Diabetes in Pregnancy Ebony Boyce Carter, MD, MPH Division of Maternal Fetal Medicine Washington University School of Medicine Disclosures I have no financial disclosures to report. Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes 1
Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes Pathophysiology of Diabetes Metabolic disease with defects in insulin secretion and/or action resulting in hyperglycemia ADA Diabees Care 2004 Jan: 27 (suppl 1) Pathophysiology: Types of Diabetes Pre-Diabetes Gestational Diabetes 2
Pathophysiology Associated with long term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. ADA Diabees Care 2004 Jan: 27 (suppl 1) Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes Prevalence: Diabetes in the United States 3
Prevalence CDC reported in 2015-100 million Americans with Diabetes & PreDiabetes. 30.3 million diabetes 84.1 million with Pre-Diabetes 1.5 million new cases in < 20 years old in 2015 23.1 million (7.2 %) adults in US population have been diagnosed with Diabetes 11.7 million are women 7.2 million adults are undiagnosed. 3.1 million are women Leading cause of Maternal and Perinatal M & M. Complicates 1% of pregnancies Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes Screening: 4
Diagnosis Diagnosis Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes 5
Perinatal Morbidity: fetus and neonate RDS Congenital Anomalies Hypoglycemia SAB Fetus IUGR w/ Type I DM Newborn Hyperbilirubinemia LGA w/ Type II DM >90 th % Shoulder Dystocia Organomegaly Stillbirth Polycythemia Long term Health Risk: Obesity, metabolic syndrome, and Type II DM Perinatal Morbidity: fetus and neonate Perinatal Morbidity: Maternal Preterm Labor Preeclampsia (15-20% vs 50% with nephropathy) Increased risk of Cesarean Progressive retinopathy 6
Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes Antepartum Management: Pre-Existing Achieve excellent glycemic control Monitor Blood glucose 4-7x/day Fasting blood glucose Premeals 1 or 2 hours postprandial Bedtime (10 pm) Antepartum Management: GDM 7
Antepartum Management: target blood glucose Antepartum Management: Diet Counseling from Registered Dietician or Certified Diabetes Educator on Medical Nutrition Therapy (MNT) MNT is an evidenced based lifestyle intervention to improve outcomes in Diabetes Mellitus. Prevent ketosis, excessive weight gain,? Fetal programming, teach sustainable food choices CHO counting vs fixed CHO per meals 40-50% Complex CHO 20% Protein 30-40% Fats Antepartum Management: Diet Increase by 300 kcal/day Normal Body Weight 30-35 kcal/kg/day Less than normal body weight 30-40 kcal/kg/day Greater than normal body weight 24 kcal/kg/day 8
Antepartum Management: Initial OB Appt. Obtain baseline labs A1C TSH Baseline preeclampsia labs 24 hour urine for total protein and Creatinine clearance or Urine protein Creatinine ratio Eye Exam EKG Early Anatomic Survey vs. Specialized Anatomic survey Fetal Echo Serial fetal growth Ultrasound Fetal testing at 32 weeks 2x/week Antepartum Management: Medications Insulin Oral agents Metformin Glyburide Insulin Only FDA approved medication for Diabetes in pregnancy. Does not readily cross the placenta No association with fetal anomalies First line treatment for Diabetes and Gestational Diabetes Risk of hypoglycemia and hypokalemia 9
Insulin Initiation Weight based Calculations Trimester Total Daily Dose (units/kg) 1 st Trimester 0.7-0.8 2 nd Trimester 0.8-1.0 3 rd Trimester 0.9-1.2 Decrease total daily dose by 20% if insulin naïve. Insulin Preparations and Pharmacokinetics Insulin Onset of Action Peak Action (hours) Lispro (humalog), Aspart (novolog), Glulisine (Apidra) 1-15 mins 1-2 4-5 Duration of Action (hours) Regular (Humulin 30-60 mins 2-4 6-8 R, Novolin R) NPH (Humulin N, 2-4 hours 4-10 hours 10-20 hours Novolin N) Glargine (Lantus) 2 hours none 24 hours Detemir (Levemir) Insulin zinc suspension (Ultralente) 2 hours 3-9 hours 10-18 hours 2-4 hours 8-14 hours 18-30 hours 10
Insulin dose adjustment Adjust weekly No evidence to support an optimal algorithm to adjust doses Increase by 20% Antepartum Management: Blood Glucose goals Time Non Diabetic range mg/dl Diabetic range mg/dl Fasting 58-80 60-95 Premeal 65-90 60-100 1hr Postprandial 95-122 <140 (< 120) 2hr Postprandial <120 Bedtime 60-90 11
Oral Medications Recommended for Gestational Diabetes Metformin -> second line agent Glyburide -> third line agent Both cross the placenta and usually are not enough for control pregestational diabetes. Not Recommended (limited safety data) Glipizide Alpha glucosidase inhibitors (Acarbose) Thiazolidinedione ( Pioglitazone) Glucagon like peptide 1 Metformin Initiate 500mg bid Increase by 500 mg q 3-5 days Requires slow dose adjustments Maximum dose is 2500 mg daily Crosses placenta Insufficient glucose control Antepartum Management: Exercise Increases insulin sensitivity Increases glucose utilization May prevent excess weight gain ACOG recommendations based on 2008 US Department of Health and Human Services for Healthy pregnant women at least 150 minutes per week of moderate-intensity aerobic activity ( equivalent to brisk walking). This activity should be spread throughout the week and adjusted as medically indicated. 12
Hypoglycemia Hypoglycemia Hypoglycemia Treat with pure glucose correlates better with glucose response Avoid protein which may enhance insulin response to dietary carbohydrates\ Avoid ingesting fats which may delay and prolong acute glycemic response of treatment Patient should carry glucose tablets All patients should be prescribed glucagon pen 13
Diabetic Ketoacidosis (DKA) Triad: hyperglycemia, anion gap metabolic acidosis and ketonemia 1-3% of pregnancies complicated by Pregestational diabetes 9-35 % Fetal Mortality rate 5-15% Maternal Mortality rate More common in Type I Diabetes with rare occurrences in Type 2 and Gestational diabetes Teach women to recognize and report symptoms Instruct women to check for urine ketones if blood glucose is > 200 mg/dl DKA Symptoms Nausea Vomiting Thirst Polyuria Polydipsia Abdominal pain Mental status changes Renal dysfunction Signs Elevated glucose > 200 Anion gap > 12 meq/l Ketonemia Low serum bicarbonate 14
Fetal Heart Rate Tracing during DKA Sibai, B. Diabetic Ketoacidosis in Pregnancy. Obset Gynecol 2014; 123:167 Antepartum Management ACOG recommends visits 1-2 weeks < 28 weeks and weekly at 28-30 weeks. Low Dose Aspirin Specialized Anatomic Survey 18-20 weeks Serial Ultrasounds to monitor fetal growth ( Final scan 3 at least 3 weeks prior to delivery) Fetal Echo vs specialized heart views on Prenatal US Fetal testing at 32 weeks Twice Weekly Delivery at 39 weeks or earlier. Vasculopathy Nephropathy Poor glucose control Prior Stillbirth Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes 15
Intrapartum Management Goal is to keep BG < 110 mg/dl Prevent maternal hyperglycemia Prevent fetal hyperglycemia Prevent Neonatal hypoglycemia Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum Postpartum Discuss preconception counseling for diabetes 16
Postpartum Management Increase 500 kcal/day if breastfeeding Decrease insulin requirement 50% reduction in pre-delivery Further reduction if breastfeeding Objectives Review the pathophysiology of diabetes Discuss the prevalence of diabetes in pregnancy Review Diabetes Screening and Diagnosis Discuss morbidity with diabetes in pregnancy Review recommendations for diabetes management Antepartum Intrapartum postpartum Discuss preconception counseling for diabetes Preconception Counseling Target A1C < 6.0 (6.5) prior to pregnancy Review medications to ensure safe for pregnancy Folic Acid prior to conception Testing for complications: Cardiovascular disease Thyroid disease Neuropathy Nephropathy 17
Summary Excellent glycemic control decreases risk of perinatal morbidity and mortality. Insulin provides the best control and decreases risk of perinatal morbidity Attempt to keep Blood glucose < 110 prior to delivery Decrease insulin after delivery of placenta by 50% Preconception counseling has been proven to improve outcomes and should be encouraged. QUESTIONS??? 18