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 womens 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 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 - 7.7 mmol/L

2 hour 5.0 - 6.6 mmol/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 Canadas 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 7.9
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

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 patient
NEJM, 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 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

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. 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