The Pregnant DiabeticQueenie G. Ngalob, MD, FPCPMay 5, 2014
Outline
• Classification of diabetes in pregnancy• Effect of diabetes and pregnancy on
• Conceptus• Mother
• Treatment recommendations for pregnant diabetics
Classification of DM in pregnancy
Gestational Diabetes
PreGestationalDiabetes
(Type 1 or Type 2)Overt Diabetes
PregnancyPreexisting
IADPSG. Diabetes Care. 2010; 33(3): 676-682
Classification of DM in pregnancy
Gestational Diabetes
PreGestationalDiabetes
(Type 1 or Type 2)Overt Diabetes
PregnancyPreexisting
• UNITE for Diabetes (Philippines)• Evaluate for risk factors on 1st prenatal visit• 75gm OGTT ASAP if with any risk factor, 24-28th week if none
Unite for Diabetes. www.endo-society.org.ph
Risk factors for GDM• Prior GDM• Glucosuria• Family history of DM• Prior macrosomic (>8lbs) baby• Macrosomia in current pregnancy• Age ≥ 25 years old• PCOS• Overweight or obese• Polyhydramnios in current pregnancy• Intake of drugs affecting carbohydrate metabolism
Unite for Diabetes. www.endo-society.org.ph
Diagnosis – 1st Prenatal Visit
Diagnosis FBS, mg/dl (mmol/l)
RBS, mg/dl (mmol/l)
HBA1C*%
Overt Diabetes**
≥ 126 (≥ 7.0)
≥ 200(≥ 11.1)
≥ 6.5
Gestational Diabetes
≥ 92-125 (≥ 5.1 – 6.9)
na na
*NGSP certified & standardized to the DCCT reference assay** repeated on another dayIf criteria not met, repeat testing at 24-28 weeks AOG using 75gm OGTT
ADA 2014,WHO 2013, EndoSoc 2013, IADPSG 2010
Diagnosis FBS, mg/dl (mmol/l)
1st hourmg/dl (mmol/l)
2nd hour mg/dl (mmol/l)
Overt Diabetes**
≥ 126 (≥ 7.0)
na ≥ 200(≥ 11.1)
Gestational Diabetes
≥ 92-125 (≥ 5.1 – 6.9)
≥ 180(≥ 10.0)
153-199(8.5-11.0)
ADA 2014,WHO 2013, EndoSoc 2013, IADPSG 2010
Diagnosis – 24th to 28th week AOG using 75 gm OGTT
Classification of DM in pregnancy
Gestational Diabetes
PreGestationalDiabetes
(Type 1 or Type 2)Overt Diabetes
PregnancyPreexisting
IADPSG. Diabetes Care. 2010; 33(3): 676-682
Effect DM on the conceptus
Fetal malformation
Perinatal mortality
Spontaneous abortion
Boulot P, et al., Diabetes Care 26:2990–2993, 2003Lapolla A., et al. Nutr Metab Cardiovasc Dis. 2008 May;18(4):291-7
Persson M, et al., Diabetes Care. 2009 Nov;32(11):2005-9Eriksson UJ, et al., . Rev Endocrinol Metabol Dis 2003;4:79–93.
Kousseff BG. Diabetic embryopathy. Curr Opin Pediatr 1999;11:348Bell R., et al., BJOG. 2008 Mar;115(4):445-52.
Fetal Malformations• 1.86-7 fold higher risk
• 3rd to 7th weeks AOG embryogenesis & organogenesis
• Rates similar between Type 1 & 2• Toxic metabolites may be
teratogenic• Pathogenesis is poorly
understood
Congenital malformationsThe poorer the glycemic control periconceptionally
or early in pregnancy, the greater the riskfor congenital anomalies.
Towner D, et al., Diabetes Care 1995;18:1446–51.Langer O, et al., J Mat Fet Med 2000;9:35–41.
Temple R, et al., BMJ 2002;325:1275–6.Schaefer-Graf UM, et al., Am J Obstet Gynecol 2000;182:313–20.
Suhonen L, et al., Diabetologia 2000;43:79–82.
Malformations associated with pre-existing diabetes
OR
CNS All 1.55anencephalus 1.9Encephalocoele 3.27
Head Anotia 4.37GI Omphalocoele 2.32
Urinary Bilateral Renal agenesis 2.43
Musculo-skeletal
All 1.66
Garne E, et al., Birth Defects Research (Part A) 94:134–140, 2012
Malformations associated with pre-existing diabetes
OR
Congenitalheart defects
All 2.07Common arterial truncus 2.59Transposition of great vessels 2.00Single ventricle 2.57Ventricular septal defect 1.43Atrial septal defect 2.15Atrioventricular septal defect 2.21Coarctation of the Aorta 1.84
Garne E, et al., Birth Defects Research (Part A) 94:134–140, 2012
Spontaneous abortions
• 4 fold increased risk
• Risk rises poor glycemic control
Temple R., BMJ. 2002 Nov 30;325(7375):1275-6.
Perinatal mortality
• 2.3 to 6- fold increased risk
• Intrauterine stillbirth (>24 weeks AOG) or neonatal death (within 28 days of life)
Feig, et al., Diabetes Care. 2014 Apr 4. [Epub ahead of print]Boulot P, et al., Diabetes Care 26:2990–2993, 2003Dunne R, et al., Diabet Med. 2003 Sep;20(9):734-8.
Lapolla A., et al. Nutr Metab Cardiovasc Dis. 2008 May;18(4):291-7Persson M, et al., Diabetes Care. 2009 Nov;32(11):2005-9
Pregnancy Loss
Cundy T, et al., Diabetes Care 30:2603–2607, 2007
Perinatal outcomes
MACROSOMIAOR 11.45
(95% CI 10.61 – 12.36)
FETAL DISTRESSOR 11.45
(95% CI 10.61 – 12.36)
PRETERMOR 4.86
(95% CI 4.47-5.28)
RESPIRATORY DISTRESS SYNDROME
OR 4.65(95% CI 2.2-9.84)
Perrson M, et al., Diabetes Care 32:2005–2009, 2009
Effect DM on the conceptus
Pantalone K, et al., Endocr Pract. 2011;17:448-455
Effect of pregnancy on the diabetic mother
DM Complications Obstetric Outcomes
DM retinopathy
DCCT group. Diabetes Care 23:1084–1091, 2000Boulot P, et al., Diabetes Care 26:2990–2993, 2003
D. Thompson et al., Can J Diabetes 37 (2013) S168eS183Chew EY, et al., Diabetes Care. 1995 May;18(5):6
No to mild retinopathySmall risk for progression
Established retinopathy can rapidly progress during and up to 1 year after pregnancy, more so in poorly controlled
(OR 1.63 to 2.48)
Effects of pregnancy on retinopathy eventually diminish
after the first year.
Chew EY, et al., Diabetes Care. 1995 May;18(5):631-7.
Patients with more severe diabetic retinopathy at
baseline were more likely to show progression
(Χ2 trend P<0.001)
Chew EY, et al., Diabetes Care. 1995 May;18(5):631-7.
Patients with higher levels of HBA1C were at greater risk for progression
DM nephropathy
Rossing K, et al., Diabetologica 2002, 45: 36-41 Miodovnik M, et al., Am J Obstet Gynecol 1996;174:1180-91
Biesenbach, et al., Nephrol. Dial. Transplant. (1992) 7 (2): 105-109Purdy LP, et al., Diabetes Care. 1996 Oct;19(10):1067-74.
Normal creatininealbuminuria and creatinine
clearance is preserved during pregnancy
Microalbuminuriamay worsen but typically
modest and reversible(BP and blood sugar are well-
controlled)
Moderate to severecan significantly deteriorate and
may not be reversible
DM nephropathy & pregnancy outcomes
Sibai BM, et al., Am J Obstet Gynecol. 2000 Feb;182(2):364-9Jensen DM, et al., Diabetes Care 33:90–94, 2010
Ekbomm P, et al, Diabetes Care 24:1739–1744, 2001
Increased risk of preeclampsia, exacerbation of hypertension
(OR 1.75-4.0)
Hypertension leads to increased risk of preterm delivery
Placental dysfunction leads to intrauterine growth restriction
and fetal distress
Obstetric Outcomes
PREECLAMPSIAOR 4.47
(95% CI 3.77 to 5.31)
VACUUM EXTRACTION/FORCEP
SOR 1.41
(95% CI 1.25 TO 1.58)
CESAREAN SECTIONOR 5.31
(95% CI 4.97 TO 5.69)
Perrson M, et al., Diabetes Care 32:2005–2009, 2009
Management of PreGDM
Preconception During Pregnancy Postpartum
• Counseling• Glycemic
control• Weight control • Co-morbidities
Management of PreGDM
Preconception Counseling
Should be provided to all diabetic women of childbearing potential or considering
pregnancy
• Start at puberty or on diagnosis
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013ADA, Diabetes Care. 2014 Jan;37 Suppl 1:S14-80
IDF 2009.
Preconception Counseling
Risk of malformations & adverse outcomes associated with unplanned pregnancy or
poor metabolic control
Use of effective contraception
Need for pregnancy to be planned, sufficient control of glucose & co-morbidities
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013ADA, Diabetes Care. 2014 Jan;37 Suppl 1:S14-80
IDF 2009.
Time, commitment and effort is required
Preconception Counseling
Diabetes Specialist
Diabetes Educator
Dietician Obstetrictian
Patient &
partner
Improved glycemic parameters
Outcome No. of Studies
Mean Difference(95% CI)
Mean HBA1C decrease in the 1st trimester
5 - 1.92%(-2.05, -1.79)
Wahabi et al. BMC Public Health 2012, 12:792
Decreased risk for congenital malformations
Wahabi et al. BMC Public Health 2012, 12:792
OR = 0.25 (0.16, 0.37)
Decreased Perinatal Mortality
Wahabi et al. BMC Public Health 2012, 12:792
OR = 0.34 (0.15, 0.75)
Preconception Glycemic Control
Strive to achieve blood glucose and HBA1C as close to normal as possible when they can be safely achieved without undue hypoglycemia.
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
• ideal preconception glucose levels not established
Bell R, et al. Diabetologia. 2012 Feb 8.
OR 1.3 (95% CI 1.2, 1.4) for every 1% increase in HBA1C
Strategies : Insulin-treated
• Intensified therapy using subcutaneous insulin
• Provide basal coverage• Human insulin : NPH• Analogs : Glargine, Detemir
• Provide prandial coverage• Human insulin : regular• Analogs : Aspart, Lispro
Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
http://dtc.ucsf.eduJacobs DM Care 20:1279, 1997
http://dtc.ucsf.eduJacobs DM Care 20:1279, 1997
Strategies : Insulin-treated
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Recommend multiple daily doses of insulin or continuous SC insulin infusion
over split-dose, premixed insulin
Changes should be done well before conception or before withdrawing contraception to allow patient to
gain expertise
Strategies : Insulin-treated
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Suggest rapid acting insulin analog (aspart or lispro) in preference to regular insulin
Basal insulins detemir and glargine : preconceptionally & during pregnancy
Strategies : OHAS-treated
No trials on use of oral hypoglycemics in
pregestational DM Shift to insulin
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Overweight & Obese
Weight reduction before pregnancy for
overweight and obese diabetic women.
Increased risk for complications during pregnancy
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Overweight (25.01-30
kg/m2)n=2882
Obese(30.01-40
kg/m2)n=1679
Morbidly obese (>40 kg/m2)
n-=248
Hypertensive disorders
1.74(1.45-2.15)
3.0(2.4-3.74)
4.87(3.27-7.24)
Gestational Diabetes
1.78(1.25-2.52)
2.95(2.05-4.25)
7.44(4.42-12.54)
Caesareansection
1.5(1.36-1.66)
2.02(1.79-2.28)
2.54(1.94-3.32)
OR for maternal outcomes according to antenatal BMI
Callaway LK, et al., Med J Aust 2006; 184 (2): 56-59.
Overweight (25.01-30
kg/m2)n-=2882
Obese(30.01-40
kg/m2)N=1679
Morbidly obese (>40 kg/m2)
n-=248
Birth defects 1.58(1.02-2.46)
3.41(1.67-6.94)
Hypoglycemia 2.57 (1.39-4.78)
7.14(3.04-16.74)
Prematurity (<34 wks)
2.13(1.13-4.01)
Admission to NICU
2.77(1.81-4.25)
OR for neonatal outcomes according to antenatal BMI
Callaway LK, et al., Med J Aust 2006; 184 (2): 56-59.
Ocular careHave a detailed ocular assessment by a suitably-trained and qualified eye care professional in advance of withdrawing
contraception or trying to conceive
If retinopathy is documented, should be appraised of risk of worsening during
pregnancy.
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Ocular care
If degree of retinopathy warrants therapy, recommend deferring conception until the
retinopathy has been treated and stabilized.
• The greater the degree of preconception retinopathy, the greater the risk of progression during pregnancy
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Chew EY, et al., Diabetes Care. 1995 May;18(5):631-7.
Chew EY, et al., Diabetes Care. 1995 May;18(5):631-7.
Patients in whom retinopathy was most likely to progress had both the poorest control at baseline and largest
improvement during early pregnancy
Renal Function
Have renal function assessed in advance
of withdrawing contraception or
trying to conceive
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
• Urine albumin-creatinine ratio
• Serum Crea• eGFR
Renal Function
If with significantly reduced GFR, refer to nephrologist before
pregnancy
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
• baseline renal assessment
• review the woman’s specific risk of worsening renal function in the event of pregnancy
Address Co-morbidities
HYPERTENSIONSatisfactory BP control
(<130/80) preconception
Withdraw ACEI and ARB
DYSLIPIDEMIAWithdraw statins
VASCULAR RISKEvaluate risk factors
screening for CAD treat and counsel
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Preconception During Pregnancy Postpartum
• Counselling• Glycemic
control• Weight control • Co-morbidities
• Targets• SMBG• MNT• Weight
management• Pharmacologic• Peripartum
Glycemic TargetsParameter Goal
mg/dl (mmol/L)
Fasting & Preprandial
≤ 95 (≤ 5.3)≤ 90 (5.0) if can be achieved without
hypoglycemia1 hour PP ≤ 140 (≤7.8)
2 hour PP ≤ 120 ( ≤ 6.7)
HBA1C ≤ 7 % (ideally ≤ 6.5)
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Self-monitoring of blood glucose (SMBG)
Recommend SMBG in all DM pregnant
patients
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Self-monitoring of blood glucose (SMBG)
Recommend SMBG in all DM pregnant
patients
Frequency• Fasting & Pre-meals• Postprandial - 1 or 2
hours after the start of each meal, choosing when is peak
• bedtime and during the night as indicate.
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Negrato CA, et al., Diabetol Metab Syndr. 2012 Dec 22;4(1):54.
HBA1C
Perform HBA1C at the initial visit and
monthly until target levels are achieved,
then 2-3 months thereafter.
Targets•EndoSoc : ≤ 7% (6.5% ideal)•ADA : <6%
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Medical Nutrition Therapy (MNT)
Recommend MNT to help achieve and
maintain desired glycemic control while providing
essential nutrient requirements
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Medical Nutrition Therapy (MNT)
• a carbohydrate-controlled meal plan
• Promotes adequate nutrition and weight gain, normoglycemia and no ketosis
• Individualized, adjusted as pregnancy progresses
• CHO : 35-45% of TCR
• 3 small to moderate-sizedmeals
• 2 to 4 snacks• Including
evening snack
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Weight Management
Follow the Institute of Medicine revised
guidelines for weight gain during pregnancy
Excess weight gain associated with macrosomia (OR 3.58)Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
2009 Institute of Medicine Recommendations for total and rate of weight gain in pregnancy,
by Prepregnancy BMI
Prepregnancy BMI Range(kg)
Rates of weight gain in 2nd & 3rd trimester
Mean (Range), kg/wk
Underweight (<18.5 kg/m2) 12.5-18 0.51 (0.44-0.58)Normal (18.5-24.9 kg/m2) 11.5-16 0.42 (0.35-0.5)Overweight (25-29.9 kg/m2)
7-11.5 0.28 (0.23-0.33)
Obese (≥ 30 kg/m2) 5-9 0.22 (0.17-0.27)
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
• Provide background/ basal coverage• Human insulin : NPH• Analogs : Glargine, Detemir
• Provide prandial coverage• Match with carbohydrate intake• Human insulin : regular• Analogs : Aspart, Lispro
Pharmacologic Therapy
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Strategies
Recommend multiple daily doses of insulin or continuous SC insulin infusion
over split-dose, premixed insulin
Suggest rapid acting insulin analog (aspart or lispro) in preference to regular insulin
Suggest use of basal insulins for pregnancy: Detemiror glargine
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Pharmacologic Therapy
Suggest that Detemir be initiated in1. Require basal insulin2. NPH insulin, in appropriate doses, has
previously resulted in, or thought that may result in problematic hypoglycemia
3. Successfully taking detemir before pregnancy.
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Mathiesen ER, et al., Diabetes Care 35:2012–2017, 2012
P 310 T1DM womenplanning to be or pregnant at 8-12 weeks AOG, A1C ≤ 8% on confirmation or pregnancy17 countries
I Detemir vs NPH insulin
O Primary: HBA1C at 36 wks AOGSecondary: A1C at 8-12, 14 and 24 wks AOG, # attaining ≤ 6%, FPG, SMBGMaternal : hypoglycemia, deterioration of retinopathy, AE, weight gain
M Open-labelled, randomized trial, noninferiority
Detemir in pregnancy
Mathiesen ER, et al., Diabetes Care 35:2012–2017, 2012
Parameter at 36 weeks AOG
Detemir(n=152)
NPH(n=158)
significance
HBA1C 6.27% 6.33% -0.06 (95% CI-0.21 to 0.08)
HBA1C ≤ 6% 41% 32% P=0.28
Estimated mean FPG
85.7 mg/dl 97.4 mg/dl P=0.017*
Mean PG from 8-point SMPG
119 mg/dl 123 mg/dl P=0.082
Results – Glycemic outcomes
Mathiesen ER, et al., Diabetes Care 35:2012–2017, 2012
Parameter at 36 weeks AOG
Detemir(n=152)
NPH(n=158)
significance
Major hypoglycemia
16% 21% P=0.615
Weight gain 11.5kg 11kg NS
Adverse Events (AE)
Reported as same ~90%
Serious AE 40% 31% * To be Reportedin another paper
Results – Maternal tolerability
Mathiesen ER, et al., Diabetes Care 35:2012–2017, 2012
Outcome Detemirn=152
NPH n=158
Serious Adverse Events 40 % 31 %
Pregnancy, puerperium, perinatal conditions
25.7 % 16.5 %
Infection & infestation 4.6 % 1.3 %
Reproductive system & breast 2.0 % 3.2 %
Nervous system 2.6 % 1.3 %
Metabolism and nutrition disorders 11.2 % 8.2 %
Hypoglycemia unawareness 2 pts 7 pts
Diabetes inadequate control 5 pts 1 pts
DKA 3 pts 0 pts
“Few events were considered by the investigator to be possibly or probably related
to one or both investigational products (between 8-12% of the mothers)”
Results – Maternal tolerability
Detemir in Pregnancy – Perinatal and Obstetric Outcomes
P 310 T1DM womenplanning to be or pregnant at 8-12 weeks AOG, A1C ≤ 8% on confirmation or pregnancy17 countries
I Detemir vs NPH insulin
O Composite pregnancy outcomeGA at delivery, SGA or LGA, birthweight, macrosomia, live births, early fetal death, perinatal mortality and induced abortions, neonatal hypoglycemia, congenital malformations, preterm delivery, preeclampsia, AE (fetal & Maternal
M Open-labelled, randomized trial, noninferiority
Hod M, et al., J Matern Fetal Neonatal Med, 2014; 27(1): 7–13
Sample size computed based on primary outcome (HBA1C at 36 weeks) and NOT to detect perinatal and obstetric outcomes
Results – perinatal & obstetric outcomesParameter- Detemir
(n=152)NPH
(n=158)significance
Composite outcome 62.7% 66.2% OR 0.86 (95% CI 0.53, 1.40)
GA at delivery (wks) 38.2 (SD 1.9) 37.8 (SD 1.5) P=0.012Live births 90.1% 93.8% P=0.284
Preterm delivery 20.3% 26.5% P=0.238
Early fetal death 7.7% 6.2% -
Perinatal death 1.4 0.7 -
Neonatal death 0 0 -
SGA 2.3% 0.7% -
LGA 46.1 53.7 0.228
Macrosomia 18.8 25.7 0.18
Neonatal hypoglyc 11.7 17.6 0.223
Hod M, et al., J Matern Fetal Neonatal Med, 2014; 27(1): 7–13
Results – Congenital Malformations based on treatment during organogenesis
Parameter Detemir(n=84)
NPH(n=154)
Signifi-cance
Congenitalmalformation
4.8% 7.1% -
Minor malformation 1.2% 5.2% -Major malformation 3.6% 1.9% -
Hod M, et al., J Matern Fetal Neonatal Med, 2014; 27(1): 7–13
Results – Adverse Events in Children
Parameter Detemir(n=84)
NPH(n=154)
significance
AE 36.8% 34.8% -Serious AE 23.7 20.3 -Severe AE 9.9 7.6 -AE possibly/probably related to basal insulin
0.7 0
Hod M, et al., J Matern Fetal Neonatal Med, 2014; 27(1): 7–13
“Detemir is well-tolerated…Further reassurance will be provided with the collection of longterm
observational data from a large cohort.”
Glargine
Suggest that pregnant women successfully using glargine before
pregnancy may continue it during
pregnancy
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Glargine
• Increased affinity to IGF-1 receptors • mitogenicity• Role of IGF-1 in fetal tissues
• Placenta perfusion study showed that glargine does not cross the placenta
Kurtzhals P, et al., Diabetes 2000; 49: 999–1005Chisalta SI, et al., Am J Physiol Endocrinol Metab 286: E896–E901, 2004.
Pollex E, et al., Diabetes Care 33:29–33, 2010
Glargine – Maternal outcomesOutcome # of
studies
N I2 Effect (OR) 95% CIGl NPH
1st TrimesterHBA1C
4 143 158 79% (Mean Diff)-0.08
-0.64, 0.49
Severe Hypoglycemia
4 155 205 52% 0.84 0.18, 3.79
Preeclampsia 8 331 371 44% 0.55 0.23, 1.32
Gestational/ New Onset HPN
4 155 205 1% 0.49 0.2, 1.2
Lepercq J, et al., Obstet Gynecol Int. 2012;2012:649070
Glargine – Neonatal outcomesOutcome # of
studies
N I2 Effect (OR) 95% CIGl NPH
Neonatal hypoglycemia
7 304 346 6% 0.99 0.63, 1.56
NICU admission 6 274 307 13% 0.79 0.45, 1.38
Congenital malformations
5 237 271 0% 0.78 0.39, 1.59
Macrosomia 4 157 198 0% 1.2 0.71, 2.02
Lepercq J, et al., Obstet Gynecol Int. 2012;2012:649070
Glargine
Lepercq J, et al., Obstet Gynecol Int. 2012;2012:649070
Current available data from retrospective studies and one prospective cohort show that glargine does not result in increased risk for the mother and fetus.
Pharmacologic Therapy
NO randomized clinical trials regarding the use
of non-insulin antihyperglycemics in
pregestational diabetes
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Pharmacologic Therapy
NO randomized clinical trials regarding the use
of non-insulin antihyperglycemics in
pregestational diabetes
Shift OHAS to insulin once pregnancy
confirmed
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Kitzmiller JL, et al., Diabetes Care. 2008 May;31(5):1060-79
Labor & Delivery
Suggested targets during labor & delivery
: 72-126 mg/dl
( 4.0-7.0 mmol/l)
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013ADA 2014 Standards of Care. Diab Care (37) : S14-80, 2014
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Labor & Delivery
Hyperglycemia during labor and delivery increases risk of• neonatal
hypoglycemia• fetal distress• birth asphyxia• abnormal heart rate
Method:• No evidence on single
best way of maintaining target BG
• No recommendation and at discretion of practitioner
Preconception During Pregnancy Postpartum
• Counselling• Glycemic
control• Weight control • Co-morbidities
• Targets• SMBG• MNT• Weight
management• Pharmacologic• Peripartum
• Lactation
Lactation
Recommend whenever possible,
women with diabetes should breastfeed
their infants.
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013
Lactation
Oral agents with data on transfer to
breastmilk1. Metformin - <1%2. Glyburide, Glipizide
<1.5%
Blumer I, et al., J Clin Endocrinol Metab 98: 4227–4249, 2013Feig DS, et al., Ann Pharmacother. 2007 Jul;41(7):1174-80
Glueck CJ, et al., J Pediatr. 2006 May;148(5):628-632
Preconception During Pregnancy Postpartum
• Counselling• Glycemic
control• Weight control • Co-morbidities
• Targets• SMBG• MNT• Weight
management• Pharmacologic• Peripartum
• Lactation
Thank you.
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