PRE GESTATIONAL DIABETES. Conflicts

Transcription

1 PRE GESTATIONAL DIABETES Christopher Goodier, MD Assistant Professor, Maternal Fetal Medicine Medical University of South Carolina Conflicts I have no relevant disclosures or conflict of interest with the material I m presenting today. 1

2 Objectives 1. Normoglycemia in Pregnancy 2. Fetal Complications 3. Maternal Comorbidities 4. Pre conception planning 5. Antenatal management Glycemia in Normal Pregnancy Hernandez. Diabetes Care

3 Glycemic Patterns Median Results Fasting 71 1 hr hr hr average = 2 SD above Recommende d 1 hr < hr < Glycemic Profiles: NON DM Parretti. Diabetes Care

4 Glycemic Profiles: NON DM Diabetes Care Volume 40, Supplement 1, January 2017 COMPLICATIONS 4

5 Fetal Complications Glucose Thresholds Fetal Complications Anomalies 140 Fetal Death 110 Respiratory Dis 110 Macrosomia 100 Growth Restriction Hypoglycemia Sacral Agenesis Spina Bifida Anencephaly Heart Defects Congenital Anomalies 5

6 Anomalies Anomaly Risk Non diabetic 2% HbA1c 7% 3% HbA1c 9% 6% HbA1c 11% 10% Guerin. Diabetes Care Glycemic Control & Stillbirth Laurenborg. Diabetes Care

7 STILLBIRTH Age Years of DM Smoke Pre HbA1c Early HbA1c Late HbA1c EGA Stillbirth yrs 64% 7.9% 7.9% 8.0% 35 wks Reference yrs 29% 7.4% 7.0% 6.3% 37 wks Women who experienced stillbirth were characterized by a high incidence of suboptimal glycemic control, diabetic nephropathy, smoking and low socioeconomic status. CO MORBIDITIES 7

8 Hypertesnion Hyperlipidemia Retinopathy Neuropathy Nephropathy Cardiovascular Co Morbidities HYPERTENSION 8

9 CHIPS Trial Multicenter international RCT less tight control (DBP <100mmHg) vs tight control (DBP <85mmHg) 987 women 1 o outcome pregnancy loss or need for highlevel neonatal care No difference (31.4% vs 30.7%). Secondary outcomes No difference Preeclampsia (48.9% vs 45.7%) Abruption (2.3% vs 2.2%) Composite serious maternal complications (3.7% vs 2.0%) Magee NJM

10 CKD Non proteinuric non Diabetic CKD Proteinuric non Diabetic CKD Non proteinuric Diabetic CKD Proteinuric Diabetic CKD BP (mmhg) GOALs Proteinuria 140/90-130/80 < 1000 mg/day** 140/90* - 130/80 < 500 mg/day SBP below 120 NOT recommended as all-cause & CV mortality KDIGO 2011 AJKD Antihypertensive medication 10

11 ACE Inhibitor/ARB Bullo, Hypertension ACE Inhibitor and ARB cont d Bullo, Hypertension

12 Preeclampsia Elevated BP and proteinuria UPC >0.3, 24 hr UTP >300mg Without severe features With severe features BP >160/>110 Symptoms Lab abnormalities Aspirin TXA2 Prostacyclin Favor vasoconstrict Favor vasodilate 12

13 Aspirin LDA inhibits TXA2 > Prostacyclin production = vasodilate Henderson, Ann Int Med

14 RETINOPATHY Retinopathy Pregnancy major risk factor Development and progression Contributing factors Glycemic control Duration Severity of retinopathy Hypertension 14

15 Prevalence: 10 27% Progression 8 70% NPDR vs PDR Retinopathy Rahman, Clinical and Experimental Ophthalmology 2007 Retinopathy Toda, Jpn J Ophthalmol (2016) 15

16 Retinopathy Toda, Jpn J Ophthalmol (2016) Neuropathy No change course neuropathy Gastroparesis Relative contraindication Increased maternal morbidity and mortality Supportive therapy Antiemetics Prokinetic agents Enteral nutrition 16

17 Medical Nutrition Therapy Provide adequate nutrient intake for a healthy pregnancy Achieve/maintain normoglycemia Provide adequate weight gain Avoid starvation ketosis Provide appropriate food, physical activity, and behavior education Medical Nutrition Therapy Caloric composition Complex, carbohydrates 40 50% Protein 20% Fats, primarily unsaturated 30 40% calories Caloric Distribution * Breakfast 10 20% Lunch 20 30% Dinner 30 40% Snacks (up to 30%) 17

18 Exercise Blood Glucose Insulin requirements Harrison, et al JPHYS, 2016 Pre pregnancy consultation Dietary Modification Monitoring of Blood Glucose Goal A1C <6% Medication Continue/Discontinue Other Exercise Blood Glucose Insulin requirements 18

19 Medication Management Hypertension ACE Inhibitor/ARB Teratogenic Favor Aldomet/Labetalol/Procardia Hyoerlipidemia Statin Teratogenic IOM Weight Gain Guidelines in Pregnancy 19

20 Antenatal testing Non stress test Biophysical Profile CST Fetal growth U/S Doppler Studies Uterine artery MCA Ductus venosus 20

21 Preconception Concluison Goal A1C <6.0% Review complications of pregnancy D/C teratogenic medications Exercise/Weight control Diet modifications Eye examination Co morbidities 21