Diabetes in Pregnancy

Screening

Gestational Diabetes Mellitus Screening Guidelines

Diabetes risk assessment High risk Average to low risk Lifelong screening for diabetes every 3 years 3 Screen at confirmation of pregnancy Positive for GDM Negative for GDM Screen at 24 to 28 weeks gestation Treat 3 Normoglycemia Positive for GDM Postpartum Negative for GDM Screen for diabetes at 6-12 weeks 1,2 Prediabetes Diabetes Treat 1. AACE.

Endocr Pract

. 2011;17(2):1-53. 2. ADA.

Diabetes Care.

2013;36(suppl 1):S11-S66.

Diabetes in Pregnancy: Risk Factors

Criteria for Early Prenatal Diabetes Testing 1,2,3 (screen patients at pregnancy confirmation)

• Inactive/sedentary lifestyle • First-degree relative (parent or sibling) with diabetes • High-risk race/ethnicity (eg, African American, Latino, Native American, Asian American, Pacific Islander) • History of gestational diabetes mellitus or previous delivery of a large baby (>9 lbs) • Hypertension (blood pressure ≥140/90 mmHg) • HDL cholesterol level <35 mg/dL and/or triglyceride levels >250 mg/dL • History of polycystic ovary syndrome (PCOS) • A1C ≥5.7%, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT) on a previous diabetes screening test • Other clinical conditions associated with insulin resistance (eg, severe obesity, acanthosis nigricans) • History of cardiovascular disease • Low maternal birth weight (<4 lbs 7 oz) 1. AACE.

Endocr Pract

. 2011;17(2):1-53. 2. ADA.

Diabetes Care

. 2013;36(suppl 1):S11-S66.

3. Innes et al.

JAMA

. 2002;287(19):2534-2541.

GDM Diagnosis

2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)

AACE- and ADA recommended ACOG recommended 1-step 75-g 2-hour oral glucose tolerance test (OGTT) 1,2 or 2 steps: a 50-g 1-hour glucose challenge test (GCT), followed by a 100-g 3-hour OGTT (if necessary) 3 Fasting plasma glucose (FPG)

GDM Diagnostic Criteria for OGTT Testing

75-g 2-hour † ≥92 mg/dL (5.1 mmol/L) 2 100-g 3-hour* ≥95 mg/dL (5.3 mmol/L) 2 1-hour post-challenge glucose ≥180 mg/dL (10.0 mmol/L) 2 ≥180 mg/dL (10.0 mmol/L) 2 2-hour post-challenge glucose ≥153 mg/dL (8.5 mmol/L 2 ≥155 mg/dL (8.6 mmol/L) 2 3-hour post-challenge glucose † A positive diagnosis requires that test results satisfy any one of these criteria * A positive diagnosis requires that ≥2 thresholds are met or exceeded ≥140 mg/dL (7.8 mmol/L) 2 3.

2.

1.

ADA. AACE.

Endocr Pract

. 2011;17(2):1-53.

Diabetes Care

. 2013;36(suppl 1):11-66. Committee on Obstetric Practice. ACOG. 2011;504:1-3.

Diabetes in Pregnancy: Established Diabetes

• All women of childbearing age diagnosed with T1DM or T2DM should receive:

– Preconception diabetes counseling, including information on the risks of uncontrolled diabetes during pregnancy 1 – Preconception evaluation and treatment of diabetes-related complications 1 – Counseling on medications contraindicated during pregnancy 1,2 • These include statins, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and most non-insulin antihyperglycemic agents – Counseling on effective contraception for all who wish to avoid pregnancy

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1.

ADA.

Diabetes Care

. 2013;36(suppl 1):S11-S66. Kitzmiller JL, et al.

Diabetes Care

. 2008;31(5):1060-79.

Diabetes in Pregnancy: Established Diabetes

• All women of childbearing age diagnosed with T1DM or T2DM should receive:

– Intensive pre- and post-conception A1C monitoring • 50% risk reduction in adverse pregnancy outcomes for every 1% decrease in A1C prior to conception 1 • Weekly A1C testing after conception can greatly improve glycemic monitoring 2 – ADA recommends preconception A1C <7.0% 3 – AACE recommends preconception A1C <6.1% 4 – Potential contraindications to pregnancy: • Ischemic heart disease, untreated active proliferative retinopathy, renal insufficiency, and severe gastroenteropathy

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Mathiesen ER, et al.

Endocrinol Metab Clin N Am

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Jovanovic L.

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5.

3. ADA.

Diabetes Care

. 2013;36(suppl 1):S11-S66. 4.

AACE.

Endocr Pract

. 2011;17(2):1-53. Jovanovic L, et al.

Mt Sinai J Med

. 2009;76(3):269-80.