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IN THE NAME OF GOD

IN THE NAME OF GOD. Diabetes care in pregnancy. M. Maleki Moghaddam.MD Fellow of Endocrinology Research Institute of Endocrine Sciences. Case Study. 31 year old woman G1P0 presents to the clinic at 6 weeks’ gestation Known type 2 diabetes on Glibenclamide and Metformin HbA1C is 8.1%

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. Diabetes care in pregnancy M. Maleki Moghaddam.MD Fellow of Endocrinology Research Institute of Endocrine Sciences

  3. Case Study • 31 year old woman G1P0 presents to the clinic at 6 weeks’ gestation • Known type 2 diabetes on Glibenclamide and Metformin • HbA1C is 8.1% • She expresses concerns about the impact on her health and her future newborn • How should she be managed?

  4. Diabetes in pregnant women may be • Pregestational, diabetes (type 1 or type 2) diagnosed before pregnancy • Gestational(GDM), diagnosed during pregnancy.

  5. Diabetes Care in Pregnancy • Preconception care • Diabetes Care during pregnancy • Postpartum care

  6. Preconception Care • Unfortunately, unplannedpregnanciesoccur in about two-thirds of womenwithdiabetes • Elevated maternal glucose or HbA1C levels during embryogenesis is associated with high rates of spontaneous abortions and major malformations in newborns Preconception Care of Women With Diabetes Diabetes Care 27: 76S-78S.

  7. Preconception Care • Counselling about the risk of malformations • Use of effective contraception • Effects of pregnancy on maternal diabetic complications • Fetal and neonatal complications of maternal diabetes • Risks of obstetrical complications that occur with increased frequency in diabetic pregnancies

  8. Preconception Care Program • Multidisciplinary team • Internist • Obstetrician • Diabeteseducators • Nurses • Dietitians • The patient is the most active member

  9. Preconception Care Program • Patient education about the effects of diabetes on pregnancyoutcomes • Appropriate use of contraception • Diabetes self-management skills • Follow up

  10. Preconception Care : goals of treatment Optimal HBA1C : • Medical nutrition therapy (MNT) • Self-monitoring of blood glucose (SMBG) • Self-administration of insulin and self-adjustment of insulin doses • Education about hypoglycaemia • Physical activity

  11. Preconception Care :Initial visit Medical & obstetric history • Duration and type of diabetes (1 or 2) • H/O acute complications • H/O chronic complications • Diabetes management : Insulin regimen, oral hypoglycaemic, SMBG, diet, physical activity

  12. Preconception Care: Physical Examination • Blood pressure, including orthostatic • Fundoscopy • Cardiovascular examination • Neurological examination

  13. Preconception Care Laboratory evaluation • HbA1C measurement • Serum creatinine • Albumin/creatinine ratio or 24 hour albumin excretion rate. • TSH and/or FT4 in women with type 1 diabetes

  14. Preconception Care : Selection of antihyperglycemic therapy • Insulin is the gold standard: efficacy, does not cross placenta • Oral hypoglycemic currently not recommended routinely

  15. Preconception Care: Goals for SMBG • Premeal, bedtime, and overnight glucose 60–99 mg/dL (3.3–5.4 mmol/L) • Peak postprandial glucose 100–129 mg/dL (5.4–7.1 mmol/L) • A1C <6.0% • Follow-up: 1 to 2 months’ intervals

  16. Preconception Care: Special considerations • Hypoglycemia • Retinopathy: glycemic control, laser photocoagulation • Folic acid 5mg/d is recommended, from before conception until 12 weeks, for women with diabetes as the risk of NTD is higher than general population

  17. Preconception Care:Special considerations Hypertension • Frequentconcomitant or complicatingdisorder • Pregnancyinduced hypertension occurs more frequently • Aggressive control • ACE inhibitors, B-blockers and diuretics avoided

  18. Preconception Care:Special considerations Nephropathy • Renal function: serum creatinine and urinary protein excretion - Potential impact of pregnancy on proteinuria - Impact of renal insufficiency on fetal growth and development.

  19. Preconception Care:Special considerations Neuropathy • Aautonomicneuropathy:gastroparesis, urinary retention, hypoglycemic unawareness, or orthostatic hypotension • Peripheralneuropathy,especially carpal tunnel syndrome, may be exacerbated by pregnancy.

  20. Preconception Care: Special considerations Cardiovasculardisease • Untreated CAD isassociatedwith a highmortality rate duringpregnancy • Exercisetoleranceshouldbe normal

  21. Preconception Care: Special considerations • As soon as possible after conception, pregnancy should be confirmed by urinary or serum B-hCG • The woman should be reevaluated by the health care team

  22. GDM: Detection & Diagnosis • Riskassessmentat the first prenatalvisit • High risk patients: • HX of GDM or delivery of a baby weighing >9 lb • Obesity • Strong family history of diabetes • Ethnic group with a high prevalence of diabetes • Insulin resistance( PCO, Acanthosisnigricans,…) • ….

  23. Screening and diagnosis of GDM • Womenathighrisk of GDM should have glucose testingat the first antenatalvisit • Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks’ gestation in women not previously diagnosed with overt diabetes. • The OGTT should be performed in the morning after an overnight fast of at least 8 h.

  24. GDM: Detection & Diagnosis The diagnosis of GDM is made when any of the following plasma glucose values are exceeded: • Fasting ≥92 mg/dL (5.1 mmol/L) • 1 h ≥ 180 mg/dL (10.0 mmol/L) • 2 h ≥ 153 mg/dL (8.5 mmol/L

  25. GDM: Obstetrics and Perinatal considerations Increase in the risk of • Intrauterine fetal death during the last 4–8 weeks of gestation • Fetalmacrosomia and its associated risk of shoulder dystocia and birth trauma • Neonatal hypoglycemia, jaundice, polycythemia, and hypocalcemia N Engl J Med 2005;352:2477-2486.

  26. Macrosomia

  27. GDM: Obstetrics and Perinatal considerations Increasedfrequency of • Maternal hypertensive disorders • Need for cesareandelivery

  28. GDM: Long term considerations • Women with GDM are at increased risk of developing T2DM, after pregnancy • Offspring of women with GDM are at increased risk of obesity, glucose intolerance, and diabetes in late adolescence and young adulthood

  29. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) Goals: • Achieve normoglycemia • Prevent ketosis • Provide adequate weight gain • Contribute to fetal wellbeing

  30. GDM:Therapeutic strategies Medical Nutrition Therapy (MNT) Calorie allotment • BMI of 22 to 27: 30 kcal/kg per day • BMI 27 to 29: 24 kcal/kg per day • BMI > 30: 12 to 15 kcal/kg per day • BMI less than 22: 40 kcal/kg per day

  31. GDM: Therapeutic strategies Medical Nutrition Therapy (MNT) • Carbohydrate intake: 35 to 40% • Protein: 20% • Fat: 40%

  32. GDM:Therapeutic strategies Medical Nutrition Therapy (MNT) Calorie distribution: 3 meals and 3 snacks • Overweight: snacks are eliminated. • Breakfast: 10% of total calories • Lunch: 30% • Dinner: 30% • Snacks: 30%

  33. GDM: Therapeutic strategies Glucose monitoring: • SMBG: Fasting and 2 hours postprandial • Goals: FPG < 95mg/dl 1 hours postprandial < 140 mg/dl 2 hours postprandial < 120 mg/dl • HbA1C every 4 weeks .

  34. Self-Blood Glucose Monitoring • Accurate meter and technique • Important to be consistent;1hour post-prandial or 2 hour post-prandial • Do not alternate between fingersticks and alternate site testing; values are different by about 15% • Ketone testing is necessary

  35. GDM: Therapeutic strategies Insulin • 15% requires insulin • When diet fails to maintain SMBG at the following levels: - Fasting plasma glucose <95 mg/dl - 2 hours PPglucose <120 mg/dl

  36. GDM: Therapeutic strategies Insulin • Premixedinsulinis not appropriate • If FPG is high, an intermediate acting insulin is given at bedtime. • If the postprandial blood glucose is high, short acting insulin is given before the meals

  37. GDM: Therapeutic strategies Insulin • If both fasting and postprandial blood glucose are high, an intermediate acting insulin is given before breakfast and at bedtime and a short acting insulin is given tid before meals

  38. GDM:Therapeutic strategies Insulin dose • Varies in different populations because of varied rates of obesity and ethnic characteristics. • Intermediate acting: 40% of total daily dose • RegularInsulin: 60% of total daily dose

  39. GDM: Therapeutic strategies Insulin dose • No absoluterule • Dose distribution is modified according to - individual requirements - amount she will eat at each meals. • Morning sickness should be taken in consideration.

  40. GDM: Therapeutic strategies Insulin dose • Greaterin obese women • May need to beincreasedprogressively as pregnancyadvances to term • SMBG guides the doses and timing of the insulin regimen

  41. GDM: Therapeutic strategies

  42. GDM: Insulin dose adjustment • 1-1.5 unit insulin need for each 15 g CHO content of meal • Adjust insulin dosebased on the preprandial blood glucose • 1 unit of insulin for every 50 mg/dL over the preprandial glucose target or • (body weight in kg) x (blood glucose – desired glucose in mg/dL)/1700]

  43. GDM: Therapeutic strategies Oral hypoglycemic agents • Concerns: Transplacental passage → fetalteratogenesis, prolonged neonatal hypoglycemia • Most restrospective studies have not demonstrated an ↑ risk of malformed infants

  44. GDM: Exercise ! • Decreases insulin resistance. • Women without medical or obstetrical contraindications should be encouraged to start or continue a program of moderate exercise to lower glucose concentrations

  45. GDM: Exercise ! Moderate regular exercise such as walking, cycling or swimming are excellent forms of exercise for pregnant women. Keeping well-hydrated and well-nourished is essential

  46. Contraindications to exercise in pregnancy • Risk of premature labor • Cardiac disease • Vaginal bleeding • Placenta previa • Hypertension • Anemia • Intrauterine growth retardation • Malpresentation • Extreme obesity • Extreme underweight

  47. Benefits of Exercise • Exercising for 15-20 minutes after a meal may help to keep blood glucose levels within the target range for women with GDM. • Individualized programs can start with 20 minutes/day, gradually increasing to 45-60 minutes/day.

  48. GDM: Management of Hypoglycemia • Results of SMBG can be useful in preventing hypoglycemia and adjusting medications • Glucose (15–20 g) is preferred treatment for conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. • If SMBG 15 min after treatment shows continued hypoglycemia, treatment should be repeated. • Once SMBG glucose returns to normal individual should consume a meal or snack to prevent recurrence of hypoglycemia.

  49. GDM: Therapeutic strategies Timing and mode of delivery • GDM is not of itself an indication for cesarean delivery or for delivery before 38 completed weeks of gestation • If glucose levels are medically managed with insulin or oral agents→induction of labor at 39 weeks of gestation. • If a concomitant medical condition (eg, HTN) is present or glycemic control is suboptimal, induction of labor at 38 weeks of gestation after confirmation of fetal lung maturity

  50. Postpartum Management of GDM • ~15% of women with GDM have impaired glucose tolerance or diabetes after delivery • Greater likelihood if • Obese • GDM diagnosed early in pregnancy • Treatment required • ADA recommends that all women with GDM be evaluated postpartum for diabetes

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