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Diabetes in Pregnancy

Diabetes in Pregnancy. Management. Diabetes in Pregnancy: Management Goals. Provide preconception care for women with preexisting T1DM or T2DM or a history of GDM Educate patients to maintain adequate nutrition and glucose control before conception, during pregnancy, and postpartum 1

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy Management

  2. Diabetes in Pregnancy: Management Goals • Provide preconception care for women with preexisting T1DM or T2DM or a history of GDM • Educate patients to maintain adequate nutrition and glucose control before conception, during pregnancy, and postpartum1 • Close to normal glycemic control prior to and throughout pregnancy offers substantial benefit for both mother and child2 • Maintenance of normoglycemia prior to and through the first trimester results in a complication risk close to that of women without diabetes3 • For all glucose management protocols, AACE recommendations stress patient safety as the first priority1,4 1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2013;36(suppl1):S11-S66.

  3. Glycemic Targets During Pregnancy: AACE & ADA Guidelines1,2 AACE. EndocrPract. 2011;17(2):1-53. ADA. Diabetes Care. 2013;36(suppl1):S11-66.

  4. Glycemic Targets During Pregnancy: Expert Recommendations Some experts recommend more stringent goals (in particular, for patients on insulin therapy) to prevent maternal and fetal complications1,2 • LeRoith D, et. al. EndocrinolMetabClin N Am. 2011;40(1): xii-919. • Castorino K et al. CurrDiab Rep, 2012;12:53-59. • L. Jovanovic; personal communication. • AACE. Endocr Pract. 2011;17(2):1-53.

  5. Why Is Glucose Control Essential During Pregnancy? • For both mothers with diabetes and their infants, risk for adverse health outcomes correlates with maternal glucose levels during the first trimester of pregnancy1 • A large, randomized controlled trial of intensive diabetes management versus standard care in patients with gestational diabetes mellitus (GDM) showed: • Rate of serious perinatal complications was reduced from 4% to 1% with treatment of GDM2 • Improvements in maternal health-related quality of life2 ADA. Diabetes Care. 2013;36(suppl1):S11-S66. 2. Crowther CA, et al. N Engl J Med. 2005;352(24):2477-86. Epub 2005 Jun 12.

  6. Diabetes in Pregnancy: Avoiding Complications 1. AACE. Endocr Pract. 2011;17(2):1-53. 2. JovanovicL, et al. Diabetes Care. 2011;34(1):53-54.3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. ADA. Diabetes Care. 2013;36(suppl1):S11-S66.

  7. Diabetes in Pregnancy: Management Approaches • Early referral to a specialist is essential1 • Collaborative effort among obstetrician/ midwife, endocrinologist, ophthalmologist, registered dietitian, and nurse educator • All team members should be engaged in patient education/care prior to and throughout pregnancy2 • Individualized treatment plans, involving a combination of: • Glucose monitoring • Medical nutrition therapy (MNT) • Pharmacotherapy • Exercise • Weight management strategies • Psychological support • Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. • 2. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.

  8. Glucose Monitoring in GDM:Self-Monitoring of Blood Glucose • Self-monitoring of blood glucose (SMBG) is the cornerstone of diabetes management in gestational diabetes mellitus (GDM)1 • ADA guidelines for pregnant patients requiring insulin: • SMBG ≥3 times daily • More frequent SMBG may be required, including:2 • Morning fasting • Premeal (breakfast, lunch, and dinner) • 1-hour postprandial (breakfast, lunch, and dinner) • Before bed3 • Disadvantages include: • Potential for human error or inconsistencies in performing SMBG and/or self-reporting • Partial glucose profile from intermittent readings; hyper- or hypoglycemic episodes may go undetected4 1. Jovanovic L, et al. Diabetes Care. 2011;34(1):53-54. 2. ADA. Diabetes Care. 2013;36(suppl1):S11-S66. 3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. Chitayat, L, et al. Diabetes TechnolTher. 2009;11:S105-111.

  9. Glucose Monitoring in GDM: A1C • Provides valuable supplementary information for glycemic control • To safely achieve target glucose levels, combine A1C with frequent self-monitoring of blood glucose (SMBG)1,2 • Recent research suggests weekly A1Cs during pregnancy:1 • SMBG alone can miss certain high glucose values • SMBG + A1C = more complete data for glucose control • Clinicians can further optimize treatment decisions with weekly A1C • Other important glucose measurements: • Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study suggests A1C is less useful than OGTT as a predictor of adverse pregnancy outcomes in women with diabetes3 1. Jovanovic L, et al. Diabetes Care. 2011;34(1):53-54. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.3. Lowe LP, et al. Diabetes Care. 2012;35:574-580.

  10. Glucose Monitoring in GDM: Continuous Glucose Monitoring • Measures glucose levels over 24-hour period1 • Continuous glucose monitoring (CGM) measures glucose concentration of interstitial fluid using subcutaneous sensor tip implanted in abdominal wall1,3 • Identifies glycemic excursions that may go undetected with SMBG1 • May be recommended when patient unable to achieve target glucose levels with SMBG alone2 • Educational tool to improve treatment adherence4 • Benefits: • Improved glycemic control during third trimester • Reduced infant birth weight • Decreased risk of infant macrosomia1,2,3 1. Hod M. Jovanovic L. Int J Clin Pract, 2010;64(166):47-52. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.3. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111. 4. AACE. Endocr Pract. 2010;16(5):1-16.

  11. CGM Devices:Professional vs Personal • Professional CGM devices • Owned by a health care professional1 • Typically implanted for 3-5 days1 • Data downloaded and analyzed by a health care professional1 • Personal CGM devices • Owned by the patient • May be implanted for longer periods (eg, several weeks)1 • Provide continuous feedback on glucose values, which may be read/interpreted by the patient in real time2 AACE. Endocr Pract. 2010;16(5):1-16. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111.

  12. Medical Nutrition Therapy (MNT) • Refer patients for nutritional counseling with registered dietitian familiar with pregnancy1,2 • MNT is based on standard nutritional recommendations during pregnancy, with customization based on: • Height • Weight • Nutritional assessment • Level of glycemic control3,4,5 • Goals: • Provide a nutritionally adequate diet for pregnancy • Achieve normoglycemia 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.5. National Academy of Sciences, Institute of Medicine, Food and Nutrition Board, Committee on Nutritional Status in Pregnancy and Lactation, Nutrition During Pregnancy: http://www.iom.edu/Reports/1990/Nutrition-During-Pregnancy-Part-I-Weight-Gain-Part-II-Nutrient-Supplements.aspx, 1990. Accessed: April 26, 2012.

  13. Management of GDM • Medical nutrition therapy (MNT) and lifestyle changes can effectively manage 80% to 90% of mild GDM cases1,2 • MNT nutritionalgoals and recommendations: • Choose healthy low-carbohydrate, high-fiber sources of nutrition, with fresh vegetables as the preferred carbohydrate sources4 • Count carbohydrates and adjust intake based on fasting, premeal, and postprandial SMBG measurements4,6 • Avoid sugars, simple carbohydrates, highly processed foods, dairy, juices, and most fruits4,5 • Eat frequent small meals to reduce risk of postprandial hyperglycemia and preprandial starvation ketosis5 • As pregnancy progresses, glucose intolerance typically worsens; patients may ultimately require insulin therapy1,3 1. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111. 2. ADA. Diabetes Care. 2013;36(suppl1):S11-66.3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.5. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 6. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.

  14. Diabetes in Pregnancy: Pharmacologic Therapy • When MNT alone fails, pharmacologic therapy is indicated • AACE guidelines recommend insulin as the optimal approach1 • Insulin therapy is required for the treatment of T1DM during pregnancy2 • Metformin and the sulfonylurea glyburide are the 2 most commonly prescribed oral antihyperglycemic agents during pregnancy1,2 • Due to efficacy and safety concerns, the ADA does not recommend oral antihyperglycemic agents for gestational diabetes mellitus (GDM) or preexisting T2DM3,4 1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.5. Micronase PI. Pifizer. Division of Pifizer, NY, NY, 2010. 6. Diabeta PI. Sanofi-Aventis U.S. Bridgewater, NJ, 2009.

  15. Insulin Use During Pregnancy 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53.3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

  16. Gestational Diabetes Mellitus (GDM): Initiation of Insulin 1. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

  17. Diabetes in Pregnancy: Insulin Following a positive pregnancy test, patients with preexisting diabetes being treated with insulin or oral antihyperglycemic medications should be transitioned to one of the above options2 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.2. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.

  18. Diabetes in Pregnancy: Insulin Dosing • Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. • Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.

  19. Insulin Pump Therapy/Continuous Subcutaneous Insulin Infusion (CSII) • CSII: Administration of rapid-acting insulin via insulin pump • Safe and reliable method for satisfying basal insulin needs in pregnant patients with gestational diabetes mellitus (GDM), T2DM, or T1DM1,2 • CSII may need to be combined with CGM for optimal glycemic control in T1DM1 • Can be used to effectively mimic physiologic insulin secretion2 • No significant difference in glycemic control for pregnancy outcomes with CSII versus multiple-dose insulin (MDI) therapy3 • Can help address daytime or nocturnal hypoglycemia or a prominent dawn phenomenon4 • Insulin aspart and lispro are the standard of care for CSII5 • Disadvantages of CSII: • Complexity–requires counseling and training • Cost • Potential for insulin pump failure/user error or infusion site problems2,4 • AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K et al. Curr Diab Rep, 2012;12:53-59.3. Hod M. Jovanovic L. Int J Clin Pract, 2010;64(166):47-52. 4. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79. • 5. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.

  20. Diabetes in Pregnancy: Hypoglycemia 1. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738. 2. Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-26. 3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79. 5. Hod M. Jovanovic L. Int J Clin Pract. 2010;64(166):47-52.

  21. Diabetes in Pregnancy: Hypoglycemia Treatment Hypoglycemia resolved (normal SMBG confirmed) Snack or meal should be consumed to prevent recurrence1 1 mg glucagon injected subcutaneously; request emergency assistance1 Severe hypoglycemia (patient cannot swallow) Suspected or confirmed hypoglycemia (blood glucose <60 mg/dL via SMBG) Preferred treatment: 15-20 g glucose1,2 15-minutes: recheck SMBG Mild to moderate hypoglycemia (patient can swallow) Alternative treatments include fast-acting carbohydrates (eg, 8 oz nonfat milk, 4 oz juice)1 Repeat treatment Hypoglycemia not resolved 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.

  22. Diabetes in Pregnancy:Physical Activity • Unless contraindicated, physical activity should be included in a pregnant woman’s daily regimen • Regular moderate-intensity physical activity (eg, walking) can help to reduce glucose levels in patients with GDM1,2 • Other appropriate forms of exercise during pregnancy: • Cardiovascular training with weight-bearing, limited to the upper body to avoid mechanical stress on the abdominal region3 1.Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.

  23. Diabetes in Pregnancy: Weight Gain • Patient’s prepregnancyBMI is used to determine goals for healthy weight gain1 • Independent of maternal glucose levels, higher maternal BMI has been associated with increased risk of: • Caesarean delivery • Infant birth weight >90thpercentile • Cord-blood serum C-peptide >90thpercentile2 • Evidence supports a goal of minimal weight gain during pregnancy for obese women1 • Patients should be advised to achieve weight objectives by maintaining a balanced diet and exercising regularly1 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. Metzger BE, et al. BJOG 2010;117:575-584.

  24. Diabetes in Pregnancy: Labor and Delivery • Counsel women on diabetes management during labor and delivery1 • During the 4-6 hours prior to delivery, there is increased risk of transient neonatal hypoglycemia1 • Labor and delivery in women with insulin-dependent type 1 diabetes should be managed by an endocrinologist or a diabetes specialist1 • Blood glucose levels should be monitored closely during labor to determine patient’s insulin requirements • Most women with gestational diabetes mellitus who are receiving insulin therapy will not require insulin once labor begins1 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.

  25. Diabetes in Pregnancy: Psychological Issues • The demands of diabetes management can have a substantial effect on pregnancy1 • Individualized psychosocial interventions are likely to help improve both pregnancy outcomes and patient quality of life1 • Include specialists in the psychological aspects of diabetes as part of the multidisciplinary healthcare team • Healthcare teams can help manage patients’ stress and anxiety before and during pregnancy • Identify and address barriers to effective diabetes management, such as fear of hypoglycemia and an inadequate social support network 1. Snoek SJ, et al. Psychology in Diabetes Care. 2nd Ed. West Sussex, England: John Wiley & Sons Inc., 2005:54.2. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.

  26. Diabetes in Pregnancy: Postpartum and Lactation • Metformin and glyburide are secreted into breast milk and are therefore contraindicated during lactation1 • Breastfeeding plus insulin therapy may lead to severe hypoglycemia1 • Greatest risk is in women with T1DM • Preventive measures are: reduce basal insulin dosage and/or carbohydrate intake prior to breastfeeding • Bovine-based infant formulas are linked to increased risk of T1DM1 • Avoid in offspring of women with a genetic predisposition for diabetes • Soy-based products are a potential substitute 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.

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