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Clinical Practice Guidelines by Diabetesasia.org

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Clinical Practice Guidelines by Diabetesasia.org

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  1. Canadian Diabetes Association Clinical Practice GuidelinesPregnancy Chapter 36 David Thompson, Howard Berger, Denice Feig, Robert Gagnon, Tina Kader, Erin Keely, Sharon Kozak, Edmond Ryan, Mathew Sermer, Christina Vinokuroff

  2. In collaboration with …

  3. Diabetes in Pregnancy: 2 Categories

  4. Diabetes in Pregnancy: Consider Phases

  5. Diabetes in Pregnancy: Consider Phases

  6. Dysglycemia in Pregnancy can Result in Adverse Pregnancy Outcome • Elevated glucose levels can have adverse effects on the fetus • 1st trimester  ↑ fetal malformations • 2nd and 3rd trimester: ↑ risk of macrosomia and metabolic complications

  7. Risk of Fetal Anomaly Relative to Periconceptional A1C Glycemic control pre-conception = essential Guerin A et al. Diabetes Care 2007;30:1-6.

  8. Need a Preconception Checklist for Women with Pre-existing Diabetes 2013 • 1. Attain a preconception A1C of ≤7.0% (if safe) • 2. Assess for and manage any complications • 3. Switch to insulin if on oral agents • 4. Folic Acid 5 mg/d: 3 months pre-conception to 12 weeks post-conception • 5. Discontinue potential embryopathic meds: • Ace-inhibitors/ARB (prior to or upon detection of pregnancy) • Statin therapy

  9. Preconception Counseling for Pregestational Diabetes • Advise reproductive age women with diabetes about reliable birth control • NOTE: Metformin in PCOS may improve fertility  need to warn about possible pregnancy • Metformin safe for ovulation induction in PCOS • Achieving a healthy weight is essential – obesity associated with adverse pregnancy outcomes

  10. Screen for Complications: Pre-pregnancy and Intrapartum Screening for: • Retinopathy: Need ophthalmological evaluation • Nephropathy: Assess creatinine + urine microalbumin / creatinine ratio (ACR) • Women with microalbuminuria or overt nephropathy are at ↑ risk for hypertension and preeclampsia

  11. Recommendations 1-2: Preconception Care • All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of glycemic control prior to pregnancy, impact of BMI on pregnancy outcomes, need for folic acid and the need to stop potentially embyropathic drugs prior to pregnancy [Grade D, Level 4]. • Women with type 2 diabetes and irregular menses/PCOS who are started on metformin or a thiazolidinedione should be advised that fertility may improve and be warned about possible pregnancy [Grade D, Consensus]. 2013

  12. Recommendation 3: Preconception Care 3. Before attempting to become pregnant, women with type 1 or type 2 diabetes should: • Receive preconception counseling that includes optimal diabetes management and nutrition, preferably in consultation with an interdisciplinary pregnancy team to optimize maternal and neonatal outcomes [Grade C, Level 3]

  13. Recommendation 3: Preconception Care (continued) • Strive to attain a preconception A1C of ≤7.0% (or A1C as close to normal as can safely be achieved) to decrease the risk of: • Spontaneous abortion [Grade C, Level 3] • Congenital anomalies [Grade C, Level 3] • Pre-eclampsia [Grade C, Level 3] • Progression of retinopathy in pregnancy [Grade A, level 1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]

  14. Recommendation 3: Preconception Care (continued) • Supplement their diet with multivitamins containing 5 mg of folic acid at least 3 months pre-conception and continuing until at least 12 weeks post-conception [Grade D, Level 4]. Supplementation should continue with a multivitamin containing 0.4-1.0 mg of folic acid from 12 weeks postconception through to 6 weeks postpartum or as long as breastfeeding continues [Grade D, Consensus].

  15. Recommendation 3: Preconception Care (continued) • Discontinue medications that are potentially embryopathic, including any from the following classes: • ACE inhibitors and ARBs prior to conception or upon detection of pregnancy [Grade C, Level 3] • Statins[Grade D, Level 4] 2013

  16. Recommendation 4: Preconception Care • Women with type 2 diabetes who are planning a pregnancy should switch from non-insulin antihyperglycemic agents to insulin for glycemic control [Grade D, Consensus]. Women with pregestational diabetes who also have PCOS may continue metformin for ovulation induction [Grade D, Consensus].

  17. Recommendations 5 and 6: Preconception and Complications • Women should undergo an ophthalmological evaluation by an eye care specialist [Grade A, Level 1, for type 1; Grade D, Level 4 for type 2]. • Women should be screened for chronic kidney disease prior to pregnancy [Grade D level 4 for type 1 diabetes Grade D, consensus for type 2 diabetes].Women with microalbuminuria or overt nephropathy are at increased risk for the development of HTN and preeclampsia [Grade A level 1]; and should be followed closely for these conditions [Grade D, Consensus]

  18. Diabetes in Pregnancy: Consider Phases

  19. Need Optimal Glycemic Control in Pregnancy for Pre-existing Diabetes • Individualized 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 • Encourage patients to SMBG pre- and postprandially

  20. Diabetes in Pregnancy: Consider Phases

  21. 2013 Glucose Management During Labour and Delivery • Maternal blood glucose levels should be kept between 4.0 -7.0 mmol/L  ↓ neonatal hypoglycemia • Women should receive adequate glucose during labour in order to meet the high energy requirements • IV Dextrose + IV insulin protocols may be helpful

  22. Postpartum care for pre-existing diabetes • Adjust insulin  at risk of hypoglycemia • Encourage women to breastfeed • Metformin and glyburide may be used during breast-feeding  no long term data but appears safe • Screen for postpartum thyroiditis in T1DM  check TSH at 6-8 weeks postpartum

  23. Recommendation 7: Management in Pregnancy for Pregestational Diabetes • Pregnant women with type 1 or type 2 diabetes should: • Receive an individualized insulin regimen and glycemic targets typically using intensive insulin therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2] b) Strive for target glucose values [Grade D consensus]: • Fasting PG below 5.3 mmol/L • 1h postprandial below 7.8 mmol/L • 2h postprandial below 6.7 mmol/L

  24. Recommendation 7: Management in Pregnancy for Pre-gestational Diabetes (continued) c) Be prepared to raise these targets if need be because of the increased risk of severe hypoglycemia during pregnancy [Grade D, Consensus] d) Perform SMBG, both pre- and postprandially to achieve glycemic targets and improve pregnancy outcomes [Grade C, Level 3] 2013

  25. Recommendations 8-9: Management in Pregnancy for Pre-gestational Diabetes • Women with pregestational diabetes may use aspart or lispro in pregnancyinstead of regular insulin to improve glycemic control and reduce hypoglycemia [Grade C level 2 for aspart , Grade C, Level 3 for lispro]. • Detemir[Grade C, Level 2]or glargine[Grade C, Level 3 ] may be used in women with pregestational diabetes as an alternative to NPH. 2013 2013

  26. Recommendation 10 and 11: Intrapartum Glucose Management • Women should be closely monitored during labour and delivery and maternal blood glucoselevels should be kept between 4.0 and 7.0 mmol/L in order to minimize the risk of neonatal hypoglycemia [Grade D, Consensus] • Women should receive adequate glucose during labour in order to meet the high energy requirements [Grade D, Consensus] 2013 2013

  27. Recommendations 12 and 13: Postpartum Glucose Management • Women with pregestational diabetes should be carefully monitored postpartum as they have a high risk of hypoglycemia [Grade D, Consensus]. • Metformin and glyburide may be used during breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for glyburide]. 2013 2013

  28. Recommendation 14 and 15: Postpartum Glucose Management • Women with type 1 diabetes in pregnancy should be screened for postpartum thyroiditis with a TSHtest at 6-8 weeks postpartum [Grade D, Consensus]. • All women should be encouraged to breast-feed, since this may reduce offspring obesity, especially in the setting of maternal obesity [Grade C level 3-]

  29. Diabetes in Pregnancy: Consider Phases

  30. Gestational Diabetes (GDM) Diagnosis • Universal screening for GDM @ 24-28 weeks Gestational Age (GA) • Screen earlier if risk factors for GDM:

  31. Why Diagnose and Treat GDM? • Macrosomia • Shoulder dystocia and nerve injury • Neonatal hypoglycemia • Preterm delivery • Hyperbilirubinemia • Caesarian section • Offspring obesity (?) • Offspring diabetes (?)

  32. HAPO: Incidence of Adverse Outcomes Increases Along Continuum Metzger BE, et al. Hyperglycemia and Adverse Pregnancy Outcomes. NEJM 2008;358(19):1991-2002.

  33. Benefits of Treatment of GDM

  34. Benefits of Treatment of GDM Horvath K et al. BMJ 2010;340:c1935

  35. Are there clear threshold glucose levels above which the risk of adverse neonatal or maternal outcomes increases? Diagnosis of GDM

  36. IADPSG Diabetes Care 2010;22:676-682

  37. HAPO: Incidence of Adverse Outcomes Increases Along Continuum – No Threshold Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.

  38. Are there clear threshold glucose levels above which the risk of adverse neonatal or maternal outcomes increases? NO

  39. IADPSG Consensus Threshold Values for Diagnosis of GDM (≥1 Value is Diagnostic) Based on odds ratio (OR) of 1.75 for primary outcome OGTT = Oral Glucose Tolerance Test HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study IADPSG. Diabetes Care 2010;22:676-682

  40. Odds Ratio (OR) of 1.75 vs. 2.0 for Primary Outcome in HAPO OGTT = Oral Glucose Tolerance Test HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study IADPSG. Diabetes Care 2010;22:676-682

  41. HAPO: Incidence of Adverse Outcomes for Glucose Categories (OR 1.75 or 2.0 ) Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.

  42. Remains a Controversial Topic …

  43. Considerations for the CDA Adopting the IADPSG Thresholds • How can we select an odds ratio threshold in the absence of a true threshold in the data? • What is the impact on the patient and workload of increasing the prevalence of GDM? • Do we have sufficient evidence with respect to treatment benefit at the various thresholds to make an informed decision? • In the absence of clear benefit, should the diagnostic criteria be changed from 2008?

  44. 2013 CDA Diagnostic Criteria for GDM 2013 PREFERRED APPROACH (2 steps) • 50 gram glucose challenge test • 75 gram oral glucose tolerance test • Using thresholds of OR 2.0 ALTERNATIVE APPROACH (1 step) • 75 gram oral glucose tolerance test • Using thresholds of OR 1.75

  45. 2013 GDM Diagnosis: Two Approaches 2013

  46. 2013 GDM Diagnosis: Preferred Approach 2013

  47. 2013 GDM Diagnosis: Preferred Approach 2013

  48. 2013 GDM Diagnosis: Preferred Approach 2013

  49. 2013 GDM Diagnosis: Preferred Approach 2013

  50. 2013 GDM Diagnosis: Preferred Approach 2013

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