Diabetes in Pregnancy Guidelines


#1

What are the guidelines for Diabetes in Pregnancy?


#2

ADA 2016 guidelines for Diabetes in Pregnancy

Diabetes in Pregnancy (Gestational Diabetes)

Screening for Gestational Diabetes Mellitus (GDM)
For screening recommendations, click here for Diabetes Screening and Diagnosis
Glycemic Targets in Pregnancy
Pregestational diabetes Gestational diabetes mellitus (GDM)
Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L)
1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L)
2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L)
A1C 6.0-6.5% (42-48 mmol/L) recommended
<6.0% may be optimal as pregnancy progresses
Achieve without hypoglycaemia

Recommendations for Pregestational Diabetes
Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM

Spontaneous abortion
Fetal anomalies
Preeclampsia
Intrauterine fetal demise
Macrosomia
Neonatal hypoglycemia
Neonatal hyperbilirubinemia

Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life
Maintain A1C levels as close to normal as is safely possible

Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia

Discuss family planning

Prescribe effective contraception until woman is prepared to become pregnant

Women with preexisting type 1 or type 2 diabetes

Counsel on the risk of development and/or progression of diabetic retinopathy
Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum

Management of Pregestational Diabetes
Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin
Insulin* management during pregnancy is complex

Requires frequent titration to match changing requirements
Referral to specialized center recommended

Women with type 1 diabetes are at high risk for hypoglycemia

Hypoglycemia education important before and during pregnancy to prevent hypoglycemia

Women with type 1 diabetes are at risk for ketoacidosis

At lower blood glucose levels than in the nonpregnant state
Provide education on prevention and treatment of diabetic ketoacidosis

Women with type 2 diabetes are at risk for obesity

Recommended weight gain during pregnancy: 15-25 lb overweight, 10-20 lb obese
Glycemic control easier to achieve than in type 1 but can require higher insulin doses

Targets:

Fasting ≤90 mg/dL (5.0 mmol/L)
1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L)
2-hr postprandial ≤120 mg/dL (6.7 mmol/L

*Most insulins are category B; glargine, glulisine, and degludec are category C

Recommendations for Gestational Diabetes Mellitus (GDM)
GDM increases the risk of macrosomia, birth complications, and maternal diabetes after pregnancy

Risks increase with progressive hyperglycemia
Risk may be reduced with diet, physical activity, and lifestyle counseling

Lifestyle management

Medical nutrition, physical activity, weight management

Pharmacologic therapy

Insulin* is first line
Requires frequent titration to match changing requirements
Referral to specialized center recommended

Sulfonylureas:
May be inferior to insulin and metformin due to increased risk of neonatal hypoglycemia and macrosomia
No long-term safety data

Metformin
May be preferable to insulin for maternal health if can control hyperglycemia
May increase risk of prematurity
Lower hypoglycemia & weight gain
Long-term outcomes in offspring not known

*Most insulins are category B; glargine, glulisine, and degludec are category C

Recommendations for Postpartum Follow-Up in Women With GDM

An oral glucose tolerance test (OGTT) is recommended at the 6- to 12-week postpartum visit
GDM is associated with increased maternal risk for type 2 diabetes

Test women with GDM every 1-3 years if her 6- to 12-wk OGTT is normal
The frequency of screening is based on the presence of risk factors: family history, pre-pregnancy BMI, or need for insulin or OAD medications during pregnancy
Ongoing screening may be done with any glycemic test (A1C, fasting plasma glucose, OGTT) using nonpregnancy cut points

Metformin and intensive lifestyle changes prevent or delay progression to type 2 diabetes

Managing Hypertension During Pregnancy
Target BP for pregnancy complicated by diabetes
SBP: 110-129 mm Hg
DBP: 65-79 mm Hg

Antihypertensive medications
Safe medications

Methyldopa
Labetalol
Diltiazem
Clonidine
Prazosin


#3

This is a useful article. May i suggest a picture that would be nice for FB sharing. Thanks


#4

Sure! That would be nice


#5


#6

Labetalol is betablocker could be used orally and IV but if the treatment not reach the target Bp 135/90 and you cannot give Diltizem as CCB that increase of heart block.


#7

is metformin use in gestational diabetes contraindicated?? if it is indicated what is the precautions and side effescts…what is the proper doses and duration of treatment…???


#8

Pregnancy Risk Factor B

Pregnancy Implications Adverse events have not been observed in animal reproduction studies. Metformin has been found to cross the placenta in concentrations which may be comparable to those found in the maternal plasma. Pharmacokinetic studies suggest that clearance of metformin may increase during pregnancy and dosing may need adjusted in some women when used during the third trimester (Charles 2006; de Oliveira Baraldi 2011; Eyal 2010; Gardiner 2003; Hughes 2006; Vanky 2005).
An increased risk of birth defects or adverse fetal/neonatal outcomes has not been observed following maternal use of metformin for GDM or type 2 diabetes when glycemic control is maintained (Balani 2009; Coetzee 1979; Coetzee 1984; Ekpebegh 2007; Niromanesh 2012; Rowan 2008; Rowan 2010; Tertti 2008). In women with diabetes, maternal hyperglycemia can be associated with congenital malformations as well as adverse effects in the fetus, neonate, and the mother (ACOG 2005; ADA 2015; Kitzmiller 2008; Metzger 2007). To prevent adverse outcomes, prior to conception and throughout pregnancy maternal blood glucose and HbA1c should be kept as close to target goals as possible but without causing significant hypoglycemia (ACOG 2013; ADA 2015; Blumer 2013; Kitzmiller 2008). Prior to pregnancy, effective contraception should be used until glycemic control is achieved (Kitzmiller 2008).

Metformin may be used to treat GDM when nonpharmacologic therapy is not effective in maintaining glucose control (ACOG 2013). Metformin or lifestyle intervention may also be used in women with a history of GDM who later develop prediabetes in order to prevent or delay type 2 diabetes (ADA 2015).

Metformin is recommended to treat insulin resistance associated with PCOS; however, its use may also restore spontaneous ovulation. Women with PCOS who do not desire to become pregnant should use effective contraception. Although studied for use in women with anovulatory PCOS, there is no evidence that it improves live birth rates or decreases pregnancy complications. Routine use to treat infertility related to PCOS is not currently recommended (ACOG 2009; Fauser 2012).