Diabetes and pregnancy

2. Diabetes and pregnancy

3. 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 ClinEndocrinolMetab, November 2013, 98(11):4227–4249

4. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

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

6. DIABETES CARE, VOLUME 33, NUMBER 3, MARCH 2010

7. DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013

8. Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab 98: 4227–4249, 2013

9. J Clin Endocrinol Metab 98: 4227–4249, 2013

10. 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 J Clin Endocrinol Metab 98: 4227–4249, 2013

11. 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 glarginepreconceptionally may continue with this therapy before and then during pregnancy J Clin Endocrinol Metab 98: 4227–4249, 2013

12. 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 J Clin Endocrinol Metab 98: 4227–4249, 2013

13. Ocular care (preconception, during pregnancy, and postpartum) • Before conception, If the degree of retinopathy warrants therapy, we recommend deferring 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 J Clin Endocrinol Metab 98: 4227–4249, 2013

14. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

15. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

16. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

17. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

18. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

19. 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) Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

20. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249

21. 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 J Clin Endocrinol Metab 98: 4227–4249, 2013

22. 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

23. 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 Blumer et al Guideline on Diabetes and Pregnancy J ClinEndocrinolMetab, November 2013, 98(11):4227–4249