenge test of 140 mg/dL or greater, followed by diagnostic 3-hr glucose challenge test.
Pt is diagnosed with gestational diabetes if two or more values exceed the following:
- fasting: 105 mg/dL
- 1 hr: 190 mg/dL
- 2 hr: 165 mg/dL
- 3 hr: 145 mg/dL
What is recommended dose of folic acid for women of childbearing age?
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