Diabetes in Pregnancy Flashcards
Diabetes in Pregnancy: 2 Categories
Pregestational diabetes - Pregnancy in pre-existing diabetes • Type 1 diabetes • Type 2 diabetes Gestational diabetes - Diabetes diagnosed in pregnancy
Dysglycemia in Pregnancy can Result in
Adverse Pregnancy Outcome
• Elevated glucose levels can have adverse effects on the fetus
• 1st trimester à ↑ fetal malformations
• 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications
Diabetes in Pregnancy: Consider Phases
Pregestational diabetes (T1D and T2D) 1. Preconception counseling 2. Management during pregnancy 3. Management in labour 4. Postpartum considerations
Gestational diabetes
- Prevention, Screening & Diagnosis
- Management during Pregnancy
- Management in labour
- Postpartum considerations
Gestational Diabetes (GDM) Diagnosis
50g GCT does not identify fasting
hyperglycemiaà straight to OGTT if high risk
Screen earlier if risk factors for GDM: Previous GDM BMI ≥30 kg/m2 Prediabetes Polycystic ovarian syndrome High risk population (nonCaucasian) Current fetal macrosomia or polyhydramnios Age ≥35 years History of macrosomic infant Corticosteroid use Acanthosis nigricans
Pathophysiology
In normal pregnancy, insulin resistance occurs in 2nd trimester
–> thought to ensure glucose supply to fetus
• Pregnancy hormones are thought to interfere with insulin binding at receptor causing insulin resistance
• If insulin resistance also in context of existing insulin resistance or beta cell defect –> GDM
Hormones contributing to insulin resistance during pregnancy:
• Placental Lactogen • Placental growth hormone • Progesterone • Cortisol • Prolactin • Estrogen • hCG • Leptin • TNFa • Resistin
GDM increases risk of:
for mother
Mother Trauma from LGA infant C-section Pre-eclampsia Pregnancy induced hypertension
Longer term
Development of T2D
Development of heart disease
Development of HTN
GDM increases risk of:
for child
LGA and trauma from getting stuck: • shoulder dystocia • Erb’s palsy/nerve injury • Brain injury Prematurity Prematurity Immature lung function Jaundice Neonatal ICU admission
Longer term
Obesity and dysglycemia
Premature puberty in girls
Multidisciplinary team
- Patient: recording and reflecting on glucose checks, meals, and physical activity
- Team: glucose, nutrition, weight gain, BP, fetal health
- Close follow up
GDM: Management During Pregnancy
• Insulin first-line
• May use aspart, lispro, glulisine: perinatal outcomes similar
• Metformin may be used as an alternative to insulin
• Good safety data in pregnancy
• Evidence of less maternal weight gain, less large-for-gestational-age, less neonatal
hypoglycemia
• Women should be informed that it crosses the placenta
• Safety data in offspring postpartum up to 2 years
• Insulin necessary in 40% on metformin
• Glyburide may be used in women who refuse insulin and not well
controlled on metformin
Target BG values
• Perform SMBG fasting and postprandially
• Glycemic targets during pregnancy:
Fasting and preprandial BG <5.3 mmol/L
1h postprandial BG <7.8 mmol/L
2h postprandial BG <6.7 mmol/L
f glycemic targets not achieved within 1-2 weeks,
initiate pharmacologic therapy
Adjusting Insulin in GDM
q If fasting high, increase evening NPH
q If post Brk high, increase Brk analogue
q If post Lun high, increase Lun analogue
q If post Sup high, increase Sup analogue
If above target for two consecutive days,
increase appropriate insulin, typically by 2 units
And don’t stop increasing insulin until targets achieved
GDM: Postpartum Management
- Encourage Breastfeeding
• Reduce neonatal hypoglycemia, childhood obesity & diabetes, AND
maternal risk of diabetes & hypertension - 75 g OGTT between 6 weeks - 6 months postpartum
to detect prediabetes or diabetes. Suggest phone
calls/email reminders to improve testing rates
Dysglycemia in Pregnancy can Result in
Adverse Pregnancy Outcome
• Elevated glucose levels can have adverse
effects on the fetus
• 1st trimester à ↑ fetal malformations
• 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications
Preexisting DM increases risk of:
Worsening preexisting vascular
complicationsàRETINOPATHY
Fetal malformations if maternal glucose high
in first trimester
LGA and trauma from getting stuck:
• shoulder dystocia
• Erb’s palsy/nerve injury
• Brain injury
Congenital Malformations – First Trimester
- Caudal regression
- Situs inversus
- Duplex ureter
- Renal agenesis
- Cardiac abnormalities
- Anencephaly
Pre-existing Diabetes
Preconception care
b) Strive to attain a preconception A1C ≤7.0% (or A1C ≤6.5% if can
safely be achieved) to decrease the risk of:
• Spontaneous abortion [Grade C, Level 3]
• Congenital anomalies [Grade C, Level 3]
• Preeclampsia [Grade C, Level 3]
• Progression of retinopathy in pregnancy [Grade A, Level 1 for type 1 diabetes; Grade
D, Consensus for type 2 diabetes]
• Stillbirth [Grade C, Level 3]
Preconception Checklist for Women with
Pre-existing Diabetes
ü Use reliable birth control until adequate glycemic control
ü Attain a preconception A1C of ≤7.0% (≤ 6.5% if safe)
ü May remain on metformin + glyburide until pregnancy, otherwise switch to
insulin
ü Assess for and manage any diabetes complications (eyes, kidneys)
ü Folic Acid 1 mg/d: 3 months pre-conception to 12 weeks post-conception
ü Discontinue potential embryopathic meds:
ü ACE inhibitors / ARB (prior to or upon detection of pregnancy in those with
significant proteinuria)
ü Statin therapy
Recommendation 11
Pre-existing Diabetes
Management in pregnancy
- Aspart, lispro or glulisine may be used in women with pre-existing
diabetes to improve postprandial BG [Grade C, Level 2 for aspart; Grade C, Level
3 for lispro; Grade D, Level 4 for glulisine] and reduce the risk of severe
maternal hypoglycemia [Grade C, Level 3 for aspart and lispro; Grade D,
Consensus for glulisine] compared with human regular insulin
Recommendation 12
__________may be
used in women with pre-existing diabetes as an alternative to NPH and is associated with similar perinatal outcomes
- Detemir [Grade B, Level 2] or glargine [Grade C, Level 3] may be
used in women with pre-existing diabetes as an alternative to
NPH and is associated with similar perinatal outcomes
Pregnancy Management for Pre-existing Diabetes
• Type 1 diabetes: Basal-bolus insulin therapy (3-4 injections per day) or continuous subcutaneous insulin infusion (CSII)
• Type 2 diabetes: Switch to insulin (MiTy study will
determine if efficacious to add metformin)
• Individualize insulin therapy with close monitoring
• Bolus insulin: May use aspart or lispro instead of regular insulin
• Basal insulin: May use detemir or glargine as alternative to NPH
(type 2 diabetes: NPH is acceptable
Pregnancy Management for Pre-existing Diabetes
• Perform SMBG pre- and postprandially (7x/day!) Target BG values Fasting and pre-prandial BG <5.3 mmol/L 1h postprandial BG <7.8 mmol/L 2h postprandial BG <6.7 mmol/L
- Aim for A1C ≤6.5% (≤6.1% if possible)
- Lower late stillbirth & infant death
- Individualize targets in those with severe hypoglycemia/unawareness
Pregnancy Management for Pre-existing Diabetes
- Type 1 diabetes: Continuous glucose monitoring should be considered in all women
- ê LGA, NICU >24 hrs, neonatal hypoglycemia, infant length of hospital stay
- Encourage weight gain according to Institute of Medicine recommendations
- ASA to reduce the risk of pre-eclampsia, starting at 12-16 weeks gestational age
Recommendation
Pre-existing Diabetes
Postpartum
- Insulin doses should be decreased immediately after delivery below prepregnant doses and titrated as needed to achieve good glycemic control [Grade D, Consensus]
- Women with pre-existing diabetes should have frequent blood glucose monitoring in the first days postpartum, as they have a high risk of hypoglycemia [Grade D, Consensus]
. For women with pre-existing diabetes,
_____________ should be encouraged immediately
postpartum to reduce neonatal hypoglycemia
- For women with pre-existing diabetes, early neonatal feeding should be encouraged immediately
postpartum to reduce neonatal hypoglycemia [Grade C, Level 3]. Breast feeding should be encouraged for a
minimum of 4 months to reduce offspring
obesity [Grade D, Consensus] and later risk of
developing diabetes [Grade C, Level 3]. Women with preexisting diabetes should receive assistance and
counseling on the benefits of breastfeeding, in order to
improve breastfeeding rates, esp
Key Clinical Points
• Be supportive, pregnancy is stressful time à avoid negative
judgement of behaviours à compassion and empathy
• Focus on positive actions—past, present, and future àblood sugar
accounting isn’t helpful if the underlying issues are not dealt with
• Try and help patients navigate cost/access issues, reach out directly to
medical team when needed
