Diabetes in Pregnancy
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Diabetes in Pregnancy

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Lecture for incoming first year residents of the Department of Medicine, Philippine General Hospital

Lecture for incoming first year residents of the Department of Medicine, Philippine General Hospital

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  • 1. DIABETES IN PREGNANCY Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital
  • 2. Definitions Gestational Pre-gestational diabetes diabetes
  • 3. Gestational Diabetes Definitions Any degree of glucose intolerance with onset or first recognition during pregnancy Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop- Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1– B167, 1998
  • 4. Pre-gestational Diabetes Definitions Diabetes diagnosed before pregnancy
  • 5. Gestational Diabetes Screening and diagnosis Rationale for treatment Monitoring of blood glucose Diet and exercise Insulin initiation and follow-up Maternal and fetal surveillance Labor and delivery Postpartum follow-up
  • 6. Screening Risk factors for GDM Increasing maternal age and weight Previous GDM Previous macrosomic infant Family history of diabetes among first-degree relatives Gestational diabetes Ethnic background with a high prevalence of diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 7. Screening Screen all pregnant women “... women with GDM without risk factors appear to be no different from women with GDM Gestational and risk factors.” diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 8. Screening All women should undergo screening at first prenatal visit and after 26th week AOG if negative on previous testing Gestational diabetes AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996
  • 9. Screening 50-g glucose Oral glucose challenge test tolerance test (OGTT) (GCT) 75-g or 100 g? Gestational “A one-stage definitive diabetes procedure is preferred.” International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 10. 75-g OGTT CHO intake of at least 150 g/day 3 days prior Fast for 10 to 16 hours 75 grams of anhydrous dextrose powder as chilled 25% solution (400 cc) flavored with calamansi Drink within 5 minutes (first swallow is time zero) Terminate test should nausea and vomiting occur Collect samples at 0, 1 and 2 hours
  • 11. 75-g OGTT Abstain from tobacco, coffee, tea, food and alcohol during test Sit upright and quietly during the test Slow walking is permitted but avoid vigorous exercise
  • 12. Diagnosis >130 mg/dL 50-g glucose Oral glucose challenge test tolerance test (OGTT) (GCT) 75-g or 100 g? Thresholds ADA ASGODIP for diagnosis 100-g 75-g 75-g Gestational FBS 95 95 - diabetes 1h 180 180 - 2h 155 155 140 3h 140 - -
  • 13. Rationale for treatment Increased risk for macrosomic or LGA infants GDM Normal 100 75 Gestational 50 % diabetes 25 0 MMC VMMC PoGH CSMC PGH AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996 Isip-Tan unpublished data
  • 14. Rationale for treatment Increased risk for Cesarean sections GDM Normal 100 80 Gestational diabetes 60 % 40 20 MMC VMMC PoGH PGH AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996 Isip-Tan unpublished data
  • 15. Monitoring blood glucose Self-monitor blood glucose levels both fasting and postprandial, preferably 1 h after a meal. Gestational diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 16. Monitoring blood glucose 5th Int’l Workshop NICE CDA 90-99 mg/dL 63-106 mg/dL 68-94 mg/dL Fasting (5.0-5.5 mmol/L) (3.5-5.9 mmol/L) (3.8-5.2 mmol/L) 1 h after <140 mg/dL <140 mg/dL 99-139 mg/dL meal (<7.8 mmol/L) (<7.8 mmol/L) (5.5-7.7 mmol/L) 2 h after <120-127 mg/dL 90-119 mg/dL meal (<6.7-7.1 mmol/L) (5.0-6.6 mmol/L) Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007) National Institute for Health & Clinical Excellence (2008) Canadian Diabetes Association (2008)
  • 17. Monitoring blood glucose Measure HbA1c in women with gestational diabetes who may have developed type 2 diabetes while pregnant Gestational diabetes International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 18. Dietary Management Determine if patient is overweight Expected pregnant weight = ideal body weight (for height) + expected weight gain/trimester
  • 19. IOM recommendations for weight gain by pre-pregnancy BMI 2009 Rates of weight gain* Total weight Prepregnancy BMI 2nd and 3rd trimester gain (lbs) (lbs/week) Underweight 1 <28-40 BMI <18.5 (1-1.3) Normal weight 1 25-35 BMI 18.5-24.9 (0.8-1) Overweight 0.6 15-25 BMI 25.0-29.9 (0.5-0.7) Obese 0.5 11-20 BMI >30.0 (0.4-0.6) * Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
  • 20. Dietary Management Recommended Daily Caloric Intake Pregravid BMI Category kcal/kg/day Low (BMI <18.5 kg/m2) 36-40 Normal (BMI 18.5-24.9 kg/m2) 30 High (BMI 25-29.9 kg/m2) 24 Obese (BMI >29.9 kg/m2) 12 Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 21. Dietary Management For considerably overweight women with GDM, reduce energy intake by no more than 30% of habitual intake Total cal/day = 1,800-2,000 Not less than 2,000 cal/day if multiple pregnancy International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 22. Dietary Management 3 meals and 3 snacks 50-60% complex high fiber CHO 18-20% CHON or at least 75 g <30% fats
  • 23. Dietary Management Avoid concentrated sweets No cookies, cakes, pies, soft drinks, chocolate, table sugar, fruit juice, juice drinks, Kool-Aid, Hi-C, nectars, jams or jellies Avoid convenience foods No instant noodles, canned soups, instant potatoes, frozen meals or packaged stuffing Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 24. Dietary Management Eat small frequent meals Eat about every 3 hours Include a good source of protein at every meal and snack (i.e. low- fat meat, chicken, fish, low-fat cheese, nuts, peanut butter, cottage cheese, eggs and turkey) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 25. Dietary Management Eat a very small breakfast No more than 1 starch exchange (<15 g CHO so limit cereal, bread, pancakes, toast, bagels, muffins and Danishes and no fruit or juice Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 26. Dietary Management Choose high-fiber foods Fresh and frozen vegetables Beans and legumes Fresh fruits (except at breakfast) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 27. Dietary Management Free foods - eat as desired cabbage mushrooms celery radish cucumber zucchini lettuce green beans spinach onion green onion garlic broccoli asparagus nopales spinach lemon/lime butter olives sour cream avocado olive oil Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 28. Dietary Management Monitor urine ketones before breakfast to detect starvation ketonuria Individualize! Monitor blood glucose levels, urine ketones, appetite and weight gain
  • 29. Exercise ACOG (expert opinion) minimum of 30 minutes exercise on most days of the week for a normal pregnancy Exercise is a useful adjunct to treatment Avoid excessive abdominal muscle contraction International Diabetes Federation (2009) Global Guideline on Pregnancy and Diabetes
  • 30. Insulin Initiation ADA Protocol Fasting whole BG >95 mg/dL 1-h postprandial whole BG >140 mg/dL 2-h postprandial whole BG >120 mg/dL Dr. Jovanovic Fasting plasma glucose >90 mg/dL (5 mmol/L) 1-h postprandial whole BG >120 mg/dL (6.7 mmol/L) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 31. Insulin Initiation Diet therapy alone for at least 2 weeks before starting insulin If fasting glucose (on OGTT) >95 mg/dL, start insulin after 1 week of dietary therapy or at diagnosis
  • 32. Insulin Regimens Human insulin Insulin analogues Insulin lispro and aspart safe and effective Limited experience with insulin glargine and detemir
  • 33. Insulin Regimens ASGODIP Protocol Intermediate-acting insulin 30 min prebreakfast Intermediate-acting insulin 30 min presupper + rapid- acting insulin Three injections of rapid-acting insulin given 30 minutes before each meal + intermediate-acting OR long-acting insulin at bedtime Initiating dose depending or start on a daily dose of 0.1 to 0.3 u/kg BW.
  • 34. Subsequent visits Date ASGODIP Protocol time CBG Comments 11/20 Every 2 weeks to check glycemic control after 160 pancakes breakfast WOF obstetric complications after 148 spaghetti (i.e. macrosomia, IUGR, lunch preeclampsia and hydramnios) after 118 dinner
  • 35. Maternal surveillance Increased frequency of preterm birth in untreated GDM Use of corticosteroids not contraindicated but intensify glucose monitoring and adjust insulin Risk of hypertensive disorders increased Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 36. Fetal surveillance ASGODIP Protocol Ultrasound at first visit to determine age of pregnancy At 20-22 weeks to detect malformations At 32-34 weeks to monitor growth HbA1c values >7.0% or fasting plasma glucose >120 mg/dL (6.7 mmol/L) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 37. Glycemic control during labor and delivery ASGODIP Protocol Infusion of 500 ml 5% dextrose/saline x 4 h CBG q 4 h Short-acting insulin for CBG > 140 mg% Dose equal to mmol of CBG i.e. 12 u for 12 mmol/L Dose equal to 1/20th of mg/dL CBG i.e. 12 u for 240 mg/dL Omit insulin for CBG < 140 mg/dL
  • 38. Glycemic control during labor and delivery ASGODIP Protocol After delivery, resume diet Generally do not require insulin GDM with high insulin requirements during pregnancy should have CBG monitoring Give insulin only if CBGs persistently high (>200 mg/dL)
  • 39. Postpartum follow-up Schedule 75-g OGTT after 6 weeks 60-70% chance of developing GDM in subsequent pregnancies 40-60% chance of developing type 2 diabetes in the future Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 40. Postpartum follow-up Annual follow-up Measure FBS Assess weight reduction Review pregnancy plans Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 41. Pre-gestational diabetes Preconception care Monitoring of blood glucose Hypoglycemia Special considerations
  • 42. Preconception Care Contraceptive advice Risks of pregnancy (maternal and fetal/neonatal) Importance of maintaining blood glucose levels Genetic counseling Personal commitment by women and her family Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 43. Preconception Care Prepregnancy Assessment History and PE Gynecologic evaluation Lab evaluation HbA1c, urinalysis and culture, 24-h urine for Crea Cl and CHON Thyroid panel: FT4 1.0-1.6 and TSH <2.5 uU/L ECG or treadmill Neuropathy testing if indicated Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 44. Preconception Care Potential Contraindications to Pregnancy Ischemic heart diease Active proliferative retinopathy, untreated Renal insufficiency Crea Cl <50 ml/min or serum crea >2 mg/dL or heavy proteinuria (>2 g/24 h) or hypertension (BP >130/80 mm Hg despite treatment) Severe gastroenteropathy Nausea/vomiting, diarrhea Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 45. Preconception Care Shift Type 2 diabetics on OHA to insulin Maternal HbA1c to assess risk of malformations Goal <1% above normal range, lower if possible Monitor every 1 to 2 months Discontinue contraception Stable glycemic control Maternal diabetic complications and coexisting medical problems acceptable Diabetes Care 26:S91-93, 2003
  • 46. Monitoring blood glucose No data to suggest that postprandial monitoring has a specific role beyond what is needed to achieve HbA1c Pre-gestational diabetes Diabetes Care 26:S91-93, 2003
  • 47. Monitoring blood glucose Self-monitored blood glucose Fasting/overnight/premeal plasma glucose 60-99 mg/dL 1-h postmeal 100-129 mg/dL A1c at initial visit Monthly until A1c <6.2% achieved then q2-4 months Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 48. Hypoglycemia Attempts to achieve normoglycemia in type 1 DM increase risk of hypoglycemia (DCCT) No evidence that hypoglycemia is an independent risk to the developing embryo Clear risk to the mother Diabetes Care 26:S91-93, 2003
  • 49. Diabetic Retinopathy May accelerate during pregnancy Gradual attainment of good metabolic control before conception Preconception laser photocoagulation with standard indications Baseline dilated comprehensive eye examination Follow up eye exam during pregnancy Diabetes Care 26:S91-93, 2003
  • 50. Diabetic Retinopathy Risk factors for progression Duration of diabetes Retinal status Elevated HbA1c Hypertension Valsalva maneuver (increases risk of retinal hemorrhage) Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
  • 51. Hypertension Type 1 diabetics frequently develop hypertension in association with diabetic nephropathy Type 2 diabetics commonly have coexisting hypertension Pregnancy-induced hypertension proteinuria in excess of 190 mg/day before conception or in early pregnancy Diabetes Care 26:S91-93, 2003
  • 52. Hypertension Aggressive monitoring and control to reduce risk of worsening nephropathy, development of retinopathy or clinical atherosclerosis SBP <130 mm Hg Avoid ACE-inhibitors, ARBs, beta- DBP <80 mm Hg blockers and diuretics in women contemplating pregnancy Diabetes Care 26:S91-93, 2003
  • 53. Diabetic Nephropathy Baseline assessment of renal function before conception and followed at regular intervals urine albumin-to-creatinine ratio 24 h albumin excretion Diabetes Care 26:S91-93, 2003
  • 54. Diabetic Nephropathy Permanent worsening of renal function in >40% of women with incipient renal failure (serum crea > 3 mg/dL or crea clearance < 50 mL/min) Permanent worsening of renal function does not occur more often in women with less severe nephropathy Diabetes Care 26:S91-93, 2003
  • 55. Diabetic Nephropathy Proteinuria >190 mg/24 h before or during early pregnancy triples risk of hypertensive disorders in second half of pregnancy Risk of IUGR during later pregnancy if protein excretion > 400 mg/24 h Discontinue ACE inhibitors in women attempting pregnancy who have microalbuminuria Diabetes Care 26:S91-93, 2003
  • 56. Neuropathy Autonomic neuropathy may complicate management gastroparesis urinary retention hypoglycemic unawareness orthostatic hypotension Peripheral neuropathy especially compartment syndromes i.e. carpal tunnel syndrome may be exacerbated Diabetes Care 26:S91-93, 2003
  • 57. Cardiovascular disease Untreated CAD is associated with a high mortality rate Successful pregnancies after coronary revascularization in women with diabetes Normal exercise tolerance to maximize probability that patient will tolerate increased cardiovascular demands of gestation Diabetes Care 26:S91-93, 2003
  • 58. Key Points Screen all pregnant Filipino women Be aware of the limitations of self-monitored blood glucose Do not wait too long to shift to insulin if diet therapy fails Gestational Ensure postpartum OGTT diabetes
  • 59. Key Points Counsel diabetic women of child-bearing potential on contraception and risks of unplanned pregnancy with poor metabolic control Shift to insulin Pre-gestational Aim for A1c <1% above normal diabetes or better
  • 60. Key Points Advise regarding possible worsening of diabetic complications during pregnancy Discontinue ACE-inhibitors in albuminuric women attempting pregnancy Pre-gestational diabetes
  • 61. Thank You http://www.endocrine-witch.info