Special Populations: Special Populations: Preconception and - - PowerPoint PPT Presentation

Special Populations: Special Populations: Preconception and Preconception and Pregnancy Pregnancy

Susan Cornell, BS, Pharm.D., CDE, CDM Susan Cornell, BS, Pharm.D., CDE, CDM

Midwestern University Chicago College of Pharmacy Midwestern University Chicago College of Pharmacy

Diabetes in Pregnancy Diabetes in Pregnancy

Diabetes is one of the most commonly Diabetes is one of the most commonly encountered complications of pregnancy encountered complications of pregnancy

• >150,000 pregnancies annually

>150,000 pregnancies annually

• Congenital malformations are most notable

Congenital malformations are most notable complication complication

~40% ~40%-

• 50% of

50% of perinatal perinatal deaths deaths Associated with maternal hyperglycemia and the Associated with maternal hyperglycemia and the consequent fetal hyperinsulinemia consequent fetal hyperinsulinemia

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:99-101

Definition of Diabetes in Pregnancy Definition of Diabetes in Pregnancy

2 groups 2 groups

• Women with pre

Women with pre-

• existing diabetes

existing diabetes (diabetes (diabetes prior to

prior to conception)

conception)

~ 0.2% ~ 0.2%-

• 0.3% type 1

0.3% type 1 ~ 65% type 2 ~ 65% type 2 ~ 2% undiagnosed type 2 ~ 2% undiagnosed type 2

• Gestational diabetes (GDM)

Gestational diabetes (GDM) (onset (onset during

during pregnancy)

pregnancy)

~ 7% of pregnancies ~ 7% of pregnancies

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:99-101

Pregnancy with pre Pregnancy with pre-

• existing

existing diabetes diabetes (diabetes (diabetes prior to

prior to conception)

conception)

Perinatal Perinatal Complications Complications

Complications are related to the level of Complications are related to the level of maternal maternal glycemia glycemia Complications in the First Complications in the First-

• Trimester:

Trimester:

• Congenital malformations (~ 6%

Congenital malformations (~ 6%– –13%) 13%)

Cardiovascular, CNS, Skeletal Cardiovascular, CNS, Skeletal

• Spontaneous abortions (~ 30%

Spontaneous abortions (~ 30%– –60%) 60%)

These complications often occur before a These complications often occur before a woman knows she is pregnant woman knows she is pregnant

Mills JL et al. Diabetes. 1979; 28:292-293

Perinatal Perinatal complications complications

Macrosomia Macrosomia

• Abnormally large body size

Abnormally large body size

• ~ 20

~ 20-

• 32% of pregnancies with diabetes

32% of pregnancies with diabetes

Still birth Still birth Respiratory distress syndrome (RDS) Respiratory distress syndrome (RDS) Hypocalcemia Hypocalcemia, , Hyperbilirubinemia Hyperbilirubinemia, , polycythemia polycythemia

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:101-106

Maternal Complications Maternal Complications

Hypertension Hypertension

• Pregnancy induced

Pregnancy induced

• Preeclampsia

Preeclampsia

• Chronic hypertension

Chronic hypertension

Hydramnios Hydramnios

• Excess amniotic fluid

Excess amniotic fluid

Possibly due to increased fetal urine production Possibly due to increased fetal urine production

Infectious postoperative complication Infectious postoperative complication Preterm delivery Preterm delivery

• Related to mother

Related to mother’ ’s blood pressure status s blood pressure status

Cesarean section Cesarean section

Cousins L. Diabetes Mellitus in Pregnancy. 1995:287-302

Normal Metabolism Normal Metabolism

Early gestation: Early gestation:

• The fetus depends on the mother for an

The fetus depends on the mother for an uninterrupted supply of fuel or nutrition uninterrupted supply of fuel or nutrition Increases occurs in: Increases occurs in:

Tissue glycogen storage Tissue glycogen storage Peripheral glucose utilization Peripheral glucose utilization Hepatic glucose production Hepatic glucose production

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:101-102

Normal Metabolism Normal Metabolism

Late Gestation: Late Gestation:

• ↑

↑ growth of fetus growth of fetus

• ↑

↑ hormones levels hormones levels

lactogen lactogen estrogen estrogen

• ↑

↑ insulin resistance insulin resistance

• ↓

↓ in food may result in in food may result in ↑ ↑ in free fatty in free fatty acids and acids and ketones ketones

↑ ↑ risk of DKA risk of DKA

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:101-106

First Trimester of Pregnancy with First Trimester of Pregnancy with Preexisting Diabetes Preexisting Diabetes

Hormone changes can result in erratic Hormone changes can result in erratic blood glucose levels blood glucose levels Meal plans should be adjusted to Meal plans should be adjusted to accommodate BG changes accommodate BG changes Critical to avoid Critical to avoid ketonemia ketonemia and and ketoacidosis ketoacidosis

Second and Third Trimesters of Second and Third Trimesters of Pregnancy with Preexisting Diabetes Pregnancy with Preexisting Diabetes

Energy requirements will increase Energy requirements will increase Insulin resistance will start to increase Insulin resistance will start to increase

• Especially in second half of pregnancy

Especially in second half of pregnancy

Insulin requirements will increase Insulin requirements will increase

• ↑

↑ dosages of rapid or dosages of rapid or short short− −acting acting insulin (bolus insulin (bolus insulin) needed to cover meals insulin) needed to cover meals

• ↑

↑ dosages of intermediate or long dosages of intermediate or long-

• acting insulin (basal

acting insulin (basal insulin) needed to maintain nocturnal insulin levels insulin) needed to maintain nocturnal insulin levels

• ↑

↑ risk of DKA in the third trimester risk of DKA in the third trimester

Jovanovic L et al. Diabetes Care. 1982:5:24-37

Treatment of Diabetes in Treatment of Diabetes in Pregnancy Pregnancy

NonPharmacological NonPharmacological

• DSME education

DSME education

Including preconception Including preconception counseling and care counseling and care

• Exercise/Activity

Exercise/Activity

• Medical Nutrition

Medical Nutrition Therapy Therapy

• SMBG

SMBG

• Weight management

Weight management Pharmacological Pharmacological

• Insulin

Insulin

Patient Education Outline for Patient Education Outline for Pregnancy with Preexisting Diabetes Pregnancy with Preexisting Diabetes

Preconception Counseling Preconception Counseling Patient education for pregnancy Patient education for pregnancy Postpartum education Postpartum education

Preconception Counseling and Preconception Counseling and Care Care

Begins 3 to 6 months prior to conception and Begins 3 to 6 months prior to conception and continues throughout pregnancy continues throughout pregnancy

• Normalize and stabilize blood glucose levels

Normalize and stabilize blood glucose levels

• Optimize diabetes control

Optimize diabetes control

Counseling for: Counseling for:

• Women with preexisting diabetes

Women with preexisting diabetes

Type 1 Type 1 Type 2 Type 2

• Women at risk for type 2 diabetes

Women at risk for type 2 diabetes

Preconception Counseling and Care: Preconception Counseling and Care:

Prior to Discontinuing Contraception Prior to Discontinuing Contraception

Assessment of complications Assessment of complications

• Microvascular

Microvascular

• Macrovascular

Macrovascular

Discontinue oral Discontinue oral antidiabetic antidiabetic agents (if agents (if applicable) applicable) Nutrition assessment and modifications Nutrition assessment and modifications

• Modify meal plans to meet anticipated pregnancy

Modify meal plans to meet anticipated pregnancy needs needs

• Calcium, iron, folic acid assessment and

Calcium, iron, folic acid assessment and supplementation supplementation

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:107-110

Preconception Counseling and Care: Preconception Counseling and Care:

Prior to Discontinuing Contraception Prior to Discontinuing Contraception

Self Self− −Management Management skill assessment skill assessment

• Review SMBG technique

Review SMBG technique

• Review insulin administration technique

Review insulin administration technique

• Review hypoglycemia prevention, awareness

Review hypoglycemia prevention, awareness and treatment skills and treatment skills

• Review glucagon emergency plan

Review glucagon emergency plan

Continue contraception until glucose goals Continue contraception until glucose goals are attained are attained

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:107-110

Medical Nutrition in Pregnancy Medical Nutrition in Pregnancy

Adequate nutrition is one of the most Adequate nutrition is one of the most important influences on the health of important influences on the health of pregnant women and their infants. pregnant women and their infants.

Recommended Dietary Allowances Recommended Dietary Allowances (RDA) in Pregnancy (RDA) in Pregnancy

Protein Protein

• 0.8 g/kg/day during 1

0.8 g/kg/day during 1st

st half of pregnancy

half of pregnancy

Same as non Same as non-

• pregnant women

pregnant women

• 1.1 g/kg/day during 2

1.1 g/kg/day during 2nd

nd half of pregnancy

half of pregnancy

Add 50 g/day for twins Add 50 g/day for twins

Carbohydrate (CHO) Carbohydrate (CHO)

• Same as preconception intake

Same as preconception intake

Minimum of 175 g/day to assure fuel for CNS for fetus and Minimum of 175 g/day to assure fuel for CNS for fetus and mother mother Use insulin Use insulin-

• to

to-

• CHO ratios for appropriate insulin doses

CHO ratios for appropriate insulin doses

usually larger at breakfast since CHO is less well tolerated due usually larger at breakfast since CHO is less well tolerated due to to increase in increase in cortisol cortisol and growth hormones. and growth hormones.

Institute of medicine of the National Academies. Dietary Reference Intakes;2002

Meal Plans in Pregnancy Meal Plans in Pregnancy

Eat meals at regular times Eat meals at regular times

• Small, frequent meals and snacks

Small, frequent meals and snacks

every 2 to 4 hours every 2 to 4 hours

• Minimize hypoglycemia

Minimize hypoglycemia

Bedtime snacks Bedtime snacks

• Decreases risk of nocturnal starvation,

Decreases risk of nocturnal starvation, ketonuria ketonuria and and ketonemia ketonemia

Match insulin to food consumption Match insulin to food consumption Check BG levels often Check BG levels often

Recommended Ranges of Total Recommended Ranges of Total Weight Gain for Pregnant Women Weight Gain for Pregnant Women

BMI < 19.8 BMI < 19.8 28 28− −40 lb 40 lb

(underweight) (underweight)

BMI 19.8 BMI 19.8 – – 26.0 26.0 25 25− −35 lb 35 lb

(normal weight) (normal weight)

BMI 26.0 BMI 26.0 – – 29.0 29.0 15 15− −25 lb 25 lb

(overweight) (overweight)

BMI > 29 BMI > 29 ~15 lb ~15 lb

(obese) (obese)

National Academy of Sciences. Nutrition during pregnancy; 1990

Recommended Ranges of Total Recommended Ranges of Total Weight Gain for Pregnant Women Weight Gain for Pregnant Women (cont.) (cont.)

Twin Gestation Twin Gestation 35 35− −45 lb 45 lb Triplet Gestation Triplet Gestation 45 45− −55 lb 55 lb

National Academy of Sciences. Nutrition during pregnancy; 1990

Self Self-

• Monitoring Blood Glucose

Monitoring Blood Glucose

Blood Glucose Goals in Diabetic Blood Glucose Goals in Diabetic Pregnancy (Preconception) Pregnancy (Preconception)

Pre Pre-

• meal

meal 80 80− −110 mg/dl 110 mg/dl 2 2− −hour postprandial hour postprandial < 155 mg/dl < 155 mg/dl

Preconception care of women with diabetes. Diabetes Care. 2003;26:S91-93

Blood Glucose Goals in Diabetic Blood Glucose Goals in Diabetic Pregnancy Pregnancy

Fasting Fasting 65 65− −100 mg/dl 100 mg/dl Pre Pre-

• meal:

meal: 65 65− −115 mg/dl 115 mg/dl 1 hour postprandial 1 hour postprandial <145 <145 mg.dl mg.dl 2 hour postprandial 2 hour postprandial < 135 mg/dl < 135 mg/dl 2 2-

• 6 hour postprandial

6 hour postprandial 65 65− −135 mg/dl 135 mg/dl

Preconception care of women with diabetes. Diabetes Care. 2003;26:S91-93

Monitoring Monitoring

Ketones Ketones

• Whenever BG > 200 mg/dl

Whenever BG > 200 mg/dl

• During illness (result of nausea/vomiting)

During illness (result of nausea/vomiting)

Urine Urine

• first morning urine

first morning urine

Blood Blood

• daily

daily

A1C A1C Blood Pressure Blood Pressure

Insulin During Pregnancy Insulin During Pregnancy

Insulin regimen should be individualized Insulin regimen should be individualized

• May require 3 to 4 injections or more daily

May require 3 to 4 injections or more daily

• Rapid or short acting at meals (bolus)

Rapid or short acting at meals (bolus)

• Intermediate or long acting at bedtime (basal)

Intermediate or long acting at bedtime (basal)

Pre Pre-

• meal Regular/ Bedtime NPH

meal Regular/ Bedtime NPH (Bolus/Basal) (Bolus/Basal)

Continuous Subcutaneous Insulin Continuous Subcutaneous Insulin Infusion (CSII) Infusion (CSII)

Insulin pump therapy Insulin pump therapy

• Lowers the amount of basal insulin

Lowers the amount of basal insulin

• ↓

↓ risk of risk of premeal premeal hypoglycemia hypoglycemia

• ↑

↑ control over postprandial glucose control over postprandial glucose excursions excursions

Ideally started prior to conception, Ideally started prior to conception, however, can be started at any point however, can be started at any point

• Especially if suboptimal glucose control

Especially if suboptimal glucose control

Rudolf MC et al. Diabetes. 1981;30:891-895

Insulin Requirements Throughout Insulin Requirements Throughout Gestation Gestation

Preconception Preconception 0.6 units/kg 0.6 units/kg First Trimester First Trimester 0.7 units/kg 0.7 units/kg Second Trimester Second Trimester 0.8 units/kg 0.8 units/kg Third Trimester Third Trimester 0.9 0.9− −1.0 units/kg 1.0 units/kg Postpartum Postpartum <0.6 units/kg <0.6 units/kg

Women > 150% of ideal body weight Women > 150% of ideal body weight ↑ ↑ 1.5 1.5-

• 2.0 units/kg

2.0 units/kg

• Insulin resistance due to obesity

Insulin resistance due to obesity

Jovanovic L et al. Diabetes Care. 1982:5:24-37

Insulin Requirements Throughout Insulin Requirements Throughout Gestation Gestation

Adjustments may be necessary in first trimester Adjustments may be necessary in first trimester due to due to ↑ ↑ incidence of hypoglycemia incidence of hypoglycemia

• Most common during sleep

Most common during sleep

• Women with history of severe hypo events at greater

Women with history of severe hypo events at greater risk risk

Family education on hypoglycemia Family education on hypoglycemia

• Prevention

Prevention

• Awareness

Awareness

• Treatment

Treatment

Glucagon administration Glucagon administration

Kimmerle R et al. Diabetes Care. 1992;15:1034-1037

Labor and Delivery Labor and Delivery

Goals of diabetes care during labor: Goals of diabetes care during labor:

• Adequate CHO intake

Adequate CHO intake

Glucose administer via continuous IV Glucose administer via continuous IV ~ 2.0 ~ 2.0− −2.5 mg/kg/minute 2.5 mg/kg/minute

• Maintain normal BG levels

Maintain normal BG levels

Measured every 1 Measured every 1− −2 hours 2 hours Short Short− −acting acting insulin insulin

• Multiple subcutaneous dosing

Multiple subcutaneous dosing

• CSII

CSII

Jovanovic L et al. Am J Med. 1983;75:607-612

Postpartum Postpartum

Immediate Immediate ↓ ↓ insulin requirements insulin requirements

• Little to no insulin may be required in the first 24

Little to no insulin may be required in the first 24− −48 48 hours post delivery hours post delivery

• ~0.6 units/kg for non

~0.6 units/kg for non-

• lactating women

lactating women

• ~ 0.4 units/kg for lactating women

~ 0.4 units/kg for lactating women

(based on current weight) (based on current weight)

Support and education Support and education

• Balance of mother

Balance of mother’ ’s s self self− −care care needs with infant needs with infant needs needs

• Assessment for postpartum depression

Assessment for postpartum depression

• ↑

↑ risk of hypoglycemia risk of hypoglycemia

Education on prevention, awareness and treatment Education on prevention, awareness and treatment

• Modification of meal plans

Modification of meal plans

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:124-125

Lactation Lactation

Breastfeeding mothers need less insulin Breastfeeding mothers need less insulin

• ↑

↑ expended calories expended calories

• May need CHO snack before/during nursing

May need CHO snack before/during nursing

Increase in hypoglycemia Increase in hypoglycemia Oral agents are not approved for use Oral agents are not approved for use during lactation during lactation

• Insulin can be used

Insulin can be used

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:124-125

Key Take Home Points Key Take Home Points

Preconception care planning is essential Preconception care planning is essential Diabetes care and blood glucose control Diabetes care and blood glucose control need to be optimal at least 3 need to be optimal at least 3− −6 months 6 months prior to conception. prior to conception.

• Contraception use should be emphasized

Contraception use should be emphasized until blood glucose goals have been attained until blood glucose goals have been attained

Key Take Home Points Key Take Home Points

Diabetes care and glucose control need to Diabetes care and glucose control need to be monitored very closely during be monitored very closely during pregnancy pregnancy Treatment plans should be reviewed Treatment plans should be reviewed regularly for necessary adjustments regularly for necessary adjustments Education and monitoring in the Education and monitoring in the postpartum period. postpartum period.

Gestational Diabetes Mellitus Gestational Diabetes Mellitus (GDM) (GDM) (onset (onset during

during pregnancy)

pregnancy)

Gestational diabetes Gestational diabetes

CHO intolerance with onset or first CHO intolerance with onset or first recognition during pregnancy recognition during pregnancy

• Includes women with undiagnosed type 2

Includes women with undiagnosed type 2 diabetes prior to pregnancy but are diagnosed diabetes prior to pregnancy but are diagnosed during pregnancy during pregnancy

• Includes women using medications or that

Includes women using medications or that have medical conditions that affect glucose have medical conditions that affect glucose tolerance. tolerance.

Biastre SA, Slocum J.. A Core Curriculum for Diabetes Educators; 2003:145-146

Metabolic Changes Metabolic Changes

Similar to the second and third trimesters Similar to the second and third trimesters

• f pregnancy with pre
• f pregnancy with pre-
• existing diabetes

existing diabetes

• ↑

↑ mobilization of glucose mobilization of glucose

• ↓

↓ insulin sensitivity insulin sensitivity

• ↑

↑ circulating hormones circulating hormones

• ↑

↑ basal insulin requirements basal insulin requirements

• ↑

↑ risk risk ketones ketones (urine & blood) (urine & blood)

Biastre SA, Slocum J.. A Core Curriculum for Diabetes Educators; 2003:145-146

Perinatal Perinatal complications complications

Similar to complications in pregnancy with Similar to complications in pregnancy with preexisting diabetes preexisting diabetes

• Macrosomia

Macrosomia

Abnormally large body size Abnormally large body size ~ 20 ~ 20-

• 32% of pregnancies with diabetes

32% of pregnancies with diabetes

• Stillbirth

Stillbirth

• Respiratory distress syndrome (RDS)

Respiratory distress syndrome (RDS)

• Hypocalcemia

Hypocalcemia, , Hyperbilirubinemia Hyperbilirubinemia, , polycythemia polycythemia

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:101-106

Long Long− −Term Term Complications of GDM Complications of GDM

↑ ↑ risk of developing GDM in future risk of developing GDM in future pregnancies pregnancies

• ~ 30

~ 30-

• 50%

50%

↑ ↑ risk of developing type 2 diabetes risk of developing type 2 diabetes ↑ ↑ risk of obesity in offspring risk of obesity in offspring ↑ ↑ risk for offspring to develop intellectual risk for offspring to develop intellectual and neurological conditions and neurological conditions

Metzger BE et al. Diabetes Care. 1998;21

Diagnosis of GDM Diagnosis of GDM

Risk assessment at first prenatal visit Risk assessment at first prenatal visit

Low Risk Low Risk High Risk High Risk

< 25 years of age < 25 years of age Obesity Obesity Normal weight prior to Normal weight prior to pregnancy pregnancy History of GDM History of GDM No family history of No family history of diabetes diabetes Family history of diabetes Family history of diabetes No history of glucose No history of glucose intolerance intolerance Glycosuria Glycosuria Ethnicity of low risk Ethnicity of low risk Ethnicity of high risk Ethnicity of high risk

Diagnosis of GDM Diagnosis of GDM

Women at low to average risk screened Women at low to average risk screened between weeks 24 between weeks 24− −28 of gestation 28 of gestation Women at high risk should be screened as Women at high risk should be screened as early as possible early as possible

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

Diagnosis of GDM Diagnosis of GDM

Screening test (step 1) Screening test (step 1)

• 50 g oral glucose load (random)

50 g oral glucose load (random)

• Plasma glucose level > 130 mg/dl

Plasma glucose level > 130 mg/dl

1 hour postprandial 1 hour postprandial

• Proceed to OGTT step 2

Proceed to OGTT step 2

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

Diagnosis of GDM Diagnosis of GDM

Diagnosis criteria (step 2) Diagnosis criteria (step 2)

• 100 g glucose load after overnight fast of no less than

100 g glucose load after overnight fast of no less than 8 hours and no more than 14 hours 8 hours and no more than 14 hours

• 3

3-

• hour test

hour test Fasting: Fasting: 95 mg/dl 95 mg/dl 1 hour 1 hour 180 mg/dl 180 mg/dl 2 hour 2 hour 155 mg/dl 155 mg/dl 3 hour 3 hour 140 mg/dl 140 mg/dl

2 or more exceed limit: GDM diagnosis 2 or more exceed limit: GDM diagnosis

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

Management of GDM Management of GDM

NonPharmacological NonPharmacological

• DSME Education

DSME Education

• Exercise/Activity

Exercise/Activity

• Medical Nutrition

Medical Nutrition Therapy Therapy

• SMBG

SMBG

• Weight Management

Weight Management Pharmacological Pharmacological

• Insulin

Insulin

Medical Nutrition Therapy for GDM Medical Nutrition Therapy for GDM

Primary treatment Primary treatment CHO controlled meal plans CHO controlled meal plans

• Control of BG levels

Control of BG levels

Appropriate weight gain Appropriate weight gain

• Avoid maternal ketosis

Avoid maternal ketosis

Meal plans to deliver appropriate nutrients Meal plans to deliver appropriate nutrients ↓ ↓ hypoglycemia, nausea, vomiting hypoglycemia, nausea, vomiting

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

MNT and SMBG MNT and SMBG

SMBG can assist in making appropriate SMBG can assist in making appropriate food adjusts in the meal plan food adjusts in the meal plan

• CHO affects postprandial BG levels

CHO affects postprandial BG levels

• Minimum of 175 g/day to assure fuel for CNS

Minimum of 175 g/day to assure fuel for CNS for fetus and mother for fetus and mother

• Monitor fasting,

Monitor fasting, preprandial preprandial, 1 , 1− − and/or 2 and/or 2− −hour hour postprandial and bedtime BG levels postprandial and bedtime BG levels

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

GDM Blood Glucose Goals GDM Blood Glucose Goals

Fasting Fasting < 105 mg/dl < 105 mg/dl 1 hour postprandial 1 hour postprandial < 155 mg/dl < 155 mg/dl 2 hour postprandial 2 hour postprandial < 130 mg/dl < 130 mg/dl

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

Exercise and Activity Exercise and Activity

Activity Activity

Can improve glucose intolerance Can improve glucose intolerance Should be encouraged Should be encouraged Best BG lowering effect observed with 1 Best BG lowering effect observed with 1 hour of activity hour of activity Obtain medical clearance before starting Obtain medical clearance before starting an exercise program during pregnancy an exercise program during pregnancy

• Avoid with HTN, preterm labor history,

Avoid with HTN, preterm labor history, persistent bleeding persistent bleeding

Avery MD et al. Obstet Gynecol. 1997;89:10-15.

Insulin Therapy Insulin Therapy

Only Human insulin used in GDM Only Human insulin used in GDM

• ↓

↓ risk of risk of transplacental transplacental transport of anti transport of anti-

• insulin

insulin antibodies antibodies

Start if BG goals not achieved Start if BG goals not achieved

• ~ 20%

~ 20%-

• 25% of women with GDM require

25% of women with GDM require insulin therapy insulin therapy

• ↓

↓ risk risk macrosomia macrosomia

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.

Insulin Therapy Insulin Therapy

Insulin regimens should be individualized Insulin regimens should be individualized

• ↑

↑ insulin needs thru progression of pregnancy insulin needs thru progression of pregnancy

• Adjust dosage accordingly to BG levels

Adjust dosage accordingly to BG levels

• Obese patients may need large amounts of

Obese patients may need large amounts of insulin insulin

Starting dose: Starting dose:

• Standardized

Standardized

• Based on body weight

Based on body weight

Jovanovic-Peterson L et al. J Am Coll Nutr. 1992;71:921-927

Oral Oral Antidiabetic Antidiabetic Agents in GDM Agents in GDM

Currently NOT recommended during Currently NOT recommended during pregnancy pregnancy No oral anti No oral anti-

• diabetic agents are approved

diabetic agents are approved by the FDA for treatment of GDM by the FDA for treatment of GDM

Postpartum Care Postpartum Care

Normal glucose tolerance returns usually Normal glucose tolerance returns usually after delivery after delivery Women with history of GDM should be Women with history of GDM should be screened for type 2 diabetes regularly screened for type 2 diabetes regularly Preconception planning should be Preconception planning should be emphasized for subsequent pregnancies emphasized for subsequent pregnancies Contraception choices reviewed Contraception choices reviewed Nutrition and activity Nutrition and activity

Metzger BE et al. Diabetes Care. 1998;21

Key Take Home Points Key Take Home Points

Women at high risk should be screened and Women at high risk should be screened and tested for GDM early tested for GDM early Diabetes care and glucose control need to be Diabetes care and glucose control need to be monitored very closely during pregnancy monitored very closely during pregnancy

• Medical Nutrition Therapy should be the primary and

Medical Nutrition Therapy should be the primary and continual treatment. continual treatment.

• Treatment plans should be reviewed regularly for

Treatment plans should be reviewed regularly for necessary adjustments necessary adjustments

Education and monitoring in the postpartum Education and monitoring in the postpartum period period

What Questions Can I Answer What Questions Can I Answer for You ??? for You ???