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Diabetes & Pregnanc y

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Women with diabetes in the first trimester would be classified as having type 2 diabetes. Women with diabetes in the first trimester would be classified as having type 2 diabetes. GDM is diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes. GDM is diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes.

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Epidemiology of glucose intolerance and GDM in women of child bearing age, Diabetes Care, 21, 1998 Prevalence of GDM Prevalence of GDM

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Preval ence of GDM% Diagnostic method yea r Population 0.6Chinese Melborne-Australia(Indian-born) 15.0 4.7-8.9IRAN 4.750&100g GTT2003TehranLarijani 8.950&100g GTT2005Bandar-abbasHadaegh 4.850&100g GTT2005ShahroodKeshavarz 750&100g GTT2007TehranMaghbooli 6.175g GTT2008TehranShirazian 7.475g GTT2009TehranShirazian

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Why Diagnose and Treat GDM?

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Dysglycemia in Pregnancy can Result in Adverse Pregnancy Outcome Elevated glucose levels can have adverse effects on the fetus 1 st trimester fetal malformations 2 nd and 3 rd trimester: risk of macrosomia and metabolic complications

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Risk of Fetal Anomaly Relative to Peri-conceptional A1C Guerin A et al. Diabetes Care 2007;30:1-6. Glycemic control pre-conception = essential

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Risks of Gestational Diabetes Risks of Gestational Diabetes MotherFetusNewbornChild/Adult Birth trauma Hyperinsulinemia Hyperinsulinemia HypoglycemiaObesity Increased cesarean delivery Cardiomyopathy Cardiomyopathy Respiratory distress Respiratory distresssyndrome Type 2 diabetes Preeclampsia/Gestationalhypertension Fetal organomegaly Hypocalcemia Metabolic syndrome Hydramnios Hyperviscosity impaired fine and gross motor functions impaired fine and gross motor functions Stillbirth Hypomagnesemia Type 2 diabetes LGA/macrosomia CardiomyopathyHyperbilirubinemia Perinatal mortality higher rates of inattention and/or hyperactivity higher rates of inattention and/or hyperactivity Metabolic syndrome Birth trauma Polycythemia Polycythemia

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GDM Pathogenesis Pregnancy is characterized by insulin resistance and hyperinsulinemia due to: placental secretion of diabetogenic hormones including: GH CRH Human placental lactogen (hPL) Progesterone increased maternal adipose deposition decreased exercise increased caloric intake These and other endocrinologic and metabolic changes ensure that the fetus has an ample supply of fuel and nutrients at all times. GDM occurs when pancreatic function is not sufficient to overcome the insulin resistance created by changes in diabetogenic hormones during pregnancy.

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Risk Factors for Gestational Diabetes Risk Factors for Gestational Diabetes

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Diabetes in Pregnancy: 2 Categories Pregestational diabetesGestational diabetes Pregnancy in pre-existing diabetes Type 1 diabetes Type 2 diabetes Diabetes diagnosed in pregnancy

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Women with diabetes in the first trimester would be classified as having type 2 diabetes. GDM is diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes.

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Need a Preconception Checklist for Women with Pre-existing Diabetes 1. Attain a preconception A1C of 7.0% (if safe) 2. Assess for and manage any complications 3. Switch to insulin if on oral agents 4. Folic Acid 5 mg/d: 3 months pre-conception to 12 weeks post-conception 5. Discontinue potential embryopathic meds: Ace-inhibitors/ARB (prior to or upon detection of pregnancy) Statin therapy

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PRECONCEPTION COUNSELING All women of childbearing age with diabetes should be counseled about the importance of strict glycemic control prior to conception. Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, and congenital heart disease, that increases directly with elevations in A1C. Spontaneous abortion is also increased in the setting of uncontrolled diabetes.

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A1C

Presentation titleSlide no 67Date n=28 n=41 n=110 n=93 0 10 20 30 40 50 60 70 80 90 Pre-term (< week 37) At term (> week 3742) % of deliveries (live or still births 22 weeks) NovoRapid HI Pre-term delivery lower frequency Hod M et al. Am J Obs Gyn,2007 *p = 0.053

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Presentation titleSlide no 68Date NovoRapid HI Neonatal hypoglycaemia Plasma glucose < 50 mg/dl Treatment given No treatment given 0 10 20 30 40 50 % of live births n=8 n=12 n=46 n=52 Hod M et al, Am J Obs Gyn,2007

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Longer-acting insulin analogs (insulin glargine, insulin detemir) have not been studied extensively in randomized trials of pregnant women.insulin glargineinsulin detemir A meta-analysis of observational data from 331 pregnancies with glargine exposure during the first, second, and/or third trimester showed no statistical increase in any maternal or neonatal adverse outcome compared with use of NPH. However, the number of women who have been treated with this drug in the first trimester is too small.

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The incidence of macrosomia was high in both glargine treated women (23.6 percent) and women treated with NPH (19.7 percent), and several-fold higher than the