PregnancyforWomenwithDiabetesissupportedbyaneducaonalgrant ...schererclin.com/documents/scherer_pregnancy_15953.pdf · The3majortypesofdiabetesinpregnancyarepreexisngtype1diabetes,preexisngtype2

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Pregnancy for Women with Diabetes is supported by an educa1onal grant from Novo Nordisk Inc. The program has been accredited by the American Associa1on of Diabetes Educators (AADE) for nurses, die11ans, and pharmacists.

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The following program is a narrated by Barbara Kocurek.

Dr. Kocurek graduated from the University of PiHsburgh in 1987 with a Bachelor of Science in Pharmacy and she received her PharmD degree from the Medical College of Virginia in 1989. Since that 1me she has been involved in diabetes educa1on in various health care sePngs. Currently she is the Diabetes Program Manager, Chronic Disease and Care Redesign for Baylor ScoH and White located in Texas. She works on glycemic control ini1a1ves to improve diabetes care in the hospitals as well as oversees the American Diabetes Associa1on (ADA) Recogni1on and data management for the diabetes educa1on programs.

Dr. Kocurek served on the Na1onal Cer1fica1on Board for Diabetes Educators (NCBDE) from 1998–2002 and was Chair for the 2000–2001 year. In 2002–2003 she served as a member of the AADE’s Nomina1ng CommiHee and in 2004 served on the Professional Development, Educa1on, and Resources CommiHee. She currently serves on AADE’s Professional Prac1ce CommiHee and in 2010 became a Fellow of the American Associa1on of Diabetes Educators.

•  Review the various types of diabetes and their impact on maternal/fetal outcomes •  Discuss guidelines for screening for diabetes in pregnancy •  Summarize the principles of preconcep1on care in women with preexis1ng

diabetes

•  Describe the management of preexis1ng diabetes and gesta1onal diabetes mellitus (GDM)

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The 3 major types of diabetes in pregnancy are preexis1ng type 1 diabetes, preexis1ng type 2 diabetes, and GDM.

Preexis1ng type 1 diabetes is characterized by autoimmune destruc1on of pancrea1c beta-‐cells, resul1ng in almost complete insulin deficiency.

Preexis1ng type 2 diabetes is a progressive insulin secretory defect and/or insulin resistance.

GDM is currently defined by the American Diabetes Associa1on (ADA) and many other authori1es as carbohydrate intolerance of variable severity that is diagnosed during pregnancy and is not clearly overt diabetes. Un1l recently, GDM was defined as any degree of glucose intolerance with onset or first recogni1on during pregnancy, whether or not the condi1on persisted aber pregnancy, and not excluding the possibility that unrecognized glucose intolerance may have antedated or begun at the same 1me as the pregnancy.

GDM is the one type of diabetes that occurs only during pregnancy. When a woman with type 1 or type 2 diabetes becomes pregnant, the condi1on is described as “preexis1ng diabetes and pregnancy” or “pregesta1onal diabetes.”

American Diabetes Associa1on. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14–S80.

Cypress M, Gleeson J. Diagnosis and classifica1on. In: Childs BP, Cypress M, SpolleH G, eds. Complete Nurse’s Guide to Diabetes Care. 2nd ed. Alexandria, VA: American Diabetes Associa1on; 2009:2–12.

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Today there are varying es1mates of the prevalence of diabetes during pregnancy in US residents. Most of these varia1ons are due to differences in the popula1ons studied and the ways in which GDM has been defined in the various studies.

It is generally agreed, however, that diabetes during pregnancy is becoming increasingly prevalent, and that minority popula1ons are dispropor1onately affected. Many experts believe that diabetes now complicates between 6% to 7% of all US pregnancies. GDM accounts for most cases of diabetes in pregnancy, affec1ng an es1mated 5% to 6% of all pregnancies.

As we will see on the next 2 slides, the distribu1on of the types of diabetes during pregnancy is changing rapidly.

Reader DM, Thomas A. Pregnancy with diabetes. In: Mensing C, ed-‐in-‐chief; Cornell S, Halstenson C, eds. The Art and Science of Diabetes Self-‐Management Educa@on Desk Reference. 3rd ed. Chicago: American Associa1on of Diabetes Educators; 2014:683–718.

Lawrence JM, Contreras R, Chen W, et al. Trends in the prevalence of preexis1ng diabetes and gesta1onal diabetes mellitus among a racially/ethnically diverse popula1on of pregnant women, 1999–2005. Diabetes Care. 2008;31:899–904.

Simmons D. Epidemiologic context of diabetes in pregnancy. In: McCance DR, Maresh M, Sacks DA, eds. A Prac@cal Manual of Diabetes in Pregnancy. Chichester, UK: Wiley-‐Blackwell; 2010:3–16.


Bardenheier BH, Elixhauser A, Imperatore G, et al. Varia1on in prevalence of gesta1onal diabetes mellitus among hospital discharges for obstetric delivery across 23 states in the United States. Diabetes Care. 2013;36:1209–1214.

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Today, preexis1ng diabetes is complica1ng an increasing propor1on of pregnancies.

The charts on this slide show the results of a retrospec1ve study of more than 175,000 California women who had a singleton delivery of at least 20 week’s gesta1on between 1999 and 2005. During the study period, the prevalence of preexis1ng diabetes compared to GDM more than doubled, from 10% to 21%. In this cohort, preexis1ng diabetes complicated 1.3% of all pregnancies, while GDM complicated 7.5% of pregnancies.

Although other studies have reported somewhat different propor1ons of cases of preexis1ng diabetes and GDM, the key finding is that preexis1ng diabetes is affec1ng a rapidly increasing percentage of pregnancies. This is cause for great concern.

Although GDM is associated with nega1ve consequences for fetal development, the risk to the fetus is usually greater in a pregnancy with preexis1ng diabetes.

Lawrence JM, Contreras R, Chen W, et al. Trends in the prevalence of preexis1ng diabetes and gesta1onal diabetes mellitus among a racially/ethnically diverse popula1on of pregnant women, 1999–2005. Diabetes Care. 2008;31:899–904.

Mayorga ME, Reifsnider OS, Neyens DM, et al. Simulated es1mates of pre-‐pregnancy and gesta1onal diabetes mellitus in the US: 1980 to 2008. PLoS One. 2013;8:e73437.

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As this graph shows, the ra1o of cases of preexis1ng type 1 to preexis1ng type 2 diabetes in pregnancy has also changed drama1cally in recent years. For the en1re US, the es1mated ra1o of type 1 to type 2 diabetes was 3:1 in 1980, 1:2 in 1988, and 1:8 in 2009. Although the frequency of type 1 diabetes has remained rela1vely stable, affec1ng about 0.3% of all pregnancies, the frequency of type 2 diabetes has risen drama1cally.

Several factors explain the rapid and substan1al increase in type 2 diabetes. First, more asymptoma1c but high-‐risk adolescents and young adults are being screened for type 2 diabetes. Therefore, many cases of early-‐onset type 2 diabetes that would once have been undetected are now being diagnosed.

In addi1on, because of the ongoing obesity epidemic in the US, women are increasingly likely to develop diabetes during their childbearing years.

Furthermore, owing to changing immigra1on paHerns, a growing propor1on of young women in the US belong to ethnic groups in which type 2 diabetes is par1cularly prevalent.


Engelau MM, Herman WH, Smith PJ, et al. The epidemiology of diabetes and pregnancy in the U.S., 1988. Diabetes Care. 1995;18:1029–1033.

Boinpally T, Jovanovič L. Management of type 2 diabetes and gesta1onal diabetes in pregnancy. Mt Sinai J Med. 2009;76:269–280.

Mathiesen ER, Ringholm L, Damm P. Management of pregnant women with type 1 and type 2 diabetes. In: Umpierrez GE. Therapy for Diabetes Mellitus and Related Disorders. 6th ed. Alexandria, VA: American Diabetes Associa1on; 2014;197–211.

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This slide shows current American Diabetes Associa1on (ADA) recommenda1ons for diagnosing diabetes in pregnancy.

Women with risk factors for undiagnosed type 2 diabetes should be screened at the first prenatal visit, using standard diagnos1c criteria.

Women not previously known to have diabetes should be screened for GDM at 24 to 28 weeks of gesta1on. Pending adop1on of a uniform approach to GDM screening, either the “one-‐step” or “two-‐step” diagnos1c approach can be used at 24 to 28 weeks.


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The ADA recommends that women who are overweight (with a body mass index [BMI] ≥25 kg/m2) be screened for type 2 diabetes in the first trimester of pregnancy if they have any of the characteris1cs shown on this slide.

With respect to these risk factors, racial and ethnic groups with an elevated risk of developing type 2 diabetes include African Americans, La1nos, Na1ve Americans, Asian Americans, and Pacific Islanders. The ADA defines impaired fas1ng glucose (IFG) as a fas1ng plasma glucose level between 100 and 125 mg/dL. Impaired glucose tolerance (IGT) is defined as a 2‒hour plasma glucose oral glucose tolerance test value of 140 to 199 mg/dL. Acanthosis nigricans is a skin disorder associated with insulin resistance and characterized by darker, thick, velvety skin in body folds and creases.

Although a BMI greater than or equal to 25 kg/m2 is generally considered the threshold for an elevated risk of developing type 2 diabetes, studies have shown that at-‐risk BMI values may be lower in some ethnic groups, such as South Asians, Chinese, and African Americans. Threshold values have not yet been defined for these groups. Therefore, health care providers should use their clinical judgment in deciding whether to screen pa1ents other than non-‐Hispanic whites when their BMI is below 25 kg/m2 but they have at least one other risk factor for type 2 diabetes.

The ADA also recommends that all women who are 45 years of age or older be screened for type 2 diabetes at their first prenatal visit, even if they have no other risk factors. American Diabetes Associa1on. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14–S80.

Chiu M, Aus1n PC, Manuel DG, et al. Deriving ethnic-‐specific BMI cutoff points for assessing diabetes risk. Diabetes Care. 2011;34:1741‒1748.

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As previously men1oned, the ADA has stated that either the one‒step or the two‒step approach can be used to screen and diagnose women for GDM between 24 and 28 weeks of gesta1on. Using the one‒step method is advocated by the Interna1onal Associa1on of Diabetes and Pregnancy Study Groups (IADPSG). Diagnos1c cut points used in interpre1ng test results are based on the results of the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study. This interna1onal study was conducted between 2000 and 2006 and included more than 25,000 pregnant women. Adop1on of the one‒step approach would substan1ally increase the propor1on of US women diagnosed with GDM—from 5% to 6% to up to 20% of pregnant women.

Following promulga1on of the IADPSG recommenda1ons, the US Na1onal Ins1tutes of Health conducted a consensus development conference to evaluate all available data. Based on this review, in 2013 the NIH consensus panel recommended con1nua1on of the 2-‐step approach for GDM screening. This strategy is commonly used in the US. In its Standards of Medical Care in Diabetes—2014, the ADA stated that there are currently insufficient data to demonstrate the superiority of one screening strategy over the other. However, long-‐term outcome studies that might resolve this issue are currently underway. According to the ADA, “establishing a uniform approach to diagnosing GDM will have extensive benefits for pa1ents, caregivers, and policymakers.”


Metzger BE, Lowe LP, Dyer AR, et al; HAPO Study Coopera1ve Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358:1991–2002. Vandorsten JP, Dodson WC, Espeland MA, et al. Na1onal Ins1tutes of Health consensus development conference: diagnosing gesta1onal diabetes mellitus. NIH Consens State Sci Statements. 2013;29:1–31.

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In the one-‐step screening approach for GDM, a 75‒gram oral glucose tolerance test (OGTT) is performed at 24 to 28 weeks of gesta1on. Plasma glucose measurements are taken while the pa1ent is fas1ng and 1 and 2 hours aber glucose administra1on.

The test should be performed in the morning, aber an overnight fast of at least 8 hours.

A diagnosis of GDM is made when any of the following plasma glucose values are exceeded:

•  Fas1ng: ≥92 mg/dL •  1 h: ≥180 mg/dL •  2 h: ≥153 mg/dL


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This slide shows the two‒step approach to screening for and diagnosing GDM at 24 to 28 weeks that is included in the ADA’s Standards of Medical Care in Diabetes—2014.

In the first step, a 50‒gram glucose load test (GLT) is performed at 24 to 28 weeks of gesta1on. The test is performed in the nonfas1ng state, and a plasma glucose measurement is taken 1 hour aber glucose administra1on.

If the 1‒h PG level is less than 140 mg/dL, no further tes1ng is necessary. (However, the American College of Obstetricians and Gynecologists [ACOG] recommends a threshold of 135 mg/dL in high-‐risk ethnic minori1es with an increased prevalence of GDM, and other experts recommend a threshold of 130 mg/dL.)

If the 1‒h PG level exceeds the threshold value, a 100‒g OGTT should be performed in the fas1ng state. Plasma glucose is measured while fas1ng , and at 1, 2, and 3 hours aber the OGTT. A diagnosis of GDM is made when at least 2 of the 4 threshold values are met or exceeded.

As shown in the table at the boHom of the slide, either of two sets of threshold values can be used: those recommended by Carpenter and Coustan or those recommended by the Na1onal Diabetes Data Group (NDDG). Note that the Carpenter/Coustan values are somewhat more stringent than those advocated by the NDDG.


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The accurate statement is: __________.

a.  GDM is defined by the ADA as any state of carbohydrate intolerance diagnosed during pregnancy

b.  preexis1ng type 2 diabetes is complica1ng an increasing propor1on of pregnancies in the US

c.  currently, the ADA recommends one‒step rather than two‒step screening for GDM d.  the one‒step test for GDM consists of a 50‒g glucose load test

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The correct answer is b.

Preexis1ng type 2 diabetes is complica1ng an increasing propor1on of pregnancies in the US.

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The pathophysiology of GDM is complex and incompletely understood.

Overcoming the normal insulin resistance of pregnancy requires a compensatory increase in insulin secre1on to maintain maternal glucose concentra1ons within the normal range. When pancrea1c beta-‐cells are unable to compensate for this insulin resistance, GDM ensues.

Women with GDM have both increased insulin resistance and decreased insulin secre1on. In GDM, the insulin response to a glycemic s1mulus is about half that of normal pregnancy.

GDM is increasingly regarded as a stage in the evolu1on of type 2 diabetes.

Jagasia S. Gesta1onal diabetes mellitus: diagnos1c criteria and epidemiology. In: Umpierrez GE. Therapy for Diabetes Mellitus and Related Disorders. 6th ed. Alexandria, VA: American Diabetes Associa1on; 2014;156–167.

Thomas-‐Geevarghese A, Ratner RE. Gesta1onal diabetes. In: Goldstein BJ, Müller-‐Wieland D, eds. Type 2 Diabetes Principles and Prac@ce. 2nd ed. New York: Informa Healthcare; 2008:341–355.

Buchanan TA, Xiang AH. What causes gesta1onal diabetes? In: Kim C, Ferrara A. Gesta@onal Diabetes During and AKer Pregnancy. London: Springer-‐Verlag London Limited; 2010:113–123.

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As shown on this slide, risk factors for GDM are similar to those for type 2 diabetes.

Body weight plays a major role in a woman’s suscep1bility to GDM. In addi1on to having a BMI of ≥30 kg/m2 or a prepregnancy weight that is at least 110% of ideal body weight, weight-‐related risk factors are substan1al weight gain in early adulthood and between pregnancies, as well as excessive gesta1onal weight gain.

Studies have also shown that the pa1ent’s weight at birth also affects the odds of developing GDM. A birth weight above 9 pounds or below 6 pounds is associated with an increased risk for GDM.

Belonging to an ethnic group with a higher predisposi1on to type 2 diabetes also increases the risk of developing GDM. At-‐risk women include Hispanic Americans, African Americans, Na1ve Americans, South or East Asians, and Pacific Islanders.

Among the clinical condi1ons associated with the development of GDM are polycys1c ovarian syndrome, hypertension, and metabolic syndrome.

Jagasia S. Gesta1onal diabetes mellitus: diagnos1c criteria and epidemiology. In: Umpierrez GE. Therapy for Diabetes Mellitus and Related Disorders. 6th ed. Alexandria, VA: American Diabetes Associa1on; 2014;156–167.

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This slide shows current plasma glucose targets recommended by the ADA and ACOG for women with GDM.

The ADA recommends a fas1ng value of ≤95 mg/dL. The ADA postmeal target is either a 1‒hour value of ≤140 mg/dL or a 2‒hour value of ≤120 mg/dL. ACOG recommends a fas1ng range of 60 to 90 mg/dL and a premeal range of 60 to 105 mg/dL. The 2‒hour postmeal target is ≤120 mg/dL, and the recommended target for the 1me between 2 AM and 6 AM is greater than 60 mg/dL.

Note that both the ADA and ACOG recommend a 2‒hour postmeal target of ≤120 mg/dL. Many experts believe that keeping postmeal values at target is especially important because elevated postmeal plasma glucose levels are closely associated with the development of macrosomia.


Landon MB, Gabbe SG. Gesta1onal diabetes mellitus. Obstet Gynecol. 2011;118:1379‒1393. Metzger BE, Lowe LP, Dyer AR, et al; HAPO Study Coopera1ve Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358:1991‒2002. The HAPO Study Coopera1ve Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associa1ons with neonatal anthropometrics. Diabetes. 2009;58:453‒459. Metzger BE, Buchanan TA, Coustan DR, et al. Summary and recommenda1ons of the Fibh Interna1onal Workshop Conference on Gesta1onal Diabetes Mellitus. Diabetes Care. 2007;30(Suppl 2):S251‒S260.

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Medical nutri1on therapy (MNT) is the cornerstone of treatment for GDM. A woman with GDM should receive nutri1onal counseling by a registered die11an (RD) whenever possible or by a qualified health care provider with experience in GDM management. A referral to a die11an should be made within 48 hours of the GDM diagnosis, and the ini1al visit should take place within 1 week of the referral.

The meal plan should fulfill minimum nutrient requirements for pregnancy as set by the Ins1tute of Medicine (IOM) and achieve glycemic goals without inducing weight loss or ketonemia. The plan should be culturally appropriate and individualized to take into account the pa1ent’s weight gain, physical ac1vity, and nutri1on goals.

Nutri1on interven1ons should emphasize overall healthy food choices, por1on control, and cooking prac1ces that can be con1nued postpartum and that may help to prevent later type 2 diabetes and obesity.

The basis of MNT for GDM involves a carbohydrate-‐controlled meal plan. Carbohydrate should generally be distributed into 3 small-‐to-‐moderate meals and 2 to 4 snacks. Consuming foods high in total carbohydrate or sucrose, such as regular sob drinks, is not recommended.


Coustan DR, ed. Gesta1onal diabetes mellitus. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:131–151.

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Meal plans should be individualized for women with GDM, but some general prac1ces are widely applicable. Plans oben recommend the following carbohydrate ranges:

•  Breakfast: 15 to 45 grams •  Lunch and dinner: 45 to 75 grams (each) •  Snacks: 15 to 45 grams

Most women find that the postbreakfast blood glucose (BG) goal is the most difficult value to achieve because of elevated hormone levels in the morning. Therefore, carbohydrate intake should be limited to 15 to 45 grams at breakfast. Breakfast cereals are oben discouraged because most contain more than 45 grams of carbohydrate. Furthermore, breakfast cereals and other highly processed foods are more likely to raise postmeal glucose levels than less processed, high-‐fiber foods.

In their eagerness to control their carbohydrate consump1on, women may cut back on nutrient-‐rich carbohydrates such as fruit, milk, and starches. Meal plans oben shib milk and fruit from meal1me to snack1me to spread out carbohydrate consump1on and reduce the glucose load at meals.

Ea1ng 1 to 2 ounces of protein with breakfast or a snack is a good way to add calories without compromising glucose levels.


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Women with GDM should monitor their BG at least 4 1mes daily: once in the morning (fas1ng) and 1 to 2 hours aber each meal. Many experts favor the 1‒hour postmeal value because it is close to the peak glucose level following a meal. Although some researchers have recently argued for the feasibility of less frequent SMBG for women with mild GDM, most experts stress the importance of 4-‐1mes-‐daily monitoring because SMBG is essen1al for determining the ongoing effec1veness of the pa1ent’s lifestyle regimen and the need for drug therapy. It also guides 1tra1on of glucose-‐lowering agents, if they are necessary.

The benefit of A1C tes1ng for women with GDM has not been established.

Many experts recommend monitoring for urine or blood ketones if a pa1ent with GDM has insufficient food intake or she is losing weight. Insufficient food intake may result from an inappropriate meal plan, not following the prescribed meal plan, nausea, vomi1ng, or inten1onally underea1ng to control BG levels. Ea1ng too liHle or at extended intervals may cause a shib from carbohydrate to fat metabolism, leading to increases in urine and blood ketones. If ketones are found in the urine or blood, the pa1ent should contact her health care provider immediately so that the cause can be iden1fied and remedied promptly.



Brown FM. Pregnancy and diabetes. In: Beaser RS and the Staff of Joslin Diabetes Center. Joslin’s Diabetes Deskbook. 3rd ed. Boston: Joslin Diabetes Center; 2014:693–719.

Mendez-‐Figueroa H, Daley J, Lopes VV, et al. Comparing daily versus less frequent blood glucose monitoring in pa1ents with mild gesta1onal diabetes. J Matern Fetal Neonatal Med. 2013;26:1268‒1272.

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Regular physical ac1vity is important because it improves BG control, reduces cardiovascular risk factors, and improves well being. In the absence of contraindica1ons, pregnant women with diabetes should be encouraged to engage in moderate-‐intensity physical ac1vity for at least 30 minutes per day. To avoid overexer1on, women should monitor the intensity of their ac1vity. In prac1cal terms, a person engaging in moderate physical ac1vity can talk, but not sing, during the ac1vity. All pregnant women should choose ac1vi1es that avoid the supine posi1on and minimize the risks of loss of balance and fetal trauma.

Women with GDM who are taking insulin need to monitor their BG levels before and aber physical ac1vity. They should also perform SMBG during the ac1vity if they experience symptoms of hypoglycemia. It is important for them to understand how to adjust their carbohydrate intake and insulin dosing based on the results of SMBG.

Maintaining adequate hydra1on before, during, and aber physical ac1vity is essen1al. Women must remain alert for warning signs that they should stop exercising immediately and seek medical aHen1on. These include excessive shortness of breath, chest pain, dizziness, headache, calf pain or swelling, vaginal bleeding, leakage of amnio1c fluid, and painful uterine contrac1ons.

Colberg SR. Aerobic exercise Rx for gesta1onal diabetes. In: Exercise and Diabetes: a Clinician’s Guide to Prescribing Physical Ac@vity. Alexandria, VA: American Diabetes Associa1on; 2013:103–115.


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Absolute contraindica1ons to aerobic exercise during pregnancy include hemodynamically significant heart disease, restric1ve lung disease, or having an incompetent cervix. Aerobic exercise is also contraindicated in women who are carrying twins and are at risk for preterm labor or for any woman carrying more than 2 fetuses.

Addi1onal contraindica1ons are persistent second-‐ or third-‐trimester bleeding, placenta previa aber 26 weeks’ gesta1on, premature labor or ruptured membranes during the current pregnancy, and preeclampsia or uncontrolled hypertension.

In addi1on, there are several rela1ve contraindica1ons to aerobic exercise during pregnancy. These are poorly controlled seizure disorder, hyperthyroidism, hemoglobin 20 cigareHes per day), and a history of previous spontaneous abor1ons (SABs) or preterm births.

Catalano PM, Block JM. Physical activity/exercise and management of pregnant women with preexisting diabetes mellitus. In: Kitzmiller JL, Jovanovic L, Brown F, et al, eds. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. Alexandria, Va: American Diabetes Association; 2008:105–111.

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To prevent poten1al fetal damage, women who are pregnant or intend to become pregnant in the near future should check with their health care provider before taking any prescrip1on drug, over-‐the-‐counter medica1on, or herbal supplement.

As part of its drug evalua1on process, in 1975 the US Food and Drug Administra1on (FDA) began to assign systemically absorbed drugs to 1 of 5 Pregnancy Categories. As shown in the table, drug classifica1ons are based on safety data from adequate, well-‐controlled human studies, human adverse reac1on reports (ARRs) from inves1ga1onal and/or marke1ng experience, data from animal reproduc1on studies, and a calcula1on of the drug’s risk/benefit ra1o. Categories are A through D and X.

The most favorable Pregnancy Category is A, indica1ng that adequate, well-‐controlled human studies have failed to demonstrate fetal risk. The least favorable category is X, indica1ng that the drug has been shown to cause fetal abnormali1es in animals and/or humans and that its risks outweigh its benefits in pregnant women. Drugs in category X are contraindicated during pregnancy, while drugs in categories C and D should be avoided unless no alterna1ve treatment is available and the therapeu1c benefit clearly outweighs the risk.

Pregnancy Categories have not been assigned to many older drugs, including NPH insulins and regular human insulins.

U.S. Food and Drug Administra1on. Code of Federal Regula1ons Sec. 201.57. Specific requirements on content and format of labeling for human prescrip1on drug and biological products described in 201.56 (b) (1). Revised April 1, 2013. Available at: hHp://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=201.57. Accessed July 2, 2014.

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Considera1ons in selec1ng an insulin for use during pregnancy are the type of coverage needed, the insulin delivery system to be used, extensive experience with older human insulins, and the Pregnancy Categories of the insulin analogs.

Although, as an older product, it does not have a Pregnancy Category, NPH insulin has been safely used for many years in pregnant women who need basal insulin. However, the role of NPH insulin as the basal insulin of choice during pregnancy is gradually changing. In March 2012, the FDA changed the Pregnancy Category of insulin detemir from C to B following review of posi1ve data from an open-‐label study in which 310 women received insulin detemir or NPH insulin. As of August 2014, insulin glargine remains in Pregnancy Category C and therefore should not normally be used during pregnancy.

As with NPH insulin, short-‐ac1ng regular human insulins have not been assigned to a Pregnancy Category but have been safely used in pregnancy for many years. However, the rapid-‐ac1ng insulin analogs are generally preferred over human insulins because of their more desirable pharmacokine1c profiles. Among the rapid-‐ac1ng insulin analogs, the 2 products in Pregnancy Category B—insulin aspart and insulin lispro—are preferred over insulin glulisine, which is currently in Category C.

Rapid-‐ac1ng inhaled insulin, which received FDA approval in June 2014, is currently a Category C product.

Coustan DR, ed. Use of insulin during pregnancy in preexis1ng diabetes. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:105–116.

Note: Full cita1ons for the other references listed on the slide appear in the Reference List for this ac1vity.

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Depending on the popula1on, between 10% and 50% of women with GDM eventually require drug therapy for BG management. Some experts recommend that a glucose-‐lowering agent be ini1ated when one-‐third of the week’s BG values exceed glycemic targets. Although other op1ons are available, most experts s1ll consider insulin the drug treatment of choice for GDM. To safely ini1ate insulin therapy, pa1ents need to be taught the basic 1ming and ac1on of insulin, the proper injec1on technique, dietary adjustments, and the recogni1on, treatment, and avoidance of hypoglycemia.

There is no widely accepted protocol for star1ng insulin therapy in GDM, and SMBG should guide the doses and 1ming of the regimen. If only postprandial plasma glucose (PPG) levels are elevated, administra1on of insulin aspart, insulin lispro, or regular human insulin at meal1mes may suffice. If fas1ng plasma glucose (FPG) is also elevated, twice-‐daily NPH insulin or once-‐daily insulin detemir may be needed as well.

Because insulin resistance increases drama1cally during the third trimester of pregnancy, insulin doses usually need to be adjusted weekly un1l 36 to 37 weeks of gesta1on. At the 1me of delivery, the typical total insulin dose is about 1 unit per kilogram.


Coustan DR, ed. Diagnos1c tes1ng and fetal surveillance. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:117–130.


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Data from randomized controlled trials support the use of glyburide, a second-‐genera1on sulfonylurea, and meormin, a biguanide, to treat GDM. Neither agent is specifically approved for use in GDM, but both are in Pregnancy Category B. In short-‐term randomized controlled trials, outcomes were similar with glyburide and insulin. However, as with insulin, glyburide must be balanced carefully with meals and snacks to avoid maternal hypoglycemia. Some evidence suggests that glyburide may be less effec1ve in obese women and those with pronounced hyperglycemia. Although ini1al evidence suggested that glyburide does not cross the placenta, a more recent study found that cord blood levels of glyburide were 70% of maternal levels. Many experts reserve glyburide for women who are unwilling to start insulin, ci1ng a lack of data on the long-‐term effects of glyburide on women and children.

The Meormin in Gesta1onal Diabetes (MiG) Study showed that perinatal outcomes were similar in women randomized to meormin and in those randomized to insulin. However, nearly 50% of the meormin-‐treated women required supplemental insulin to meet their glycemic targets. Meormin crosses the placenta, and cord levels twice as high as maternal levels have been reported. Again, many experts believe that meormin is an appropriate op1on only for women who are unwilling to take insulin.

Other glucose-‐lowering agents and injectable agents other than insulin should not be used to treat GDM at the present 1me due to lack of evidence.


Coustan DR, ed. Diagnos1c tes1ng and fetal surveillance. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:117–130.


Rowan JA, Hague WM, Gao W, et al; MiG Trial Inves1gators. Meormin versus insulin for the treatment of gesta1onal diabetes. N Engl J Med. 2008;358:2003–2015.

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Among women with a history of GDM, 30% to 84% will develop GDM in a future pregnancy. Non-‐Hispanic white women are less likely than members of minority popula1ons to develop recurrent GDM.

During the 5 to 15 years aber their first GDM episode, between 40% and 60% of women will develop type 2 diabetes. A meta-‐analysis found that women with a history of GDM were 7 1mes more likely to develop type 2 diabetes than women with no history of GDM.

In the Diabetes Preven1on Program trial, which enrolled pa1ents with IGT, the rate of progression to type 2 diabetes was 17.1% per year in women with a history of GDM and 9.8% per year in women without a history of GDM.

Independent predictors of developing type 2 diabetes aber GDM are elevated FPG, high maternal BMI before or during pregnancy, and insulin use. Insulin use during GDM is a risk factor because it indicates that a severe metabolic derangement is present.

Kim C, Berger DK, Chamany S. Recurrence of gesta1onal diabetes mellitus: A systema1c review. Diabetes Care. 2007;30:1314–1319.

Ratner RE. Preven1on of type 2 diabetes in women with previous gesta1onal diabetes. Diabetes Care. 2007;30(Suppl 2):S242–S245.

Bellamy L, Casas JP, Hingorani AD, et al. Type 2 diabetes mellitus aber gesta1onal diabetes: A systema1c review and meta-‐analysis. Lancet. 2009;373:1773–1779.

Lobner K, Knopff A, Baumgarten A, et al. Predictors of postpartum diabetes in women with gesta1onal diabetes mellitus. Diabetes. 2006;55:792–797.

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Because some cases of GDM may represent preexis1ng undiagnosed type 2 diabetes, the ADA recommends that women with a history of GDM be screened for diabetes 6 to 12 weeks postpartum, using the nonpregnant OGTT criterion. Using this criterion, diabetes is diagnosed when the 2‒hour PG level is ≥200 mg/dL. (A FPG value of ≥126 mg/dL can also be used to diagnose diabetes.) Since many women with GDM receive prepartum glucose-‐lowering treatment for hyperglycemia, the A1C is an unreliable screening tool at the postpartum visit.

Women with a history of GDM should be screened for the development of diabetes or prediabetes at least every 3 years for the rest of their lives. ADA criteria for prediabetes are: IFG, defined as FPG from 100 mg/dL to 125 mg/dL; IGT, defined as a 2‒hour PG value of 140 mg/dL to 199 mg/dL, using the 75‒g OGTT; or an A1C of 5.7% to 6.4%.

Lifestyle interven1ons and/or meormin should be offered to women with a history of GDM who develop prediabetes. Lifestyle interven1ons include par1cipa1on in an effec1ve ongoing support program targe1ng weight loss of 5% to 7% of body weight and increasing physical ac1vity to at least 150 minutes per week of moderate ac1vity, such as walking.

Despite the importance of follow-‐up screening at 6‒12 weeks postpartum, recent studies have shown that only about 60% of women obtain it and that rates are even lower among women who are uninsured or underinsured and have limited health literacy. Intensive follow-‐up by health care providers is important because it has been shown to increase postpartum screening rates.


Amorosa JM, Do S, Son M, et al. Risk factors for poor compliance with postpartum oral glucose tolerance tes1ng in women with gesta1onal diabetes mellitus. Obstet Gynecol. 2014;123 (Suppl 1):135S.

Ehrenthal DB, Maiden K, Rogers S, et al. Postpartum healthcare aber gesta1onal diabetes and hypertension. J Womens Health (Larchmt). 2014 Aug 4. [Epub ahead of print] Mendez-‐Figueroa H, Daley J, Breault P, et al. Impact of an intensive follow-‐up program on the postpartum glucose tolerance tes1ng rate. Arch Gynecol Obstet. 2014;289:1177–1183.

30

Even when postpartum screening does not iden1fy type 2 diabetes or prediabetes, women with a history of GDM remain at high risk of developing type 2 diabetes and require careful long-‐term management. They should be encouraged to:

•  Begin and con1nue breaseeding because of its benefits for mother and child •  Use contracep1on that is appropriate during breaseeding and does not increase

diabetes risk

•  Follow a MNT plan developed in consulta1on with a die11an. (This plan will be different from the MNT plan used during pregnancy.)

•  Reduce their weight to prepregnancy weight or to goal weight •  Engage in regular physical ac1vity, with a goal of at least 150 minutes of moderate-‐

intensity exercise per week

•  Have regular monitoring for cardiovascular risk factors, following guidelines used for the general popula1on

The most appropriate contracep1ve choices for breaseeding mothers with a history of GDM are intrauterine devices containing copper or levonorgestrel, or low-‐dose combina1on oral contracep1ves. Long-‐term use of progesterone-‐only contracep1ves should be avoided because they are associated with a 3‒fold increased incidence of progression to diabetes.

Khandelwal M. GDM: postpartum management to reduce long-‐term risks. Curr Diabetes Rep. 2008;8:287–293.

Di Cianni G, Ghio A, Resi V, et al. Gesta1onal diabetes mellitus: An opportunity to prevent type 2 diabetes and cardiovascular disease in young women. Womens Health (Lond Engl). 2010;6:97–105.

31

Children born to mothers who had GDM have an increased risk of becoming obese and of developing insulin resistance, IGT, and type 2 diabetes. Females are at increased risk for developing GDM during their own pregnancies. Dyslipidemia, hypertension, and other types of cardiovascular disease (CVD) may also develop.

To reduce the risk for poor outcomes, parents need to be educated about the long-‐term health risks to their child. As men1oned previously, the mother should be encouraged to breaseed since breaseeding is nega1vely associated with being overweight in early childhood.

It is important for health care providers to advise the en1re family to eat a healthy diet and remain ac1ve.

Providers should also monitor the growth and development of children born to mothers with GDM, paying special aHen1on to their weight, metabolic status, and the emergence of dyslipidemia and other cardiovascular risk factors.

PePH DJ. Long-‐term implica1ons for the baby of the hyperglycemic mother. In: McCance DR, Maresh M, Sacks DA, eds. A Prac@cal Manual of Diabetes in Pregnancy. Chichester, UK: Wiley-‐Blackwell; 2010:251–257.

Schaefer-‐Graf UM, Hartmann R, Pawliczak J, et al. Associa1on of breast-‐feeding and early childhood overweight in children from mothers with gesta1onal diabetes mellitus. Diabetes Care. 2006;29:1105–1107.

Metzger BE, Buchanan TA, Coustan DR, et al. Summary and recommenda1ons of the Fibh Interna1onal Workshop-‐Conference on Gesta1onal Diabetes Mellitus. Diabetes Care. 2007;30(Suppl 2):S251–S260.

Fraser A, Lawlor DA. Long-‐term health outcomes in offspring born to women with diabetes in pregnancy. Curr Diab Rep. 2014;14:489.

32

Key recommenda1ons for the diagnosis and management of GDM include the following.

Women should be screened for GDM at 24 to 28 weeks of gesta1on, using either the one-‐step or two-‐step screening method.

It is important for women diagnosed with GDM to maintain glycemic control through MNT and physical ac1vity. SMBG should be used to determine the need for drug therapy and to guide dose 1tra1on. Insulin is the preferred treatment for women who require glucose-‐lowering medica1on, although glyburide or meormin are also used.

Women should be reevaluated for glucose intolerance at 6 to 12 weeks postpartum.

Because women with a history of GDM and their children are at increased risk for metabolic and other disorders, health care providers need to provide ongoing monitoring and management for both the mother and her child.




33

The accurate statement is: __________.

a.  most women with GDM have normal insulin secre1on b.  the current ADA premeal glycemic goal for women with GDM is ≤90 mg/dL c.  SMBG is not necessary for women with GDM who do not take insulin d.  a child born aber a pregnancy affected by GDM has a long-‐term risk of obesity

34

The correct answer is d.

A child born aber a pregnancy affected by GDM has a long-‐term risk of obesity.

35

Before the discovery of insulin, the rate of maternal mortality in pregnancies complicated by preexis1ng diabetes was as high as 44%, and perinatal mortality was approximately 60%. Since then, the outlook for pregnant women and their children has improved drama1cally. The most drama1c progress occurred during the past 3 decades because of an increasing emphasis on maternal glucose control and beHer fetal surveillance and neonatal care.

Despite these improvements, this graph shows that the odds for adverse maternal and neonatal outcomes remain substan1ally higher in pregnancies complicated by diabetes than in other pregnancies. For example, the odds of having a spontaneous abor1on (SAB) during the first trimester are 2 1mes higher, and the odds of delivering a child with a congenital anomaly are 3.3 1mes higher in a pregnancy complicated by preexis1ng diabetes than in pregnancies without diabetes. A major reason why the odds of adverse outcomes remain elevated is that, as in the general popula1on, more than 50% of pregnancies in women with preexis1ng diabetes are unplanned. Therefore, glucose levels at concep1on and during the first weeks of pregnancy, when organogenesis is taking place, may be extremely high.


Bell R, Glinianaia SV, Tennant PW, et al. Peri-‐concep1on hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-‐exis1ng diabetes: a popula1on-‐based cohort study. Diabetologia. 2012;55:936–947.

Coustan DR, ed. Prepregnancy counseling, assessment, and management of women with preexis1ng diabetes or previous gesta1onal diabetes. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:1–26.

37

Pregnancy profoundly affects the management of diabetes. Placental hormones, growth factors, and cytokines cause a progressive increase in insulin resistance during the second half of pregnancy. This necessitates intensive MNT and frequently adjusted insulin administra1on to prevent hyperglycemia that would be dangerous to the fetus.

Insulin resistance enhances the risk of diabe1c ketoacidosis (DKA) in response to the stress of concurrent illnesses or drugs used to manage obstetrical complica1ons.

Insulin-‐induced hypoglycemia has a more rapid onset during pregnancy and occurs with increased frequency in pregnant women, especially during the first trimester. Women with type 1 diabetes are at greater risk for developing hypoglycemia than those with type 2 diabetes. Furthermore, there is an increased risk of severe hypoglycemia during early pregnancy in women with type 1 diabetes.

Factors contribu1ng to the increased risk of hypoglycemia during early pregnancy include vomi1ng, inconsistent food intake due to nausea, transfer of glucose across the placenta from the maternal bloodstream to the developing fetus during periods of fas1ng, enhanced insulin sensi1vity, and diminished counterregulatory responses of epinephrine and glucagon to hypoglycemia.

Women with type 2 diabetes oben start pregnancy with marked insulin resistance and obesity, adding to the difficulty of aHaining op1mal glycemic control.

Kitzmiller JL, Block JM, Brown FM, et al. Managing preexis1ng diabetes for pregnancy: summary of evidence and consensus recommenda1ons of care. Diabetes Care. 2008;31:1060‒1079.

Einstein FH. Pathophysiology of diabetes in pregnancy. In: McCance DR, Maresh M, Sacks DA, eds. A Prac@cal Manual of Diabetes in Pregnancy. Chichester: Wiley-‐Blackwell; 2010:17‒25.

McCance DR, Holmes VA. Insulin regimes in pregnancy. In: McCance DR, Maresh M, Sacks DA, eds. A Prac@cal Manual of Diabetes in Pregnancy. Chichester, UK: Wiley-‐Blackwell; 2010:99–108.

Mathiesen ER, Ringholm L, Damm P. Management of pregnant women with type 1 and type 2 diabetes. In: Umpierrez GE. Therapy for Diabetes Mellitus and Related Disorders. 6th ed. Alexandria, VA: American Diabetes Associa1on; 2014:197–211.

38

Preconcep1on counseling for the woman with preexis1ng diabetes should begin at the onset of puberty and con1nue un1l permanent steriliza1on or menopause. A planned pregnancy is a major objec1ve of counseling, and the health care provider should review with the woman her op1ons for contracep1on and help her choose the one most appropriate for her situa1on. The provider needs to explain to the woman the risks of pregnancy to herself and to her developing baby. It is essen1al for the woman to understand that op1mizing BG levels before and during the early weeks of pregnancy significantly reduces the risks of SABs and congenital anomalies. The pa1ent should be encouraged to aim for a preconcep1on A1C target of less than 7%. She also needs to understand that with con1nued op1mal glucose control throughout pregnancy, the risks of developing further complica1ons are significantly decreased. The provider must advise the woman of her own personal risks when undertaking pregnancy, emphasizing her need to be evaluated for the presence of diabetes complica1ons and other general medical problems before concep1on. Gene1cs is another important aspect of preconcep1on counseling, and it is important for the provider to explain that although the risk of developing type 1 or 2 diabetes is higher for the child of a mother with diabetes than for the general popula1on, the risks are not high enough to advise a woman against pregnancy on gene1c grounds. The provider must also explain that having diabetes and being pregnant is oben stressful for both the pa1ent and her family. “Diabetes and Reproduc1ve Health,” a booklet developed for adolescents, is an excellent preconcep1on planning resource for younger pa1ents. It is available for free from the ADA.

Coustan DR, ed. Prepregnancy counseling, assessment, and management of women with preexis1ng diabetes or previous gesta1onal diabetes. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:1–26. Charron-‐Prochownik D, Downs JS. Diabetes and Reproduc@ve Health for Girls. Alexandria, VA: American Diabetes Associa1on; 2014.

39

The prepregnancy assessment of a woman with preexis1ng diabetes begins with a detailed medical history, followed by a physical examina1on. The examina1on should focus especially on possible diabetes-‐related complica1ons and other organ-‐system abnormali1es not directly related to diabetes, such as hypertension. A gynecologic evalua1on is important to rule out infec1on and structural abnormali1es. An eye examina1on must be performed through dilated pupils by an ophthalmologist. If this examina1on reveals preprolifera1ve re1nopathy or macular edema, laser photocoagula1on and other appropriate treatments should be undertaken and the woman’s re1nal status stabilized before pregnancy.

If the woman has had diabetes for more than 10 years or diabetes with hypertension for any period of 1me, the provider should consider ordering an electrocardiogram (EKG). More extensive cardiac tes1ng to rule out underlying ischemic heart disease may also be warranted, especially if there is a history of chest pain. It is important to conduct a neurological assessment and lower-‐extremity examina1on for evidence of neuropathy, vascular disease, deformity, or infec1on.

In addi1on to an A1C test, clean-‐catch urinalysis with culture and sensi1vity should be performed. Evalua1on of the woman’s renal status would include a 24‒hour urine collec1on for crea1nine clearance, total protein, and microalbumin. Thyroid tes1ng should include the thyroid-‐s1mula1ng hormone (TSH) level. If there are any signs or symptoms of thyroid disease, free thyroxine (T4) and an1microsomal an1body tes1ng are also warranted.


40

The discovery of certain diabetes-‐related complica1ons may serve as absolute or rela1ve contradic1ons to pregnancy. If the woman is found to have ischemic cardiac disease, the risks of maternal mortality are high and the woman should be counseled against becoming pregnant. It is advisable to ask her to consider permanent steriliza1on.

If the women displays severe chronic renal disease (serum crea1nine >1.5 mg/dL and/or crea1nine clearance 300 mg/24 h), especially when accompanied by hypertension that does not respond adequately to treatment, is associated with poor pregnancy outcomes.

A woman who has undergone renal transplanta1on may be able to undertake pregnancy successfully if her medical status is otherwise stable, although the risk remains significant.

As already men1oned, a woman with ac1ve prolifera1ve re1nopathy needs to delay the pregnancy un1l an ophthalmologist can treat her eye disease and confirm that the re1nopathy has stabilized.

Severe gastroenteropathy, characterized by persistent nausea, vomi1ng, and/or diarrhea, is a rela1ve contraindica1on. In this situa1on, metabolic control and nutri1on for both the woman and her developing baby are difficult to maintain.


41

Providers should consider referring women with preexis1ng diabetes for addi1onal diabetes educa1on and childbirth educa1on classes. Women may feel overwhelmed by the intensive self-‐care associated with pregnancy, and diabetes educa1on helps women prepare emo1onally for these new demands. Similarly, childbirth educa1on classes help the expectant mother learn about the emo1onal and physical changes of pregnancy. Many pregnant women with diabetes experience high anxiety levels, which can compromise adherence to the treatment regimen. Emo1onal support and educa1on for these pa1ents is essen1al. Psychological disorders, which can effect glycemic control, occur in up to one third of pa1ents with diabetes, including pregnant women. Psychological assessment and treatment should be incorporated into rou1ne care rather than wai1ng for iden1fica1on of a specific problem or deteriora1on in psychological status. It is important to screen pregnant women for depression and to refer symptoma1c pa1ents to a mental health clinician. Structured psychotherapy can be a useful first-‐line therapy for mild depression, but drug therapy is needed for severe depression. The risk of fetal exposure to untreated major depressive disorder is greater than the danger of fetal exposure to an1depressant drugs. An1depressants that can be used safely during pregnancy include selec1ve serotonin reuptake inhibitors (SSRIs), except for paroxe1ne, tetracyclic an1depressants, and other agents, including bupropion and vilazodone. Paroxe1ne should be avoided because of data linking use during the first trimester of pregnancy to an increased risk of congenital anomalies. Monoamine oxidase inhibitors (MAOIs) should be avoided because of the risk of hypertensive crisis.

Reader DM, Thomas A. Pregnancy with diabetes. In: Mensing C, ed-‐in-‐chief; Cornell S, Halstenson C, eds. The Art and Science of Diabetes Self-‐Management Educa@on Desk Reference. 3rd ed. Chicago: American Associa1on of Diabetes Educators; 2014:683–718. Coustan DR, ed. Psychological impact of diabetes and pregnancy. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:39‒52. Kitzmiller JL, Block JM, Brown FM, et al. Managing preexis1ng diabetes for pregnancy: summary of evidence and consensus recommenda1ons for care. Diabetes Care. 2008;31:1060–1079. Epstein RA, Moore KM, Bobo WV. Treatment of nonpsycho1c major depression during pregnancy: pa1ent safety and challenges. Drug Health Pa@ent Saf. 2014;6:109‒129.

42

It is important to screen all pa1ents for ea1ng disorders because of the high prevalence of these disorders in young women with type 1 and type 2 diabetes.

Management principles include addressing factors that may have triggered disordered ea1ng, involving the family in treatment, teaching the use of regular meal and snack 1mes and responding to hunger and sa1ety cues, and encouraging nondepriva1onal approaches to ea1ng.

Providers should offer intensified interven1ons for women with anorexia nervosa to ensure adequate prenatal nutri1on and fetal development and use specifically adapted cogni1ve behavior therapy for women with bulimia or binge-‐ea1ng disorder.


Coustan DR, ed. Psychological impact of diabetes and pregnancy. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:39‒52.

Kitzmiller JL, Block JM, Brown FM, et al. Managing preexis1ng diabetes for pregnancy: summary of evidence and consensus recommenda1ons for care. Diabetes Care. 2008;31:1060–1079.

43

Once a woman with preexis1ng diabetes has undergone prepregnancy counseling and assessment and her fitness for undertaking a pregnancy safely has been established, her health care provider should help her develop a plan for prepregnancy management. The goal of prepregnancy management is to normalize BG levels before concep1on.

The woman can then be introduced to the team concept of pa1ent management. Ideally, the diabetes care team should include a primary care physician, an endocrinologist, an obstetrician skilled in the management of high-‐risk pregnancies, a cer1fied diabetes educator, a social worker, a registered die11an, and a neonatologist or pediatrician.


44

In prepara1on for pregnancy, the woman should have an individual consulta1on with a registered die11an, who will work with her to develop a meal plan with a calorie content that will help her aHain or maintain glycemic control and manage her weight. To reduce the risk of neural tube defects, it is important for the provider to prescribe a prenatal vitamin containing at least 400 μg of folate. The provider should also encourage adequate intake of all vitamins and minerals through a well-‐balanced diet of fruits, vegetables, whole grains, low-‐fat dairy products, and lean protein.

Pregnant women should prac1ce general principles of good health, such as discon1nuing smoking, alcohol intake, and any unnecessary drugs.

Instruc1on in an appropriate exercise rou1ne will enhance the woman’s physical fitness and help her to maintain op1mal BG control.

The woman should con1nue or begin an intensive insulin regimen, using either basal-‐bolus or insulin pump therapy. Any oral or noninsulin glucose-‐lowering agents must be discon1nued. Instruc1on in or review of SMBG techniques is important. The pa1ent should test her BG levels frequently (at least before and 1 hour aber meals) to assess the adequacy of her insulin regimen. Based on BG paHerns, the diabetes team can prescribe adjustments in diet, exercise, or insulin to help aHain glycemic targets. The pa1ent and her partner must be reminded about the signs, symptoms, and management of hypoglycemia. The pa1ent should fill a current glucagon prescrip1on, and the partner should be taught how to administer glucagon. If achieving glucose control or hypoglycemia is problema1c, the provider can consider using con1nuous glucose monitoring (CGM) to obtain a 24‒hour overview of the pa1ent’s glycemic paHerns.



45

This slide shows the glycemic targets recommended by the ADA and ACOG for women with preexis1ng type 1 or type 2 diabetes who become pregnant.

The ADA recommends plasma glucose ranges of 60 to 99 mg/dL for premeal, bed1me, and overnight BG and 100 to 129 mg/dL for peak postprandial glucoses. The A1C target is less than 6.0%. Note that these are op1mal glycemic goals to be pursued if they can be aHained without excessive hypoglycemia.

The targets recommended by ACOG are ≤95 mg/dL for fas1ng plasma glucose, ≤100 mg/dL for premeal plasma glucose, ≤140 mg/dL for 1‒hour postmeal plasma glucose, ≤120 mg/dL for 2‒hour postmeal plasma glucose, and ≥60 mg/dL for overnight plasma glucose. The A1C target is ≤6.0%.


American College of Obstetricians and Gynecologists CommiHee on Prac1ce Bulle1ns—Obstetrics. ACOG Prac1ce Bulle1n Number 60: Pregesta1onal diabetes mellitus. Obstet Gynecol. 2005;105:675‒685.

46

Pregnant women with diabetes can follow most weight gain, hydra1on, and nutri1on recommenda1ons for pregnant women without diabetes. IOM-‐recommended weight-‐gain ranges for pregnant women are 28 to 40 pounds if the pa1ent is underweight (BMI 30 kg/m2).

According to the Academy of Nutri1on and Diete1cs (AND), adequate water intake is 3 L/day, with approximately 2.3 L (about 10 cups) consumed as water and other beverages and the rest consumed as food.

The IOM published dietary reference intakes (DRIs) for energy, carbohydrate, fiber, fat, faHy acids, cholesterol, protein, and amino acids in 2005 and DRIs for calcium and vitamin D in 2011. According to advice updated by the FDA in 2014, pregnant women should eat 8 to 12 ounces of a variety of fish each week; choose fish lower in mercury; avoid 1lefish from the Gulf of Mexico, shark, swordfish, and king mackerel; and limit white (albacore) tuna to 6 ounces per week. Because pregnant women are at a 5-‐fold risk of developing listeriosis, they should avoid deli meats, hot dogs, and lunch meats unless reheated un1l steaming hot; unpasteurized sob cheeses; refrigerated patés and meat spreads; refrigerated smoked seafood, unless cooked; and raw and unpasteurized milk. According to the AND, all FDA-‐approved nonnutri1ve sweeteners are approved for use by the general public, including pregnant women. However, most registered die11ans and diabetes educators recommend limi1ng daily use to 3 servings or less. Reader DM, Thomas A. Pregnancy with diabetes. In: Mensing C, ed-‐in-‐chief; Cornell S, Halstenson C, eds. The Art and Science of Diabetes Self-‐Management Educa@on Desk Reference. 3rd ed. Chicago: American Associa1on of Diabetes Educators; 2014:683–718.

Note: Full cita1ons for the other references listed on the slide appear in the Reference List for this ac1vity.

47

DKA is a serious complica1on that can lead to fetal death unless promptly and effec1vely managed. Increased insulin resistance and lipolysis raise the risk of DKA during pregnancy. Other risk factors include hyperemesis, gastroparesis, and treatment with cor1costeroids or beta-‐mime1c, tocoly1c medica1ons, such as terbutaline or ritodrine. Although DKA usually occurs in pa1ents with type 1 diabetes, it can also arise in pregnant women with type 2 diabetes. Therefore, all women with preexis1ng diabetes who are planning pregnancy or are already pregnant should be educated about DKA preven1on and symptoms.

Nausea, vomi1ng, abdominal pain, fever, and small oral intake are all sugges1ve of DKA. Pregnant women should perform urine ketone measurements when they are sick or when their BG levels remain above 200 mg/dL and promptly report posi1ve values to their health care provider. Up to 30% of pregnant women with DKA have BG levels that are only moderately elevated (

The risk of hypoglycemia increases during pregnancy, and is especially common during the first trimester. Women with a history of frequent hypoglycemia or hypoglycemia unawareness before pregnancy are at heightened risk. Some of the classic signs of hypoglycemia, including anxiety, nausea, palpita1ons, tremor, swea1ng, warmth, confusion, dizziness, headache, hunger, and weakness, may be difficult to dis1nguish from pregnancy symptoms. Hypoglycemia unawareness is prevalent in pregnant women, but it is at least par1ally reversible by several weeks of me1culous avoidance of iatrogenic hypoglycemia.

Protocols to minimize the occurrence of maternal hypoglycemia include intensive educa1on of pa1ents and significant others, frequent SMBG, proper 1ming of adequate meals and snacks, correct administra1on of insulin doses, and careful management of physical ac1vity. There is some evidence that use of insulin analogs, especially with insulin pump therapy, reduces the risk of maternal hypoglycemia.

Mild hypoglycemia should be treated using the “15‒15 rule.” Following this rule, the pa1ent consumes 15 grams of a low-‐fat carbohydrate, such as 8 ounces of milk or 3 to 4 glucose tablets. Fibeen minutes later, the pa1ent should perform SMBG to ensure that the BG level has returned to normal. If it is s1ll low, another 15 grams of carbohydrate should be taken.

When a pregnant woman experiences severe hypoglycemia and cannot swallow, a family member or coworker should inject glucagon and call an emergency service for help.

Kitzmiller JL, Block JM, Brown FM, et al. Managing preexis1ng diabetes for pregnancy: summary of evidence and consensus recommenda1ons for care. Diabetes Care. 2008;31:1060–1079. Coustan DR, ed. Prepregnancy counseling, assessment, and management of women with preexis1ng diabetes or previous gesta1onal diabetes. In: Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Associa1on; 2013:1–26.

49

Insulin pump therapy is an aHrac1ve insulin delivery system during pregnancy for several reasons. By lowering the amount of circula1ng basal insulin, it decreases the incidence of premeal hypoglycemia and controls the drama1c rise in postprandial glucose that oben occurs during pregnancy. Correct use of an insulin pump improves insulin absorp1on, decreases severe hypoglycemia, enhances lifestyle flexibility, and simplifies the management of morning sickness.

Although using an insulin pump can benefit highly mo1vated pa1ents during pregnancy, most compara1ve studies have shown similar outcomes with insulin pump therapy and mul1ple daily injec1ons of insulin.

Pregnant women who are contempla1ng insulin pump therapy should be advised that serious complica1ons can arise. For example, there is the poten1al for frequent and severe hyperglycemia if insulin delivery is interrupted or an infec1on develops at the infusion site.

Reader DM, Thomas A. Pregnancy with diabetes. In: Mensing C, ed-‐in-‐chief; Cornell S, Halstenson C, eds. The Art and Science of Diabetes Self-‐Management Educa@on Desk Referenc

Documents

PregnancyforWomenwithDiabetesissupportedbyaneducaonalgrant ...schererclin.com/documents/scherer_pregnancy_15953.pdf · The3majortypesofdiabetesinpregnancyarepreexisngtype1diabetes,preexisngtype2