Diabetes and Pregnancy Flashcards
Prevalence of Hyperglycemia in Pregnancy
Was 16.7% in 2021
- Increases with maternal age
- More common in low and middle income countries
Gestational Pregnancy Prevalence
Percentage of diabetes in pregnancy is 75-90% Gestational Diabetes
Effects of Dysglycemia on fetus development
1st Trimester (Pre-existing diabetes)
- Increase risk of fetal malformations
2nd and 3rd Trimester (Gestational diabetes)
- Increase risk of macrosomia and metabolic complications
Diabetes in Pregnancy
- Categories
Presentational Diabetes
- Preexisting diabetes (Type 1 or 2)
Gestational Diabetes
- Diabetes diagnosed in pregnancy
Why does Gestational Diabetes occur?
- When does it typically occur?
- Occurs because of hormone changes which cause insulin to be less effective
–> Does no affect insulin production - Most likely to occur in 2nd/3rd trimester
Gestational Diabetes
- Screening
- Women should be screened between 24 and 28 weeks gestation
- Screening should involve an oral glucose tolerance test (OGTT)
Gestational Diabetes
- Diagnosis
Women are diagnosed at varying levels of maternal hyperglycemia and maternal/fetal risk
- Hard to set thresholds
–> Set it too low and then people who may not need pharmacological therapy suddenly require medications according to the threshold)
Lots of debate on which strategy is best
Gestational Diabetes
- Prevention
For women with high risk of GDM based on pre-existing risk factors
- Screen A1c (or FBG if A1c is unreliable) in the first trimester
- Nutritional Counseling
–> Healthy eating
–> Prevention of excess weight gain
Risk Factors of Gestational Diabetes
- High Risk Population
- Previous GDM
- History of macrosomic infant
- Current fetal macrosomia
- Current Polyhydramnios
- Prediabetes
- BMI greater than 30mg/m2
- Older than 35 years old
- Corticosteroid use
- Polycystic Ovarian Syndrome
- Acanthosis nigricans
Acanthosis Nigricans
Risk factor for GDM
- Discoloration of body folds and creases
- Sign of insulin resistance
Gestational Diabetes
- Pathophysiology
Normal Pregnancy:
- Insulin resistance starts in 2nd trimester
- Supplies glucose to the baby
- Hormones interfere with insulin binding
- Insulin resistance in mother
Insulin Resistance + Pre-existing insulin resistance and/or beta cell deficit can lead to GDM
Hormones that contribute to Insulin Resistance during Pregnancy
- Placental Lactogen
- Placental Growth Hormone
- Human Chorionic Gonadotropin (hCG)
- Cortisol
- Prolactin
- Estrogen
- Progesterone
- Leptin
- TNFalpha
- Resistin
What can pass the placenta
Insulin does not pass the placenta
Glucose passes through the placenta
- Fetus produces its own insulin allowing it to use the glucose for growth
–> Leads to Macrosomia
Implications of Gestational Diabetes
- Mother
Trauma from LGA infant
C-section
Pre-eclampsia
Pregnancy Induced Hypertension
Implications of Gestational Diabetes
- Mother (Long-Term)
Type 2 Diabetes
Hypertension
Heart Disease
Implications of Gestational Diabetes
- Baby
LGA and trauma from getting stuck in birth canal
- Shoulder dystocia
- Erb’s palsy/nerve injury
- Brain injury
Prematurity
Neonatal Hypoglycemia
Immature Lung function
Jaundice
Neonatal ICU Admission
Implications of Gestational Diabetes
- Baby (Long-Term)
Obesity and Dysglycemia
Premature puberty in girls
Gestational Diabetes Initial Management
- Nutrition Counseling
- Healthy diet replacing high-glycemic index foods with low-glycemic index foods
- Weight gain and healthy lifestyle interventions during pregnancy
- Recommended weight gain based on pre-pregnancy BMI to reduce LGA and C-section
(Diet, Exercise, Weight Management)
Gestational Weight Gain Guideline
- According to Pre-Pregnancy BMI
BMI < 18.5: 28-40
BMI 18.5-24.9: 25-35
BMI 25.0-29.9: 15-23
BMI > 30: 11-20
Gestational Diabetes Management
- Glycemic Target
SMBG Fasting and Post Prandially
- Fasting and Preprandial < 5.3
- 1h postprandial < 7.8
- 2h postprandial < 6.7
If targets not reached within 1-2 weeks initiate pharmacology therapy
Gestational Diabetes Management
- Pharmacological
Insulin First Line (Short acting)
- Aspart, Lispro, Glulisine
Metformin as alternative
Glyburide
- Refuse insulin
- Can’t tolerate metformin
Does metformin cross the placenta
Yes it does. good safety data however
Gestational Diabetes Management
- Postpartum Management
Encourage breastfeeding for 3-4 months after delivery
- Reduces neonatal hypoglycemia, Childhood obesity, Diabetes
- Reduces maternal diabetes and hypertension
75 g OGTT between 6 weeks to 6 months postparatum
- To detect prediabetes or diabetes
Stop insulin after delivery
- Insulin sensitivity will return
Pre-existing Diabetes increases risk of:
- Mother
Worsening of pre-existing complications:
- Nephropathy, retinopathy
Pre-existing Diabetes increases risk of:
- Baby
Malformations if glucose is high in first trimester
Most common fetal anomalies periconceptional
Renal Agenesis (Development of one kidney)
Anencephaly (Underdevelopment of brain)
Cardiac Abnormalities
Pregestational Diabetes
- Preconception Counseling
Counsel women at reproductive age with diabetes
- Birth Control
- Metformin in PCOS can increase fertility (can induce ovulation in PCOS)
- Achieve a healthy weight before conception (obesity associated with adverse pregnancy outcomes)
Pre-Pregnancy and Intrapartum
Retinopathy
- Ophthalmological evaluation
Nephropathy
- Assess creatinine + urine albumin to creatinine ratio (Women with albuminuria or overt nephropathy are at increased risk of hypertension and preeclampsia)
Preconception Checklist for Women with Pre-existing Diabetes
- Birth Control
Use reliable birth control
Folic Acid 1mg/day for 3 months preconception to 12 months post-ceonception
Preconception Checklist for Women with Pre-existing Diabetes
- A1c
Attain A1c below 7.0% (Try <6.5% if safe)
Preconception Checklist for Women with Pre-existing Diabetes
- Antihyperglycemic Therapy
May remain on metformin + glyburide
- If on other antihyperglycemic therapies switch to insulin
Preconception Checklist for Women with Pre-existing Diabetes
- Diabetic Complications
Assess for and manage any diabetes complications
Preconception Checklist for Women with Pre-existing Diabetes
- Folic Acid
1 mg / daily
- 3 months preconception to 12 months post conception
Preconception Checklist for Women with Pre-existing Diabetes
- Embryopathic Medications
Discontinue ACEi/ARB after detecting pregnancy
Discontinue Statin Therapy
Pre-existing Diabetes (Type 1 Diabetes)
- Pharmacological
Basal-bolus insulin therapy (3-4 injections per day) or continuous subcutaneous insulin infusion
Pre-existing Diabetes (Type 2 Diabetes)
- Pharmacological
Switch to insulin, monitor and determine if metformin is needed
Pre-existing Diabetes (Which Insulin to use)
- Pharmacological
Bolus
- Can use aspart or lispro instead of regular
Basal
- Can use detemir or glargine instead of NPH (NPH is acceptable for type 2)
Pre-existing Diabetes
- ASA
Can start at 12-16 weeks to reduce risk of pre-eclampsia
Pre-existing Diabetes
- Postpartum care
- Adjust insulin (prevent hypoglycemia)
- Encourage breastfeeding
- Metformin and Glyburide appear to be safe
- Screen for postpartum thyroiditis in type 1 diabetes (Check TSH at 2-4 months postpartum)
