PREGESTATIONAL DIABETES (TYPE 1 AND 2)

Transcription

1 PREGESTATIONAL DIABETES (TYPE 1 AND 2) Women with diabetes prior to pregnancy need to evaluate and optimize their baseline to assure the healthiest pregnancy possible.[1] The overall prevalence of pregnant women with pregestational diabetes mellitus increased from 0.81 percent in 1999 to 1.82 percent in [2] Women with poorly controlled sugars during the period of fetal organogenesis, which is nearly complete by seven weeks postconception, have a high incidence of spontaneous abortion and fetuses with congenital anomalies. [3] The rate of major congenital anomalies in women with pregestational diabetes is far higher than those in the general population. In the United Kingdom, the likelihood is approximately 12.3% and in South Africa 3%, with an overall average of 8% in 17 studies published since The rate of major anomalies in the general population is reported at ranging from 1.6% to 3.1% in the same studies published since Some differences exist based on whether a woman has Type 1 or 2 diabetes. The severity and duration of type 1 disease and the existence of vascular complications were associated with prematurity and perinatal mortality. Poor metabolic control, obesity and their consequences are the primary factors associated with adverse perinatal outcome in Type 2 diabetics (eg, malformation, macrosomia). [4]

2 Maternal Health Physiological changes associated with pregnancy can adversely impact maternal health. Nephropathy, retinopathy, hypertension, cardiovascular disease and thyroid disease can all affect and be affected by pregnancy. Nephropathy- the risk of permanent loss of renal function correlates with the pre-pregnancy creatinine concentration. Pregnancy is not associated with permanent worsening of renal function in the majority of diabetic women in the absence of uncontrolled hypertension or a baseline serum creatinine concentration above 1.5 mg/dl. [5,6] Women with significant renal insufficiency, pre-pregnancy, have about a 50% likelihood of worsening renal function after pregnancy. [7] The pre-pregnancy presence of nephropathy is related to the duration of diabetes (Type 1 greater than Type 2) and relative lack of control of glucose levels. Retinopathy- diabetic retinopathy worsens in some women during pregnancy, although it is not likely to develop de novo in women with no retinopathy before pregnancy. [8] Long term reduction of retinopathy is positively correlated with tight glycemic control. Soft exudates and microaneurysms are the main findings on fundoscopic examination. The pre-pregnancy presence of retinopathy is related to the duration of diabetes (Type 1 greater than Type 2) and relative lack of control of glucose levels Hypertension- the prevalence of hypertension and preeclampsia is increased in pregnant women with diabetes and is related to both pregestational hypertension and vascular disease. Acker reported the prevalence of preeclampsia in diabetics with and without vascular disease was 17 and 8 percent, respectively, compared to a rate of 5 to 8 percent in nondiabetic pregnancies. [9] This is a circumstance wherein modification of maternal glucose levels can decrease the incidence of toxemia.

3 Cardiovascular Disease- women with diabetes have a higher likelihood of having atherosclerosis due both to diabetes and to its associated conditions such as dyslipidemias. Because pregnancy increases cardiac output it a thorough evaluation pre-pregnancy is warranted. [10,11] Thyroid Disease- there is a well described association between Type 1 diabetes and immunemediated thyroid dysfunction. [12,13] The risk of developing thyroid dysfunction is 5 to 10 percent annually in women with type 1 diabetes. Management It is highly desirable for women with type 2 diabetes to be of normal body weight. Although not possible once pregnancy has been diagnosed, weight loss is always recommended at a preconceptional consultation to pregestational diabetic, over weight women. Long-term enhancement of average glucose levels is the key to long-term health and living with diabetes. During pregnancy outcomes for both mother and fetus are enhanced by tight glycemic control in women with pregestational diabetes. Long-term health is also improved with tight glycemic control. The preconceptional consultation is the time to move toward achieving appropriate pregnancy-standard glycemic control. At DWC, we believe in achieving fasting blood sugars less than 100 and two-hour postprandial blood sugars less than 120 with four times daily blood sugar determination (fasting and two hours postprandial breakfast, lunch, and dinner). If these glycemic levels can be achieved with diet that is fine, and if oral hypoglycemic agents or insulin are required to achieve optimal glucose control that will be instituted. Based on patient's insurance, it is possible to have home nursing service such as Alere provide the diabetic teaching and diabetic control with insulin, and in other cases, it is essential for the DWC physicians to provide this service in the hospital.

4 References 1. American Diabetes Association. Preconception care of women with diabetes. Diabetes Care 2004; 27 Suppl 1:S Lawrence JM, Contreras R, Chen W, Sacks DA. Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, Diabetes Care 2008; 31: Temple R, Aldridge V, Greenwood R, et al. Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: population based study. BMJ 2002; 325: Gonzalez-Gonzalez NL, Ramirez O, Mozas J, et al. Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus. Acta Obstet Gynecol Scand 2008; 87: Miodovnik M, Rosenn BM, Khoury JC, et al. Does pregnancy increase the risk for development and progression of diabetic nephropathy? Am J Obstet Gynecol 1996; 174: Kitzmiller JL, Brown ER, Phillippe M, et al. Diabetic nephropathy and perinatal outcome. Am J Obstet Gynecol 1981; 141: Irfan S, Arain TM, Shaukat A, Shahid A. Effect of pregnancy on diabetic nephropathy and retinopathy. J Coll Physicians Surg Pak 2004; 14: Star J, Carpenter MW. The effect of pregnancy on the natural history of diabetic retinopathy and nephropathy. Clin Perinatol 1998; 25: Acker, DB, Barss, VA. Obstetrical complications. In: Diabetes Complication Pregnancy, 2nd edition, Brown, FM, Hare, JW (Eds), Wiley-Liss, New York p Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005; 353: Laing SP, Swerdlow AJ, Slater SD, et al. Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia 2003; 46: Perros P, McCrimmon RJ, Shaw G, Frier BM. Frequency of thyroid dysfunction in diabetic patients: value of annual screening. Diabet Med 1995; 12: Hillier TA, Vesco KK, Pedula KL, et al. Screening for gestational diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2008; 148:766.

5 PREGESTATIONAL DIABETES ORDERS Labs Prenatals HgB A1-C Fasting glucose 24-hour urine collection (Total Protein & Createnine clearance rate ml / minute) DWC Glycemic Record Diabetic Supplies Lancets alcohol wipes test strips glucometer Opthalmology Consultation Dietician Consultation Alere Consultation