Transcript Diabetes in Pregnancy

Diabetes in Pregnancy:
Care Principles
Elizabeth Guevara, FNP-BC
Maternal Fetal Medicine - DM
Why Do We Care?
Insulin Requirements
Blood Glucose Ranges
GDM Background &
Incidence
 1964: Formal diagnostic criteria established for
gestational diabetes based on mother’s
increased risk of future development of diabetes
 lifetime risk of diabetes exceeded 70%
 GDM incidence in U.S. formerly ~2-10%, now
estimated ~18% with the ADA-endorsed IADPSG
2011 criteria
 Change from 2-step diagnosis (50 gm screen with
100 gm 3-hr GTT confirmation) to 75 gm 2-hr GTT
GDM: Recurrence Risk
 35-80% risk of GDM recurrence
 Higher risk of recurrence if:
 Parity: >1 in 1st GDM pregnancy
 Greater infant birth weight in 1st GDM pregnancy
 Maternal obesity (BMI > 30)
 Early GDM (<24 wks) in 1st GDM pregnancy
 Insulin requirement in 1st GDM pregnancy
 Weight gain > 7 kg in 1st GDM pregnancy
 Interval between pregnancies < 24 months
GDM: Future T2DM Risk
“The closer you are to diabetes in pregnancy, the
sooner you will become diabetic.”
 Variable quoted rates of conversion to T2DM
 22% some degree of glucose intolerance in immediate
postpartum period (2-hr GTT @ 6-8 wks PP)
 3.2% impaired fasting glucose (IFG)
 11% impaired glucose tolerance (IGT)
 2.1% both IFG and IGT
 5.8% (~5-10%) overt T2DM
 20-50% risk over the 10 years following pregnancy:
marked increased risk in first 5 years then plateaus after
10 years
 35-60% chance of developing T2DM in the following 1020 years
GDM: PP T2DM Risk Factors
 Impaired glucose tolerance postpartum
 Elevated fasting glucose during pregnancy: FPG > 121 in
pregnancy  risk 21-fold
 Obesity, especially abdominal obesity
 Postpartum weight gain
 Early GDM diagnosis (<20-24 wks gestation)
 Insulin use/requirement during pregnancy
 Physical Inactivity
 Diet higher in fat content (38-40% of total calories)
 High glycemic index / low fiber diet
GDM: Modifiable Risk
Factors
 Breastfeeding for at least 6 months
 Postpartum Weight loss
 Return to pre-pregnancy weight by 3 months PP
 Lose 5-10% of body weight
 Lose at least 10 pounds prior to next pregnancy
 Regular physical activity
Basic New Patient Teaching
 Medical Nutrition Therapy (MNT)
 Exercise
 Blood Glucose Meter Use & Testing Schedules
Medical Nutrition Therapy
 Food Groups
 “Carbohydrates” (starches)
 Dairy
 Fruits
 Vegetables
 Protein
 Fats
 Portion Amounts
 Measuring Cups
 Hand Jive
Carbohydrates/Starches
 Portion = 15 grams total carbohydrates
 Examples
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Bread: 1 slice whole grain
Tortilla: 1 corn or wheat (6”)
Rice & Pasta: 1/3 cup
Beans: ½ cup
Hot Cereal: ½ cup
Potato: 1 small or ½ medium (or ½ cup total)
Winter Squash, Corn, Peas, Sweet Potato: ½ cup
Crackers: 6 saltines
English Muffin: ½
Milk / Calcium-Rich Foods
 Portion = 15 grams total carbohydrates
 Examples
 Milk (~1%): 8 oz.
 Yogurt: 6 oz. plain or light yogurt (no fructose in
ingredients)
Fruits
 Portion = 15 grams total carbohydrates
 Examples: highly variable amounts
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Apple, Nectarine, Orange: 1 small
Banana: 1 small…in reality ½ normal banana
Blueberries: ¾ cup
Grapefruit: ½ large
Grapes: 17 small
Mango: ½ cup
Papaya & Melon: 1 cup
Pineapple: ¾ cup
Strawberries & Watermelon: 1 ¼ cups
Vegetables
 Portion = 5 grams total carbohydrates
 Amounts: 1 cup raw or ½ cup cooked
 Exceptions:
 Jicama: ½ cup
 Vegetable Juice: ½ cup
 “Starchy” vegetables: corn, peas, potato, sweet
potato / yam, winter squash (acorn, butternut,
kabocha, pumpkin, etc.) – count as Carbohydrate
Protein
 Portion ~ 7 grams protein
 Examples
 Canned Meats: ¼ cup
 Cheese: 1 oz.
 Cottage Cheese: ¼ cup
 Eggs: 1 whole or 2 egg whites
 Meats/Fish/Fowl: 1 oz.
 Peanut Butter: 1 tbsp natural
 Tofu: ½ cup
Fats
 Portion ~ 4.5 grams unsaturated fat
 Examples
 Avocado: 2 tbsp
 Olives: 8 black, 10 green
 Nuts
 Almonds: 6 whole
 Peanuts: 10 whole
 Pecans: 2 whole
 Walnuts: 2 whole
 Vegetable Oil: olive, canola 1 tsp
 Avoid All Animal (Saturated) Fats
Free Foods
 Portion = less than 5 grams total carbohydrates (<20
calories)
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Artificial Sweetener (no saccharin: crosses the placenta)
Broth (low sodium)
Decaffeinated Coffee & Tea
Drink Mix (sugar free)
Gelatin (sugar free)
Herbs (dried & fresh)
Lemon
Lettuce
Mushroom
Radish
Foods to Eliminate
 Avoid during pregnancy to prevent inducing
hyperglycemia
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Bagel / Muffin
Coffee Creamer / Flavored Milk
Condiments / Sauces: BBQ Sauce, Ketchup, Teriyaki Sauces
Fruit Juices / Flavored Drinks / Sodas
Ice Cream / Frozen Yogurt
Instant Cereals*
Jam / Jelly
Sugars: Honey, Sugar, Syrup
Sweets: Cake, Candy, Cookies, Custard, Donuts, Pies, Pudding
Basic Tenets of MNT in Pregnancy
 3 Meals & 3 Snacks Daily
 Meals
 Breakfast: 1-2 carbs, 1 protein, 1+ vegetables, ?1 fat
 1 egg, 1 whole wheat toast, spinach, ?oil
 No milk or fruit
 Lunch: 3 carbs, 4 proteins, 2+ vegetables, ?1 fat
 3 chicken tacos with salsa, side salad, ?avocado
 No milk or fruit
 Dinner: 3 carbs, 4 proteins, 2+ vegetable, ?1 fat
 1 medium baked potato, grilled fish, ½ cup corn,
broccoli, ?oil
 No milk or fruit
MNT for Diabetes in Pregnancy
 3 Meals & 3 Snacks Daily
 Snacks: between each meal and ~30-60 minutes
before bed
 1st 2 snacks: 1 milk, 1 fruit, 1 protein, ?1 fat
 8 oz. milk or 6 oz. yogurt, ½ banana, 1 cheese stick
(mozzarella), ?walnuts
 No “carbohydrate” foods
 Last snack: 1 dairy, 1 carb, 1 protein, ?1 fat
 8 oz. milk, ½ sandwich: 1 whole wheat bread, turkey,
lettuce, tomato ?mayo
 No fruit
MNT Timing
 Goal: no more than 10 hours between last snack &
breakfast
 Avoid elevated fasting blood glucose
 Avoid ketone production
 Meals are usually ~3 hours apart
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0800 Breakfast
1000 Snack
1300 Lunch
1600 Snack
1900 Dinner
2200 Snack
2230 Go to sleep
Nothing to eat until breakfast
Exercise
 Minimum goal = 30 minutes daily
 Standard recommendation: 10 minutes after
each meal
 Exercise after eating increases glucose uptake by
muscles
 Decreases postprandial blood glucose level
 Type of exercise
 Baseline level of exercise prior to pregnancy
 Avoid exercise that might cause trauma
 Exercise class: let instructor know to tailor routine for
pregnancy
SMBG Testing
 The minimum 4: all types of diabetes in pregnancy
 Fasting
 1 Hour PC (time from first bite of food)
 The extra 2: for patients on MDI insulin (3-4x daily)
 AC Dinner
 AC Last Snack
 Type 1 Diabetes: often 2-4 am test & AC lunch
 Additional tests
 Hypoglycemia symptoms
 When blood glucose result is radically different than
anticipated
Putting it Together
 Patient Log Brought To Each Visit!
Labs, Diagnostics, Delivery
 Hemoglobin A1C
 Ultrasounds for Growth
 30 weeks: on medication
 36-37 weeks: intended vaginal delivery
 Fetal Monitoring / Nonstress Test
 32-36 weeks: weekly testing if on meds
 40-41 weeks: no medication
 Vaginal Delivery Timing
 39-40 weeks: on medication
 40-41 week: no medication & good control
It Goes Beyond Pregnancy
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= Healthier Outcomes for
Individual, Familial & Societal Health