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Diabetes in Pregnancy Ass. Pro. : S. Rouholamin

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Page 1: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Diabetes in Pregnancy

Ass. Pro. : S. Rouholamin

Page 2: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Objectives• Discuss Gestational Diabetes Mellitus (GDM)

and Treatment• Recognize common problems of GDM in

Pregnancy• Discuss long term followup of Gestational

Diabetes Mellitus (GDM)• Discuss needs of pre-existing diabetes in

pregancy

Page 3: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes Mellitus

Page 4: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes

• Reduced sensitivity to insulin in 2nd and 3rd trimesters

• “Diabetogenic State” when insulin production doesn’t meet with increased insulin resistance

Hod and Yogev Diabetes Care 30:S180-S187, 2007Crowther, et al NEJM 352:2477–2486, 2005 Langer, et al Am J Obstet Gynecol 192:989–997, 2005

Page 5: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes

• Human placental lactogen, leptin, prolactin, and cortisol result in insulin resistance

• Lack of diagnosis and treatment-increased risk of perinatal morbidities

Hod and Yogev Diabetes Care 30:S180-S187, 2007Crowther, et al NEJM 352:2477–2486, 2005 Langer, et al Am J Obstet Gynecol 192:989–997, 2005

Page 6: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes

• Occurs in 2-9% of pregnancies

• ~135,000 cases in U.S. annually

• Management can include insulin (usually preferred, better efficacy) or sulfonylureas (in very select cases)

Am J Obstet Gynecol 192:1768–1776, 2005Diabetes Care 31(S1) 2008 Diabetes Care 25:1862-1868, 2002

Page 7: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes and Type 2 Diabetes Risk

• Gestational Diabetes should be considered a pre-diabetes condition

• Women with gestational diabetes have a 7-fold future risk of type 2 diabetes vs.women with normoglycemic pregnancy

Lancet, 2009, 373(9677): 1773-9

Page 8: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Screening

• Screen all very high risk and high risk

• Very high risk: Previous GDM, strong FH, previous infant >9lbs

• High risk: Those not in very high risk or low risk category

Page 9: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Screening

• Low Risk (all of following)

• Age <25 years

• Weight normal before pregnancy• Member of an ethnic group with a

low prevalence of diabetes

Diabetes Care 31(S1) 2008

Page 10: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

• Low Risk (all of following)(cont’d)• No known diabetes in first-degree

relatives

• No history of abnormal glucose tolerance

• No history of poor obstetrical outcome

Gestational Diabetes-Screening

Diabetes Care 31(S1) 2008

Page 11: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes Screening

• 2 step approach

oral glucose tolerance test (OGTT)

• 1) 50gm 1 hour OGTT

• 2) 100gm 2 hour OGTT

Page 12: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Screening

• GDM screening at 24–28 weeks:

• Two-step approach: – 1) Initial screening: plasma or serum

glucose 1 h after a 50-g oral glucose load

– Glucose threshold – 140 mg/dl identifies 80% of GDM– 130 mg/dl identifies 90% of GDM

Diabetes Care 31(S1) 2008

Page 13: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Screening• GDM screening at 24–28 weeks:

• Two-step approach (cont’d)

• 2) 3 hour OGTT*

(100g glucose load) Fasting: >95 mg/dl (5.3 mmol/l)

1 h: >180 mg/dl (10.0 mmol/l)2 h: >155 mg/dl (8.6 mmol/l)3 h: >140 mg/dl (7.8 mmol/l)

*2 of 4 Diabetes Care 31(S1) 2008

Page 14: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes Management

• Dietician

• Diabetes Educator

• Consider referral to Diabetologist or Endocrinologist

• Moderate Physical Activity ~30 minutes daily when appropriate

Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus

Diabetes Care 30:S251-S260, 2007

Page 15: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Glucose Control in GDM

• Preprandial: <95 mg/dl, and either:

1-h postmeal: <140 mg/dl

or2-h postmeal: <120 mg/dl

and Urine ketones negative

Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care 21(2):B161–B167, 1998

Page 16: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Medications

• Patients who do not meet metabolic goals within one week or show signs of excessive fetal growth

• Insulin has been the usual first choice

• Sulfonylureas (glyburide) may be used in select patients

• Other diabetes medications not recommended in GDM

Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus Diabetes Care 30:S251-S260, 2007

Langer et al N Engl J Med 343:1134–1138, 2000

Page 17: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Diabetes MedicationsInsulins-Safety

• Aspart, Lispro, NPH, R, Lispro protamine all Category B and used in pregnancy

• All other insulins Category C

• Human Insulins-Least Immunogenic

• Breastfeed-All insulins considered safe

Data from Package Inserts

Page 18: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes-Management

• Fasting, pre-meal, 2-hour post-prandial blood glucose probably all important

• Mean blood glucose >105-115, greater perinatal mortality

• A1C in GDM probably not important Am J Obstet Gynecol 192:1768–1776, 2005

ADA Position StatementPettit, et al Diabetes Care 3:458–464, 1980 Karlsson, Kjellmer Am J Obstet Gynecol 112:213–220, 1972Langer, et al Am J Obstet Gynecol 159:1478–1483, 1988

Page 19: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Insulin Dosing-GDM• Insulin dosing:• Can use usual weight based dosing

(i.e., 0.5 u/kg)• Practical dosing can be to start

10 units NPH with evening meal• Most will titrate to BID, with eventual

addition of Regular or Rapid Acting BID

Page 20: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Alternate Insulin Dosing in GDM

• Regular or rapid acting (lispro or aspart) with meals, NPH at bedtime

• NPH + Regular or rapid acting in AM, regular or rapid acting at supper, NPH at bedtime

• Titrate insulin based on SBGM values, tested fasting, pre-meal, 2 hour post-meal, bedtime, occasional 3 AM.

Page 21: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

GDM Complications

• Macrosomia • Fractures • Shoulder dystocia• Nerve palsies (Erb’s C5-6)• Neonatal hypoglycemia• Pregnancy outcomes can be very

poor with HTN/nephropathyGabbe, Obstetrics: Normal and Problem Pregnancies 2002

Page 22: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes: Post-natal

• Fasting glucose rechecked 6-12 weeks following delivery

• Every 6 months thereafter to be screened for type 2 diabetes

• Higher risk of developing Type 2 Diabetes

Kitzmiller, et al Diabetes Care 30:S225-S235, 2007

Page 23: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Metabolic changes in pregnancy

• Lipid metabolism:– Increased lipolysis (preferential use of fat for

fuel, in order to preserve glucose and protein)

• Glucose metabolism:– Decreased insulin sensitivity – Increased insulin resistance

Page 24: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Metabolic changes in pregnancy

• Increased insulin resistance– Due to hormones secreted by the placenta that

are “diabetogenic”: • Growth hormone• Human placental lactogen• Progesterone• Corticotropin releasing hormone

– Transient maternal hyperglycemia occurs after meals because of increased insulin resistance

Page 25: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Diabetes in Pregnancy:Clinical implications

Fetal macrosomiaFetal macrosomia

Shoulder dystociaShoulder dystocia

Page 26: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Diabetes in Pregnancy: Clinical Implications

• Obstetric complications (cont’d.):– Preterm delivery– Intrauterine fetal demise– Traumatic delivery (e.g., shoulder dystocia)– Operative vaginal delivery

• vacuum-assisted• forceps-assisted

Page 27: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Diabetes in Pregnancy: Clinical Implications

• Fetal macrosomia– Disproportionate amount of adipose tissue concentrated around

shoulders and chest

• Respiratory distress syndrome• Neonatal metabolic abnormalities:

– Hypoglycemia– Hyperbilirubinemia/jaundice– Organomegaly– Polycythemia

• Perinatal mortality• Long term predisposition to childhood obesity and

metabolic syndrome

Page 28: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

GDM: Risk factors• Maternal age >25 years• Body mass index >25 kg/m2

• Race/Ethnicity– Latina– Native American– South or East Asian, Pacific Island ancestry

• Personal/Family history of DM• History of macrosomia

Page 29: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

GDM: Diagnosis

• Fasting blood glucose >126mg/dL or random blood glucose >200mg/dL

• 100 gm 3-hour glucose tolerance test (GTT) with 2 or more abnormal values

Carpenter and Coustan

National Diabetes and Data Group

Fasting 95 mg/dL 105 mg/dL

1 hour 180 mg/dL 190 mg/dL

2 hour 155 mg/dL 165 mg/dL

3 hour 140 mg/dL 145 mg/dL

Page 30: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management:Glycemic control

• Glycosylated Hemoglobin A1C (Hgb A1C) level should be less than or equal to 6%– Levels between 5 and 6% are associated with fetal

malformation rates comparable to those observed in normal pregnancies (2-3%)

– Goal of normal or near-normal glycosylated hemoglobin (Hgb A1C) level for at least 3 months prior to conception

• Hgb A1C concentration near 10% is associated with fetal anomaly rate of 20-25%

Page 31: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management:Overview

• Nutrition therapy

• Home self glucose monitoring

• Medical therapy if glycemic control not achieved with diet/exercise– Subcutaneous insulin – Oral hypoglycemic agents (Glyburide, Metformin)

• Antenatal monitoring

Page 32: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management: Glycemic Control

• Blood glucose goals during pregnancy – Fasting < 95mg/dL– 1-hr postprandial < 130-140mg/dL– 2-hr postprandial am < 120mg/dL– 2 am < 120mg/dL

• Nocturnal glucose level should not go below 60 mg/dL

• Abnormal postprandial glucose measurements are more predictive of adverse outcomes than preprandial measurements

Page 33: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management:Nutrition

• Caloric requirements:– Normal body weight - 30-35 kcal/kg/day– Distributed 10-20% at breakfast, 20-30% at lunch, 30-

40% at dinner, up to 30% for snacks (to avoid hypoglycemia)

• Caloric composition:– 40-50% from complex, high-fiber carbohydrates– 20% from protein– 30-40% from primarily unsaturated fats

Page 34: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management:Subcutaneous Insulin Therapy

• Insulin requirements increase rapidly, especially from 28 to 32 weeks of gestation– 1st trimester: 0.7-0.8 U/kg/d– 2nd trimester: 0.8-1 U/kg/d– 3rd trimester: 0.9-1.2 U/kg/d

Page 35: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management:Oral Hypoglycemic Agents

• Glitazones (Avandia, Actos)– Sensitize muscle and fat cells to accept insulin more readily– Decrease insulin resistance

• Sulfonylureas– Augment insulin release– 1st generation

• Concentrated in the neonate hypoglycemia

– 2nd generation (Glyburide)• Low transplacental transfer

• Biguanide (Metformin, aka Glucophage)– Increases insulin sensitivity– Crosses placenta

Page 36: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Summary:Pregestational Diabetes

• Referral to perinatologist and/or endocrinologist• Multidisciplinary approach

– Regular visits with nutritionist– Hgb A1C every trimester– Fetal Echocardiogram– Level II ultrasound– Opthamologist– Baseline kidney and liver function tests

Page 37: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Summary:Pregestational Diabetes

• Optimize glycemic control – frequent insulin dose adjustments– Type 1: often have insulin pump– Type 2: subcutaneous insulin

• Fetal monitoring starting at 28-32 weeks, depending on glycemic control

• Ultrasound to assess growth at 36 weeks• Delivery at 38-39 weeks

Page 38: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Summary:GDM

• Begin with diet / walk after each meal• If borderline/mild elevations, consider

metformin (start at 500 mg daily)– Counsel about increased PTD rates– Unlikely pre-existing DM

• If elevations start out moderate to severe or metformin fails, proceed to subcutaneous insulin therapy – NPH (long acting) – Humalog/Novalog (short acting)

Page 39: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Intrapartum

• Attention to labor pattern, as cephalopelvic disproportion may indicate fetal macrosomia

• Careful consideration before performing operative vaginal delivery

• Hourly blood glucose monitoring during active labor, with insulin drip if necessary

• Notify pediatrics if patient has poorly controlled blood sugars antepartum or intrapartum

Page 40: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Postpartum

• For patients with pregestational diabetes, halve dose of insulin and continue to check blood glucose in immediate postpartum period

• For GDM patients who required insulin therapy (GDMA2), check fasting and postprandial blood sugars and treat with insulin as necessary

• For GDM patients who were diet controlled (GDMA1), no further monitoring nor therapy is necessary immediately postpartum

Page 41: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Management Postpartum

• For all GDM patients, perform 75 gram 2-hour OGTT at 6 week postpartum visit to rule out pregestational diabetes

• Most common recommendation is for primary care physician to repeat 2-hour OGTT every three years

Page 42: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• 28 y/o caucasian female

• 2nd pregnancy

• 1st pregnancy at age 22, term male infant, 10 lbs 2oz, normal delivery

• “Thinks had high blood sugar”

• Very high risk (>9 lb infant, possible GDM)

Page 43: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study• No other significant medical history No tobacco• Physical Exam: VS normal

5’ 2”

210 lbs

BMI 38.4

Remainder consistent with 12 weeks gestation

Page 44: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• 26 weeks, no problems, maybe slightly large for dates

• 12 lb weight gain

• Went directly to 3 hour GTT (100g)

Page 45: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• FBG: 94 ( > 95)

• 1 hour: 192 (>180)

• 2 hour: 160 (>155)

• 3 hour: 149 (>140)

• 3 of 4 values abnormal= GDM

Page 46: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• Referred to Diabetes Educator and Dietician

• SMBG: FBG, pre-meal, 2 hour post-prandial, HS, 3 am prn

• Meal Plan

• No contraindications to exercise, encouraged to walk 15 min/daily

Page 47: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Glucose Control in GDM

• Preprandial: <95 mg/dl, and either:

1-h postmeal: <140 mg/dl

or2-h postmeal: <120 mg/dl

and Urine ketones negative

Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care 21(2):B161–B167, 1998

Page 48: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• Returns one week later

• Has been following meal plan “90% of time”

• Has walked 15 minutes 2 times

• Has 4 FBG > 100

• 6 other values above target

Page 49: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• Referred to Diabetes Educator for insulin start

• NPH 10 units, 3 units Insulin aspart BID

• Phone followup q 3 days

• Continues appropriate clinic appointments

Page 50: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study

• 1-2 SMBG values out of target 1st week

• 3 weeks later, FBG, 2 hour post lunch and 2 hour post supper elevated about ~50% of time

• NPH increased in PM (or could move to HS), insulin aspart added at lunch (2 or 3 units) and increased at supper

Page 51: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Case Study• Normal vaginal delivery at 38 weeks

• 8lb 10oz healthy female infant

• Patients FBS day after delivery 90

• Enrolled in Diabetes Prevention Program

• Converted to type 2 diabetes 2 years later

• Had lap-band 4 years later

Page 52: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Gestational Diabetes Mellitus

Risk of Type 2 Diabetes• Meta analysis: 20 studies 675,455 women

• 7-fold increase in risk of type 2 diabetes following gestational diabetes vs. normoglycemic pregnancy

• Post pregnancy surveillance important

Bellamy, L. et al. Lancet, 2009, 373(9677): 1773-9

Page 53: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Type 2 Diabetes Prevention

• Lifestyle- over 50% reduction of future type 2 diabetes

• Bariatric (Lap-Band-future preg?)- strong consideration in BMI >40 or >35 with co-morbid conditions

• Future treatments/prevention- no current medication role, possible in future

Page 54: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Pre-Existing Diabetes and Pregnancy

• Pre-conception counseling (Diabetes Educator and Dietician included)

• Recommended pre-conception A1C as close to normal (6.0%) without signficant hypoglycemia

• More Type 2 patients in child bearing years (diagnosed at younger age)

Kitzmiller, et al Diabetes Care 31:1060-1079, 2008

Page 55: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Preconception Counseling• Whenever possible, organize multidiscipline patient-

centered team care for women with preexisting diabetes in preparation for pregnancy.

• Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic nephropathy, neuropathy, and retinopathy, as well as cardiovascular disease (CVD), hypertension, dyslipidemia, depression, and thyroid disease. (Celiac?)

Lawrence, et al Diabetes Care 31:899-904, 2008 Kitzmiller, et al Diabetes Care 31:1060-1079, 2008

Page 56: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Preconception Counseling

• Medication use should be evaluated before conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, angiotensin II receptor blockers (ARBs), and most noninsulin therapies. Aspirin should also be stopped.

• Continue multidiscipline patient-centered team care throughout pregnancy and postpartum.

Lawrence, et al Diabetes Care 31:899-904, 2008 Kitzmiller, et al Diabetes Care 31:1060-1079, 2008

Page 57: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

• Educate pregnant diabetic women about the strong benefits of

• Long-term CVD risk factor reduction

• Breastfeeding

• Effective family planning with good glycemic control before the next pregnancy

Preconception Counseling

Lawrence, et al Diabetes Care 31:899-904, 2008 Kitzmiller, et al Diabetes Care 31:1060-1079, 2008

Page 58: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Pre-existing Type 2 Diabetes Pregnancy

• Oral agents are not used in pre-existing type 2 diabetes in pregnancy

• Convert to insulin, similar to GDM insulin dosing

Page 59: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Pre-existing Type 2 Diabetes Pregnancy

• If already on insulin, continue• Insulin needs increase as pregnancy

progresses• Controversy: Switch glargine or detemir

to NPH?• Continue lispro, aspart, or R if using

Page 60: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Pre-existing Type 1 Diabetes and Pregnancy

• All continue on insulin

• Controversy: glargine or detemir converted to NPH?

• Continue Regular/Rapid Acting

• If on pump, continue

Page 61: Diabetes in Pregnancy Ass. Pro. : S. Rouholamin. Objectives Discuss Gestational Diabetes Mellitus (GDM) and Treatment Recognize common problems of GDM

Summary• Start insulin if not meeting goals

after one week in GDM

• Pre-existing type 2, convert to insulin

• Pre-existing type 1, continue insulin

• Meet targets, avoid hypoglycemia