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Diabetes and PregnancyAn Endocrine Society Clinical Practice Guideline Provide By diabetesasia.org

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Diabetes and PregnancyAn Endocrine Society Clinical Practice Guideline Provide By diabetesasia.org

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  1. Diabetes and Pregnancy An Endocrine Society Clinical Practice Guideline Authors : BlumerI, Hadar E, Hadden DR, JovanovičL, MestmanJH, Murad MH, YogevY. Published : J ClinEndocrinol Metab. 2013 Nov;98(11):4227-49 Presentation by : Dr. JagjitKhosla(Junior Resident, Endocrine, GTBH, Delhi)

  2. Diabetes and Pregnancy Overt Diabetes • Women diabetic before the onset of pregnancy Gestational diabetes • Diabetes first detected in course of pregnancy Presentation by : Dr. Jagjit Khosla 2 Monday, January 20, 2014

  3. Gestational diabetes Current definition • Any degree of glucose intolerance with onset or first definition during pregnancy Definition supported by ES • 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 Presentation by : Dr. Jagjit Khosla 3 Monday, January 20, 2014

  4. Gestational diabetes - Pathophysiology • Insulin resistance emerging in the 2ndtrimester of pregnancy – Progesterone – Cortisol – Human placental lactogen – Prolactin and estrogen also contribute • Some pts. cannot balance insulin needs and develop GDM • Placental insulinase enzyme and obesity Presentation by : Dr. Jagjit Khosla 4 Monday, January 20, 2014

  5. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Gestational diabetes Glucose monitoring and glycemic targets Nutrition therapy and weight gain targets for women with overt or gestational diabetes Blood glucose-lowering pharmacological therapy during pregnancy Labor, delivery, lactation and postpartum care

  6. Diabetes and Pregnancy ES Guidelines 2013 Preconception care of women with diabetes

  7. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.1 – Preconception counselling to all diabetic women Sufficient glycemic control Assessment of comorbidities Discontinuing unsafe medications Folate supplementation Smoking cessation Presentation by : Dr. Jagjit Khosla 7 Monday, January 20, 2014

  8. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.1 – Preconception counselling to all diabetic women 1. Better preconception glycemic control 2. Lower rates of congenital anomalies and spontaneous abortions Presentation by : Dr. Jagjit Khosla 8 Monday, January 20, 2014

  9. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.2 – Achieve blood glucose and HbA1c close to normal  Fetal malformations  Spontaneous abortions  Perinatal mortality Maternal Hyperglycemia in first few wks of pregnancy Presentation by : Dr. Jagjit Khosla 9 Monday, January 20, 2014

  10. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.2 – Achieve blood glucose and HbA1c close to normal Risk of congenital anomaly HbA1c levels Presentation by : Dr. Jagjit Khosla 10 Monday, January 20, 2014

  11. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.3a – Insulin therapy Multiple daily doses of insulin or, Continuous sc insulin infusion Split-dose, premixed insulin therapy vs 1. More likely to achieve target levels 2. Flexibility Presentation by : Dr. Jagjit Khosla 11 Monday, January 20, 2014

  12. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.3b – Insulin therapy Change/start insulin regimen in advance 1. Better expertise of patient 2. Optimization Presentation by : Dr. Jagjit Khosla 12 Monday, January 20, 2014

  13. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.3c – Insulin therapy Regular insulin Rapid-acting insulin analog vs 1. Achieve postprandial B.G. targets better 2. Less risk of hypoglycemia 3. Greater lifestyle flexibility and better quality of life 4. Insulin lispro and Insulin aspart safe in pregnancy Presentation by : Dr. Jagjit Khosla 13 Monday, January 20, 2014

  14. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.3d – Insulin therapy CONTINUE Long-acting insulin analogs Intermediate acting Insulin Long-acting Insulin analogs vs 1. Lower rates of nocturnal hypoglycemia 1. NPH is cheaper 2. Insulin detemir approved for use in pregnancy (Category B) 3. Insulin glargine safe in pregnancy Presentation by : Dr. Jagjit Khosla 14 Monday, January 20, 2014

  15. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.4 – Folic acid supplementation  Start 3 months before conceiving  5 mg daily dose ↓ Risk of Neural tube defects Presentation by : Dr. Jagjit Khosla 15 Monday, January 20, 2014

  16. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.5a – Ocular care Detailed ocular assessment Retinopathy present Retinopathy needing therapy Patient counselling for risk of worsening First treat retinopathy Conceive only when it is stabilized Presentation by : Dr. Jagjit Khosla 16 Monday, January 20, 2014

  17. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.5b – Ocular care Women with Established Retinopathy Ocular assessment every trimester Post-pregnancy assessment within 3 months after delivery Presentation by : Dr. Jagjit Khosla 17 Monday, January 20, 2014

  18. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.5c – Ocular care Women with No Retinopathy Ocular assessment soon after conception Then, periodically as indicated Presentation by : Dr. Jagjit Khosla 18 Monday, January 20, 2014

  19. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.6 – Renal function Renal dysfunction in Type 1 DM ↑ Risk of Adverse Maternal & Fetal outcomes (e.g. preeclampsia) Mild Preconceptional Renal dysfunction Reversible worsening Irreversible worsening Mod-Severe Preconceptional Renal dysf. Presentation by : Dr. Jagjit Khosla 19 Monday, January 20, 2014

  20. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.6a – Preconceptional Renal function assessment 1.6b – Regular renal function monitoring during pregnancy in women with preconceptional renal dysfunction Presentation by : Dr. Jagjit Khosla 20 Monday, January 20, 2014

  21. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.7a – Management of Hypertension Satisfactory BP Control <130/80 mm Hg Preconceptional Uncontrolled HTN ↑ Risk of Adverse outcomes (e.g. preeclampsia) Presentation by : Dr. Jagjit Khosla 21 Monday, January 20, 2014

  22. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.7b – Management of Hypertension Safer alternatives : ACE Inhibitors or Angiotensin-receptor blockers  Methyldopa  Labetalol  Diltiazem  Clonidine  Prazosin Presentation by : Dr. Jagjit Khosla 22 Monday, January 20, 2014

  23. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.7c – Management of Hypertension Exception for using ACEI or ARBs : Severe renal dysfunction with uncertainity about conception Loss of Renal protective properties vs Risk of teratogenesis Presentation by : Dr. Jagjit Khosla 23 Monday, January 20, 2014

  24. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.7d – Management of Hypertension If ACEI or ARBs continued upto time of conception DISCONTINUE immediately upon confirmation of pregnancy Presentation by : Dr. Jagjit Khosla 24 Monday, January 20, 2014

  25. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.8a – Elevated vascular risk If vascular risk factors present Screen for CAD before conceiving Presentation by : Dr. Jagjit Khosla 25 Monday, January 20, 2014

  26. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.8b – Elevated vascular risk If CAD present  Severity assessment  Management  Counselling Presentation by : Dr. Jagjit Khosla 26 Monday, January 20, 2014

  27. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.9 – Management of dyslipidemia 1. Dyslipidemia seldom poses threat during pregnancy 2. Unproven safety of statins, fibrates and niacin during pregnancy Presentation by : Dr. Jagjit Khosla 27 Monday, January 20, 2014

  28. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.9a – DO NOT use Statins 1.9b – DO NOT use Fibrates or Niacin 1.9c – Bile acid-binding resins may be used to treat hypercholestrolemia Presentation by : Dr. Jagjit Khosla 28 Monday, January 20, 2014

  29. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.10 – Thyroid function assessment Autoimmune thyroid Type 1 DM Hypothyroidism  ↓ Fertility  ↑ Risk of spontaneous abortion  ↑ Risk of Impaired fetal brain development Uncontrolled Hypothyroidism Presentation by : Dr. Jagjit Khosla 29 Monday, January 20, 2014

  30. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.10 – Thyroid function assessment Serum TSH Thyroid peroxidase Antibodies Presentation by : Dr. Jagjit Khosla 30 Monday, January 20, 2014

  31. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.11 – Weight reduction in overweight/obese Severe calorie restriction (<1500 kcal/d or 50% reduction) ↑ Ketosis Impaired fetal brain development Presentation by : Dr. Jagjit Khosla 31 Monday, January 20, 2014

  32. Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.11 – Weight reduction in overweight/obese Severe calorie restriction (<1500 kcal/d or 50% reduction) Moderate calorie restriction (1600-1800 kcal/d or 33% reduction) Presentation by : Dr. Jagjit Khosla 32 Monday, January 20, 2014

  33. Diabetes and Pregnancy ES Guidelines 2013 Gestational Diabetes

  34. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit (<13 wks gestation) Fasting Plasma glucose, or HbA1c, or Untimed Random plasma glucose Presentation by : Dr. Jagjit Khosla 34 Monday, January 20, 2014

  35. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit Diagnosis Fasting Glucose Random Glucose HbA1c Overt Diabetes ≥ 126 mg/dL ≥ 200 mg/dL ≥ 6.5 % Gestational Diabetes 92-125 mg/dL NA NA Presentation by : Dr. Jagjit Khosla 35 Monday, January 20, 2014

  36. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit If Overt diabetes on screening test but no Symptoms of hyperglycemia Second test to confirm diagnosis (Fasting glucose, Random glucose, HbA1c or OGTT) Presentation by : Dr. Jagjit Khosla 36 Monday, January 20, 2014

  37. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.2 Testing for gestational diabetes at 24 to 28 weeks gestation by using 75-g OGTT Diagnosis Fasting Glucose 1 hr Glucose 2 hr Glucose Overt Diabetes ≥ 126 mg/dL NA ≥ 200 mg/dL Gestational Diabetes 92-125 mg/dL ≥ 180 mg/dL 153-199 mg/dL Presentation by : Dr. Jagjit Khosla 37 Monday, January 20, 2014

  38. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.3 Management of elevated blood glucose 2.3a – Target blood glucose levels close to normal Medical Nutrition therapy + Daily moderate exercise (≥ 30 min) 2.3b - If hyperglycemia persists 2.3c - Blood glucose-lowering pharmacological therapy Presentation by : Dr. Jagjit Khosla 38 Monday, January 20, 2014

  39. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4 Postpartum care in GDM patients 2.4a – Fasting glucose measured for 24 to 72 hrs after delivery to rule out ongoing hyperglycemia 2.4b – 2 hr, 75g OGTT at 6 to 12 wks after delivery to rule out pre-diabetes or diabetes. Presentation by : Dr. Jagjit Khosla 39 Monday, January 20, 2014

  40. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4 Postpartum care in GDM patients 2.4c – Child’s permanent medical record should contain : Child’s birth weight Whether born to mother with GDM Presentation by : Dr. Jagjit Khosla 40 Monday, January 20, 2014

  41. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4 Postpartum care in GDM patients 2.4d – Counselling of GDM patients : Lifestyle measures to ↓ risk of Type 2 DM Need for planning future pregnancies Regular diabetic screening Presentation by : Dr. Jagjit Khosla 41 Monday, January 20, 2014

  42. Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4 Postpartum care in GDM patients 2.4e – Discontinue blood glucose-lowering medication immediately after delivery Exception : Suspected overt diabetes with accompanying hyperglycemia Presentation by : Dr. Jagjit Khosla 42 Monday, January 20, 2014

  43. Diabetes and Pregnancy ES Guidelines 2013 Glucose monitoring and glycemic targets

  44. Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets 3.1 Self-monitoring of blood glucose in pregnant women with overt or gestational DM Pre- Lunch Post- Lunch Pre- Dinner Post- Dinner Fasting Post-BF Bedtime Post-meal either 1 or 2 hrs Presentation by : Dr. Jagjit Khosla 44 Monday, January 20, 2014

  45. Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets 3.2a-c – Glycemic targets in overt or GDM Target values Preprandial blood glucose ≤ 95 mg/dL 1 hr after start of a meal ≤ 140 mg/dL 2 hr after start of a meal ≤ 120 mg/dL Target preprandial blood glucose ≤ 90 mg/dL, if possible Presentation by : Dr. Jagjit Khosla 45 Monday, January 20, 2014

  46. Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets 3.2d – Glycemic target only in overt diabetes HbA1c ≤ 7% Ideally HbA1c ≤ 6.5% Presentation by : Dr. Jagjit Khosla 46 Monday, January 20, 2014

  47. Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets 3.3 – Continuous glucose monitoring be used if self-monitoring is not sufficient to assess glycemic control Presentation by : Dr. Jagjit Khosla 47 Monday, January 20, 2014

  48. Diabetes and Pregnancy ES Guidelines 2013 Nutrition therapy and weight gain targets for women with overt or gestational diabetes

  49. Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets 4.1 Medical nutrition therapy for all pregnant women with overt or gestational DM  Carbohydrate controlled meal  Adequate nutrition  Appropriate weight gain  Normoglycemia  Avoid ketosis Presentation by : Dr. Jagjit Khosla 49 Monday, January 20, 2014

  50. Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets 4.2a Women with overt or gestational DM to follow Institute of medicine revised guidelines (2009) for weight gain during pregnancy Presentation by : Dr. Jagjit Khosla 50 Monday, January 20, 2014

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