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Gestational Diabetes Update
Leigh Caplan RN CDE
Marsha Feldt RD CDE
SUNDEC - Diabetes Education Centre
May 22, 2009
Learning Objectives
• Review physiology of pregnancy and gestational diabetes
• Review CDA clinical practice guidelines for diagnosis and management of gestational diabetes
• Highlight nutrition therapy approaches• Discuss role of hospital based gestational diabetes
programs• Discuss post partum considerations for diabetes
risk and prevention
Case study:
Sue comes to see you for nutrition counselling
• 32 years old, BMI 25• family history of type 2• G1P0 26 wks gestation• Informs you she just received the diagnosis of
gestational diabetes• GTT results - 5.1, 10.7, 9.1
What do you do?
• Definition: Hyperglycemia with onset or first recognition during Pregnancy
• Prevalence 3.7% in non-aboriginal 8-18% in aboriginal populations
CDA CPG 2008
Gestational Diabetes
Physiology in Late Pregnancy
• Characterized by accelerated growth of the fetus
• A rise in blood levels of several diabetogenic hormones
• Food ingestion results in higher and more prolonged plasma glucose concentration
Physiology in Late Pregnancy
• Maternal insulin and glucagon do not cross the placenta
• During late pregnancy a women’s basal insulin levels are higher than non-gravid levels
• Food ingestion results in a twofold to threefold increase in insulin secretion
(Franz, M.J., 2001)
Physiology of GDM
• Gestational hormones
induce insulin
resistance
• Inadequate insulin
reserve and
hyperglycemia ensues
Fetal Risks
• Macrosomia - shoulder dystocia and related complications • Jaundice• Hypoglycemia• No increase in congenital anomalies
Exposure to GDM in utero
• LGA children or those born to obese mother have a 7% risk of developing IGT at 7-11 yrs age
• Breastfeeding may lower risk CDA CPG 2008
Gestational Diabetes
Maternal Risks
• C-section
• Pre-eclampsia
• Recurrence risk of GDM is 30-50%
• 30-60% lifetime risk in developing IFG, IGT or type 2 diabetes
CDA CPG 2008
Gestational Diabetes
GDM Screening
• All women should be screened for GDM between 24-28 weeks– vs. risk factor based approach which can
miss up to ½ the cases of GDM
• Women with multiple risk factors should be screened in the first trimester
Risk Factors: for first trimester screening
• > 35 yrs• BMI > 30 • Previous diagnosis of GDM• Delivery of a mascrosomic baby• Member of a high-risk population
– (Aboriginal, Hispanic, South Asian, Asian, African)• Acanthosis nigricans• Corticosteroid use• PCOS
Diagnosis of Gestational Diabetes
Gestational Diabetes Screen (GDS)
1 hr after 50g load of glucose
Value 75 g OGTT indicated
<7.8 mmol/L no
7.8-10.2 mmol/L yes
> 10.3 mmol/L No - GDM
Diagnosis of Gestational Diabetes
75 g OGTT
• GDM = 2 or more values greater than or equal to
• IGT = single abnormal value
Fasting > 5.3 mmol/L
1 hr > 10.6 mmol/L
2 hr > 8.9 mmol/L
Management of Gestational Diabetes
• Strive to achieve glycemic targets• Receive nutrition counselling from an
Registered Dietitian• Encourage physical activity • Avoid ketosis• If BG targets are not reached within 2
weeks then insulin therapy should be started
Target Blood Glucose Values for GDM
• Fasting/Pre-prandial: 3.8 – 5.2 mmol/L
• 1 hour 5.5 - 7.7mmol/L
• 2 hour 5.0 - 6.6mmol/L
Nutrition Therapy as treatment for GDM
• A tool to achieve appropriate nutrition and glycemic goals of pregnancy
• to normalize fetal growth and birth weight
Medical Nutrition Therapy for GDM
Definition:
A carbohydrate controlled meal plan with adequate nutrition for appropriate weight gain, normoglycemia, and the absence of ketones
Clinical Outcomes
• Achieve and maintain normoglycemia
• Promote adequate calories for wt gain in absence of ketones
• Consume food providing adequate nutrients for maternal and fetal health
GDM Nutrition Controversies
• What is a healthy weight gain for an obese woman with GDM?
• How far to manipulate energy intake?
• Does the balance of carbohydrate and fat matter?
Excess Weight Gain
• May increase incidence of GDM in future pregnancy
Obese women have larger babies• More likely to develop macrosomia if
gain >25lb• More likely to develop macrosomia with
high post prandial BG levels
Calorie Restricted Diets
• Avoid severe restriction - <1500 kcal not recommended
• Avoid ketones • 33% calorie restriction slowed wt gain
and improved BG – 1800 kcal
Role of Carbohydrate
• Carbohydrate can be modified to control postprandial glucose elevations
• High fiber not associated with lower glucose levels in GDM
• Lower carb intake (<42%) associated with; less insulin; less LGA
• Postprandial correlated with %CHO at meal; breakfast less tolerance
Emphasis for GDM
• Healthy Eating following CFG appropriate for adequate weight gain
• DRI= minimum 175 g CHO/day• Spacing of CHO into 3 meals & 2 to 4 snacks
• Smaller amounts of CHO at breakfast*
• Evening snack is important to prevent ketosis overnight
• Encourage activity as tolerated
Carbohydrate Counting with “Beyond the Basics”
• Canadian Diabetes Association meal planning guide
• Based on Canada’s food guide groups
• Each food group outlines portion sizes of various foods
• Each carbohydrate choice (grains/starch, fruit, milk) = 15 grams carbohydrate
Grains – 8-10 choices Fruit – 2-3 choices Milk – 3-4 choices
Dietary Fat in GDM
• up to 40% of total energy intake during pregnancy
• choose food source which are lower in saturated and transfats
Artificial Sweeteners
When used within ADI– Aspartame – does not cross placenta; no adverse
effects– Sucralose (splenda) – acceptable– Acesulfame potassium – acceptable
• Saccharin – crosses placenta; not acceptable• Cyclamates – not acceptable
Back to Sue 3 weeks later
• Trying to work with meal plan• Weight has been stable for 3 weeks• Blood glucose readings:
– Fasting 5.0 to 5.7– 2 hours pc breakfast 4.6 to 5.3– 2 hours pc lunch 5.7 to 6.5– 2 hours pc dinner 7.2 to 7.9What do you discuss with Sue?
Purpose of Insulin
• To achieve plasma glucose control nearly identical to those observed in women without diabetes
• Must be individualized • Insulin requirements will
change with various
stages of gestation(ADA. Medical Management of Pregnancy
Complicated by Diabetes., 2000)
Types of Insulin
Approved in pregnancy• Fast acting: Humalog , NovoRapid• Short acting: Regular/R• Intermediate acting: NPH/N
– Detemir can be used if woman unable to tolerate NPH ( Ongoing study to evaluate use in pregnancy)
– Glargine – avoid use
Devices for Insulin Delivery
Considerations for Adjusting Insulin
• Look for patterns in blood glucose readings
• Adjust for hypoglycemia first
• Then adjust for high blood glucose
Can oral hypoglycemia agents be used to treat GDM?
• Glyburide– Does not cross the placenta– Controlled BG in 80% of women– Women with high FBG less likely to respond to
Glyburide– More adverse perinatal outcomes compared to
insulin• Not approved in Canada
– use is considered off-label and requires appropriate discussions of risks with patient
CDA CPG 2008
Metformin – alone or with insulin was not associated with
increased perinatal complications compared with insulin
– Less severe hypoglycemia in neonates– Does cross the placenta – long term study MiG
TOFU ongoing
• Not approved in Canada– use is considered off-label and requires
appropriate discussions of risks with patientNEJM, 2008
Postpartum Physiology:
Once the placenta is delivered:
• Hormones clear from circulation
• They will be monitored in hospital if blood glucose remains elevated may require medications
Postpartum Focus:
• Encourage follow up with health care provider to have – OGTT (6 weeks to 6 months 75 g OGTT)– weight management, – postpartum visit with a registered dietitian– Encourage breastfeeding– Monitoring occasionally with meter– Future pregnancy
Breastfeeding and DM meds
• Both metformin and glyburide/glipizide are found at low concentrations (or not at all) in breast milk– Hale et al, Diabetologia 2002– Feig et al, Diabetes Care 2005– Can be considered however, more long-
term studies needed
SUNDEC– Diabetes Education Centre
(416) 480-4805
• Multidisciplinary team of health professionals ( RN, RD)
• Self referral• Individual counselling• Group education classes
• Type 2, Pre-diabetes, Diabetes Prevention and Seniors programs
Case 2Justine
Justine was diagnosed with gestational diabetes at 20 weeks, – pre-preg BMI = 28.7, GTT results were: 6.2, 10.2, 9.8
She is now at 25 weeks • FBS 6.1 – 7.4• 3 meals and 1 -2 snacks.
– Diet history: Oatmeal at breakfast, lunch and dinner consist of aprox. ½ cup rice, lots of vegetables and meat, in the afternoon a piece of fruit, 2 cups of milk at bed
• What would you do?
www.diabetes.ca
Resources and References
Canadian Diabetes Association: www.diabetes.ca-Recommendations for Nutrition Best Practice in the
Management of GDM-2003 Canadian Diabetes Association Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada
Nutrition for a Healthy Pregnancy: National Guidelines for the Child Bearing Years
Healthy Eating is in Store for you:www.healthyeatingisinstore.ca
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