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 prior to prior to conception) conception) (diabetes ~ 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 during during pregnancy) pregnancy) (onset ~ 7% of pregnancies ~ 7% of pregnancies Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:99-101
Pregnancy with pre- -existing existing Pregnancy with pre diabetes diabetes (diabetes prior to prior to conception) conception) (diabetes
Perinatal Complications Complications Perinatal Complications are related to the level of Complications are related to the level of maternal glycemia glycemia maternal Complications in the First- -Trimester: Trimester: Complications in the First � 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 complications complications Perinatal 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, , Hyperbilirubinemia Hyperbilirubinemia, , Hypocalcemia 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 ketones ketones acids and ↑ 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 ketonemia ketonemia and and Critical to avoid 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 − acting short − � ↑ ↑ dosages of rapid or dosages of rapid or short 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 Pharmacological NonPharmacological Pharmacological � DSME education DSME education � Insulin Insulin � � 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 �
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 antidiabetic antidiabetic agents (if agents (if Discontinue oral 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 − Management Self − Management skill assessment skill assessment Self � 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.
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