GD Flashcards
WHat are the 2 categories of diabetes in pregnancy?
- Pregestational diabetes: Pregnancy in pre-existing diabetes
• Type 1 diabetes • Type 2 diabetes - Diabetes in Pregnancy: Diabetes diagnosed in pregnancy
what is gestational diabetes?
type of diabetes that is diagnosed during the second or third semester of pregnancy
how common is GDM?
between 3 and 20% of women develop it, depending on the risk factors
Does GDM stay after birth?
usually goes away
When and how should women be tested for GDM?
do oral glucose tolerance test 24-26 weeks gestation
doctor may decide to do an earlier test if other risk are present: obesity, family history, history of gestational diabetes
6 weeks – 6 months postpartum it is important that women have another oral glucose tolerance test to make sure.
GDM risk factors
- Previous dx of GDM
- Hx of prediabetes- predisposes to be insulin resistant
- Age ≥ 35 years
- Obesity (a body mass index greater than or equal to 30 kg/m2)
- Family hx of type 2 diabetes
- Polycystic Ovary Disease (PCOS)
- Acanthosis nigricans (darkened patches on skin)
- Corticosteroid use
- Hx of macrosomic infant (large for gestational age(LGA);>4kg)
- Member of high risk population (e.g.African,Arab,Asian,Hispanic,IndigenousorSouthAsian)
Risks of persistent hyperglycemia during pregnancy for the mother
- Increased need for C-Section
- Higher rates of pre-eclampsia
- Development of metabolic syndrome and T2DM later on in life
Risks of persistent hyperglycemia during pregnancy for the fetus
- Fetal macrosomia and increased risk for infant shoulder dystocia during childbirth
- Neonatal metabolic instabilities including hypoglycemia and hyperbilirubinemia
- Stillbirth (increased risk for untreated GDM)
Why is there hypoGL in the fetus? How is it managed?
hypoGL can happen because during pregnancy when BG is high, the baby adapts (produces more insulin)
when baby gets born, his/her insulin levels still remains high-> low BG
babies have to put on IV with D5 and their BG is tested during first few hours after birth
which fetal risk factors can be decreased via GDM treatment?
treating GD can decrease the risk of macrosomia and shoulder dystocia
GDM prevention reccs
In women at high risk for GDM based on pre-existing risk factors, nutrition counseling should be provided on healthy eating and prevention of excessive gestational weight gain in early pregnancy, ideally before 15 weeks of gestation, to reduce the risk of GDM
when should dietary changes be introduced to prevent GDM?
thus women should focus on the diet PRIOR to getting pregnant to decrease the risk of gestational diabetes
Incidence of GDM is higher in women that
- consume 5 or more regular soft drinks per week (regular soft drink intake was found to be an independent risk factor for GDM)
- Have a higher intake of red meat, processed meat, animal fat and cholesterol prior to pregnancy
- Have a pre-pregnancy BMI greater than25
- Have a higher ferritin level as well as a higher heme iron intake
- Follow a typical western dietary pattern
- Have an excessive rate of weight gain in the first trimester of pregnancy (weight gain of 0.41Kg per week or more have a 40-74% higher risk)
Gestational Diabetes (GDM) Screening in Quebec
Universal screening for GDM @ 24-28 weeks gestational age
Screen earlier if risk factors for GDM (Rescreen at 24-28 weeks if earlier screen was negative)
Early Screening for Women at High Risk for Type 2 Diabetes
Women at high risk of type 2 diabetes:
- Screen with A1C (or FPG if A1C unreliable) in first trimester
- A1C ≥6.5% or FPG ≥7.0 mmol/L-> treat like type 2 diabetes
- Confirm diagnosis post-partum
2018 GDM Diagnosis: Two Approaches
2-step approach- preferred
1-step (alternative)
describe 2 step GDM diagnosis approach
women 24-28w ->50g glucose challenge test with 1h PG value
(If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy)
Results:
1. Uf 1h PG value is <7.8 we consider it as normal and re-access at 24-28w if the test was done earlier
2. If 1h PG is 7.8-11-> 75g oral glucose test is done and fasting, 1h and 2h plasma glucose values are measure
Cut-offs for diagnosis:
FBG≥ 5.3
1h BG≥ 10.6
2h BG≥ 9
only one value has to be met and exceeded to diagnose GDM
3. if 1h PG is ≥11.-> diagnose right away
describe 1 step GDM diagnosis approach
All pregnant women 24-28 weeks(If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy)
75g glucose are given fasting, 1hPG, and 2h PG are tested GDM is diagnosed if FPG≥5.1mmol 1hPG≥10mmol 2hPG≥8.5 mmol if 1 value is met or exceeded-> GDM
Blood glucose targets in pregnancy
Fasting Blood Glucose: <5.3 mmol/L
Blood glucose 1-hour after meals: < 7.8 mmol/L
Blood glucose 2-hours after meals: < 6.7 mmol/L
When is pharmacologic therapy initiated if glycemic targets not achieved? What is the starting treatment?
If glycemic targets not achieved within 1-2 weeks, initiate pharmacologic therapy. We would start with 4 units of long acting insulin in the evening and adjust daily based on fasting blood glucose levels)
Blood Glucose Targets (If on HS or meal-time insulin insulin)
Fasting Blood If on HS insulin: 4.2-4.7 mmol/L
Blood glucose 1-hour after meals (if on meal-time insulin): 5.5-7.2 mmol/L
What dictates which type of insulin is administered?
Normaly we start with bed-time
if BG is high at 1 particular meal- insulin will be prescribed for that meal, or 3 meals if 3 meals are affected
if the client is having trouble controlling the diet- sliding target insulin is give, so the amount is adjusted according to the amount of food consumed
What can ketones in the urine indicate?
- When found in the urine, they can indicate insufficient intake, too much time between meals/snacks, dehydration or blood glucose levels are too high
- Small amounts of ketones in the morning urine can result from not eating enough the previous day.
what is the cut-off for hypoglycemia in pregnancy?
different cut-off value for hypoGL: BG <3.8mmol
What are the potential causes of hypoGL
- Ate less than usual or delayed your meal
- were more active than usual
- took more medication than planned
- had alcohol with the food
What is the 1st line med for GDM management?
Insulin first-line
• May use aspart, lispro, glulisine: perinatal outcomes similar
insulin is safe for mom and fetus
What is the alternative med for GDM management?
- Metformin may be used as an alternative to insulin
• Good safety data in pregnancy
• Evidence of less maternal weight gain, less large-for-gestational-age, less neonatal hypoglycemia
• Women should be informed that it crosses the placenta
• Safety data in offspring postpartum up to 2 years
• Insulin necessary in 40% on metformin - Glyburide may be used in women who refuse insulin and not well controlled on metformin
when do women with GDM usually give birth?
women with GDM are usually made give birth before 40 weeks
cannot do earlier that 37 or 38 weeks because babies lungs are not fully developed and f they did deliver before that, they would have to give betamethasone which can increase BG
betamethasone is primarily used to speed up lung development in preterm fetuses.
can we do anything if we only have 1 week before labour?
even if we only have 1 week, we can work on blood glucose control which will help reduce the risk of neonatal hypoglycaemia during the first few hours of birth
when is there a change in hormones that leads to an increased insulin resistance?
24-28 weeks
A first nutrition intervention should occur within __ hours of diagnosis of GDM and followed by __s during the pregnancy
A first nutrition intervention should occur within 48 hours of diagnosis of GDM and followed by 3 other visits during the pregnancy
what is the aim of a diet in GDM
avoid insulin therapy
institute of medicine guidelines for gestational weight gain
BMI <18.5
Recommended range of total weight gain (Kg): 12.5-18.0
Recommended weekly rate of weight gain in 2nd and 3rd trimesters: 0.5kg/week
BMI 18.5 - 24.9
Recommended range of total weight gain (Kg): 11.5 – 16.0
Recommended weekly rate of weight gain in 2nd and 3rd trimesters: 0.4Kg/wk
BMI 25.0 - 29.9
Recommended range of total weight gain (Kg): 7.0-11.5
Recommended weekly rate of weight gain in 2nd and 3rd trimesters: 0.3kg/week
BMI >30
Recommended range of total weight gain (Kg): 5-9
Recommended weekly rate of weight gain in 2nd and 3rd trimesters: 0.2kg/week
reccs for a mom with excessive weight but underweight baby
gain more weight
which BMI class requires little to no weight gain
obese class 2 and 3
what do energy intake requirements in pregnancy reflect? What are thee aimed at?
Energy intake requirements in pregnancy reflect the amount of energy needed to support maternal and fetal metabolism and fetal growth and accumulation of energy depots during pregnancy.
Energy requirements during pregnancy are not aimed at weight maintenance but rather for appropriate rates of weight gain which in turn helps to minimize risks of adverse outcomes in the mother and her offspring.
is there an accurate way to predict recommended energy intake?
Current methods to assess energy intake requirements are limited in their prediction of energy expenditure and storage.
what Are the estimate recommendations for caloric intake per day for gestational weight gain for each class of BMI
underweight women store 360 Kcal/day as fat tissue,
normal weight women store about 240 Kcal/day
overweight women store 165 Kcal/day and obese women do not store energy at all but instead mobilize 260 Kcal/day from adipose tissue
what do we use to predict energy requirements for pregnant women?
BMI of ≤18.5 35-40 Kcal/kg
BMI of 18.5: 30-34Kcal/kg
BMI of 25-30: 25-29Kcal/kg
BMI of ≥ 30: ≤ 24Kcal/kg
or
14–18 years of Age
a) Estimated Energy Requirement (kcal/day) = Total Energy Expenditure + Energy Deposition
b) EER = 135.3 − (30.8 × age [y]) + PA × [(10.0 × weight [kg]) + (934 × height [m])] + 25
19 Years and Older
a) Estimated Energy Requirement (kcal/day) = Total Energy Expenditure
b) EER = 354 − (6.91 × age [y]) + PA × [(9.36 × weight [kg]) + (726 v height [m])]
PAL factors
14-18 yo Sedentary ( P AL 1.0– 1.39): 1.0 Low Active (P AL 1.4–1.59): 1.16 Active (P AL 1.6–1.89): 1.31 Very Active (P AL 1.9–2.5): 1.56
19+ yo Sedentary ( P AL 1.0– 1.39): 1.0 Low Active (P AL 1.4–1.59): 1.12 Active (P AL 1.6–1.89): 1.27 Very Active (P AL 1.9–2.5): 1.45
Which method of energy estimation usually over estimates Energy Requirements for preggy women
TEE
DRI’s for Macronutrients
- No DRI for fat
- ADA Standards of Care 2020 state that pregnant women with GDM also require a minimum of 28 g of fiber and that protein intake should be a minimum of 71 g per day.
≤ 18 y-50 y
Carbohydrate 175
Protein 1.1
Fat N/A
DRI’s for calcium
≤ 18 y: 1300
19-50: 1000
Health Canada recommendations for supplements for pregnant women
- Health Canada recommends a supplement that has 16 to 20 mg of iron in each daily dose.
- Health Canada also recommends that pregnant women take a daily multivitamin containing 400 mcg (0.4 mg) of folic acid (Health Canada, 2009).
- Women can find both nutrients in a multivitamin.
- Caution women not to take more than one daily dose of their multivitamin. This will help women not to go over the UL for vitamin A, which is 3,000 mcg retinol activity equivalent (RAE)8 or 10,000 IU .
DRI’s for iron and folate
Iron: 27mg/day
Folate: 600mg/day
DRI’s for sodium. Dangers for excess?
women with GDM are at high risk of pre-eclampsia-> important to monitor sodium intake
18-50 y.o: Ai 1500; Ul 2300
Recommendations for Caffeine Intake
• Maximum daily caffeine intake of no more than 300 mg/day —a little over two eight-ounce (237 ml) cups of coffee. This total should include natural sources of caffeine, including herbs such as guarana and yerba mate.
Herbal teas that are dangerous and safe
To avoid: chammomile! Juniper berries, Labrador tea, Pennyroyal, sassafras, lobelia, senna leaves, duck roots, comfrey, buck thorn bark, alloe
Safe: citrus/orange peel, Ginger, lemon balm, linden flower, rose hip
Recommendations for Fish (Mercury)
• Maximum of 300 g per week of canned albacore tuna • The following fish have higher levels of mercury and their intake should be avoided • shark, • Marlin • Swordfish • Escolar • Orange roughy
Cheese safety
• All hard cheeses are safe in pregnancy even if they’re made with unpasteurised milk.
Other than mould-ripened soft cheeses, all other soft types of cheese are OK to eat, provided they’re made from pasteurised milk
Nutrition Intervention
for Gestational Diabetes
- Eating small, frequent meals will help spread carbohydrate intake evenly throughout the day. This will help keep blood glucose levels within target as well as minimize nausea and formation of ketones.
- Including a source of protein at each meal and snack to also help to stabilize blood glucose levels.
- A minimum of 175 g of carbohydrate per day is recommended for all pregnant women.
advice for when pregnant women want to consume desserts like ice cream
If consuming them, take in small quantities at meals where the protein and fibre from other foods can help regulate rise in blood glucose levels. Encourage patients to test a variety of foods and let their numbers do the talking.
and carbs in the __ form tend to increase BG faster
and carbs in the liquid form tend to increase BG faster
when is the hardest time to control BG?
often GDM have problems to control BG fasting in the morning and 1h after breakfast
this is often affected by behaviour the night before
often times, BG will go low during nigh-> liver will try to compensate-> high BG
What can be done to control high blood glucose levels in the morning
- they may need to limit carbohydrate choice at bedtime snack to whole grain bread or crackers with egg, cheese or peanut butter as most women have an easier time getting to target with these choices.
- Encourage them to try taking their bedtime snack as late as possible so that there isn’t more than 8 hours between that snack and breakfast the following morning.
Which foods are not recommended at breakfast or bedtime snack
- Remembering that even low GI cereals can raise blood glucose levels above target for many women with GDM so often fruit, cereal and milk products are not recommended at breakfast or bedtime snack
- Many women struggle with keeping their 1 hour post meal blood glucose in target if they choose milk, yoghurt, cereal or fruit at breakfast. It is often best to wait for a mid morning or mid afternoon snack to have these foods remembering to add a source of protein.
what is the target carb amount per meal?
30-40g
what is the tips she gave if women don’t like cheese as a snack
eat 10 almonds instead
What is the maximum time gap between bedtime snack and the breakfast the following morning
8h
Artificial sweetener recommendation during pregnancy
Cyclamates (Sucaryl®, Sugar Twin®, Sweet N’Low® and Weight Watcher’s® Table-Top Sweetener are NOT recommended for use during pregnancy
• The Canadian Food Inspection Agency requires a statement that the sweetener should be used only on the advice of a physician whereas
Diabetes Canada suggests they are safe in pregnancy but recommend caution in exceeding the acceptable daily intake (ADI) which would translate into a maximum of 2 packets of Sugar Twin® per day
What are the benefits of physical activity
- improve glycemic control
- Facilitate weight control
- Improve insulin sensitivity
The risk of GDM is inversely proportional to the degree of PA in the first year PRIOR to pregnancy. Risk reduction 51 and 48% if a woman exercised prior to and early on in pregnancy and if started before pregnancy and continued throughout pregnancy risk
reduction of 69%
CSEP 2019 recommendations for PA during Pregnancy
- All women without contraindication should be physically active throughout pregnancy.
- Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications.
- Physical activity should be accumulated over a minimum of three days per week; however, being active everyday is encouraged.
- Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial.
- Pelvic floor muscle training (e.g.,Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction in proper technique is recommended to obtain optimal benefits.
- Pregnant women who experience light headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position.
Physical activity recommendations in terms of time in blood glucose control
- Exercising 1 hour after meals can be beneficial in decreasing the hyperglycemic impact of the meal
- Exercising 10 minutes after a meal improves blood glucose more so than 30 minutes of exercise at another time of day
Practical tips for follow/up
- Weight check to see that rate of weight gain and /or total weight gain to date are within targets
- If weight gain is higher than target and fetus is at high percentile weight on 32 week ultrasound it will be more important to focus on managing weight gain than if fetus is on lower percentile based on 32 week ultrasound results
- BG control at various times of day which can guide which recommendations to make re potential changes in dietary habits or requiring insulin either at bedtime and/or meal(s)
GDM: Glycemic Management During Labour and Delivery
Keep maternal blood glucose between 4.0 and 7.0 mmol/Làreduce risk of neonatal hypoglycemia
Gestational Diabetes Postpartum recommendations
- Women with GDM should be encouraged to breastfeed immediately after delivery in order to avoid neonatal hypoglycemia and to continue for at least 3-4 months postpartum in order to prevent childhood obesity and diabetes in the offspring and to reduce risk of type 2 diabetes and hypertension in the mother
- In women with prior GDM who has IGT on postpartum screening, healthy behaviour interventions with or without metformin can be used in women to prevent/delay the onset of diabetes
Describe the results and interpretation of 75 g oral glucose tolerance test postpartum
- Done six weeks to six months postpartum
- If diagnosed with diabetes early in pregnancy, do FPG or OGTT at 6-8 weeks postpartum
- Normal- Healthy behaviour interventions
- Impaired glucose tolerance - Healthy behaviour interventions +/- metformin
- Type 2 diabetes- Healthy behaviour interventions +/- metformin +/- insulin
Tips for blood glucose control in terms of carbohydrates and their portions
watch the portions (e.g. rice)- if portion decreases, but BG doesn’t improve-> of the client if she wants to go for alternatives- e.g. brown rice
How soon should the woman have breakfast after waking up? Why?
break the fast within 30 min of waking up- the faster you go w/o the food, the higher your BG be
When would be concerned when the baby is underweight and the mom is over-weight
when we think the weight gain is related to fluid retention and they have high BP- signs of pre-eclampsia
What is her risk of hypoglycaemia and the baby after birth
when the umbilical cord is cut, there’s no more supply of glucose to the baby, but the baby is producing insulin - risk of hypoGL in newborns, especially in those who have GDM mom
What are the possible reasons for ketones in blood
- body is used fats for energy-> not eating enough CHO, breaks are too long in-between the meals, BG is too high which means that cells are not getting glucose and have to use other ways of generating energy
- dehydration
How does the time of test for ketones affect the results
if testing after meals-> presence of ketones will be more a sign of dehydration than anything else
if tested before meals-> better indication of adequacy of CHO, timing of meals and snacks
What are random blood glucose high numbers and pattern of high numbers
random high numbers are more indicative of lifestyle (exercise, food, sleep, stress)
a pattern of high numbers is more indicative of insulin problems
usually we adjust __ insulin to help control morning BG
usually we adjust bedtime insulin to help control morning BG
what AC BG would suggest the need for insulin?
with BG levels in the morning around 6 mmol/L the doctor would definitely suggest evening insulin
what do you need to check when ketones are present in the blood?
1) are they eating enough carbohydrate 2) are they taking their snacks 3) are their BG levels above target 4) are they drinking enough fluids.
If they are testing their urine for ketones before meals then we are looking at the first 3 reasons for ketone formation. If they are testing their urine for ketones after meals it could also be because of dehydration if they are consuming adequate carbs and taking their snacks.
