Diabetes and pregnancy

Risks of Adverse pregnancy outcomes in gestational diabetes

• increasing frequency of birth weight above the 90th percentile• Primary cesarean section• neonatal hypoglycemia, and elevated• cord C-peptide level (a surrogate marker for fetal

hyperinsulinemia)• preeclampsia,• preterm delivery• shoulder dystocia/birth injury• Hyperbilirubinemia• neonatal intensive care admission.

Blumer et al Guideline on Diabetes and Pregnancy J Clin Endocrinol Metab, November 2013, 98(11):4227–4249

Definition of gestational diabetes

• The current definition: • any degree of glucose intolerance with onset or

first definition during pregnancy

• Redefining gestational diabetes:• the condition associated with degrees of maternal• hyperglycemia less severe than those found in

overt diabetes but associated with an increased risk of adverse pregnancy outcomes


DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013

DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010

DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013

J Clin Endocrinol Metab 98: 4227–4249, 2013

Diabetes and Pregnancy: An Endocrine SocietyClinical Practice Guideline

Preconception care of women with diabetes

• glycemic control, Insulin therapy• Folic acid supplementation• Ocular care (preconception, during pregnancy, and

postpartum)• Renal function • Management of hypertension• Elevated vascular risk• Management of dyslipidemia• Thyroid function• Overweight and obesity


Insulin therapy

• Multiple daily doses of insulin or continuous sc insulin infusion in preference to split-dose, premixed insulin therapy

• Rapid-acting insulin analog therapy (with insulin aspart or insulin lispro) in preference to regular (soluble) insulin

• Women with diabetes successfully using the long-acting insulin analogs insulin detemir or insulin glargine preconceptionally may continue with thistherapy before and then during pregnancy


Folic acid supplementation

To reduce the risk of neural tube defects:• Beginning 3 months before withdrawing

contraceptive measures or otherwise trying• to conceive, 5 mg/d, till 12 weeks of gestation

and then 0.4-1 mg/d

Continue folic acid till the end of lactation


Ocular care (preconception, during pregnancy, and postpartum)• Before conception, If the degree of retinopathy warrants

therapy, we recommenddeferring conception until the retinopathy has been treated and found to have stabilized, then each trimester and within 3 months of delivering, and then as needed.Established retinopathy can rapidly progress during, and up to 1 year after, pregnancy and can lead to sight threatening deterioration

• Those pregnant women with diabetes not known to have retinopathy have ocular assessment performed soon after conception and then periodically as indicated during pregnancy


Risk factors for progressionof retinopathy during pregnancy

• pregnancy; esp. in those women with retinopathy preconceptionally

• Preexisting hypertension • poorly controlled hypertension during pregnancy • preeclampsia • poor glycemic control at the onset of and during

pregnancy


Renal function (preconception and during pregnancy)• Assess renal function preconception:

urine albumin to creatinine ratio, serum creatinine, and estimated GFR

• If GFR is significantly reduced, she should be visited by a nephrologist• Mild preconceptional renal dysfunction manifesting only as

microalbuminuria may worsen during pregnancy with greater amounts of proteinuria

• More severe preconceptional renal dysfunction, as evidenced by a reduced GFR and elevated serum creatinine, can significantly deteriorate during pregnancy and may not be reversible


Management of hypertension• Maintain BP control<130/80 mm Hg, preconception• Discontinue ACE inhibitor or angiotensin-receptor blocker

in almost all cases before withdrawing contraceptive, because they are teratogenic

• when ACE inhibitors or angiotensin- receptor blockers have been continued up to the time of conception, that the medication should be withdrawn immediately upon the confirmation of pregnancy

• Safe medications: methyldopa, labetalol, diltiazem,• clonidine, and prazosin


Elevated vascular risk

• Myocardial infarction during pregnancy is associated with adverse maternal and fetal outcomes including maternal and fetal demise

• High maternal (11%) and fetal (9%) mortality

rates


Management of dyslipidemia

• Do not use statin

• Do not use fibrate or nicotinic acid, unless in severe hypertriglyceridemia

• Bile acid-binding resins may be used in women with diabetes to treat hypercholesterolemia


Thyroid function

For women with type 1 diabetes:• Measure TSH and, if their thyroid peroxidase

status is unknown, measurement of TPOAb before withdrawing contraceptive measures or otherwise trying to conceive

• Measure TSH 3 and 6 months after delivery (postpartum thyroiditis)


Overweight and obesity

• Reduce caloric intake by 33%• Not less than 1500 kcal/d to prevent ketosis • Moderate energy restriction (1600–1800

kcal/d) in pregnant women with overt diabetes improves mean glycemia and fasting insulinemia without inhibiting fetal growth or birth weight or inducing ketosis


Management of diabetes during peregnancy and postpartum

• Weight • Carbohydrate intake• Blood glucose, post partum care• Folate, vitamin and minerals• Insulin, glibenclamide, metformin• Target glucose for labor (72-126 mg/dl)• Lactation• Postpartum contraception• Screening for postpartum thyroiditis


Noninsulin antihyperglycemic agent therapy

• Glyburide (glibenclamide), alternative to insulin in women with GDM who fail to achieve sufficient glycemic control after a 1-week trial of medical nutrition therapy and exercise except for those women with a diagnosis of gestational diabetes before 25 weeks gestation and for those women with fasting plasma glucose levels 110 mg/dL (6.1 mmol/L), in which case insulin therapy is preferred

• Metformin therapy be used for glycemic control only for those women with gestational diabetes who do not have satisfactory glycemic control despite medical nutrition therapy and who refuse or cannot use insulin or glyburide and are not in the first trimester

Lactation

• whenever possible women with overt or gestational diabetes should breastfeed their infant

• breastfeeding women with overt diabetes successfully using metformin or glyburide therapy during pregnancy should continue to use these medications, when necessary, during breastfeeding


Diabetes and pregnancy

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