Diabetes in Pregnancy - Idaho Perinatal · 2016-02-04 · Gestational Same as type 2 diabetes Onset...

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2/4/2016 1 Diabetes in Pregnancy Mark Alanis, MD, MSCR Assistant Clinical Professor Maternal-Fetal Medicine University of Colorado Health Memorial Hospital, Colorado Springs, CO disclosures I have no relevant financial conflicts of interest with any commercial entity to disclose. I will discuss the off-label use of insulin and insulin pumps for use in pregnancy. I will not discuss the off label use of any other pharmaceutical agent or medical device during this lecture.

Transcript of Diabetes in Pregnancy - Idaho Perinatal · 2016-02-04 · Gestational Same as type 2 diabetes Onset...

Page 1: Diabetes in Pregnancy - Idaho Perinatal · 2016-02-04 · Gestational Same as type 2 diabetes Onset during pregnancy, resolves in postpartum; Rare, other Pancreatic damage or insufficiency,

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Diabetes in

PregnancyMark Alanis, MD, MSCRAssistant Clinical ProfessorMaternal-Fetal MedicineUniversity of Colorado Health

Memorial Hospital, Colorado Springs, CO

disclosuresI have no relevant financial conflicts of interest with any

commercial entity to disclose.

I will discuss the off-label use of insulin and insulin pumps

for use in pregnancy.

I will not discuss the off label use of any other

pharmaceutical agent or medical device during this

lecture.

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objectivesAt the end of this lecture, you will be better prepared to:

Counsel patients on the risks of gestationald and

pregestational diabetes

Sort through the confusion about gestational diabetes

testing paradigms

Reduce diabetes-related adverse outcomes through

achieving maternal euglycemia

Frederick BantingBorn 1891, died 1941

Canadian physician scientist

Discovery of insulin, 1922

Nobel prize, 1923

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Pricilla WhiteBorn 1900, died 1989

Mentored by Elliot P. Joslin

Among first to show importance of strict glucose control in pregnancy

White’s Classification in 1949

Banting Medal recipient

White’s ClassificationDescription Class Fetal Growth

Gestational Diabetes, no insulin A1 No vascular disease

High Risk for MacrosomiaGestational Diabetes, insulin A2

Age of onset, ≥ 20 y B1

Duration < 10 y, no vascular lesions B2

Age of onset, 10-19 y C1

Duration 10-19 y, no vascular lesions C2

Age of onset, < 10 y D1

Duration, ≥ 20 y D2

Benign (non-proliferative) retinopathy D3 Vascular disease

High Risk for IUGRCalcified arteries of the legs D4

Calcified arteries of the pelvis E

Nephropathy F

Many failures G

Cardiac disease H

Proliferating retinopathy R

Renal transplant T

Pridjian G. Obstet Gynecol Clin N Am 2010;37:143, adapted from: White P. Am J Obstet Gynecol 1978;130:228

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ADA Classification

Diabetes Type Findings Phenotype

Type 1 Autoimmune destruction of β-cells;

33% concordance among mono-

zygotic twins; Absolute insulinopenia

Onset in childhood or

adolescence; Thin;

Ketoacidosis

Type 2 Progressive insulin secretory defect;

insulin resistance; 58-100%

concordance among mono-zygotic

twins

Adult-onset, obese,

metabolic syndrome,

hyperosmolar coma

Gestational Same as type 2 diabetes Onset during

pregnancy, resolves in

postpartum;

Rare, other Pancreatic damage or insufficiency,

genetic defects in insulin action

Cystic fibrosis

American Diabetes Association, Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013;36, Suppl 1: S11

85%

15%

Gestational DM

Pregestational DM

Epidemiology

Albrecht SS, et al. Diabetes Care 2010;33:768

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Prevalence increasing rapidly

Percent of Deliveries (%)

Type N 1994 1999 2004 % change

All diabetes 1,863,746 3.49 4.04 5.47 56.3

GDM 1,578,703 2.95 3.42 4.61 56.2

Type 1 130,300 0.24 0.31 0.33 33.2

Type 2 87,477 0.09 0.16 0.42 366.7

Hospital Discharge Data 1994-2004 of 43+ million delivery discharges

Albrecht SS, et al. Diabetes Care 2010;33:768

U.S. Adults Aged 18 Years or older

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2010

2010

DIABETES

OBESITY

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New diagnoses 2002-2005

Ra

te (

pe

r 100,0

00 p

er

ye

ar)

Youths 10-19 years of age

Type 2

Type 1

0

40

CDC, 2011 National Diabetes Fact Sheet, data from SEARCH for Diabetes in Youth Study:

Type 1 DiabetesAcute onset

Childhood or adolescence

Islet cell autoimmune antibodies

β-cell destruction

Absolute insulinopenia

Lifelong requirement for insulin

Threat of diabetic ketoacidosis

High rate of vascular disease

High rate of pregnancy complications

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Type 2 DiabetesInsidious onset

Asymptomatic

Relative insulin deficiency

Decreased insulin sensitivity in skeletal muscle

Decreased insulin response on hepatic glucose production

Inadequate β-cell response for given glucose level

Typically older, overweight or obese, family history

Most pregnant patients are White’s Class B

High rate of pregnancy complications

Gestational DiabetesOnset in late second trimester

Asymptomatic

Relative insulin deficiency

Decreased insulin sensitivity in skeletal muscle

Decreased insulin response on hepatic glucose production

Inadequate β-cell response for given glucose level

Typically older, overweight or obese, family history

Lower rate of pregnancy complications

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lots of risks…

how do you communicate it all?

Counseling the pregestational diabetic patient

Which diabetic patient has

the highest risk for

pregnancy

complications?a) Type 1 diabetes

b) Type 2 diabetes

c) Gestational diabetes

d) No difference between the 3

types

ARS

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Pregnancy affects retinopathy

in what way?a) It occurs de novo due to pregnancy

b) If already present at conception, it worsens during

pregnancy, then returns to baseline

c) If already present at conception, it worsens during

pregnancy, permanently

d) It is not affected by pregnancy

ARS

The most common cause of

perinatal mortality in diabetic

pregnancies is:a) Stillbirth

b) Congenital anomaly

c) Respiratory distress

d) Preterm birth

ARS

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What is the incidence of

brachial plexus injury with

shoulder dystocia?a) 5%

b) 15%

c) 25%

d) 35%

ARS

Which is true in normal pregnancy?a) Fasting glucose increases

over gestation

b) Insulin sensitivity increases in

first trimester

c) Postprandial glucose

increases over gestation

d) All of the above

ARS

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Diagnosing DiabetesType 1

Pregestation

Autoantibodies

Clinical characteristics

1-2% of persistent DM after diagnosis of GDM

Type 2

Pregestation

Clinical characteristics

98% of persistent DM after diagnosis of GDM

Gestational

Two-Step versus One Step

Overly confusing set of parameters

Philosophical argument of individual versus public health benefit

GDM Screening Dilemmas

Two

Step

1-hour 50 g

glucose load

3-hour 100 g

glucose load

GDM

Yes or No

When should

you do it?

What cutoff

to use?

Should you

fast?

High false negative

and positive rates

Very

inconvenient

What cutoffs

to use?

Arbitrary

diagnosis

Risk versus harm

with diagnosis

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GDM Screening Dilemmas

One

Step

2-hour 75 g

glucose load

GDM

Yes or No

Moderately

inconvenient3-fold increase in

prevalence

Arbitrary

diagnosis

1979 - 2009 20102008 2011 2012 2013 2014

Timeline of Recent

GDM Diagnostic

Crisis

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HAPOHyperglycemia and Adverse Pregnancy Outcomes

HAPO Study Group N Engl J Med 2008;358:1991

HAPO and IADPSG

Study Features

>25,000 patients

International, multicenter

2-hour, 75 g glucola

Providers blinded to test

results

Intent was to redefine

GDM diagnostic testing

cutoffs based on

outcomes ...but this

wasn’t the case

IADPSG had two goals:

1. Use HAPO to develop

cutoffs discretely linked

to GDM-related

morbidities

2. Develop international

standard diagnostic

guidelines

Cutoffs later arbitrarily

defined based Odds Ratios

of 1.75 for morbidities

International Association of Diabetes in Pregnancy Study Group

HAPO Study Group N Engl J Med 2008;358:1991IADPSG Diabetes Care 2010;33:676

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More GDM Diagnostic DilemmasShould you try to differeniate type 1 from

type 2 diabetes in unclear situations?

What do you call a patient whom you

diagnose early in pregnancy:

pregestational or gestational?

Should the hemoglobin A1c be used to

diagnose diabetes mellitus in pregnancy?

It’s not

important

ADA/IADPSG:

overt diabetes

ACOG:

undiagnosed type

2 DM

It can, but it

shouldn’t be

the only test

you order

EVEN More Diagnostic DilemmasShould early screening be performed?

Should you use NDDG or Carpenter-

Coustan criteria for the diagnosis in Two-

Step screening?

Should the One-Step paradigm be used

for the diagnosis of GDM?

ACOG: either

No! (ACOG and NIH)

Yes! (ADA, IADSPG, WHO)

Yes!(ADA and ACOG)

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GDM Screening Test Features

USPSTF Systematic Review Ann Intern Med 2013;159:115

A 1-hour, 50 g glucose cutoff of 140 mg has 15% false negative rate (CC criteria)

2-Step versus 1-StepCriteria Year Fasting

mg/dL

1-hour

mg/dl

2-hour

mg/dL

3-hour

mg/dL

Two

-Ste

p

(100 g

lo

ad

)

C-C 1982 95 180 155 140

NDDG 1979 105 190 165 145

CDA 2008 95 191 160

On

e-S

tep

(75 g

loa

d) WHO 1985 126 140

IADPSG 2010 92 180 153

NIH Consensus Development Conference Statement Vol. 29, Number 1. March 4-6, 2013

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GDM Screening and ACOG

Still allows for no lab screening for low-risk patients

Use either 135 mg/dL or 140 mg/dL for 1-hour cutoff

Use either Carpenter-Coustan or National Diabetes

Data Group for 3-hour cutoffs

Screen at-risk patients early in pregnancy GDM in previous pregnancy

Known impaired glucose metabolism

Obesity

Does NOT say WHEN or HOW to perform early screening

2013 Practice Bulletin No. 137

Maternal and Obstetric Fetal and Neonatal

Complications

Kidney dysfunction

Retinopathy

Myocardial infarction

Preeclampsia

Cesarean section

Preterm birth

Miscarriage and stillbirth

Structural malformations

Fetal overgrowth

Fetal growth restriction

Birth injury

Prematurity

Hypoglycemia

Infant death

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Retinopathy in pregnancy #1 cause of blindness

Asymptomatic until very

late stages

Macular edema

Retinal hemorrhage

Neovascularization

Retinal detachment

Neovascular glaucoma

Laser therapy to correct

Retinopathy progression

0

10

20

30

40

50

60

None Mild Mod-Severe

%

Progression by

baseline statusAssociated with

Pregnancy (2-fold)

Intensive insulin therapy

Initial A1c

Duration of disease

Chronic hypertension

Baseline retinal status

2-5 years after pregnancy

pregnancy effects

resolve

Chew EY, et al. Diabetes Care 1995;18:631Diabetes Control and Complications Trial Group. Diabetes Care 2000;23:1084

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Diabetic NephropathyDefinition

≥ 300 mg albuminuria in 24 hours

≥ 500 mg proteinuria in 24 hours

≥ 300 albumin-to-creatinine ratio (μg/mg) on spot urine

Microalbuminuria

30-299 mg albuminuria in 24 hours

30-299 μg/mg albumin-to-creatinine ratio on spot urine

Number 1 cause of end stage renal disease

Renal dialysis

Kidney transplantation

1 in 10-20 pregestational diabetic patients

Abnormal renal arteriolar dilation

Cannot handle hyperfiltration

Alteration in renin-angiotensin

Transient, mild worsening in pregnancy for mild disease

Possibly permanent worsening if severe disease

Preeclampsia, preterm birth, IUGR, stillbirth

Worst outcomes in: Baseline proteinuria > 3 g in 24

hours (heavy proteinuria) or baseline serum creatinine

≥ 1.5 g/dL (severe renal disease)

Peripheral dilation 5 weeks’

50% increase in renal blood flow 12 weeks’

50% increase in GRF 8 weeks’Physiology

Diabetes

Outcomes

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Microalbuminuria NephropathyRenal

InsufficiencyEnd Stage Renal

Disease

Diabetic Nephropathy

87%

3%

5%3% 2%

Normal (< 30mg/24h)

DM1 micro UA

DM2 micro UA

DM1 nephropathy

DM2 nephropathy

Damm JA, et al. Diabetes Care, in press

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Microalbuminuria

0

5

10

15

20

25

30

35

40

45

Preeclampsia PTB < 34 wk PTB < 37 wk

% Normal UA

Micro UA

Jensen DM, et al. Diabetes Care 2010;33:90

Diabetic NephropathyKitzmiller Grenfel Reece Gordon Rosenn

Year 1991 1986 1988 1996 1997

Subjects 26 20 31 45 61

Preeclampsia (%) 15 55 35 53 51

IUGR (%) 21 - 19 11 11

Delivery < 34 wk (%) 31 27 23 16 25

Perinatal mortality (%) 11 0 7 0 6

Gabbe Obstetrics: Normal and Problem Pregnancies, 6th Ed., 2012. Chapter 39: Diabetes Mellitus Complicating Pregnancy pp. 887-921

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Kidney Disease: Take Home1. Diabetic kidney disease is a progression from

microalbuminuria to overt nephropathy to impaired creatinine clearance to end stage renal disease

2. Microalbuminuria and nephropathy both strongly increase risk of preeclampsia

3. Good glucose control in pregnancy strongly reduces risk of preterm birth < 34 weeks in setting of microalbuminuria

4. Overt nephropathy strongly increases risk of IUGR and preterm birth < 34 weeks of gestation

Heart diseaseRare (24 case reports in literature between 1953-2007)

Mortality:

Before 1980 = 50% survived

After 1980 = 95% survived

Relative contraindication to pregnancy if untreated

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Diabetic ketoacidosis Kussmaul respirations

Maternal acidosis yields fetal acidemia

Severely hypovolemic, insulinopenic, hypokalemic

First: massive volume replacement with normal saline

Second: IV regular insulin 0.2 U/kg push

Third: Hang potassium 40-80 mEq in IV fluids

Fourth: continuous IV regular insulin infusion 0.1 U/kg/h

Fifth: BMP every 1-2 hours until anion gap closes

Sixth: reduce IV insulin infusion to 0.05 U/kg/h when serum glucose < 200 mg/dL

Medical ManagementFor prevention of maternal complications

Preconception consultation

Health maintenance screening:

Comprehensive eye exam, annually

Diabetic foot exam, annually

Evaluation of heart and kidneys

Laser photocoagulation if retinopathy

24-hour urine albumin, total protein, creatinine clearance

Aggressive management of blood pressure, <135/85

Strict diet, exercise, and tight glucose control

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Fetal Complications

In Utero Consequences Spontaneous Abortion

Congenital anomaly

Fetal overgrowth

Stillbirth

Hypertrophic cardiomyopathy

Respiratory distress syndrome

Polycythemia, jaundice

Neonatal mortality

Infant mortality

Lifelong risks of obesity, cardiovascular disease

MOST can be

negated by

early and

aggressive

glucose control

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What’s so bad about a big baby?

“big babies are so cute!”

1. Hypertrophic cardiomyopathy

2. Increased perinatal mortality

3. Shoulder dystocia

4. Brachial plexus injury

5. Respiratory distress syndrome

6. Hypoglycemia

7. Hyperbilirubinemia

8. Polycythemia

9. Epigenetic alterations to vascular tree

10. Childhood obesity, hypertension, and diabetes

11. Heart disease, Alzheimer’s disease

Fetal Overgrowth Large for gestational age = ≥ 90th percentile

Macrosomia = birth weight ≥ 4000 or 4500 g

Abnormal anthropometry

Increased fat mass

Broad chest

Increased shoulder diameter

Is birth weight best indicator for fetal overgrowth?1. In utero metabolism affects fat mass, not lean mass.

2. Normal body fat percentage is about 12-15% at birth.

3. Body fat percentage may be best measure of fetal growth.

Catalano PM and Hauguel-De Mouzon S. Am J Obstet Gynecol 2011;204:479

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Pedersen Hypothesis

Maternal

hyperglycemia

Fetal

hyperglycemia

Fetal

hyperinsulinemia

Increased

accretion of fat

MacrosomiaAltered

anthropometry

Structural AnomaliesStrong Association

Cardiac Defects most (septal and outflow defects)

Neural tube defects anencephaly

Moderate Association

Renal bilateral agenesis

Anogenital hypospadias

Almost pathognomonic

Caudal regression Sirenomelia, sacral agenesis

Correa A, et al (National Birth Defects Prevention Study) Am J Obstet Gynecol 2008;199:237Garne E, et al. Birth Defects Res A Clin Mol Teratol 2012;94:134

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Folic Acid and Spina Bifida

0

1

2

3

4

5

No Folic Acid Folic Acid

No diabetes

Diabetes

Parker SE, et al. Am J Obstet Gynecol 2013:209:239

Perinatal Mortality

Gabbe Obstetrics: Normal and Problem Pregnancies, 6th Ed., 2012. Chapter 39: Diabetes Mellitus Complicating Pregnancy pp. 887-921

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Offspring MortalityDeath Rates per 1000 deliveries

Type Diabete

s

No

Diabetes

Odds

Ratio

95% CI

Stillbirth 9.7 4.0 2.5 1.02-5.9

Perinatal

Mortality

17.4 5.9 3.0 1.6-5.9

Infant

Mortality

15.5 2.8 8.9 5.2-15.3

Yang J, et al. Obstet Gynecol 2006;108:644

Perinatal MortalityType 1 vs. Type 2 Diabetes Mellitus

Balsells M, et al. J Clin Endocrinol Metab 2009;94:4284

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Pregestational Diabetes

0

10

20

30

40

50

60

%

Type 2

Type 1

Clausen TD, et al. Diabetes Care 2005;28:323

Shoulder Dystocia

0

5

10

15

20

25

4000-4250 4250-4500 4500-4750 4750-5000

% U

na

ssis

ted

SV

D

Birth Weight

Non-Diabetic

Diabetic

Nesbitt TS, et al. Am J Obstet Gynecol 1998;179:476

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Principles of

ManagementBe aggressive! Time is of the essence!

Chief Principle #1

Oral agents have no place in the management

of pregestational diabetes during pregnancy

Preconception is the best opportunity to switch

from oral agents to insulin in order to achieve

glucose control

No matter what type of diabtes, the goal is

normal blood glucose levels

Corner stone of management is diet and hypoglycemic therapy

to achieve euglycemia

Managing Preexisting Diabetes in Pregnancy: American Diabetes Association Consensus Recommendations. Diabetes Care 2008;31-1060

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Normal glucose values Pooled analysis of

12 studies

Non-obese, non-

diabetic women

Period Plasma Glucose

Fasting 71 ± 8

1-hour post-

prandial

109 ± 13

2-hour post-

prandial

99 ± 10

24-hour average 88 ± 10

Hernandez et al. Diabetes Care 2011;34:1660Fifth International Workshop-Conference on Gestational Diabetes. Diabetes Care 2007;30:S251

ACOG/ADA

95*

140

120

110*

* Not included in 2013

Practice Bulletin

Insulin needs in early

pregnancy in type 1 diabetes

Gabbe Obstetrics: Normal and Problem Pregnancies, 6th Ed., 2012. Chapter 39: Diabetes Mellitus Complicating Pregnancy pp. 887-921

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Fasting glucose over gestation

Riskin-Mashiah S, et al. J Perinat Med 2011;39:209

Chief Principle #2

Time Glucose

(mg/dL)

Early AM, fast ≤ 95

Pre-prandial ≤ 100

1h post-prandial ≤ 140

2h post-prandial ≤ 120

2-6 AM > 60

Finger Sticks of Capillary Glucose

4 per day for GDM (fasting and

1- or 2-hour postprandial)

Variable (7 or more) per day

for pregestational DM

Hypoglycemia increases during

pregnancy, and further increases

with tighter monitoring than these

targets without known benefit

Frequent self monitoring of blood glucose and tight adherence

to recommended targets (ACOG)

ACOG Practice Bulletin No. 60. 2005ACOG Practice Bulletin No. 137. 2013

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Diet

SM blood

glucose

Intensive therapy

SQ insulin

Home Glucose Monitors Quality and storage are two most important issues

FDA Standards

Monitor should automatically convey glucose after

conversion to plasma standard

Readings need to be ± 20% within actual blood glucose

value 95% of the time when > 75 mg/dL

Readings need to be ± 15% within actual blood glucose

95% of the time when < 75 mg/dL

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Continuous glucose monitoringSmall RCT (n = 71) showed benefits

Intermittent use of CGM (5-7 d continuous every 4-6 weeks)

Decreased mean birth weight

Decreased macrosomia (OR = 0.38)

Improved A1c (5.8% vs. 6.4%)

Follow-up RCT (n = 154) showed no benefit

No difference in A1c

No difference in hypoglycemia episodes

No difference in macrosomia

Compliance was very poor (49% per protocol)

Secher AL, et al. Diabetes Care 2013;36:1877Murphy HR, et al. BMJ 2008;337:a1680

DietEarly referral to nutritionist

Caloric intake extremely important

Normal BMI: 35 kcal/d

Overweight: 25 kcal/d

Obese: 15 kcal/day

Excessive calories causes excessive gestational weight

gain, increasing further risks for preeclampsia, preterm birth,

and macrosomia

Total gestational weight gain per IOM guidelines

Balanced: 50% carbohydrate, 20% protein, 30% fat

Gabbe Obstetrics: Normal and Problem Pregnancies, 6th Ed., 2012. Chapter 39: Diabetes Mellitus Complicating Pregnancy pp. 887-921IOM. Weight Gain During Pregnancy: Reexamining the Guidelines, 2009 (www.iom.edu/reports)

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Oral Agents- GDM

Increases insulin secretion

Do not prescribe in women with sulfa allergy

Crosses placenta

Comparable to insulin in intention-to-treat studies*

Pharmacokinetics unpredictable in pregnancy

duration ~4.5 hours

Bad job of controlling fasting

glucose

Increased risk of hypoglycemia

Increases glucose uptake in skeletal muscle

Inhibits gluconeogenesis in liver

Crosses placenta

Very low risk of hypoglycemia

Comparable to insulin in intention-to-treat trial**

* Very high rates of switching back to insulin during trials: 20-40% for glyburide, 50%

for metformin

Glyburide Metformin

Subcutaneous insulinBrand Onset (h) Peak (h) Duration (h)

Short-acting

Regular (Lilly) Humulin-R 0.5 2-4 5-7

Regular (Novo Nordisk) Novolin-R 0.5 2.5-5 6-8

Lispro Humalog 0.25 0.5-1.5 4-5

Aspart NovoLog 0.25 1-3 3-5

Intermediate-acting

Lente insulin (Lilly) Humulin L 1-3 6-12 18-24

Lente insulin (Novo

Nordisk)

Novolin L 2.5 7-15 22

NPH (Lilly) Humulin-N 1-2 6-12 18-24

NPH (Novo Nordisk) Novolin N 1.5 4-20 24

Long-acting insulin

Ultralente (Lilly) Humulin Ultralente 4-6 8-20 >36

Glargine Lantus 1 none 24

Detemir Levemir 1-2 none 24

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Subcutaneous insulinAnalogues (lispro or aspart) preferred over regular insulin

faster onset and peak action to coincide with meals

decreased duration of action to prevent hypoglycemia between meals

Multiple-shot regimen vs. continuous infusion necessary

Glargine and detemir cannot be combined with other insulins in single shot like NPH can

Pregnant women often have differing basal insulin needs depending on time of day, making NPH easier to tailor to individual needs

Do not combine with oral hypoglycemic agents

Subcutaneous insulinMeta-analysis of lispro vs. regular insulin: numerous retrospective & prospective studies, improved postprandial glucose, lower insulin requirements, possibly increased rates of LGA, trend for lower hypoglycemia with lispro

One RCT of aspart vs. regular insulin (n = 322): no differences in outcomes), trend for lower hypoglycemia with aspart

One RCT of detemir vs. NPH (n = 310)

Tiny improvement in A1c (0.3%) with detemir

More women able to achieve target A1c with detemir

Slightly improved fasting glucose (12-16 mg/dL) with detemir

Mathiesen ER, et al. Diabetes Care 2012;35:2012Murphy HR, et al. BMJ 2008;337:a1680

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Subcutaneous InsulinNew Start

First trimester 0.7 U/kg/d

Second trimester 0.8

U/kg/d

Third trimester 1.0 U/kg/d

Divided Doses- usually 50-

60% as basal insulin and

40-50% as rapid acting

insulin

For example: New start at 24 weeks’ Patient weight 100 kg

Fasting glucose 115 mg/dL Postprandial glucose 155

mg/dL

Total insulin = 0.8 U x 100 kg = 80 units/day

Basal insulin 60% of total = 48 units

Rapid insulin 40% of total = 32 units (e.g. 12/8/12)

Insulin Adjustments Total daily insulin

demands increase, on average, 3-fold over gestation

Basal insulin increases 30-50% overall

Bolus insulin needs increase 400% overall

Many patients have lower first trimester demands

Roeder HA, et al. Am J Obstet Gynecol 2012;207:324

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Chief Principle #3

Antepartum Assessment

Daily fetal kick counts at

28 weeks’

Twice weekly testing with

NST or BPP at 32 weeks of

gestation

Delivery at term if no

complications

Follow a standard management plan in third trimester, delivery

at 39 weeks’

ACOG Practice Bulletin No. 60. 2005

Ultrasound

Level II ultrasoud exam at

mid-gestation

Fetal echocardiogram

Repeat scan every 4-6

weeks for fetal growth

and fluid

Blood PressureFor patients with

preexisting

Hypertension

Microalbuminuria

Nephropathy

American Diabetes

Association guidelines

SBP of 110-129 mmHg

DBP of 65-79 mmHg

For preexisting HTN:

Recommendations based on maternal longterm health and decreased heart and renal disease and incidence of stroke

For diabetic kidney disease:

Numerous small studies

Decreased proteinuria, preeclampsia, and preterm birth

ADA. Standards of Medical Care in Diabetes - 2013. Diabetes Care 2013;S1:11

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DeliveryACOG GDM Recommendations

Well-controlled with Diet: scheduled delivery not recommended

Well-controlled on hypoglycemia agent: 39+ wk

Poorly-controlled: Does not discuss

NIH Recommendations Well-controlled: 39 wk

Vascular disease: 37-39 wk

Poorly-controlled: 34-39 wk (individualize)

Very high rate of cesarean (75% in several studies for pregestational diabetic patients) and glucose control does not appear to affect

A1c ≥ 6.4% associated with abnormal fetal testing at term and prompt cesarean delivery

Use delayed cord clamping with caution

Miailhe G, et al. Obstet Gynecol 2013;121:983Lepercq J, et al. Obstet Gynecol 2010;115:1014Spong CY, et al. Obstet Gynecol 2011;118:323