Management of hyperglycaemia in pregnancy

1. Management of hyperglycaemia in pregnancy Dr Vinita Malhotra Shanti Surgical Home

2. Whom to manage • All women diagnosed to have HIP must be treated irrespective of gestation • WHY?? • For a good maternal and perinatal outcome

3. Aims of management • To maintain blood sugar levels at • Fasting- < 95mg% • 2hr post meals - < 120 mg% • 2am to 6am - > 60 mg% • To ensure fetal and maternal wellbeing

5. Education • Need for strict glycemic control • Glycemic goals • Symptoms of hypoglycemia and its management • Importance of healthy diet and exercise • If requires insulin then how to take • Need for regular follow up • Use of glucometer

6. Monitoring • Depends on whether on MNT or insulin + MNT • On MNT 2 weekly till 28 wks • After 28 wks weekly • On insulin + MNT 7 times a day ideal or every third day till glycemic goals achieved • Thereafter every week

7. Diet / MNT – Must in all • General principles: 10 -12 kg weight gain • Calorie counting: wise distribution of calories • Dietician charts a diet plan according to Body Weight • Obese women : 25-30 kcal / kg • Non-obese : 30-35 kcal /kg • Underweight: 35-40 kcal/kg • Dietary compliance is evaluated and reinforced during hospital visits

8. MNT Goals • To provide adequate nutrition for the mother and fetus • To provide sufficient calories for appropriate maternal weight gain • Help maintain normal BSL and prevent complications • Avoid ketosis • Minimizing insulin requirement • In short it is excellent glucose control with appropriate weight gain and adequate nutrient intake for optimum outcome

9. Weight gain goals

10. Composition of diet • Carbohydrates – 50 – 60% • Proteins – 10 - 20% • Fats – 25 – 30%

11. Important tips for diet planning • Eat at same time • Avoid overeating at one time and prolonged fasting • Divide meal plan into 3 major meals and 2 – 3 small snacks

12. Glycemic index • The extent of rise in blood sugar in response to a food in comparison with the response to an equivalent amount of glucose • The CHO that produce only small fluctuation in blood glucose and insulin levels are called low GI foods and are recommended for use by GDM women • Patients need help in choosing proper food items • This concept of GI of food needs to be taught to the patients

13. Glycemic index of foods Diet with low GI are generally rich in fibre and high fibre improves glucose tolerance

17. Food item Protein (g) Calories

18. Choice of diet • CHO with low GI • Lean proteins • Balance of Poly and mono unsaturated fats • Avoid • Eating for two • Fast & feasts • Health Drinks What to Eat? (Quality of food) Diet 18

19. General tips • Fried foods should be avoided. The woman can take food steamed, boiled or sautéd food in a non-stick pan • Whole fruits should be preferred over juices • Prefer fish or chicken over red or organ meat • Fiber should be increased in the diet by including salad, beans, non- starchy vegetables, whole fruit, whole grain cereals, whole pulses • The woman must drink water, buttermilk, soups, soy milk and other unsweetened healthy beverages instead of soda or fruit juices

20. How to achieve compliance • Explaining relevance of proper diet • Making the choice through every day items available to the patient • Culturally acceptable diet • Using the signaling system for every day diet • Quantifying food items in easily understandable way

21. Exercise - why

23. Hip and exercise • Exercising for 15-20 minutes after a meal helps to keep blood glucose within the target range • Start with 20 minutes/day, gradually increasing to 45-60 minutes/day • Important to maintain balance and avoid falls

24. Exercises in GDM WALL SQUATS WALL PUSHUPS WEIGHT TRAINING FOR UPPER LIMB

25. Recap • Confirm, whether the woman has understood the instructions properly. Asks her to repeat key messages: • Daily exercise for 20-30 mins • 3 small meals + 2-3 snacks daily • Don’t skip meal • Keep sugar handy • Come for regular check-ups • Ensure institutional delivery

27. When to start insulin • When sugars are not controlled with Medical Nutrition Therapy • FPG >90mg% • 2hr PPBS >120mg% • HIP at diagnosis with • FPG>120mg% • 2hr PPBS >199mg%

28. Rule of thumb for starting insulin • Calculation by gestation • 1st trimester 0.7u/kg/day • >18weeks 0.8u/kg/day • >26weeks 0.9u/kg/day • >36weeks 1u/kg/day • Calculation by PP blood sugar • 120-160mg% 4units • 160-200mg% 6units • >200mg% 8units

29. Insulin injection details • Insulin injection given subcutaneously • Site – Front/lateral aspect of thigh or over abdomen • Human premix 30/70 insulin used • Insulin syringe - 40 IU syringe • Insulin vial – 40 IU/ml • Insulin syringe can be used safely for 14 injections if capped and stored properly at room temperature, for disposal should be burnt or buried • Insulin vial to be store in refrigerator in lower compartment between 4-8 0C or in earthen pot • Once opened insulin vial should be used with in a month

31. Hypoglycemia • Tell the woman that if the blood sugar level falls <70mg/dL, it is called hypoglycemia or low blood sugar. • What she needs to do if she develops hypoglycemia? • Take 3 teaspoons of glucose powder (15-20 grams) or 6 teaspoon sugar, dissolved in a glass of water and drink • After taking oral glucose, you must take rest and avoid any physical activity

32. Oral hypoglycemic agents • Not yet endorsed by GOI • Metformin and glyburide have been studied and found to be safe

33. Obstetric management • More frequent visits 1 – 3 weekly • Regular BP, weight monitoring • Clinical and sonographic fetal growth monitoring every 2 – 4 weeks • Fetal wellbeing monitoring – need for education on fetal movement count • Institutional delivery at higher centre specially in women on insulin

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