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Diabetes and Pregnancy

Diabetes and Pregnancy. J. David Spencer, D.O., F.A.C.O.O.G. CDC National Diabetes Fact Sheet, 2011. Diabetes : a group of diseases due to high levels of blood glucose Defects in insulin production and / or the action of insulin

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Diabetes and Pregnancy

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  1. Diabetes and Pregnancy J. David Spencer, D.O., F.A.C.O.O.G.

  2. CDC National Diabetes Fact Sheet, 2011 • Diabetes : a group of diseases due to high levels of blood glucose • Defects in insulin production and / or the action of insulin • Affects 25.8 million people, 8.3 % of the population of the United States

  3. CDC National Diabetes Fact Sheet, 2011 • 18.8 million people diagnosed with Diabetes • 7 million people undiagnosed • 1.9 million people over age 20 dxed in 2010 • 12.6 million, or 10.8 % of U.S. women over age 20 have diabetes

  4. Pre-Diabetes • Higher than normal blood glucose or glycosylated Hemoglobin A1C levels, but not high enough to be classified as diabetes. • American Diabetes Association values placing person at risk for DM: • Fasting blood sugar: 100 – 125 mg/dl. • 2 hours after 75 gram glucose load:140-190 • Hemoglobin A1C value: 5.7 – 6.4 % (or <6%)

  5. PreDiabetes increases risk of • Developing type 2 diabetes • Heart disease • Stroke • Gestational diabetes

  6. Diabetes definitions • Pregestational or Overt Diabetes : a woman diagnosed with diabetes prior to becoming pregnant • Gestational Diabetes : a woman with glucose intolerance first diagnosed while pregnant

  7. ADA Criteria to Dx Diabetes • Casual (random) blood glucose value over 200 mg/dl, with classic symptoms: polydipsia, polyuria, unexplained weight loss, ketoacidosis OR Fasting (no caloric intake for 8 to 14 hours) plasma glucose over 125 mg/dl OR After 75 gram glucose load, 2 hour plasma glucose over 200 mg/dl

  8. ADA clinical types of DM • Type 1 : formerly insulin dependent, or juvenile onset diabetes • Type 2 : Formerly non-insulin dependent, or adult onset diabetes • Other types of DM : genetic, drug related, chemical diabetes • Gestational diabetes

  9. Types of DM in pregnancy • Type 1 diabetic women : approx. 2 % of pregnancies that have diabetes • Type 2 diabetic women : approx. 8 % of pregnancies with diabetic mother • Gestational Diabetes Mellitus : Women who develop diabetes in pregnancy account for about 90 % of pregnancies with diabetes

  10. Diabetes and Obesity • Incidence of DM in the U.S. is increasing • Incidence of Obesity in the U. S. is an epidemic • Strong relationship of obese patients developing diabetes. • This correlation has been called Diabesity • In 2008, about 60 % of reproductive age women in the U. S. were overweight or obese • (What percent now?)

  11. Hyperglycemia and Pregnancy • Diabetic women planning to become pregnant should optimize their health prior to conception with: • Nutritional management • Weight management • Glycemic control • BUT about 50% of all pregnancies are unplanned, therefore unprepared

  12. Pregestational DM control • Euglycemia at the time of conception reduces the risks of : spontaneous abortion : congenital anomalies • Very strong positive correlation between hyperglycemia during embryonic organogenesis and congenital (not chromosomal) anomalies

  13. Birth defects affect about 1 in 33 pregnancies and are a leading cause of pregnancy loss and neonatal deaths in the U. S. • Not totally understood is how hyperglycemia causes congenital anomalies • Diabetic women with good glycemic control have no increase incidence of birth defects compared to general population

  14. Unrecognized / undiagnosed or poorly controlled diabetes increases maternal as well as fetal risks in pregnancy • Many reproductive age women are in this category, and coupled with unplanned pregnancies, many women and their babies are at risk

  15. Preconception counseling in women with diabetes • Goals - achieve and maintain excellent control of diabetes without hypoglycemia - evaluate any other medical conditions that may complicate a pregnancy • Glycosylated Hemoglobin A1C measurements reflect blood sugar levels of preceeding 8 to 12 weeks can be useful in assessing blood sugar control before becoming pregnant

  16. Medical conditions before conception • Obesity – even if not (yet) diabetic, overweight and obese women have more complications in pregnancy, and a higher than usual rate of Gestational Diabetes Mellitus. • Weight loss will decrease some of the complications of pregnancy in obese women • Most weight loss medications should not be used in pregnancy – so stop before conceiving

  17. Medical conditions before conception • Diabetics may have hyperlipidemia, and Statin drugs are Category X and should not be used especially early in gestation • Dietary changes may help some, if statins have been used

  18. Medical conditions before conception • In women who have had diabetes for over 10 years, over 30 % have hypertension. • Some commonly used anti-hypertensive medications are not teratogenic, and may be continued in pregnancy - Methyldopa - Calcium channel blockers - Beta blockers

  19. Anti-hypertensive meds that should be stopped before pregnancy • Diuretics : may affect fetal renal development, amniotic fluid levels • Angiotensin Converting Enzyme inhibitors and Angiotensin Receptor Blockers • -probably safe in first trimester, but later in pregnancy reduce fetal renal blood flow, decrease fetal urine output and result in oligohydramnios

  20. Pregestational DM management • If nutritional management and exercise do not result in normal blood sugar levels, medication is indicated. • Insulin • Oral hypoglycemic agents

  21. Insulin • Insulin most like human insulin is preferred for use in pregnancy - fewer antibodies -limited transplacental crossing - no teratogenicity • Most clinical experience with Lispro (Humulin) Aspart (Novolog), Regular and NPH insulin • Type 1 diabetics should remain on insulin in pregnancy

  22. Oral hypoglycemic drugs • First generation sulfonylureas should not be used in pregnancy – placental transfer results in fetal hyperinsulinemia, prolonged newborn post-partum hypoglycemia • Glyburide, second generation – low placental transfer. • Stimulates maternal pancreas to produce more insulin • May be continued in pregnancy

  23. Oral hypoglycemic drugs • Metformin – frequently used in women with insulin resistance, metabolic syndrome, infertility, polycystic ovary syndrome • Does cross placenta, no teratogenicity, minimal fetal affects. • Decreases maternal peripheral resistance to insulin, inhibits gluconeogenesis • May be continued in pregnancy

  24. Preconception evaluation • The control of blood sugar levels, and evaluation of medical conditions and pre-pregnancy medications, will allow the woman to have a healthier and safer start to her pregnancy

  25. Metabolic changes in pregnancy • Occur to assure adequate supply of metabolic fuels to the growing fetus and accommodate energy needs of the mother • Some of these changes can be affected by pre-gestational diabetes.

  26. Glucose homeostasis is a balance of insulin secretion and insulin resistance • Both effects occur at increased rates in pregnancy • Insulin receptor sites are decreased by Human Chorionic Somatomammotropin, Prolactin, and Placental Human Growth Hormone. • Endogenous glucose production is increased

  27. Metabolic changes in pregnancy • Pregnancy hormones cause hyperplasia of pancreatic islet beta cells, increasing insulin • After eating, increases in insulin release cause increases in glucose uptake in muscle, fat • In fasting state in pregnancy, increased insulin levels magnify the hypoglycemic state, but gluconeogenesis and transfer of glucose through placenta maintain fetal glucose levels

  28. Metabolic changes in pregnancy • In the third trimester of pregnancy : • Fetal growth accelerates • Maternal and fetal metabolic demands increase • Insulin resistance increases • Pregestational, or gestational impairments of glucose metabolism adversely affect control of blood sugar levels, resulting in hyperglycemia

  29. Diabetes developing in pregnancy • Gestational diabetes mellitus is impaired glucose tolerance with onset or first recognition during pregnancy • 5 to 10 % of U. S. pregnancies are complicated by diabetes • Women with Type 1 diabetes - about 1-2 % • Women with Type 2 diabetes - about 10 % • Women developing DM in pregnancy – 90%

  30. Screening for Gestational Diabetes Mellitus (GDM) • Because of serious complications of unrecognized diabetes in pregnancy, screening for GDM has been done for many decades • Initial screening looks at maternal factors • Blood tests make the diagnosis

  31. Screening by risk factors • Low risk (the woman must meet all criteria) • Age less than 25 • Weight normal before pregnancy (BMI 19-25) • No history of abnormal glucose tolerance • No history of adverse pregnancy outcome • No known first degree relatives with diabetes • Ethnicity with low prevalence of diabetes

  32. Screening by risk factors • High risk • Over age 25 (some use 30) • Obese (BMI over 30 kg/m2, or weigh over 90 kg) • Polycystic ovary syndrome • History of gestational diabetes • Previous Macrosomic / Large for Gestational age infant • Previous unexplained pregnancy loss

  33. Screening by risk factors • High risk -Strong immediate family history of diabetes -Previous child with congenital anomaly -Elevated blood sugar (FBS >140; RBS >200) -“Prediabetes” – mildly elevated glucose or Glycosylated Hemoglobin A1C -Member of ethnic group with increased incidence of diabetes

  34. Screening for Gestational DM • Low risk patients – oral glucose load 24 to 28 weeks gestation • High risk patients – screen with blood test as soon as possible in the pregnancy.

  35. Testing for GDM • One step – first option 2 hour glucose tolerance test 75 gram oral glucose load, draw blood sugar 2 hours later some modify and do Fasting : <95 mg/dl 1 hour : <180 mg/dl 2 hour : <155 mg/dl

  36. Testing for GDM • One step – second option 3 hour glucose tolerance test Fasting (for 8 – 14 hours) : <95 mg/dl 100 gram oral load of glucose 1 hour post-prandial : <180 mg/dl 2 hour post-prandial : <155 mg/dl 3 hour post-prandial : < 140 mg/dl A diagnosis of GDM is made with 2 abnormal values

  37. Testing for GDM • Two step option First done is 50 gram oral glucose load, without regard to time of day or last meal blood sugar one hour later : <140 (or <130) • If elevated, the previously described 3 hour glucose tolerance test, with 100 gram load, same values, is performed

  38. Other variables of tests • Abnormal glucose screening tests, or elevated glycosylated hemoglobin A1C prior to 20 weeks gestation is strongly suspicious for unrecognized, undiagnosed pregestational DM • Uncommonly, type 1 DM may be discovered as presenting with ketoacidosis in pregnancy, especially if in first trimester • Both, by definition, are still GDM

  39. Gestational diabetes dxed early in pregnancy with high risk patient may very well be pregestational diabetes • Possible DM related underlying medical conditions need to be investigated, such as diabetic vasculopathy

  40. White classification of Diabetes in pregnancy • Proposed in the 1970’s, as a reflection of duration and multi-organ medical impact of women with diabetes who became pregnant

  41. White Classification of Diabetes in Pregnancy

  42. Monitoring Diabetes • Glycosylated Hemoglobin A1C – in pregnancy mean red blood cell production increases, RBC life is shortened • Gly Hgb A1C in pregnancy is a reflection of mean RBC blood glucose levels over 4 to 6 weeks, not 8 – 12 weeks • More frequent monitoring of this test will give better reflection of long term glycemic state

  43. Nutritional issues in pregnancy • Caloric demands are increased in pregnancy • Carbohydrate type and amount should be decreased in diabetics in pregnancy • Weight gain recommendation in pregnancy has changed

  44. Institute of Medicine Guidelines for weight gain in pregnancy (2009)

  45. Weight gain in pregnancy • Weight gain beyond IOM guidelines in pregnancy is associated with increased adverse maternal and neonatal outcomes

  46. Monitoring blood glucose levels • Home glucose monitoring determines if diet or medication maintains tight glycemic control • Fasting blood sugar value should be < 95 mg/dl • 1 hour postprandial value should be <140 • 2 hour postprandial value should be <120 • Peak postprandial glucose concentration is 60 to 90 minutes after eating

  47. Poor glucose control • Hyperglycemia and Adverse Pregnancy Outcomes study (HAPO) – even small elevations in blood glucose levels in pregnancy are associated with increased maternal and fetal complications in pregnancy

  48. Medical management of DM • Type 1 diabetics are maintained on insulin, although type and dose will change in pregnancy • Type 2 and GDM mothers may try oral hypoglycemic drugs, but may need insulin to give appropriate control • Nutritional management is maintained

  49. Diabetic complications in pregnancy • Frequent home glucose monitoring is required to avoid prolonged hyperglycemic or hypoglycemia in the pregnant diabetic patient • Perinatal mortality decreased due to improved diabetic metabolic control, fetal surveillance, and neonatal care - 1960’s > 20 % - now < 5%

  50. Maternal morbidity inpregnancy with diabetes • Risk and severity of complications are related to severity and duration of hyperglycemia • Poorly controlled gestational diabetics may have serious complications • Women with pregestational diabetes are at increased risk if poorly controlled prior to and during pregnancy

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