Diabetes in Pregnancy Gestational Diabetes Protocols in a Primary Care Setting

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. The Impact of Maternal Hyperglycemia During Pregnancy Modified Pedersen Hypothesis. Embryo. . IgG=immunoglobulin G. Mother. . . Placenta. Inexact Prevalence of Diabetes in Pregnancy in the United States. GDM=gestational diabetes mellitus. . . . Nondiabetes 92%. More than 200,000 sort 2 diabetes mellitus 135,000 GDM 6000 sort 1 diabetes mellitus = 341,000 pregnancies entangled by hyper

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Diabetes in Pregnancy Gestational Diabetes Protocols in a Primary Care Setting DAC September 8, 2006 La Familia Medical Center Paula Devitt,RN,CDE Sylvia Ornelas,CHW

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Maternal hyperglycemia Insulin Fetal pancreas fortified Fetal hyperinsulinemia IgG-immunizer bound Insulin resistance disorder The Impact of Maternal Hyperglycemia During Pregnancy Modified Pedersen Hypothesis Placenta Fetus Mother IgG=immunoglobulin G

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Approximate Prevalence of Diabetes in Pregnancy in the United States 4.022 Million Births in 2002 More than 200,000 sort 2 diabetes mellitus + 135,000 GDM + 6000 sort 1 diabetes mellitus = 341,000 pregnancies confused by hyperglycemia every year Diabetes 8% Diabetes 8% half GDM 24% Diagnosed T2DM Nondiabetes 92% 2% T1DM GDM=gestational diabetes mellitus

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In our practice a large number of the patients who were analyzed amid pregnancy were truly undiscovered sort 2 diabetics To deliver this is to screen all ladies of origination age for diabetes. To instruct all pregnant ladies on sound sustenance and on practice We set up an incorporated gathering pre-birth class for all pregnant ladies. To start with trimester, 2 nd trimester (26-28 weeks) and third trimester.

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Diabetes in Early Pregnancy (DIEP) Trial Probability of Pregnancy Loss by A1C Status Rate of pregnancy misfortune (%) Diabetes No diabetes Mills JL et al. N Engl J Med . 1988;319:1617-1623

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Diabetes and Pregnancy Type 1 and Type 2 Diabetes Preexisting diabetes conclusion Preconception care is basic Treat with insulin If untreated amid initial couple of weeks' growth, related with Spontaneous fetus removal Birth absconds If untreated amid second or third trimester, related with Fetal macrosomia Birth damage Maternal hypertension Maternal preeclampsia Future diabetes as well as stoutness in kid American Diabetes Association. Diabetes Care. 2006

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Potential Complications in Infants of Mothers With Diabetes Intrauterine death Spontaneous fetus removal Stillbirth Macrosomia Visceromegaly Cardiomegaly Hepatic expansion Birth harm Shoulder dystocia Erb's paralysis Diaphragmatic loss of motion Facial loss of motion Cerebral ischemia Hemorrhage in cerebrum, eyes, liver, genitalia Jovanovic L, ed in boss. Restorative Management of Pregnancy Complicated by Diabetes . third ed. Alexandria, Va: American Diabetes Association; 2000:133-149

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Potential Complications in Infants of Mothers With Diabetes Asphyxia Respiratory pain disorder Congenital distortions Cardiac imperfections Musculoskeletal disfigurements Metabolic variations from the norm Hypoglycemia Hypokalemia Hypocalcemia Hyperbilirubinemia Erythrocytosis Jovanovic L, ed in boss. Therapeutic Management of Pregnancy Complicated by Diabetes . third ed. Alexandria, Va: American Diabetes Association; 2000:133-149 Mills JL et al. Diabetes . 1979;28:292-293

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Preconception Care of Established Diabetes Blood Glucose Goals SMBG Fasting/premeal: 80 to110 mg/dL 1 hour postmeal: <155 mg/dL A1C In typical range (<6%, however in a perfect world <5%) Monitor until A1C is steady at <7 SMBG=self-observing of blood glucose Joslin Diabetes Center and Joslin Clinic; Guideline for Detection and Management of Diabetes in Pregnancy 9/14/2005

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Preconception Care of Established Diabetes Medical Goals Switch from oral specialist treatment to physiologic basal-bolus insulin substitution (sort 2 diabetes) Prevent hypoglycemia and ketoacidosis Blood weight <130/80 mm Hg Protein discharge levels <150 mg/24 hours Free T 4 >1.0 yet <1.6 ng/dL TSH <2.5 IU/mL Establish restorative group for continuous administration American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S76-S78

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Exception to suspending oral against diabetic meds amid pregnancy Metformin might be kept amid first trimester on patients with PCOS or sort 2 DM with anovulatory fruitlessness. At first visit ought to start expanding insulin to control glucose and decrease metformin.

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Other Meds ACE inhibitors must be halted before pregnancy or first trimester because of danger of fetal damage or end in 2 nd and third trimester. ARBs must be halted before pregnancy (Diltiazem in broadened discharge might be a helpful substitute. Stop all cholesterol bringing down specialists. Joslin Diabetes Center and Joslin Clinic; Guideline for Detection and Management of Diabetes in Pregnancy 9/14/2005

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Diabetes and Pregnancy Gestational Diabetes Mellitus Mainstay of treatment is therapeutic sustenance treatment (MNT) Add insulin if MNT does not keep up normoglycemia If untreated, related with: Late-term intrauterine fetal demise Fetal macrosomia Neonatal hypoglycemia or potentially jaundice Maternal hypertension Future diabetes as well as heftiness in youngster Glucose narrow mindedness of variable degree with onset or first acknowledgment amid pregnancy

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 180 mg/dL STOP Check Fasting BS >95 Diabetic Refer to HE, A1C Otherwise, regulate 3-h 100-g OGTT (at least 2 strange qualities, understanding has GDM) 1 h 180 mg/dL 2 h 155 mg/dL 3 h 140 mg/dL 140–180 mg/dL Administer FPG and 3-h 100-g OGTT on particular day Rescreen later in development If FPG  95 mg/dL STOP Patient has GDM Refer to Health Ed  130 mg/dL STOP Patient does not have GDM If quiet has GDM chance elements, rescreen at 24–28 weeks' growth GDM Screening and Diagnosis Universal Screening Guidelines Average and high hazard: Screen at admission Low hazard: Screen at 24 to 28 weeks' incubation Screen with 1-h 50-g GCT FPG=fasting plasma glucose Jovanovic-Peterson L et al. Am J Perinatol . 1997;14:221-228/ADA 2006 Diabetes Care

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SMBG During Pregnancy Complicated by Diabetes Blood Glucose Goals and Testing Frequency *2:00 – 4:00 AM if nighttime hypoglycemia is suspected

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Medical Nutrition Therapy in Pregnancy Complicated by Diabetes General Dietary Guidelines Eat 3 day by day suppers; nibble as required Eat a little breakfast Control starch consumption Eat low glycemic nourishments. Try not to limit under 130Gm of CHO. Pick nourishments high in fiber Choose sustenances low in soaked fat Avoid concentrated desserts Take a multivitamin with iron, folic corrosive, and calcium

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Nutrition Flags at a medicinal visit allude back to wellbeing instruction Poor weight pick up Ketones in their pee Refer Back to Health Education: Blood Sugars out of objective Need extra bolster Karla calls every patient week after week for Blood Sugars.

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Physical Activity in GDM Can enhance fringe insulin resistance and glucose levels Can hinder requirement for insulin Encouraged for ladies with no obstetric contraindications Avoid physical movement related with maternal hypertension or fetal trouble (eg, resistance preparing, bring down body weight-bearing activity) Upper-body cardiovascular preparing is a decent choice Jovanovic L, ed in boss. Medicinal Management of Pregnancy Complicated by Diabetes . third ed. Alexandria, Va: American Diabetes Association; 2000:111-132 Jovanovic-Peterson L et al. Am J Obstet Gynecol . 1989;161:415-419

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Prenatal Management Pre-existing DM . To begin with visit • A1C • gather 24 hr pee (protein, creatinine leeway, creatinine) • plan EKG • Schedule eye exam • Eye exam every trimester with set up eye mind supplier or allude for Joslin Vision Program in Health Education (Retinal Specialist on our group: Michael Seligson ) Class D-T renal assessment every trimester.

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Prenatal Mgt DM Schedule ultrasound arrangement Dating filter at 10 – 12 weeks Targeted check including fetal resound at 18-20 weeks Growth examine at 26 weeks and at regular intervals from that point NST + AFI twice week after week beginning at 32 weeks; begin at 28 - weeks if ineffectively controlled or class D-T.

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GDM Management Diet controlled • Follow fasting and 1 hr or 2 hr postprandial plasma glucose (1hour objective <130, 2 hour objective <120). • Growth check at 34-36 weeks to assess development Not controlled with eating routine alone Follow fasting and 1 hr or 2 hr postprandial plasma glucose (1hour objective <130/120, 2 hour objective <120). Development examine at regular intervals after insulin or oral solution began (yet no sooner than 26 weeks) Initiate twice week after week antenatal testing at 28 - 32 weeks

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Insulin Therapy: GDM Current body wt in kg x (.2-1.0 units) = Total every day measurement Total day by day dosage (TDD) is just a beginning stage. Insulin Should be balanced PRN to control blood glucose. Utilize Lispro to cover suppers, NPH to cover overnight Lispro ought to be taken 15 minutes before or promptly after every feast Units of Lispro TDD x .25 pre-breakfast TDD x .25 pre - lunch TDD x .25 pre – supper TDD x .25 NPH at sleep time Give NPH at sleep time to cover morning fasting. NPH dosage must be balanced in view of fasting blood sugars. NPH most basic middle of the road insulin utilized. Lantus offers a more consistent basal scope with less infusions. UNM Protocol

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Insulin Therapy: Insulin Bolus: (Humalog or Novolog) Current body wt in kg x (.6 to 1.0 units) =TDD Do not blend with other insulin Determine pre-dinner insulin utilizing principle of 1500 Premeal amendment 1500/TDD = mg/dl that 1 unit of insulin will diminish blood glucose Insulin/CHO Ratio (1500/TDD) x .33 = grams of CHO secured by 1 unit of insulin We more often than not begin with 1 unit for each serving of CHO and titrate up to keep post-prandial <120 TDD x .5 = general run for basal scope dosage. NPH titrated to keep up fasting at objective. Lantus day by day (Not considered in pregnancy) Concern Lantus may empower insulin-like development variable more than different insulins. Lantus:C

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Insulin Delivery Throughout Pregnancy Calculating Daily Insulin Dose for Pregnancy With Preexisting Diabetes Gestational week Insulin measurement 4 – 12 – 24 – 38 – 4

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