Medical Management of Pregnancy Complicated by Diabetes
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About this ebook
Topics include:
--Pre and Inter-pregnancy counceling, assessment, and management
--Contraception in diabetes and prediabetes
--Nutrition management of preexisting diabetes
--Risk assessment, fetal surveillance and delivery in prenancies complicated by diabetes
--Neonatal care of infants of mothers with diabetes
--Management of gestational diabetes
--Diagnostic testing and fetal surveillance
--Use of insulin in pregnancy and assessment of glycemic control
--Postpartum concerns for women with diabetes
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Medical Management of Pregnancy Complicated by Diabetes - American Diabetes Association
MEDICAL MANAGEMENT OF
PREGNANCY COMPLICATED BY DIABETES
SIXTH EDITION
Edited by
Erika Werner, MD
Associate Publisher, Books, Abe Ogden; Director, Book Operations, Victor Van Beuren; Managing Editor, Books, John Clark; Associate Director, Book Marketing, Annette Reape; Acquisitions Editor, Jaclyn Konich; Senior Manager, Book Editing, Lauren Wilson; Composition, Cenveo Publisher Services; Cover Design, American Diabetes Association; Printer, Lightning Source®.
©2019 by the American Diabetes Association. All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including duplication, recording, or any information storage and retrieval system, without the prior written permission of the American Diabetes Association.
Printed in the United States of America
1 3 5 7 9 10 8 6 4 2
The suggestions and information contained in this publication are generally consistent with the Standards of Medical Care in Diabetes and other policies of the American Diabetes Association, but they do not represent the policy or position of the Association or any of its boards or committees. Reasonable steps have been taken to ensure the accuracy of the information presented. However, the American Diabetes Association cannot ensure the safety or efficacy of any product or service described in this publication. Individuals are advised to consult a physician or other appropriate health care professional before undertaking any diet or exercise program or taking any medication referred to in this publication. Professionals must use and apply their own professional judgment, experience, and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise, or medication. The American Diabetes Association—its officers, directors, employees, volunteers, and members—assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the suggestions or information in this publication.
Matt Petersen conducted the internal review of this book to ensure that it meets American Diabetes Association guidelines.
The paper in this publication meets the requirements of the ANSI Standard Z39.48-1992 (permanence of paper).
ADA titles may be purchased for business or promotional use or for special sales. To purchase more than 50 copies of this book at a discount, or for custom editions of this book with your logo, contact the American Diabetes Association at the address below or at booksales@diabetes.org.
American Diabetes Association
2451 Crystal Drive, Suite 900
Arlington, VA 22202
DOI: 10.2337/9781580406987
Library of Congress Cataloging-in-Publication Data
Names: Werner, Erika, editor. | American Diabetes Association.
Title: Medical management of pregnancy complicated by diabetes / [edited by] Erika Werner.
Description: 6th edition. | Arlington : American Diabetes Association, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018050557 | ISBN 9781580406987 (softcover : alk. paper)
Subjects: | MESH: Pregnancy in Diabetics–therapy | Diabetes, Gestational–therapy | Diabetes Mellitus | Pregnancy Outcome
Classification: LCC RG580.D5 | NLM WQ 248 | DDC 618.3–dc23 LC record available at https://lccn.loc.gov/2018050557
Contents
Foreword
Acknowledgments
List of New Contributors
Pre- and Interpregnancy Counseling, Assessment, and Management
Highlights
Preexisting Diabetes
Prepregnancy Counseling
Prepregnancy Assessment
Prepregnancy Management
Previous Gestational Diabetes Mellitus
Selected Readings
References
Assessment of Glycemic Control
Highlights
Normoglycemia during Pregnancy
Self-Monitoring of Capillary Blood Glucose
Site of SMBG
Timing of SMBG
Continuous Glucose Monitoring in Pregnancy
Factors Affecting Glucose Levels
Other Measures of Metabolic Control
Ketonuria and Ketonemia
Selected Reading
References
Lifestyle Management for Diabetes in Pregnancy
Highlights
Weight Gain Recommendations
Controversy: Calorie Restriction for Obese Patients
Nutritional Management in Pregnancy
For Preexisting Diabetes
For Gestational Diabetes Mellitus
Individualized Meal Planning and Recordkeeping
Macronutrients
Energy
Carbohydrate
Dietary Fiber
Glycemic Index
Resistant Starch and High-Amylose Foods
Protein
Dietary Fat
Micronutrients
Sodium
Folate
Iron
Vitamin D and Calcium
Other Nutrients
Vitamin and Mineral Supplementation
Food Safety
Caffeine
Alcohol
Nonnutritive Sweeteners
Herbal Medicines and Supplements
Listeria
Mercury
Exercise as a Treatment Modality
Selected Readings
References
Medication Management of Diabetes in Pregnancy
Highlights
Metabolic Changes during Pregnancy
Antenatal Insulin Use
Insulin Pumps
Dosage Adjustment
Hypoglycemia
Insulin Use and Preterm Delivery
Insulin Use during Labor and Delivery
Oral Antidiabetic Agents for Women with GDM
Metformin
Glyburide
References
Risk Assessment, Fetal Surveillance, and Delivery in Pregnancies Complicated by Diabetes
Highlights
Screening, Diagnostic Testing, and Fetal Surveillance
Genetic Screening
Ultrasound
Antenatal Testing
Timing and Mode of Delivery
Selected Readings
References
Common Complications of Diabetes in Pregnancy
Highlights
Hyperemesis and Gastroparesis
Nonpharmacologic Treatments
Pharmacologic Treatments
Insulin Adjustments
Preterm Birth
Preeclampsia
Diabetic Ketoacidosis
Congenital Anomalies and Perinatal Deaths
References
Neonatal Care of Infants of Mothers with Diabetes
Highlights
Overview
Newborn Outcomes
Congenital Anomalies
Cardiomyopathy
Macrosomia, Birth Injury, and Asphyxia
Intrauterine Growth Restriction
Respiratory Distress
Hypoglycemia
Hypocalcemia and Hypomagnesemia
Hyperbilirubinemia and Erythremia
Nursery Care
Glucose Homeostasis
Resuscitation
Long-Term Follow-Up
Offspring Adiposity and Cardiometabolic Health
Offspring Cognitive Abilities
References
Postpartum Concerns for Women with Diabetes
Highlights
Postpartum Care
Breast-Feeding
Nutrition Recommendations
Postpartum Nutrition Management
Macronutrients
Micronutrients
Selected Readings
References
Contraception in Women with Diabetes and Prior Gestational Diabetes Mellitus
Highlights
Hormonal Contraceptives Background
Long-Acting Reversible Contraceptives: Intrauterine Devices and Implants
Intrauterine Devices
Implants
Non-LARC Hormonal Contraceptives
Combined Estrogen and Progestin Contraceptives
Progestin-Only Contraceptives
Permanent Sterilization
Selected Readings
References
Index
Foreword
This sixth edition is intended to provide updated guidance on the care of pregnant women with preexisting diabetes, including both types 1 and type 2 diabetes, as well as women with gestational diabetes mellitus. The care of pregnant women with diabetes and gestational diabetes mellitus requires a committed healthcare team and considerable resources. It is our hope that the information in this book will be helpful in enabling the various healthcare professionals who make up that team to have access to practical advice and carry out their mission. Each of the contributors is engaged actively in optimizing the care of pregnant women with diabetes either through clinical care or research. Although there are many reasonable approaches to providing that care, we have outlined herein those that we find to be most effective.
Acknowledgments
The last edition of this book was edited by Dr. Donald Coustan, a gifted clinician, educator, and researcher. Dr. Coustan has mentored many of us who now care for women with diabetes in pregnancy. His work has forever changed diabetes-in-pregnancy care and inspired the next generation of diabetes-in-pregnancy leaders. Although we have updated this edition, the fifth edition was beyond thorough, and as such, we used it as the foundation for most of what is included here. Therefore, we would like to acknowledge the important contributions of the many health professionals who contributed to previous editions of this book.
Susan Biastre, RD, LDN, CDE
Richard M. Cowett, MD
Julie M. Daley, RN, MS, CDE
Stephanie Dunbar, MPH, RD
Carol J. Homko, RN, PhD, CDE
Donna Jornsay, RN, BSN, CPNP, MSS, ACSW
Sue Kirkman, MD
John L. Kitzmiller, MD
Siri Kjos, MD, MSEd
Abbot R. Laptook, MD
Lisa Marasco, MA, IBCLC, FILCA
Noreen Hall Papatheodorou, MSS, ACSW
Anne M. Patterson, RD, MPH
List of New Contributors
Nansi S. Boghossian, PhD, MPH
Assistant Professor
Arnold School of Public Health of University of South Carolina
Department of Epidemiology and Biostatistics
Columbia, SC
Ebony Boyce Carter, MD, MPH
Assistant Professor
Washington University School of Medicine
Department of Obstetrics and Gynecology
St. Louis, MO
Erin Cleary, MD
Assistant Professor
Warren Alpert Medical School of Brown University
Obstetrics and Gynecology
Women and Infants Hospital of Rhode Island
Providence, RI
Maureen Hamel, MD
Assistant Professor
University of Pittsburgh
Division of Maternal Fetal Medicine
Pittsburgh, PA
Christina Han, MD
Associate Professor
University of California, Los Angeles
Obstetrics and Gynecology
Center for Fetal Medicine and Women’s Ultrasound
Los Angeles, CA
Lorie Harper, MD, MSCI
Associate Professor
University of Alabama at Birmingham
Division of Maternal-Fetal Medicine
Birmingham, AL
Teri L. Hernandez, PhD, RN
Associate Professor of Medicine and Nursing
University of Colorado, Anschutz Medical Campus
Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes
Denver, CO
Pre- and Interpregnancy Counseling, Assessment, and Management
Highlights
Preexisting Diabetes
Prepregnancy Counseling
Prepregnancy Assessment
Prepregnancy Management
Previous Gestational Diabetes Mellitus
Selected Readings
References
Highlights
Pre- and Interpregnancy Counseling, Assessment, and Management
■ With proper counseling and management by the healthcare team, the outcome of most pregnancies complicated by diabetes can approach that of the general population.
■ General guidelines for prepregnancy counseling and management of women with preexisting diabetes are as follows:
•Ensure that pregnancy is planned; counsel the woman about contraception methods and their expected efficacy and failure rates.
•Clearly identify for the woman and her partner the risks of congenital anomalies and spontaneous abortions, and their relation to A1C leading up to conception.
•Achieve optimum control of blood glucose levels before conception. Ideally, A1C should be normal (6%) or near normal before discontinuing contraception.
•Provide realistic information about chronic complications of type 1 diabetes (T1D) and type 2 diabetes (T2D), their potential impact on pregnancy and childbearing, and the effect of pregnancy on chronic complications.
•Assess the woman’s baseline health status, paying special attention to retinopathy, nephropathy, hypertension, neuropathy, and ischemic heart disease.
•Identify any gynecologic abnormalities before conception, and treat infertility as early as possible in view of the risk to pregnancy associated with increasing duration of diabetes and advancing maternal age.
•Provide genetic counseling, including the risks of advanced maternal age, if applicable.
•Provide realistic information about additional medical costs associated with a pregnancy complicated by diabetes, such as extra office visits, possible hospitalization, special tests, and possible intensive neonatal care.
•Encourage good general principles of health, nutrition, and hygiene, including cessation of smoking and alcohol consumption.
•Prescribe a prenatal vitamin with folate as part of the preconception treatment plan and review all other medications, making changes if teratogenic effects are possible.
•Identify any problems requiring psychosocial consultation.
•Once the decision is made to attempt pregnancy, provide appropriate optimism that careful glycemic control and meticulous obstetric care result in an excellent outcome in the vast majority of patients.
•Diagnose pregnancy as early as possible and document estimated due date.
■ Interpregnancy counseling and management of women with previous gestational diabetes mellitus should include the following:
•Testing for diabetes or prediabetes, measuring glucose levels, and assessing the need for treatment if diabetes or prediabetes is found.
•Evaluating weight status and advising weight reduction, if appropriate.
•Reviewing the risk of gestational diabetes mellitus in future pregnancy (~50% risk) and of T2D (up to 70% lifetime risk).
•Advising careful family planning with use of effective contraception until pregnancy is desired.
Pre- and Interpregnancy Counseling, Assessment, and Management
PREEXISTING DIABETES
Women with preexisting diabetes (type 1 diabetes [T1D] or type 2 diabetes [T2D]) who desire pregnancy present a broad array of challenging problems for the healthcare team. In the pre-insulin era, maternal mortality was as high as 44%, and perinatal mortality was 60% (Hare and White 1977). Children with true T1D, however, seldom lived to childbearing ages. After the discovery of insulin, maternal and fetal or neonatal survival improved dramatically. During the past five decades, advances in the care of the individual with diabetes in general, as well as advances in fetal surveillance and neonatal care, have continued to improve outcomes in most diabetic pregnancies to near that of the general population (Diabetes Control and Complications Trial Research Group 1996). The most common maternal (Table 1.1) and fetal or neonatal (Table 1.2) complications have decreased dramatically.
Table 1.1—Examples of Maternal Complications in Diabetic Pregnancy
Table 1.2—Examples of Potential Perinatal Morbidity or Mortality in Infants of Mothers with Diabetes
Morbidity and mortality associated with major congenital anomalies and spontaneous abortion (SAB) are of major concern in preexisting T1D and T2D. The magnitude of both appears to be related to metabolic control. The true prevalence of SAB pregnancies is not known, but it has been reported to be as high as 30–60%, depending on the degree of hyperglycemia at the time of conception, which is double that of the general population (Miodovnik et al. 1984). The increased risk of congenital anomalies among women with T1D ranges from 6%–12%, a two- to fivefold increase over the 2–3% incidence observed in the general population (Kitzmiller et al. 1978, Reece et al. 1988, Bell et al. 2012). This increased risk of congenital anomalies accounts for ~40% of the perinatal loss in T1D (Reece and Hobbins 1986). The combined risk of congenital anomalies and SAB in poorly controlled diabetes in early pregnancy can approach 65% (Greene 1993). In a nationwide prospective study, which included first-trimester questionnaires filled out by all pregnant women with T1D in the Netherlands over a 1-year interval, congenital malformations occurred in 4.2% of self-reported planned pregnancies but in 12.2% of unplanned pregnancies (Evers et al. 2004). Congenital malformations also increased when the mother has T2D (Macintosh et al. 2006) or obesity (Watkins et al. 2003). It is speculated that the relationship between obesity and anomalies is related to undiagnosed T2D; with an anticipated increased prevalence of undiagnosed T2D, a parallel increase in congenital anomalies also can be expected (Zabihi and Loeken 2010).
The types of congenital anomalies observed in diabetes are varied (Table 1.3). Most are of cardiac, neural tube, or skeletal origin; they are more commonly multiple, more severe, and more often fatal than those found in the general population.
Table 1.3—Congenital Anomaly Rates in Pregnancies of Women with and without Preexisting Diabetes per 1,000 Singleton Pregnancies and Relative Risk (95% Confidence Interval [CI])
Source: Adapted from Bell et al. (2012).
The etiology of the increased prevalence of congenital anomalies in diabetes has been the subject of intense research. In an experimental setting, hyperglycemia and other metabolic abnormalities are teratogenic, singly or in combination (Kalter and Warkany 1983, Freinkel et al. 1984, Reece and Hobbins 1986, Reece et al. 1988, Sadler et al. 1989). More recently, studies have demonstrated that biochemical disturbances and oxidative stress influence altered expression of essential developmental control genes; the timing of such environments may explain the unpredictable number or pattern of specific anomalies in any one fetus (Zabihi and Loeken 2010). Fetal organogenesis is largely complete by 9 weeks after the last menstrual period (7 weeks postconception) (Mills et al. 1979). Poorly controlled diabetes during the early weeks of pregnancy, in many cases before a woman even knows that she has conceived, significantly increases the risk of a first-trimester SAB or delivering an infant with a major anomaly (Greene et al. 1989).
The glycosylated hemoglobin or A1C, which expresses an average of the circulating glucose for the 2–3 months before its measurement, has become a useful tool in assessing a woman’s metabolic control early in pregnancy, during the critical period of organogenesis. Several studies have shown a definite association between A1C levels in early pregnancy (<13 weeks) and increased risk of congenital anomalies and SABs (Table 1.4) (Miller et al. 1981, Ylinen et al. 1984, Greene et al. 1989, Eidem et al. 2010, Bell et al. 2012).
Table 1.4—Risk of Major Congenital Anomalies in Women with Preexisting Diabetes, by Periconception Glycated Hemoglobin