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Diabetes in Pregnancy Management. Diabetes in Pregnancy: Management Goals Provide preconception care for women with preexisting T1DM or T2DM or a history.

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Presentation on theme: "Diabetes in Pregnancy Management. Diabetes in Pregnancy: Management Goals Provide preconception care for women with preexisting T1DM or T2DM or a history."— Presentation transcript:

1 Diabetes in Pregnancy Management

2 Diabetes in Pregnancy: Management Goals Provide preconception care for women with preexisting T1DM or T2DM or a history of GDM –Educate patients to maintain adequate nutrition and glucose control before conception, during pregnancy, and postpartum 1 Close to normal glycemic control prior to and throughout pregnancy offers substantial benefit for both mother and child 2 –Maintenance of normoglycemia prior to and through the first trimester results in a complication risk close to that of women without diabetes 3 For all glucose management protocols, AACE recommendations stress patient safety as the first priority 1,4 1. AACE. Endocr Pract. 2011;17(2): Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40: Castorino K, Jovanovic L. Clin Chem. 2011;57(2): ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.

3 Glycemic Targets During Pregnancy: AACE & ADA Guidelines 1,2 Glucose Increment Patients with GDM Patients with Preexisting T1DM or T2DM Preprandial, premeal ≤95 mg/dL (5.3 mmol/L)Premeal, bedtime, and overnight glucose: mg/dL ( mmol/L) Postprandial, post-meal 1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or 2-hour post-meal: ≤120 mg/dL (6.7 mmol/L) Peak postprandial glucose mg/dL ( mmol/L) A1CA1C ≤6.0% 1.AACE. Endocr Pract. 2011;17(2): ADA. Diabetes Care. 2013;36(suppl 1):S11-66.

4 Glycemic Targets During Pregnancy: Expert Recommendations Glucose Increment Patients With Gestational Diabetes Mellitus (GDM) 1 Patients With Preexisting T1DM or T2DM 1,2 Preprandial, premeal ≤90 mg/dL (5.0 mmol/L) 1,2 Postprandial, post-meal 1-hour post-meal: ≤120 mg/dL (6.7 mmol/L) 1,2 A1CA1C <5.0% 3 A1C <6.0% 4 1.LeRoith D, et. al. Endocrinol Metab Clin N Am. 2011;40(1): xii Castorino K et al. Curr Diab Rep, 2012;12: L. Jovanovic; personal communication. 4.AACE. Endocr Pract. 2011;17(2):1-53. Some experts recommend more stringent goals (in particular, for patients on insulin therapy) to prevent maternal and fetal complications 1,2

5 Why Is Glucose Control Essential During Pregnancy? For both mothers with diabetes and their infants, risk for adverse health outcomes correlates with maternal glucose levels during the first trimester of pregnancy 1 A large, randomized controlled trial of intensive diabetes management versus standard care in patients with gestational diabetes mellitus (GDM) showed: –Rate of serious perinatal complications was reduced from 4% to 1% with treatment of GDM 2 –Improvements in maternal health-related quality of life 2 1.ADA. Diabetes Care. 2013;36(suppl 1):S11-S Crowther CA, et al. N Engl J Med. 2005;352(24): Epub 2005 Jun 12.

6 Diabetes in Pregnancy: Avoiding Complications Advances in diagnosis and treatment have dramatically reduced morbidity and mortality in both mothers and infants 1,2 Preconception care Renal impairment, cardiac disease, neuropathy 3 Careful evaluations at each visit 1 st trimester through 1 st year postpartum Examine active lesions more frequently1 Regular ophthalmologic exams Target: systolic BP mmHg; diastolic BP mmHg Lifestyle changes, behavior therapy, and pregnancy-safe medications (ACE inhibitors and ARBs contraindicated in pregnancy) 3 Hypertension management 1. AACE. Endocr Pract. 2011;17(2): Jovanovic L, et al. Diabetes Care. 2011;34(1): Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.

7 Early referral to a specialist is essential 1 Collaborative effort among obstetrician/ midwife, endocrinologist, ophthalmologist, registered dietitian, and nurse educator –All team members should be engaged in patient education/care prior to and throughout pregnancy 2 Individualized treatment plans, involving a combination of: –Glucose monitoring –Medical nutrition therapy (MNT) –Pharmacotherapy –Exercise –Weight management strategies –Psychological support Diabetes in Pregnancy: Management Approaches 1.Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:

8 Glucose Monitoring in GDM: Self-Monitoring of Blood Glucose Self-monitoring of blood glucose (SMBG) is the cornerstone of diabetes management in gestational diabetes mellitus (GDM) 1 ADA guidelines for pregnant patients requiring insulin: –SMBG ≥3 times daily –More frequent SMBG may be required, including: 2 Morning fasting Premeal (breakfast, lunch, and dinner) 1-hour postprandial (breakfast, lunch, and dinner) Before bed 3 Disadvantages include: –Potential for human error or inconsistencies in performing SMBG and/or self-reporting –Partial glucose profile from intermittent readings; hyper- or hypoglycemic episodes may go undetected 4 1. Jovanovic L, et al. Diabetes Care. 2011;34(1): ADA. Diabetes Care. 2013;36(suppl 1):S11-S Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Chitayat, L, et al. Diabetes Technol Ther. 2009;11:S

9 Glucose Monitoring in GDM: A1C Provides valuable supplementary information for glycemic control To safely achieve target glucose levels, combine A1C with frequent s elf-monitoring of blood glucose ( SMBG) 1,2 Recent research suggests weekly A1Cs during pregnancy: 1 –SMBG alone can miss certain high glucose values –SMBG + A1C = more complete data for glucose control –Clinicians can further optimize treatment decisions with weekly A1C Other important glucose measurements: –Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study suggests A1C is less useful than OGTT as a predictor of adverse pregnancy outcomes in women with diabetes 3 1. Jovanovic L, et al. Diabetes Care. 2011;34(1): Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Lowe LP, et al. Diabetes Care. 2012;35:

10 Glucose Monitoring in GDM: Continuous Glucose Monitoring Measures glucose levels over 24-hour period 1 –Continuous glucose monitoring (CGM) measures glucose concentration of interstitial fluid using subcutaneous sensor tip implanted in abdominal wall 1,3 Identifies glycemic excursions that may go undetected with SMBG 1 –May be recommended when patient unable to achieve target glucose levels with SMBG alone 2 Educational tool to improve treatment adherence 4 Benefits: –Improved glycemic control during third trimester –Reduced infant birth weight –Decreased risk of infant macrosomia 1,2,3 1. Hod M. Jovanovic L. Int J Clin Pract, 2010;64(166): Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S AACE. Endocr Pract. 2010;16(5):1-16.

11 CGM Devices: Professional vs Personal Professional CGM devices –Owned by a health care professional 1 –Typically implanted for 3-5 days 1 –Data downloaded and analyzed by a health care professional 1 Personal CGM devices –Owned by the patient –May be implanted for longer periods (eg, several weeks) 1 –Provide continuous feedback on glucose values, which may be read/interpreted by the patient in real time 2 1.AACE. Endocr Pract. 2010;16(5): Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S

12 Refer patients for nutritional counseling with registered dietitian familiar with pregnancy 1,2 MNT is based on standard nutritional recommendations during pregnancy, with customization based on: –Height –Weight –Nutritional assessment –Level of glycemic control 3,4,5 Goals: –Provide a nutritionally adequate diet for pregnancy –Achieve normoglycemia Medical Nutrition Therapy (MNT) 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Kitzmiller JL, et al. Diabetes Care. 2008;31(5): Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): ADA. Diabetes Care. 2004;27(suppl 1):S National Academy of Sciences, Institute of Medicine, Food and Nutrition Board, Committee on Nutritional Status in Pregnancy and Lactation, Nutrition During Pregnancy: Nutrient-Supplements.aspx, Accessed: April 26, 2012.http://www.iom.edu/Reports/1990/Nutrition-During-Pregnancy-Part-I-Weight-Gain-Part-II- Nutrient-Supplements.aspx Target Glucose Levels for Normoglycemia 3 Preprandial glucose ≤95 mg/dL (5.3 mmol/L) 1-hour postprandial glucose ≤140 mg/dL (7.8 mmol/L) or 2-hour postprandial glucose ≤120 mg/dL (6.7 mmol/L)

13 Management of GDM Medical nutrition therapy (MNT) and lifestyle changes can effectively manage 80% to 90% of mild GDM cases 1,2 MNT nutritional goals and recommendations: –Choose healthy low-carbohydrate, high-fiber sources of nutrition, with fresh vegetables as the preferred carbohydrate sources 4 –Count carbohydrates and adjust intake based on fasting, premeal, and postprandial SMBG measurements 4,6 –Avoid sugars, simple carbohydrates, highly processed foods, dairy, juices, and most fruits 4,5 –Eat frequent small meals to reduce risk of postprandial hyperglycemia and preprandial starvation ketosis 5 As pregnancy progresses, glucose intolerance typically worsens; patients may ultimately require insulin therapy 1,3 1. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S ADA. Diabetes Care. 2013;36(suppl 1):S ADA. Diabetes Care. 2004;27(suppl 1):S Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:

14 Diabetes in Pregnancy: Pharmacologic Therapy When MNT alone fails, pharmacologic therapy is indicated –AACE guidelines recommend insulin as the optimal approach 1 –Insulin therapy is required for the treatment of T1DM during pregnancy 2 Metformin and the sulfonylurea glyburide are the 2 most commonly prescribed oral antihyperglycemic agents during pregnancy 1,2 Due to efficacy and safety concerns, the ADA does not recommend oral antihyperglycemic agents for gestational diabetes mellitus (GDM) or preexisting T2DM 3,4 1. AACE. Endocr Pract. 2011;17(2): Castorino K, Jovanovic L. Clin Chem. 2011;57(2): ADA. Diabetes Care. 2004;27(suppl 1):S Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): Micronase PI. Pifizer. Division of Pifizer, NY, NY, Diabeta PI. Sanofi-Aventis U.S. Bridgewater, NJ, MedicationCrosses Placenta ClassificationNotes MetforminYesCategory B 1 Metformin and glyburide may be insufficient to maintain normoglycemia at all times, particularly during postprandial periods 2 GlyburideMinimal transfer Some formulations category B, others category C 1,5,6

15 Insulin Use During Pregnancy Patient Education Insulin administration, dietary modifications in response to self-monitoring of blood glucose (SMBG), hypoglycemia awareness and management 1 Basal Insulin Intermediate- or long-acting insulin administered by injection, or Rapid-acting insulin administered by insulin pump 2,3 Postprandial Hyperglycemia Recommended approach: rapid-acting insulin analogues 2 Alternative approach: regular insulin to control postprandial glucose spikes; must be administered minutes prior to meals (considered less effective than rapid-acting insulin and may increase hypoglycemia risk) 3 Insulin Options Insulin NPH: safe intermediate alternative (category B) 2 Insulin detemir: safe long-acting alternative (category B) 2,3 Lispro and aspart: safe rapid-acting insulin analogues (category B) 2,3 Insulin glargine: frequently prescribed in pregnancy; however, safety in pregnancy has not been definitively established (category C) 2,3 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): AACE. Endocr Pract. 2011;17(2): Castorino K, Jovanovic L. Clin Chem. 2011;57(2): ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

16 Glucose Levels for Insulin Initiation in GDM 1 Fasting plasma glucose ≤105 mg/dL (5.8 mmol/L) 1-hour postprandial plasma glucose ≤155 mg/dL (8.6 mmol/L) 2-hour postprandial plasma glucose ≤130 mg/dL (7.2 mmol/L) Gestational Diabetes Mellitus (GDM): Initiation of Insulin 1. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

17 Diabetes in Pregnancy: Insulin Insulin Options Shown to Be Safe During Pregnancy 1 NameTypeOnset Peak Effect Duration Recommended Dosing Interval Aspart Rapid-acting (bolus) 15 min60 min2 hrs Start of each meal Lispro Rapid-acting (bolus) 15 min60 min2 hrs Start of each meal Regular insulin Intermediate- acting 60 min2-4 hrs6 hrs minutes before meal NPH Intermediate- acting (basal) 2 hrs4-6 hrs8 hrsEvery 8 hours Detemir Long-acting (basal) 2 hrsn/a12 hrsEvery 12 hours 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Kitzmiller JL, et al. Diabetes Care. 2008;31(5): Following a positive pregnancy test, patients with preexisting diabetes being treated with insulin or oral antihyperglycemic medications should be transitioned to one of the above options 2

18 Diabetes in Pregnancy: Insulin Dosing Insulin Dosing Guidelines During Pregnancy and Postpartum 1 Weeks gestation Total daily dose (TDD) of insulin † 1-13 weeks(0.7 x weight in kg) or (0.30 x weight [lbs]) weeks(0.8 x weight in kg) or (0.35 x weight [lbs]) weeks(0.9 x weight in kg) or (0.40 x weight [lbs]) 38 weeks to delivery(1.0 x weight in kg) or (0.45 x weight [lbs]) Postpartum (and lactation) ‡ (0.55 x weight in kg) or (0.25 x weight [lbs]) † The total daily dose (TDD) of insulin should be split, so that 50% is used for basal insulin and 50% is used for premeal rapid-acting insulin boluses ‡ Nighttime basal insulin should be decreased by 50% in lactating women (to prevent severe hypoglycemia) Special notes for T1DM: Between 10 and 14 weeks gestation, patients with T1DM undergo a period of increased insulin sensitivity; insulin dosage may need to be reduced accordingly during this time frame From weeks 14 through 35 of gestation, insulin requirements typically increase steadily After 35 weeks gestation, insulin requirements may level off or even decline 2 Obese patients may require higher insulin dosages than non-obese individuals 2 1.Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Kitzmiller JL, et al. Diabetes Care. 2008;31(5):

19 Insulin Pump Therapy/Continuous Subcutaneous Insulin Infusion (CSII) CSII: Administration of rapid-acting insulin via insulin pump –Safe and reliable method for satisfying basal insulin needs in pregnant patients with gestational diabetes mellitus (GDM), T2DM, or T1DM 1,2 CSII may need to be combined with CGM for optimal glycemic control in T1DM 1 –Can be used to effectively mimic physiologic insulin secretion 2 –No significant difference in glycemic control for pregnancy outcomes with CSII versus multiple-dose insulin (MDI) therapy 3 –Can help address daytime or nocturnal hypoglycemia or a prominent dawn phenomenon 4 Insulin aspart and lispro are the standard of care for CSII 5 Disadvantages of CSII: –Complexity–requires counseling and training –Cost –Potential for insulin pump failure/user error or infusion site problems 2,4 1.AACE. Endocr Pract. 2011;17(2): Castorino K et al. Curr Diab Rep, 2012;12: Hod M. Jovanovic L. Int J Clin Pract, 2010;64(166): Kitzmiller JL, et al. Diabetes Care. 2008;31(5): Castorino K, Jovanovic L. Clin Chem. 2011;57(2):

20 Diabetes in Pregnancy: Hypoglycemia Pathophysiology May be related to fetal absorption of glucose from the maternal bloodstream via the placenta, particularly during periods of maternal fasting Risk Factors History of severe hypoglycemia before pregnancy Impaired hypoglycemia awareness Longer duration of diabetes A1C ≤6.5% at first pregnancy visit High daily insulin dosage 1 Causes of Iatrogenic Hypoglycemia Administration of too much insulin or other anti- hyperglycemic medication Skipping a meal Exercising more than usual 2,3 Clinical Consequences Signs of hypoglycemia: anxiety, confusion, dizziness, headache, hunger, nausea, palpitations, sweating, tremors, warmth, weakness 4 Risks of hypoglycemia: coma, traffic accidents, death 1,5 Severe hypoglycemia can lead to maternal seizures or hypoxia Management Inform patients of increased risk of severe hypoglycemia during early pregnancy 4 Educate patients on hypoglycemia prevention: Frequent SMBG Regular meal timing Accurate medication administration Careful management of exercise programs 4 1. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40: Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40: Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): Kitzmiller JL, et al. Diabetes Care. 2008;31(5): Hod M. Jovanovic L. Int J Clin Pract. 2010;64(166):47-52.

21 Diabetes in Pregnancy: Hypoglycemia Treatment Suspected or confirmed hypoglycemia (blood glucose <60 mg/dL via SMBG) Severe hypoglycemia (patient cannot swallow) 1 mg glucagon injected subcutaneously; request emergency assistance 1 Mild to moderate hypoglycemia (patient can swallow) Preferred treatment: g glucose 1,2 Alternative treatments include fast-acting carbohydrates (eg, 8 oz nonfat milk, 4 oz juice) 1 15-minutes: recheck SMBG Hypoglycemia resolved (normal SMBG confirmed) Snack or meal should be consumed to prevent recurrence 1 Hypoglycemia not resolved Repeat treatment 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3): Kitzmiller JL, et al. Diabetes Care. 2008;31(5):

22 Diabetes in Pregnancy: Physical Activity Unless contraindicated, physical activity should be included in a pregnant woman’s daily regimen Regular moderate-intensity physical activity (eg, walking) can help to reduce glucose levels in patients with GDM 1,2 Other appropriate forms of exercise during pregnancy: –Cardiovascular training with weight-bearing, limited to the upper body to avoid mechanical stress on the abdominal region 3 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2): ADA. Diabetes Care. 2004;27(suppl 1):S Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):

23 Diabetes in Pregnancy: Weight Gain Patient’s prepregnancy BMI is used to determine goals for healthy weight gain 1 Independent of maternal glucose levels, higher maternal BMI has been associated with increased risk of: –Caesarean delivery –Infant birth weight >90 th percentile –Cord-blood serum C-peptide >90 th percentile 2 Evidence supports a goal of minimal weight gain during pregnancy for obese women 1 Patients should be advised to achieve weight objectives by maintaining a balanced diet and exercising regularly 1 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2): Metzger BE, et al. BJOG 2010;117:

24 Diabetes in Pregnancy: Labor and Delivery Counsel women on diabetes management during labor and delivery 1 During the 4-6 hours prior to delivery, there is increased risk of transient neonatal hypoglycemia 1 Labor and delivery in women with insulin-dependent type 1 diabetes should be managed by an endocrinologist or a diabetes specialist 1 Blood glucose levels should be monitored closely during labor to determine patient’s insulin requirements –Most women with gestational diabetes mellitus who are receiving insulin therapy will not require insulin once labor begins 1 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):

25 Diabetes in Pregnancy: Psychological Issues The demands of diabetes management can have a substantial effect on pregnancy 1 Individualized psychosocial interventions are likely to help improve both pregnancy outcomes and patient quality of life 1 –Include specialists in the psychological aspects of diabetes as part of the multidisciplinary healthcare team –Healthcare teams can help manage patients’ stress and anxiety before and during pregnancy –Identify and address barriers to effective diabetes management, such as fear of hypoglycemia and an inadequate social support network 1. Snoek SJ, et al. Psychology in Diabetes Care. 2 nd Ed. West Sussex, England: John Wiley & Sons Inc., 2005: Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):

26 Diabetes in Pregnancy: Postpartum and Lactation Metformin and glyburide are secreted into breast milk and are therefore contraindicated during lactation 1 Breastfeeding plus insulin therapy may lead to severe hypoglycemia 1 –Greatest risk is in women with T1DM –Preventive measures are: reduce basal insulin dosage and/or carbohydrate intake prior to breastfeeding Bovine-based infant formulas are linked to increased risk of T1DM 1 –Avoid in offspring of women with a genetic predisposition for diabetes –Soy-based products are a potential substitute 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):


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