management of diabetes in pregnancy 2018

Women with greater initial degrees of hyperglycemia may require earlier initiation of pharmacologic therapy. In pregnant patients with diabetes and chronic hypertension, blood pressure targets of 120–160/80–105 mmHg are suggested in the interest of optimizing long-term maternal health and minimizing impaired fetal growth. TE>0j2-BS!D!ct#[G1(eI94rX-?W/8lVeCJC@sCj_t3J0?ss\sf>OIV9MZ]V+n"@8 << Hypertension in pregnancy. >> /Rotate 0 /Length 587 /Type /Page The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment … In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. This guideline covers managing diabetes and its complications in women who are planning pregnancy or are already pregnant. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules. Holmsen ST, Bakkebo T, Seferowicz M, Retterstol K. Statins and breastfeeding in familial hypercholesterolaemia. The physiology of pregnancy requires frequent titration of insulin to match changing requirements. Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. Both type 1 diabetes and type 2 diabetes in pregnancy confer significantly greater maternal and fetal risk than GDM, with some differences according to type of diabetes as outlined below. 1 0 obj >> care.diabetesjournals.org These levels should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight. Interpregnancy or postpartum weight gain is associated with increased risk of adverse pregnancy outcomes in subsequent pregnancies (63) and earlier progression to type 2 diabetes. Perinatal mortality and morbidity is increased in diabetic pregnancies through increased stillbirths and congenital malformation rates. false /Parent 2 0 R Obstet Gynecol 2013;122:1122–1131, Sign In to Email Alerts with your Email Address. Because GDM may represent preexisting undiagnosed type 2 or even type 1 diabetes, women with GDM should be tested for persistent diabetes or prediabetes at 4–12 weeks postpartum with a 75-g OGTT using nonpregnancy criteria as outlined in Section 2 “Classification and Diagnosis of Diabetes.”. All pregnant women presenting with polyuria and polydipsia should be investigated with blood tests including urea and electrolytes, calcium levels and thyroid function tests. Randomized, double-blind, controlled trials comparing metformin with other therapies for ovulation induction in women with polycystic ovary syndrome have not demonstrated benefit in preventing spontaneous abortion or GDM (42), and there is no evidence-based need to continue metformin in such patients once pregnancy has been confirmed (43–45). /Resources 35 0 R care.diabetesjournals.org Faculty: Susan J. /Contents 45 0 R Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Volume 42, Supplement 1, Pages A1-A18, S1-S326 (April 2018) © 2021 by the American Diabetes Association. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including high-risk obstetrician, endocrinologist, or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. Undiagnosed or inadequately treated GDM … /Rotate 0 doi: 10.2337/dc21-S014. Diabetes Care. << /Parent 2 0 R Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (18,19). endobj Recommended weight gain during pregnancy for overweight women is 15–25 lb and for obese women is 10–20 lb (51). 8 0 obj /ColorSpace 60 0 R NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. None of the currently available insulin preparations have been demonstrated to cross the placenta. /Type /Page For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction. /Type /Page This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. >> /Metadata 4 0 R In the second trimester, rapidly increasing insulin resistance requires weekly or biweekly increases in insulin dose to achieve glycemic targets. Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve glycemic control. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. In general, specific risks of uncontrolled diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, and neonatal hyperbilirubinemia, among others. 10 0 obj << This applies to women in the immediate postpartum period. In the prospective Nurses' Health Study II, subsequent diabetes risk after a history of GDM was significantly lower in women who followed healthy eating patterns (62). Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 systematic review (37). As in type 1 diabetes, insulin requirements drop dramatically after delivery. << endstream The purposes of this document are to provide a brief overview of the understanding of GDM, review management guidelines that have been validated by appropriately conducted clinical research, and identify gaps in current knowledge toward which future research can … 13 0 obj More information is available at http://www.diabetesjournals.org/content/license. This guideline covers managing diabetes and its complications in women who are planning pregnancy or are already pregnant. Findings Management considerations vary depending on whether women are in the preconception, pregnancy, or postpartum stage. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin. We do not capture any email address. ABSTRACT: Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. These values represent optimal control if they can be achieved safely. /Length 1677 To minimize the occurrence of complications, beginning at the onset of puberty or at diagnosis, all women with diabetes of childbearing potential should receive education about 1) the risks of malformations associated with unplanned pregnancies and poor metabolic control and 2) the use of effective contraception at all times when preventing a pregnancy. B. Pregnancy in women with normal glucose metabolism is characterized by fasting levels of blood glucose that are lower than in the nonpregnant state due to insulin-independent glucose uptake by the fetus and placenta and by postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones. E, Potentially teratogenic medications (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be avoided in sexually active women of childbearing age who are not using reliable contraception. stream In a pregnancy complicated by diabetes and chronic hypertension, target goals for systolic blood pressure 120–160 mmHg and diastolic blood pressure 80–105 mmHg are reasonable (54). /Parent 2 0 R /Kids [5 0 R 6 0 R 7 0 R 8 0 R 9 0 R 10 0 R 11 0 R] Medications should be added if needed to achieve glycemic targets. /CropBox [0 0 593.9719848633 782.9860229492] /Subtype /XML During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, and intrauterine growth restriction (8). If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. 2017-11-21 In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (65). Key Points. << Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. /Annots [23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R] /Thumb 13 0 R There are various types of diabetes insipidus that occur due to different pathology that occurs outside of, during, and as a result of pregnancy. /Count 7 Evidence 2018 surveillance of diabetes in pregnancy: management from preconception to the postnatal period (NICE guideline NG3) Overview of 2018 surveillance methods NICE's surveillance team checked whether recommendations in diabetes in … Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after self-monitoring of blood glucose. Your diabetes health care team likely includes an endocrinologist or other diabetes specialist, a diabetes educator, a registered dietitian, and an eye specialist. 4 0 obj >> /Thumb 49 0 R Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to ensure that retinopathy does not progress. /MediaBox [0 0 593.9719848633 782.9860229492] 2. doi:10.2337/dc18-S013 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. /Rotate 0 /ProcSet [/PDF /Text] Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. endobj >> /Parent 2 0 R View This Abstract Online; 13. Insulin is the preferred agent for management of both type 1 diabetes and type 2 diabetes in pregnancy because it does not cross the placenta, and because oral agents are generally insufficient to overcome the insulin resistance in type 2 diabetes and are ineffective in type 1 diabetes. The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. E. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent self-monitoring of blood glucose. /Type /Page /Annots [37 0 R 38 0 R 39 0 R] The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). /Type /Pages /MediaBox [0 0 593.9719848633 782.9860229492] These are mainly the result of early fetal exposure to maternal hyperglycaemia. In a 2015 study targeting diastolic blood pressure of 100 mmHg versus 85 mmHg in pregnant women, only 6% of whom had GDM at enrollment, there was no difference in pregnancy loss, neonatal care, or other neonatal outcomes, although women in the less intensive treatment group had a higher rate of uncontrolled hypertension (55). Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy. The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study, Committee on Practice Bulletins--Obstetrics, Practice Bulletin No. Insulin sensitivity increases with delivery of the placenta and then returns to prepregnancy levels over the following 1–2 weeks. endobj /Filter [/ASCII85Decode /FlateDecode] /Shading 61 0 R http://dx.doi.org/10.2337/dc18-S013 ISBN: 978-1-4731-3017-3 2018 surveillance of diabetes in pregnancy: management from preconception to the postnatal period << B, Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women.

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