Diabetes and pregnancy - Endocrine society guidelines 2013

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This presentation talks about diabetes mellitus in relation to pregnancy. It classifies diabetes in pregnant pts as overt and gestational diabetes. Then it discusses the various guidelines given by Endocrine Society in 2013 for management of diabetic patients during pregnancy

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Diabetes and pregnancy - Endocrine society guidelines 2013

  1. 1. Diabetes and Pregnancy An Endocrine Society Clinical Practice Guideline Authors : Blumer I, Hadar E, Hadden DR, JovanovičL, Mestman JH, Murad MH, Yogev Y Published : J Clin Endocrinol Metab. 2013 Nov;98(11):4227-49 Presentationby : Dr. Jagjit Khosla(Junior Resident,Endocrine, GTBH, Delhi)
  2. 2. Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 2 Diabetes and Pregnancy • Women diabetic before the onset of pregnancy Overt Diabetes • Diabetes first detected in course of pregnancy Gestational diabetes
  3. 3. Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 3 Gestational diabetes • Any degree of glucose intolerance with onset or first definition during pregnancy Current definition • 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 Definition supported by ES
  4. 4. Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 4 Gestational diabetes - Pathophysiology • Insulin resistance emerging in the 2nd trimester of pregnancy – Progesterone – Cortisol – Human placental lactogen – Prolactin and estrogen also contribute • Some pts. cannot balance insulin needs and develop GDM • Placental insulinase enzyme and obesity
  5. 5. Preconceptioncare of womenwith diabetes Gestational diabetes Glucose monitoring and glycemictargets Nutritiontherapy and weight gain targets for womenwith overtor gestational diabetes Bloodglucose-lowering pharmacological therapy during pregnancy Labor, delivery,lactationand postpartum care Diabetes and Pregnancy : ES Guidelines
  6. 6. Diabetes and Pregnancy ES Guidelines 2013 Preconceptioncare of women with diabetes
  7. 7. 1.1 – Preconception counselling to all diabetic women Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 7 Diabetes and Pregnancy : ES Guidelines  Sufficient glycemic control  Assessment of comorbidities  Discontinuing unsafe medications  Folate supplementation  Smoking cessation Preconception care of women with diabetes
  8. 8. 1.1 – Preconception counselling to all diabetic women Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 8 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1. Better preconception glycemic control 2. Lower rates of congenital anomalies and spontaneous abortions
  9. 9. 1.2 – Achieve blood glucose and HbA1c close to normal Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 9 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Maternal Hyperglycemia in first few wks of pregnancy  Fetal malformations  Spontaneous abortions  Perinatal mortality
  10. 10. 1.2 – Achieve blood glucose and HbA1c close to normal Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 10 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Risk of congenital anomaly HbA1c levels
  11. 11. 1.3a – Insulin therapy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 11 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Multiple daily doses of insulin or, Continuous sc insulin infusion Split-dose, premixed insulin therapy vs 1. More likely to achieve target levels 2. Flexibility
  12. 12. 1.3b – Insulin therapy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 12 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Change/start insulin regimen in advance 1. Better expertise of patient 2. Optimization
  13. 13. 1.3c – Insulin therapy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 13 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Rapid-acting insulin analog Regular insulinvs 1. Achieve postprandial B.G. targets better 2. Less risk of hypoglycemia 3. Greater lifestyle flexibility and better quality of life 4. Insulin lispro and Insulin aspart safe in pregnancy
  14. 14. 1.3d – Insulin therapy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 14 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes CONTINUE Long-acting insulin analogs 1. Lower rates of nocturnal hypoglycemia 2. Insulin detemir approved for use in pregnancy (Category B) 3. Insulin glargine safe in pregnancy Long-acting Insulin analogs Intermediate acting Insulinvs 1. NPH is cheaper
  15. 15. 1.4 – Folic acid supplementation Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 15 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes  Start 3 months before conceiving  5 mg daily dose ↓ Risk of Neural tube defects
  16. 16. 1.5a – Ocular care Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 16 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Detailed ocular assessment Retinopathy present Patient counselling for risk of worsening Retinopathy needing therapy First treat retinopathy Conceive only when it is stabilized
  17. 17. 1.5b – Ocular care Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 17 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Women with Established Retinopathy Ocular assessment every trimester Post-pregnancy assessment within 3 months after delivery
  18. 18. 1.5c – Ocular care Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 18 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Women with No Retinopathy Ocular assessment soon after conception Then, periodically as indicated
  19. 19. 1.6 – Renal function Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 19 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Renal dysfunction in Type 1 DM ↑ Risk of Adverse Maternal & Fetal outcomes (e.g. preeclampsia) Mild Preconceptional Renal dysfunction Mod-Severe Preconceptional Renal dysf. Reversible worsening Irreversible worsening
  20. 20. 1.6a – Preconceptional Renal function assessment 1.6b – Regular renal function monitoring during pregnancy in women with preconceptional renal dysfunction Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 20 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes
  21. 21. 1.7a – Management of Hypertension Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 21 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes <130/80 mm HgSatisfactory BP Control Preconceptional Uncontrolled HTN ↑ Risk of Adverse outcomes (e.g. preeclampsia)
  22. 22. 1.7b – Management of Hypertension Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 22 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes ACE Inhibitors or Angiotensin-receptor blockers Safer alternatives :  Methyldopa  Labetalol  Diltiazem  Clonidine  Prazosin
  23. 23. 1.7c – Management of Hypertension Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 23 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Exception for using ACEI or ARBs :  Severe renal dysfunction with uncertainity about conception Loss of Renal protective properties Risk of teratogenesisvs
  24. 24. 1.7d – Management of Hypertension Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 24 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes If ACEI or ARBs continued upto time of conception DISCONTINUE immediately upon confirmation of pregnancy
  25. 25. 1.8a – Elevated vascular risk Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 25 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes If vascular risk factors present Screen for CAD before conceiving
  26. 26. 1.8b – Elevated vascular risk Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 26 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes If CAD present  Severity assessment  Management  Counselling
  27. 27. 1.9 – Management of dyslipidemia Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 27 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1. Dyslipidemia seldom poses threat during pregnancy 2. Unproven safety of statins, fibrates and niacin during pregnancy
  28. 28. Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 28 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes 1.9a – DO NOT use Statins 1.9b – DO NOT use Fibrates or Niacin 1.9c – Bile acid-binding resins may be used to treat hypercholestrolemia
  29. 29. 1.10 – Thyroid function assessment Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 29 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Autoimmune thyroid Type 1 DM Uncontrolled Hypothyroidism  ↓ Fertility  ↑ Risk of spontaneous abortion  ↑ Risk of Impaired fetal brain development Hypothyroidism
  30. 30. 1.10 – Thyroid function assessment Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 30 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes  Serum TSH  Thyroid peroxidase Antibodies
  31. 31. 1.11 – Weight reduction in overweight/obese Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 31 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Severe calorie restriction (<1500 kcal/d or 50% reduction) ↑ Ketosis Impaired fetal brain development
  32. 32. 1.11 – Weight reduction in overweight/obese Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 32 Diabetes and Pregnancy : ES Guidelines Preconception care of women with diabetes Severe calorie restriction (<1500 kcal/d or 50% reduction) Moderate calorie restriction (1600-1800 kcal/d or 33% reduction)
  33. 33. Diabetes and Pregnancy ES Guidelines 2013 Gestational Diabetes
  34. 34. 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit (<13 wks gestation) Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 34 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes  Fasting Plasma glucose, or  HbA1c, or  Untimed Random plasma glucose
  35. 35. 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 35 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes Diagnosis Fasting Glucose Random Glucose HbA1c Overt Diabetes ≥ 126 mg/dL ≥ 200 mg/dL ≥ 6.5 % Gestational Diabetes 92-125 mg/dL NA NA
  36. 36. 2.1 Universal testing for overt diabetes in non-diabetic women at first prenatal visit Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 36 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes If Overt diabetes on screening test but no Symptoms of hyperglycemia Second test to confirm diagnosis (Fasting glucose, Random glucose, HbA1c or OGTT)
  37. 37. 2.2 Testing for gestational diabetes at 24 to 28 weeks gestation by using 75-g OGTT Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 37 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes Diagnosis Fasting Glucose 1 hr Glucose 2 hr Glucose Overt Diabetes ≥ 126 mg/dL NA ≥ 200 mg/dL Gestational Diabetes 92-125 mg/dL ≥ 180 mg/dL 153-199 mg/dL
  38. 38. 2.3 Management of elevated blood glucose Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 38 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.3a – Target blood glucose levels close to normal Medical Nutrition therapy + Daily moderate exercise (≥ 30 min) Blood glucose-lowering pharmacological therapy If hyperglycemia persists 2.3b - 2.3c -
  39. 39. 2.4 Postpartum care in GDM patients Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 39 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4a – Fasting glucose measured for 24 to 72 hrs after delivery to rule out ongoing hyperglycemia 2.4b – 2 hr, 75g OGTT at 6 to 12 wks after delivery to rule out pre-diabetes or diabetes.
  40. 40. 2.4 Postpartum care in GDM patients Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 40 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4c – Child’s permanent medical record should contain :  Child’s birth weight  Whether born to mother with GDM
  41. 41. 2.4 Postpartum care in GDM patients Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 41 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4d – Counselling of GDM patients :  Lifestyle measures to ↓ risk of Type 2 DM  Need for planning future pregnancies  Regular diabetic screening
  42. 42. 2.4 Postpartum care in GDM patients Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 42 Diabetes and Pregnancy : ES Guidelines Gestational Diabetes 2.4e – Discontinue blood glucose-lowering medication immediately after delivery Exception : Suspected overt diabetes with accompanying hyperglycemia
  43. 43. Diabetes and Pregnancy ES Guidelines 2013 Glucose monitoring and glycemic targets
  44. 44. 3.1 Self-monitoring of blood glucose in pregnant women with overt or gestational DM Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 44 Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets Fasting Post-BF Pre- Lunch Post- Lunch Pre- Dinner Post- Dinner Bedtime Post-meal either 1 or 2 hrs
  45. 45. 3.2a-c – Glycemic targets in overt or GDM Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 45 Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets Target values Preprandial blood glucose ≤ 95 mg/dL 1 hr after start of a meal ≤ 140 mg/dL 2 hr after start of a meal ≤ 120 mg/dL Target preprandial blood glucose ≤ 90 mg/dL, if possible
  46. 46. 3.2d – Glycemic target only in overt diabetes Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 46 Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets HbA1c ≤ 7% Ideally HbA1c ≤ 6.5%
  47. 47. 3.3 – Continuous glucose monitoring be used if self-monitoring is not sufficient to assess glycemic control Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 47 Diabetes and Pregnancy : ES Guidelines Glucose monitoring and glycemic targets
  48. 48. Diabetes and Pregnancy ES Guidelines 2013 Nutrition therapy and weight gain targets for women with overt or gestational diabetes
  49. 49. 4.1 Medical nutrition therapy for all pregnant women with overt or gestational DM Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 49 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets  Carbohydrate controlled meal  Adequate nutrition  Appropriate weight gain  Normoglycemia  Avoid ketosis
  50. 50. 4.2a Women with overt or gestational DM to follow Institute of medicine revised guidelines (2009) for weight gain during pregnancy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 50 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets
  51. 51. Institute of Medicine revised guidelines(2009) Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 51 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets Prepregnancy BMI Total weight gain Rate of weight gain in 2nd & 3rd Trimester Underweight (<18.5 kg/m2) 12.5-18 Kg 0.51 Kg/wk (0.44-0.58) Normal weight (18.5-24.9 Kg/m2) 11.5-16 Kg 0.42 Kg/wk (0.35-0.50) Overweight (25-29.9 Kg/m2) 7-11.5 Kg 0.28 Kg/wk (0.23-0.33) Obese (≥30 Kg/m2) 5-9 Kg 0.22 Kg/wk (0.17-0.27) Assuming 0.5-2 kg weight gain in 1st trimester
  52. 52. 4.2b Obese women with overt or GDM should reduce calorie intake Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 52 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets Moderate Calorie restriction (1600-1800 kcal/d, 33% reduction)
  53. 53. 4.3 Limit carbohydrate intake to 35-45% of total calories Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 53 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets  3 small to moderate sized meals  2 to 4 snacks incl. evening snacks Minimum 175g/d Carbohydrate
  54. 54. 4.4 Same guidelines for intake of minerals and vitamins as for women without diabetes except Folic acid Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 54 Diabetes and Pregnancy : ES Guidelines Nutrition therapy and weight gain targets Folic acid 5mg/d beginning 3 months before conceiving Folic acid dose reduced to 0.4 to 1 mg/d after 12 wks gestation Folic acid to be continued until completion of breastfeeding
  55. 55. Diabetes and Pregnancy ES Guidelines 2013 Blood Glucose-loweringpharmacological therapy during pregnancy
  56. 56. 5.1a Long-acting insulin analog detemir may be initiated during pregnancy if  Women needs Basal insulin  NPH has resulted in or may result in hypoglycemia Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 56 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy Continue insulin detemir, if patient successfully taking it before pregnancy
  57. 57. 5.1b Continue insulin glargine if pt.successfully using it before pregnancy  Not FDA approved, but safe in pregnancy Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 57 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy
  58. 58. 5.1c Rapid-acting insulin analogs lispro and aspart be used in preference of regular insulin Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 58 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy Rapid-acting insulin analog Regular insulinvs
  59. 59. 5.1d Continue using continuous sc insulin infusion during pregnancy if initiated before pregnancy. Otherwise, multiple daily dose insulin preferred. Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 59 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy Continuous sc insulin infusion associated with :  ↑ Risk of maternal ketoacidosis  ↑ Risk of Neonatal Hypoglycemia
  60. 60. 5.2 Noninsulin antihyperglycemic agents Glibenclamide Metformin Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 60 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy
  61. 61. 5.2a Glibenclamide Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 61 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy Alternative to insulin therapy in GDM if  Insufficient glycemic control after 1-wk trial of MNT & exercise  Patient refuse or cannot use insulin Insulin preferred (Glibenclamide less effective) if :  GDM diagnosed before 25 wks gestation  Fasting plasma glucose > 110 mg/dL
  62. 62. 5.2b Metformin Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 62 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy  Cross placenta freely  Safety in pregnancy not established  High glycemic control failure rates  ↑ Rates of preterm birth
  63. 63. 5.2b Metformin Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 63 Diabetes and Pregnancy : ES Guidelines Blood Glucose-lowering pharmacological therapy Used for GDM only if  Insufficient glycemic control after 1-wk trial of MNT & exercise  Patient refuse or cannot use insulin or glibenclamide  Patient not in first trimester
  64. 64. Diabetes and Pregnancy ES Guidelines 2013 Labor, delivery, lactation, and postpartum care
  65. 65. 6.1 Blood glucose targets during labor & delivery Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 65 Diabetes and Pregnancy : ES Guidelines Labor, delivery, lactation, and postpartum care Blood glucose – 72 to 126 mg/dL  Neonatal Hypoglycemia  Fetal distress  Birth asphyxia  Abnormal fetal heart rate
  66. 66. 6.2a Lactation Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 66 Diabetes and Pregnancy : ES Guidelines Labor, delivery, lactation, and postpartum care Breastfeed infant whenever possible Breastfeeding reduces risk of  Childhood obesity  Impaired glucose tolerance and diabetes in both mother & child  Helps postpartum weight loss in mother
  67. 67. 6.2b Lactation Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 67 Diabetes and Pregnancy : ES Guidelines Labor, delivery, lactation, and postpartum care Metformin conc. in breast milk low Glibenclamide not detected in breast milk Continue Metformin or glibenclamide, if needed, during breastfeeding
  68. 68. 6.3 Postpartum contraception Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 68 Diabetes and Pregnancy : ES Guidelines Labor, delivery, lactation, and postpartum care No effect of Overt or GDM on choice of contraception
  69. 69. 6.4 Screening for postpartum thyroiditis in Type1 diabetic women Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 69 Diabetes and Pregnancy : ES Guidelines Labor, delivery, lactation, and postpartum care TSH at 3 and 6 months postpartum
  70. 70. Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 70 • Preconception care of diabetics include counselling, ocular and renal function assessment, thyroidfunction assessment, screening for vascular risk factors and weight reduction in obese/overweights. • Strict blood glucose and B.P. control be achieved in advance • Folic acid supplementation to be started 3 months before conceiving • Discontinue/Avoid ACEI, ARBs & anti-dyslipidemics, consider alternatives • Assess risk of worsening retinopathy and renal dysfunction Preconception care of women with diabetes
  71. 71. • Universal screening of all pregnants for overt diabetes at first visit • Test for GDM at 24-28 wks gestation by 2hr 75g OGTT • Manage hyperglycemia initially by lifestyle therapy, if it fails then pharmacological therapy used • Discontinue B.G. lowering therapy immediately after delivery in GDM • 2hr 75g OGTT at 6-12 wks postpartum to rule out diabetes • Counsel GDM patients to reduce risk of T2DMin future Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 71 Gestational Diabetes
  72. 72. • Self-monitoring blood glucose levels atleast 7 times a day (or continuous glucose monitoring used) in overt or GDM patients • Achieve glycemic targets • Preprandial B.G. <90mg/dL, • 1hr Postprandial B.G. <140mg/dL, • 2hr Postprandial B.G. <120mg/dL • HbA1c <7% in overt diabetics Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 72 Glucose monitoring and glycemic targets
  73. 73. • Medical nutrition therapy for all pregnant with overt or GDM • Achieve weight gain targets as suggestedby Institute of Medicine • Moderate calorie intake reduction in obese and limiting CHO intake • Folic acid to continue from 3 months before conceiving to until completion of breastfeeding • Intake of minerals and vitamins like other non-diabetic pregnants Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 73 Nutrition therapy and weight gain targets
  74. 74. • Long acting Insulin analog detemir better than NPH but expensive • Rapid-acting insulin analog (lispro & aspart) better than regular insulin • Insulin glargine is safe to continue during pregnancy • Multiple daily dose insulin preferred for initiation during pregnancy • Glibenclamide good alternative to insulin in GDM • Metformin to be used as last option in GDM, if Insulin/glibenclamide cannot be given. Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 74 Blood Glucose-lowering pharmacological therapy
  75. 75. • Blood glucose to be maintained between 72 to 126 mg/dL during labor & delivery • Breastfeeding should be done by all women, even if pt. on metformin or gllibenclamide • Screen type 1 diabetics for postpartum thyroiditis Summary Monday, January 20, 2014 Presentation by : Dr. Jagjit Khosla 75 Labor, delivery, lactation, and postpartum care
  76. 76. Thank you Presentation by Dr. Jagjit Khosla

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