Management of diabetes during pregnancy


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Management of diabetes during pregnancy

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Management of diabetes during pregnancy

  1. 1. Management of Diabetes during pregnancy Prof . Aboubakr Elnashar Benha university, Egypt Aboubakr Elnashar
  2. 2. Diabetes during pregnancy: 1. Gestational diabetes mellitus (GDM). 2. Pregestational diabetes: type 1 diabetes mellitus (T1DM) type 2 diabetes mellitus (T2DM). Aboubakr Elnashar
  3. 3. Preconception care 1. Educate 2. Encorage 3. Review 4. Assess Antenatal care •Screening & Diagnosis •M: G control Assess •F: Wt Wellbeing Cong mal Delivery Intrapartum care Monitor Blood glucose Postpartum care Aboubakr Elnashar
  4. 4. A. Pre-Conception Care I. Health education: 1. Risks of DM can be reduced but not eliminated. 2. Avoidance of unplanned pregnancy: HbA1C  10%: Don't allow HbA1C  6.1%: allow 3. Hypoglycaemia awareness. 4. Pregnancy-related nausea/vomiting & their effect on glycaemic control. 5. Frequent appointments during ANC. Aboubakr Elnashar
  5. 5. Risks  Miscarriage Cong malformation Stillbirth Macrosomia (>4 kg or birth wt centile >90) Sh dystocia: B trauma Res distress Neonatal hypoglycemia and poor feeding Hypoglycemia D Ketoacidosis  Induction of labour or CS PET Worsening of Retinal and renal dis Aboubakr Elnashar
  6. 6. II. Encourage patient to: 1. Dietary restrictions 2. Exercises 3. Reduce wt if BMI  27 4. Self-monitoring by glucometer monthly HbA1C ketone strips. Aboubakr Elnashar
  7. 7. III. Review, replace& offer mediations: 1. Discontinue: a. Hypoglycaemic agents except: Metformin Glibenclamide (Daonil). b. Anti-hypertensive agents e.g. angiotensin-converting enzyme inhibitors (ACE) (Captopril)* angiotensin-II receptor antagonists )angiotensin ii receptor blocker) (ARB) (Candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan ( Diovan c. Anti- cholesterol e.g Statin (Levacor, Zocor, Pravachol, Lipitor, Crestor( 2. Give: Folic Acid (5 mg OD) *Captopril (Category D): oligohydramnios, pulmonary hypoplasia, IUGR Aboubakr Elnashar
  8. 8. Safety of medications before and during pregnancy Metformin: safe Rapid-acting insulin analogues(aspart, lispro): safe long-acting insulin analogues (ultrlent, glargine) : Evidence is limited. Isophane (NPH) insulin: first-choice long-acting insulin during pregnancy. Aboubakr Elnashar
  9. 9. IV. Assess: 1. Retina 2. Renal function: refer to Nephrologist if (i) Microalbuminuria  2 gm /d (ii) Creatinine  120 M mol/L=1.25 mg 1mg=88.4 M mol/L 3. Thyroid status: D.M. Type I Aboubakr Elnashar
  10. 10. B. Antenatal care I. Screening •Who? All pregnant women. •When: At booking At 24-28 w •How? FBS: 90 > mg/dl Aboubakr Elnashar
  11. 11. •FBG: High sensitivity (81%) Good specificity (76%) with a cut off of 86 mg/dl (4.8 mmol/l) (Perucchini et al, 1999) Easier Cheaper More acceptable Can be applied to all pregnant women More than once during pregnancy. Suitable for screening Aboubakr Elnashar
  12. 12. II. Diagnosis The 75 g WHO OGTT Fasting venous & capillary blood glucose are similar. After a meal or a glucose challenge, capillary are higher than venous levels. It is not necessary for both values to be abnormal No need for GTT FBS 125 mg/dl or Random venous plasma glucose 200 mg/dl if confirmed on a subsequent day Plasma glucose Mg/dl Fasting 100 2-h 145 Aboubakr Elnashar
  13. 13. Recommendations of International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2010 1-step 75-g OGTT screening at-risk individuals during 1st ANV. Aboubakr Elnashar
  14. 14. 1. Diabetic Centre 2. ANC clinic: /1-2 w  Objective: Medical TT: M: Glycemic control Retinal and renal assessment Obstetric TT: F: wellbeing Wt Cong malformation Delivery Aboubakr Elnashar
  15. 15. Medical treatment Goals achieving normoglycemia preventing postprandial glucose excursions optimizing compliance Aboubakr Elnashar
  16. 16. I. Glycemic control Objective: These targets are the same for type 1, type 2 and gestational diabetes). {1. Outcomes (birth-weight and neonatal hypoglycaemia) correlate better with postprandial than with preprandial glucose levels. 2. Postprandial targets: better improvements in maternal HbA1Clevels}. Capillary blood glucose Mg/dl(mmol/L) Fasting <105(5.9) 1 Hour <140 (7.8) 2 Hours <125 (7.0) Aboubakr Elnashar
  17. 17. Fasting and premeal blood glucose: 90 mg/dL (5.0 mmol/L) and  Postprandial glucose: 120 mg/dL (6.7 mmol/L). Aboubakr Elnashar
  18. 18. Monitoring 1. SMBG: self-monitored blood glucose Fasting levels and 1 h after every meal. 1H is recommended (NICE, 2008) Women taking insulin should also test before bedtime Experts recommend that finger-stick blood glucose measurement be performed 6–8 times/d, specifically, first thing in the morning (fasting), premeal, 1 h after the start of each meal (postprandial glucose), and at bedtime. In pregnancy, postprandial serum glucose peaks at approximately 1 h after a meal. Aboubakr Elnashar
  19. 19. 2. Hb A1c  weekly. extremely useful, in conjunction with patient diaries, to assist patients to achieve excellent glycemic control and prevent the complications of diabetes in pregnancy. Do not use HbA1c routinely in 2nd and 3rd trimesters {1. falls in response to physiological changes in pregnancy 2. Time scale is not appropriate in pregnancy Reflects BG levels in the preceding 4-12 w and not subtle changes in BG}. Aboubakr Elnashar
  20. 20. 3. Women with type 1 diabetes should be offered ketone testing strips for use if they become hyperglycaemic or feel unwell 4. More evidence is being published that supports a minimal weight gain for pregnant women who are obese, which is a large portion of the GDM and T2DM population. 5. Medical review on a regular basis (1-2 weekly) Aboubakr Elnashar
  21. 21. How? 1. Diet •The first line therapy for 1-2 w • > 30 w or FBS >105 mg/dl: Insulin started simultaneously with the diet •3 meals & 4 snacks with last snack at bed time •Caloric needs acc to BMI (The American Diabetes Association, 2003) < 30 kg/m2: 30 Kcal/kg >30 kg/m2: 25 Kcal/kg Aboubakr Elnashar
  22. 22. Carbohydrates 40% Protein 30%, Fat 30% (Garner, 1995). Concentrated sweets & added sugars: eliminated. Complex CHO with high fiber contents: preferable {slower glucose rise after ingestion} The classic food pyramid model: Recommends that carbohydrates such as bread, cereal, rice, and pasta comprise the majority of the meal, is now antiquated. It has been replaced with a new meal planning target that emphasizes more vegetables and whole grains Aboubakr Elnashar
  23. 23. 2. Exercise •Reduce insulin requirement by as much as 50%. •Effect appears after 4 w. •1h after mealtimes. •For 20-30 min •Upper extremity or lower extremity ms excerises while recumbent do not increase uterine contractions (Durak et al, 1990 ;de Veciana and Mason, 2000). Gentle aerobic exercise Walking (Homko et al, 1998). Aboubakr Elnashar
  24. 24. 3. Insulin •Types NICE: glulisine, glargine and detemir. are avoided during pregnancy. Lispro and Aspart benefits: 1. fewer hypoglycaemic episodes 2. better control Aboubakr Elnashar
  25. 25. Aboubakr Elnashar
  26. 26. Regular insulin: inappropriate for use during pregnancy. {cannot control the postprandial spike in blood glucose adequately unless it is administered 60–90 min before the onset of the meal} Aboubakr Elnashar
  27. 27. Calculation of insulin dose: 1. Initial insulin dose: TDD 2. Adjustments acc to a. meal and blood glucose diaries b. results of point-of-care Hb A1c measurements. Aboubakr Elnashar
  28. 28. 4. Oral hypoglycaemic agents: Sulphonylureas, chlorpropamide, tolbutamide: Not recommended for use in pregnancy. 1. crossed the placenta & stimulated fetal insulin secretion: fetal macrosomia & hyperinsulinaemic hypoglycaemia and seizures in neonates. 2. Major congenital malformations in animals (Greene, 2000) Aboubakr Elnashar
  29. 29. Metformin and Glibenclamide= glyburide(Daonil) Safe (NICE, 2008). Metformin PCOS: Decrease 1st T abortion & G DM Cross placenta, but no increase in cong malformation an alternative to insulin therapy in pregnant women with type 2 diabetes Glibenclamide Cross placenta in small amounts New oral hypoglycemic: Nateglinide (Starlix) Very few data Aboubakr Elnashar
  30. 30. Hypoglycaemia blood glucose of <3.5 mmol/L(63 mg/dl) Common with: 1. Tighter glycaemic control 2. Type 1 diabetes: much more likely to suffer recurrent hypoglycaemia (61%) than those with type 2 (21%). Educate family about the symptoms and tt of hypogly-caemia. Aboubakr Elnashar
  31. 31. Treatment: 1. Conscious: a. consuming 10-15 g of glucose (4 teaspoons of sugar, 1/2 a can of juice or 3 glucose tablets) b. slower releasing carbohydrate (bread or a sand-wich). 2. unconscious: Glucagon (0.5-1 mg) IM: rapid onset and lasts 90 minutes. Aboubakr Elnashar
  32. 32. 3. In hospital: 150 mL of 10% dextrose IV Once a patient is conscious, they should be given oral therapy as above. 4. If after 10 m the blood glucose remains less than 5 mmol/L(90 mg/dl), the treatment should be repeated. 5. Insulin doses with the next meal should not be withheld but may require modification. Aboubakr Elnashar
  33. 33. Diabetic ketoacidosis (DKA)  occurs when there is insufficient insulin to metabolize blood glucose. 1. failure to appreciate the increasing insulin requirements in pregnancy 2. missed insulin doses 3. concurrent illness such as infection, steroid therapy and stress. plasma glucose: ≥12 mmol/L(216 mg/dl), arterial pH: ≤7.3 ketonuria or ketonaemia poor maternal and fetal outcome CTG abnormalities are typical in 3rd T and resolve with treatment of the hyperglycaemia. Aboubakr Elnashar
  34. 34. Treatment should involve the diabetic teams, treatment of the precipitating cause intravenous insulin via a sliding scale. continuous CTG may be necessary, but should be given careful consid-eration. CTG abnormalities are to be expected in a woman with DKA, and it would be unsafe to perform an emergency caesarean until the woman is stable from metabolic and haemodynamic perspectives. Severe hyperglycaemia requiring intensive treatment is defined as persistent pre-meal blood glucose values of greater than 12 mmol/L on two consecutive occasions, or a random level of more than 15 mmol/L(270 mg/dl). Involvement ofAboubakr Elnashar
  35. 35. II. Retinal and renal assessment 1.At booking if not done in the pre-ceeding 12 m 2.At 28 w if booking is normal 3.The presence of hypertension also worsens progression of retinopathy, thus it has been suggested that, in women with these complications, blood pressure should be kept at 120-130/70-80 mmHg. Betablockers should be avoided as antihypertensives due to their possible adverse effects of glucose metabolism. Aboubakr Elnashar
  36. 36. Obstetric I. Screening for F malformation 1.Screening for Down Syndrome 2.Anomaly scan including detailed four-chambered assessment of the fetal heart. Aboubakr Elnashar
  37. 37. II. Fetal wellbeing: Indications: Insulin is required Poorly controlled diabetics Hypertension History of IUFD Tests: no reliable test. A combination of tests must be employed. Kick chart, NST, AFI, Doppler Aboubakr Elnashar
  38. 38. III. Screening for macrosomia •Clinical & US: inaccurate (±10-20%). •US: The best single measurement: Serial measurements of AC Aboubakr Elnashar
  39. 39. IV. Delivery • Time:  Induction at 38w in insulin requiring GDM: lower rate of: macrosomia (10% Vs 23%), CS (25% Vs 30%) and Shoulder dystocia (0% Vs 3%) (Kjos et al, 1993).  Delivery before 38W: Poor glucose control Poor compliance Co morbidities e.g. hypertension Corticosteroids: <36 w  Induction of labour at 40 w in Diet controlled GDM Aboubakr Elnashar
  40. 40. Care for Preterm Labour 1. Steroids 2. Re-adjustment of hypoglycaemic agents 3. Tocolysis: can be given (not betamimmetic) Aboubakr Elnashar
  41. 41. •Mode: Elective CS: > 4000 & 4250g (Inzucchi, 1999). Aboubakr Elnashar
  42. 42. C. Intra-partum care •The target glucose level: 75-125 mg/d •Blood glucose/h -> 125 mg/dl: 2-4 u IV regular insulin and assess the coming hour. -< 75mg/dl: 10% dextrose infusion and assess after 15 min. Women with GDM controlled with insulin should be instructed to stop insulin use once labor starts, and then reevaluate their glycemic control with frequent SMBG testing in the postpartum period. Aboubakr Elnashar
  43. 43. •IV dextrose and insulin: -Indication: Type 1 diabetes BG not maintained between 75& 125 mg/d. -Strength of solution: (1 u/ ml) (50 u insulin in 50 ml 5% dextrose) -Rate: if blood glucose 0-70 mg/dl= 0.5 u/h 71-140 mg/dl= 1 u/h 141-215 mg/dl= 2 u/h Aboubakr Elnashar
  44. 44. D. Postpartum care I. Breast feeding: Encouraged {Reduces the insulin requirement by 25% Breast- feed babies have a much lower risk of developing DM} Glyburide and metformin are secreted into breast milk and should not be used during lactation in women with T2DM. Breastfeeding can cause life-threatening hypoglycemia for lactating women on insulin, especially those with T1DM. Women who are both breastfeeding and on a form of basal insulin must either decrease their basal rate during lactation or eat a carbohydrate-containingAboubakr Elnashar
  45. 45. II. Glycemic control Insulin-treated pre-existing diabetes: •Reduce insulin (30-50%) •Self-monitor blood glucose to establish correct dose •{Risk of hypoglycaemia, especially while breastfeeding} To have food available before or during breastfeeding. Once women with type 1 diabetes are eating normally, s.c. insulin should be recommenced at either the pre- pregnancy dose or at a 25% lower dose if the women intends to breast-feed, Aboubakr Elnashar
  46. 46. Type 2 diabetes: •Resume or continue taking metformin and glibenclamide •Not to take any other oral hypoglycaemic agents while breastfeeding. Aboubakr Elnashar
  47. 47. Gestational diabetes: •Stop hypoglycaemic medication •Advise: weight control, diet and exercise •FBS at 6-w postnatal, then annually. Aboubakr Elnashar
  48. 48. III. Contraception •Copper IUCD, Mirena: not associated with PID (Kimmerle et al, 1993 ; Kjos et al,1994) •DMPA: Deterioration of CHO tolerance increase risk of diabetes •NORPLANT: No deterioration (Fahmy et al, 1991 ; Konje et al,1992; Singh et al,1992) Aboubakr Elnashar
  49. 49. GDM: not a contraindication for COC Diabetes with retinopathy/nephropathy/neuropathy or with other vascular disease or disease duration >20 yr: contraindicated or relatively contraindicated depending upon severity Low-dose COCs •didn't influence development of Diabetes (Kjos et al,1998) •Non smoker, <35 years, healthy: no hypertension, nephropathy, retinopathy, or other vascular disease. Progestin-only Pill with breast feeding: 3 fold risk of diabetes (Kjos et al,1998) Should be prescribed with caution, if at all. Aboubakr Elnashar
  50. 50. Aboubakr Elnashar
  51. 51. Summary Diabetes during pregnancy is the most common complication of pregnancy. Pregestational planning is imperative for all women with preexisting diabetes. Pregnant women who have no known diabetes but who have any risk factors for GDM should be screened with the 75-g OGTT at the initial prenatal visit, and all women should be screened by 28 weeks gestation. Aboubakr Elnashar
  52. 52. Clinicians should be prepared for an increase in the number of women identified with diabetes during pregnancy and develop a thorough and efficient model for outpatient management. Patient education is the foundation for successful management of diabetes during pregnancy. The goal of therapy will continue to be normoglycemia before, during, and after all pregnancies complicated by diabetes. The world of diabetes is rapidly evolving, with many new tools on the horizon for diagnosis, monitoring, and treatment. These tools will make the management of diabetes in pregnancy easier and possibly safer. Aboubakr Elnashar
  53. 53. Some promising developments for diabetes in pregnancy include weekly point-of-care Hb A1c testing, the routine use of CGMs in T1DM, and the implementation of universal screening guidelines. With these potentially cost-effective advances in diabetes during pregnancy comes the hope of preventing macrosomia and decreasing the prevalence of childhood obesity and T2DM in the offspring of diabetic mothers. Aboubakr Elnashar
  54. 54. Benha University Hospital Aboubakr Elnashar