Preconception Carefor

Women with Diabetes

Objectives and GoalsTo Understand…

Preconception Care (PCC): definition and purpose

The role that PCC plays for women with diabetes Identify different aspects of pregnancy

readiness Pregnancy Spacing for better health

Preconception Care: Definition

“Preconception care is comprised of interventions that aim to identify and modify

biomedical behavior and social risks

to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors to be acted on before conception...”(CDC, 2009)

Every woman, every time (MOD, 2001)

Preconception Care

Sweet Success PCC Goals… To Prevent excess spontaneous abortions and

congenital malformations in infants of diabetic mothers Achieve A1C levels < 6.5% Assure effective contraception until stable and

acceptable glycemia is achieved Identify, evaluate, and treat long-term diabetic

complications (GFC, in print)

Main Elementsin the SS Model of Care…

1. Physician directed medical assessment, laboratory testing, treatment, maternal and fetal care.

2. Patient education about interaction of diabetes and pregnancy, and self-care

3. Educator-directed assessment and education of diabetes self-management skills

4. Mental health professional counseling when indicated to assess coping, reduce stress and improve adherence to diabetic treatment plan

(GFC, in print)

Risks to Moms…

Pyelonephritis Preterm delivery Traumatic delivery Operative delivery Progression of disease

Hypoglycemia Pregnancy Loss Pre-eclampsia Polyhydramnios Hyperglycemia Diabetic Ketoacidosis

Risks for Babies…

Organogenesis largely completed by week 8 of gestation

Poorly controlled blood glucose in this period of time risks of anomalies &SAB

Poorly controlled blood glucose risk and predisposes to chronic diseases including diabetes (Diabetes Care, January 2003)

Critical Periods of Development

4 5 6 7 8 9 10 11 12

Weeks gestationfrom LMP

Central Nervous System

Heart

Arms

Eyes

Legs

Teeth

Palate

External genitalia

Ear

Missed Period Mean Entry into Prenatal Care

Most susceptibletime for majormalformation

Why Plan and Change?

Preconception Care Identifies risks Provides interventions tooptimal outcomes Maximizes maternal health Builds more effective patient/provider relationship prior to conception Improves early access to prenatal care Reduces poor outcomes Creates rewarding experience for couples

The Big PCC Picture…Team-Work!

Readiness for pregnancy Complete medical examination Laboratory Evaluation Normal Blood glucose control Planned Pregnancy

Readiness for Pregnancy…Healthy Coping

General Mental Health Diabetic Self-Care High-Risk Factors Network of Social Support Resources/consultations

Complete Medical Exam…History Assessment

Type of diabetes Risk for diabetes (previously pre-diabetes) Age at onset, including duration Status of medical conditions/treatments

organ involvement hospitalizations complications pregnancy history

Co-morbidities Current Medications Alcohol or chemical substance use

Medical Exam… Physical Assessment*

Metabolic control Blood pressure Cardiovascular examination Retinal Renal Neurological Dental Evaluation Foot Exam Immunological Status Pelvic exam/pap smear

*Thefocus of assessment is to evaluate level of end organ damage, retina, kidney, vasculature, heart and nervous system and any other medical conditions

Medical Exam and Labs…

1. Metabolic Control: A1c: Goal < 6.5 Fasting Lipid Profile: HDL: >50 mg/dL Triglycerides (TG) <150 mg/dL Total LDL Cholesterol <100 mg/dL

recommendation with DM & CAD < 70 mg/dL Serum TSH screening and or free thyroxin level Celiac disease screening in type 1

Medical Exam and Labs…

2. Blood pressure Controlled. Goal: < 130/80

3. Cardiovascular exam / Electrocardiogram (EKG/ECG) Consider testing or referral for peripheral atherosclerotic vascular disease if a woman is at high risk or demonstrates signs and symptoms.

EKG: women > 34; DM1 >10 years, DM2; or with signs and symptoms of angina, or exercise intolerance.

4. Dilated retinal exam: Ophthalmologist knowledgeable in diabetic eye conditions.

Medical Exam and Labs…

5. Renal status to test for potential nephropathy: Random urine: Normal random

microalbumin/creatinine<30mg/day

If abnormal:

24 hour urine collection is for total protein, and or/creatinine Total protein <150 mg/mg per 24 hours

Serum creatinine 0.7-0 .9

Medical Exam and Labs…..

6. Neurological:

Assessment of autonomic dysfunction

Hypoglycemia unawareness, orthostatic hypotension, excessive nausea and vomiting

Gastrointestinal autonomic neuropathy or gastroparesis

Medical Exam and Labs…

7. Dental Examination: Refer if woman does not have regular dental health care.

8. Foot exam: By PCP or podiatrist.

8. Immunological Status: Update all pertinent immunizations. (GFC, in print)

Summary of Laboratory Evaluation

Recommended PCC testing:

A1c Complete Blood Count Serum TSH/T4 Random Urine

Serum Creatinine 24 hour urine protein Microalbumin

Lipid profile

Planned Pregnancy…Management Includes

Contraception is utilized until glycemic control is achieved Smoking cessation Nutritional Supplementation

Folate 400µg/day 4 mg/day with Hx neural tube defect or cleft palate defect Multiple Vitamin

Medications compatible with pregnancy 1. Intensive insulin regimen2. Medical nutrition therapy 3. Activity evaluation

Intensive Glycemic Control

Current regimen Set realistic goals Insulin adjustments Evaluate self-management skills

Hypo/hyperglycemia Safeguards Signs and Symptoms Glucagon Ketones

Preconception: Plasma Glucose Values

Time Plasma Glucose ValuesFasting 60-89 mg/dL

Premeal/Bedtime/ Overnight 70-99 mg/dL

Peak Postmeal 100-129 mg/dL

Daily Average 87-100 mg/dL

Medical Nutrition Therapy…Healthy Eating

Determine energy needs Achieve desirable body weight Maintain balance in diet plan Evaluate adherence Educate about diet issues and pregnancy Reinforce importance of dietary

supplements

Activity Evaluation…Being Active

Endorphins to enhance mental well-being Improves insulin sensitivity Improves strength and endurance Improves BMI Improves cardiovascular status Enhances a healthy lifestyle Safeguards against hyperglycemic episodes

Any contraindications? Limitations?

Management Continues with Optimal Control…

Blood pressure normalization Cardiovascular/Neurologic

Stability Stabilized retinopathy A1c < 6.5 % Evaluate Insulin Therapy

During Gestation

Early Referral to Sweet Success Program Management will continue for optimal

control Psychosocial wellbeing Glycemic control Cardiovascular Retinal Renal Metabolic Fetal wellbeing

Preconception Care for Women with GDM History

Pregnancy History Converted? Contraception? Weight reduction achieved? Exercise? Current Diet? Folate? MVI/PNV? Immunizations/General Health? Utilize the “teachable moment”

Preconception Care…for GDM Patients

If Postpartum Screen was NEGATIVE: Test fasting every year thereafter Test every 3rd year using 2 hour OGTT Test at next PCC or at first prenatal visit Attain normal BMI, life style of healthy coping, healthy

eating; being active is recommended

If Postpartum Screen was POSITIVE: She should present for preconception care

Other Conditions Requiring Preconception Care:

Polycystic Ovary Syndrome A clinical diagnosis of chronic

hyperandrogenism and anovulation The leading cause of infertility The most common endocrinopathy

affecting 6-10% of women of reproductive age.

Not all have cysts Many are normal weight

Clinical Features Associated with PCOS

Menstrual dysfunction-as early as age 12 15-30% have regular menses Infertility and /or miscarriage

Facial and upper back acne Obesity in ~ 60% Excessive hair growth Androgenetic alopecia Acanthosis Nigricans in ~ 30% Ovarian cortex containing multiple atretic follicles in ~

80%

Metabolic Aberrations in PCOS

Most significant is

Insulin Resistance (IR) with compensatoryHyperinsulinemia

Endocrinopathy with PCOS

Chronically elevated Luteinizing hormone to FSH (LH:FSH = 3:1)

↑ Levels free testosterone (usually ovarian source but can also be adrenal)

↓ Sex hormone-binding globulin Normal prolactin except for ~15% who have

slight elevations

Insulin Sensitizers to Treat Insulin Resistance and Secondary Infertility

Multinational study: Metformin vs. placebo for obese women with PCOS34% ovulation vs. 4 % in placebo group90% Metformin plus clomid vs. 8% in

placebo group8 fold increase in conception when taking

Metformin (Nestler et al. 2002)

PCOS and Type 2 DM

35 % of women with PCOS have clinical IGT and do not know it.

10 % of women with PCOS are diagnosed with Type 2 DM by age 40(Ehrman et al. Diabetes Care, Jan 1999)

PCOS and GDM

Hypothesized that all have insulin resistance with compensatory hyperinsulinemia

~ 40% PCOS develop GDM

40 -52% GDM’s have PCOS ovarian morphology

Resources

www.cdph.ca.gov/programs/cdappFor Sweet Success information www.marchofdimes.orgFor California Preconception Initiative Professional Resources for PCC www.everywoman.org For California Preconception link

(provider/consumer link) www.cdc.gov/NCBDDD/preconceptional/default

.htm For Centers for Disease Control & Prevention link

OK… Now…

Get Pregnant…

……………………………………..FAST….

.

Thank You!

Contact Information

Gretchen Page , MPH, CNM Manager, Inland Counties Regional Perinatal Programs,

LLUMC/Children’s Hospital (909) 558-3996gpage@llu.edu