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Gestational Diabetes
Update
Leigh Caplan RN CDE
Marsha Feldt RD CDE
SUNDEC - Diabetes Education Centre
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?
Gestational Diabetes
Definition:
Hyperglycemia with onset or first
recognition during Pregnancy
Prevalence
3.7% in non-aboriginal
8-18% in aboriginal populations
CDA CPG 2008
Physiology of GDM
Gestational hormones
induce insulin
resistance
Inadequate insulin
reserve and
hyperglycemia ensues
Gestational Diabetes
Fetal Risks
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
GDM Screening
All women should be screened for GDM
between 24-28 weeks
vs. risk factor based approach which can
miss up to the cases of GDM
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
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
1 hour
5.5 - 7.7
mmol/L
2 hour
5.0 - 6.6
mmol/L
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
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
Artificial Sweeteners
When used within ADI
Aspartame does not cross placenta; no adverse
effects
Sucralose (splenda) acceptable
Acesulfame potassium 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 7.9
What 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
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
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
Case 2
Justine
Justine was diagnosed with gestational diabetes at 20
weeks,
pre-preg BMI = 28.7, GTT results were: 6.2, 10.2, 9.8
www.diabetes.ca