Ch36 Prefneja

L Y
2018 Clinical Practice Guidelines

ON
SE
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NA
Diabetes and SPregnancy
O
E R
P
Chapter 36
Denice S Feig MD FRCPC, Howard Berger MD, Lois
Donovan MD FRCPC, Ariane Godbout MD FRCPC,
Tina Kader MD FRCPC, Erin Keely MD FRCPC, Rema
Sanghera MA RD
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2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy
2018
Pregnancy Chapter
• Longest chapter
• Most recommendations (n=42) L Y
ON
SE
L U
NA
SO
R
PE
Diabetes in Pregnancy: 2
Categories
Pregestational diabetes Gestational diabetes
L Y
Pregnancy in O N
pre-existing diabetes SEDiabetes diagnosed in
L U pregnancy
• Type 1 diabetes NA
• Type 2 diabetes SO
E R
P
Diabetes in Pregnancy: Consider

Phases
1. Preconception counseling L Y Screening &

1. Prevention,
E ON
Diagnosis
S
U Management during
2. Management during AL 2.
pregnancy O N Pregnancy
R S
P E
3. Management in labour 3. Management in labour
4. Postpartum considerations 4. Postpartum considerations


Phases

1. Prevention,
E ON
Diagnosis
S
U Management during
2. Management during AL 2.
pregnancy O N Pregnancy
R S
P E

Dysglycemia in Pregnancy can Result

in Adverse Pregnancy Outcome
• Elevated glucose levels can haveY adverse
NL
effects on the fetus EO S
• 1 trimester  ↑ fetal
st U
L malformations
NA
nd rd
SO
• 2 and 3 trimester: ↑ risk of macrosomia and
E R
P
metabolic complications
Risk of Fetal Anomaly Relative to

Periconceptional A1C
Glycemic control pre-conception = essential
L Y
ON
SE
L U
NA
SO
R
PE
Guerin A et al. Diabetes Care 2007;30:1-6.

Preconception Counseling for

Pregestational Diabetes
• Advise reproductive age women with diabetes
L Y
about reliable birth control N O
E
S may improve fertility 
• NOTE: Metformin in PCOS
L U
A
need to warn aboutNpossible pregnancy
S O
E
• Metformin safeR for ovulation induction in PCOS
P
• Achieving a healthy weight is essential – obesity
associated with adverse pregnancy outcomes
PCOS, polycystic ovary syndrome

Screen for Complications:

Pre-pregnancy and Intrapartum
Screening for:
L Y
ON
1.Retinopathy: Need ophthalmological
S E
evaluation L U
NA
2.Nephropathy:RS O
Assess creatinine + urine
PE
albumin to creatinine ratio (ACR)
• Women with albuminuria or overt
nephropathy are at ↑ risk for hypertension
and preeclampsia
Preconception Checklist for 2018
Women with Pre-existing Diabetes

 Use reliable birth control until adequate glycemic control
 Attain a preconception A1C of ≤7.0% (≤ 6.5% if safe)
L Y
 O
May remain on metformin + glyburide Nuntil pregnancy,
otherwise switch to insulin US
E
AL

O N diabetes complications
Assess for and manage any
R S

PE3 months pre-conception to 12 weeks post-
Folic Acid 1 mg/d:
conception
 Discontinue potential embryopathic meds:
 ACE inhibitors / ARB (prior to or upon detection of
pregnancy in those with significant proteinuria)
 Statin therapy
ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker PERSONAL USE ONLY
Recommendation 1
Pre-existing Diabetes
Preconception care
L Y
N type 1 or type
1. All women of reproductive ageOwith
S E
2 diabetes should receive ongoing counselling on
L U
A
reliable birth control, the importance of
N to pregnancy, the impact
glycemic controlSOprior
E R
P
of BMI on pregnancy outcomes, the need for folic
acid and the need to stop potentially
embryopathic drugs prior to pregnancy [Grade D,
Level 4]
BMI, body mass index

PERSONAL USE ONLY
Recommendation 2
Preconception care
L Y
O
2. Women with type 2 diabetes with Nirregular
SE
menses/PCOS who lose U significant weight or are
AL
started on metformin
O N or a TZD should be advised
S
R improve and be counselled
that fertility may
PE
regarding possible pregnancy and receive
preconception counseling [Grade D, Consensus]
PCOS, polycystic ovary syndrome; TZD, thiazolidinedione

PERSONAL USE ONLY
Recommendation 3
Preconception care
L Y
3. Before attempting to become pregnant, women
N
EO
with type 1 or type 2 diabetes
S should:
L U
NA
a) Receive preconception
O counselling that includes
R S management, including
optimal diabetes
PE
nutrition, preferably in consultation with an
interprofessional pregnancy team to optimize
maternal and neonatal outcomes [Grade C, Level 3]
PERSONAL USE ONLY

Recommendation 3 (cont’d)
Preconception care
L Y
O
b) Strive to attain a preconception N A1C ≤7.0% (or
S E
A1C ≤6.5% if can safelyUbe achieved) to decrease
the risk of: A L
O N
• Spontaneous R S abortion [Grade C, Level 3]
P E
• Congenital anomalies [Grade C, Level 3]
• Preeclampsia [Grade C, Level 3]
• Progression of retinopathy in pregnancy [Grade
A, Level 1 for type 1 diabetes; Grade D, Consensus for type 2 diabetes]
• Stillbirth [Grade C, Level 3]
PERSONAL USE ONLY

Preconception care
c) Supplement their diet with multivitamins L Y containing 1 mg
O N
of folic acid at least 3 months preconception and
S E of gestation to prevent
continuing until at least 12 weeks
L UD, Level 4]
A
congenital anomalies [Grade
N
O
RS
PE
PERSONAL USE ONLY

Preconception care
L Y
d). Discontinue medications O N are potentially
that
embryopathic, including SEany from the following
L U
classes:
N A
i. ACE inhibitors SO and ARBs
E R
• prior toPconception in women with hypertension alone
[Grade C, Level 3]
• upon detection of pregnancy in women with CKD [Grade

D, Consensus]
ii. Statins [Grade D, Level 4]
ACE, angiotensin converting enzyme; CKD, chronic kidney disease

PERSONAL USE ONLY
2018
Recommendation 4
Preconception care
L Y
N
4. Women on metformin and/orOglyburide
preconception may continue SE on these agents if
L U
A
glycemic control is adequate until pregnancy is
ON 3]. Women on other
achieved [Grade C,SLevel
E R agents, should switch to
P
antihyperglycemic
insulin prior to conception as there are no safety
data for the use of other antihyperglycemic agents
in pregnancy [Grade D, Consensus]
PERSONAL USE ONLY

Recommendation 5 2018
Assessment and management of complications
5. Women should undergo an ophthalmological evaluation by
L Yplanning, the first
a vision care specialist during pregnancy
O N
trimester, as needed during pregnancy
S E after that and,
U
again, within the ﬁrst year postpartum in order to identify
L B, Level 1 for type 1 diabetes;
progression of retinopathyA[Grade
O Ndiabetes]. More frequent retinal
R S
Grade D, Consensus for type 2
P
surveillance duringE pregnancy as determined by the vision
care specialist should be performed for women with more
severe pre-existing retinopathy and poor glycemic control,
especially those with the greatest anticipatory reductions in
A1C during pregnancy, in order to reduce progression of
retinopathy [Grade B, Level 1 for type 1 diabetes; Grade D, Consensus for
type 2 diabetes]
PERSONAL USE ONLY

2018
Recommendation 6
Assessment and management of complications
L Y
6. Women with albuminuria or CKDO N should be
SE
followed closely for the development of
L U
N A
hypertension and preeclampsia [Grade D,
Consensus]
SO
R
PE
CKD, chronic kidney disease

PERSONAL USE ONLY
Diabetes in Pregnancy: Consider Phases


1. Prevention,
E ON
Diagnosis
U S
2. Management during pregnancyAL 2. Management during
O N Pregnancy
R S
P E
PERSONAL USE ONLY

Pregnancy Management for Pre-

existing Diabetes
• Type 1 diabetes: Basal-bolus insulin therapy
(3-4 injections per day) or continuous
L Y
O N
subcutaneous insulin infusion E (CSII)
US
• Type 2 diabetes: Switch AL to insulin (MiTy study
O N
will determine if efficacious to add metformin)
R S
E
• IndividualizePinsulin therapy with close
monitoring
• Bolus insulin: May use aspart or lispro instead of
regular insulin
• Basal insulin: May use detemir or glargine as
alternative to NPH (type 2 diabetes: NPH is
acceptable)

existing Diabetes
• Perform SMBG pre- and postprandially
L Y
ON
Target BG values
S E
L U
Fasting and pre-prandial BG <5.3 mmol/L
A
N BG <7.8 mmol/L
1h postprandial
SO
R
PE
2h postprandial BG <6.7 mmol/L
• Aim for A1C ≤6.5% (≤6.1% if possible)

• Lower late stillbirth & infant death
• Individualize targets in those with severe
hypoglycemia/unawareness
BG, blood glucose; SMBG, self-monitoring of blood glucose

existing Diabetes
• Type 1 diabetes: Continuous glucose
LY in all women
monitoring should be considered
N
•  LGA, NICU >24 hrs, neonatalOhypoglycemia, infant
length of hospital stay US
E
AL
N according to Institute of
• Encourage weightOgain
R S
Medicine recommendations
PE
• ASA to reduce the risk of pre-eclampsia, starting
at 12-16 weeks gestational age
LGA, large for gestational age; NICU, neonatal intensive care unit; ASA, acetylsalicylic acid
CONCEPTT trial, Lancet 2017;390:2347-2359.

Institute of Medicine Guidelines for

Gestational Weight Gain
Pre-Pregnancy BMI Recommended Recommended
(kg/m2) range of total range of total
weight gain (kg)
L Y weight gain (lb)
ON
BMI <18.5 E
12.5 – 18.0
S
28 – 40
BMI 18.5 - 24.9 11.5L– U
16.0 25 – 35
N A – 11.5
SO
BMI 25.0 - 29.9 7.0 15 – 23
E R
BMI >30
P 5.0 – 9.0 11 – 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus
Report. May 2009. The National Academies Press. Washington, DC.

existing Diabetes
Retinopathy Surveillance
• one visit in first trimester L Y
ON
• visits thereafter: as needed
S E
• more often in: L U
N A
O
• more severe retinopathy
S
• large drop E R
P in A1C
• poor glycemic control
Nephropathy
• Good BP control
• Watch for hypertension, preeclampsia
BP, blood pressure
Management of pregnant women

with diabetes on insulin receiving
betamethasone
L Y
Following the first dose of betamethasone
O N
Day 1 E dose by 25%
Increase the night insulin
S
L U
Days 2 & 3 A
Increase all insulin
N doses by 40%
O
Sall insulin doses by 20%
R
PE
Day 4 Increase
Day 5 Increase all insulin doses by 10 to 20%
Days 6 & 7 Gradually taper insulin doses to pre-

betamethasone doses
Mathiesen et al Acta Obstet Gynecol Scand 2002;1:835-839


existing Diabetes:
Fetal Surveillance & Delivery
• Fetal surveillance should be startedY at 30-32
N L
wks gestational age, then weekly
O from 34-36
wks until delivery SE
L U
• Earlier onset and/or NA frequent: those at
more
SO
highest risk E R
P
• Uncomplicated: induce 38-39 wks gestational
age to decrease stillbirth
• Induction prior to 38 wks for other
fetal/maternal indications
2018
Recommendation 7
Management in pregnancy
L Y
O N
7. Once pregnant, women with pre-existing diabetes
S E
should receive care by an interprofessional
L U
A
diabetes health-care team, including diabetes
ON dietitian), obstetrical care
educators (nurseSand
ER
provider, andPphysician/nurse practitioner, with
expertise in diabetes and pregnancy to minimize
maternal and fetal risks [Grade C, Level 3]
PERSONAL USE ONLY

2018
Recommendation 8
L Y
8. Once pregnant, women with type ON 2 diabetes
should be switched to insulin SE for glycemic
L U
A
control [Grade D, Consensus]. Non-insulin
Nagents should only be
antihyperglycemic SO
R
discontinued PEonce insulin is started [Grade D,
Consensus]
PERSONAL USE ONLY

9. Pregnant women with pre-existing diabetes should:
L Y
•
ON
Receive an individualized insulin regimen and glycemic targets
E
typically using intensive insulin therapy by basal-bolus injection
S
U
therapy [Grade A, Level 1B, for type 1 diabetes; Grade A, Level 1 for type 2
L
A
diabetes] or CSII [Grade C, Level 3 for type 1 diabetes]
N
•
SO<5.3 mmol/L
Strive for target BG values [Grade D, Consensus for all values]:
•
E R
Fasting and preprandial
• P <7.8 mmol/L
1-hour postprandial
• 2-hour postprandial <6.7 mmol/L
• Aim for an A1C of ≤6.5% during pregnancy (≤6.1% if possible), if can be
achieved safely, to lower the risk of late stillbirth and infant death [Grade
D, Level 4]
• Be prepared to raise BG and A1C targets in the presence of severe
hypoglycemia during pregnancy [Grade D, Consensus]
• Perform SMBG, both pre- and postprandially, to improve pregnancy
outcomes [Grade C, Level 3]
BG, blood glucose; CSII, continuous subcutaneous insulin infusion; SMBG, self-monitoring of blood glucose PERSONAL USE ONLY
2018
Recommendation 10
L Y
ON
10. Health-care providers should discuss appropriate
S E
weight gain at the initial U
visit and regularly
A L
throughout pregnancy
O N [Grade D, Consensus].
Recommendations S
R for weight gain during
P E
pregnancy should be individualized based on the
Institute of Medicine guidelines by pre-
pregnancy BMI to lower the risk of LGA infants
[Grade B, Level 2]
BMI, body mass index; LGA, large for gestational age

PERSONAL USE ONLY
2018
Recommendation 11
L Y
11. Aspart, lispro or glulisine may ONbe used in women
with pre-existing diabetes to SEimprove postprandial
L U
A
BG [Grade C, Level 2 for aspart; Grade C, Level 3 for lispro;
Grade D, Level 4 for SON and reduce the risk of
glulisine]
E R hypoglycemia [Grade C, Level 3 for
severe maternalP
aspart and lispro; Grade D, Consensus for glulisine]
compared with human regular insulin
BG, blood glucose

PERSONAL USE ONLY
Recommendation 12
L Y
N [Grade C, Level
12. Detemir [Grade B, Level 2] or glargine
O
3] may be used in women with SE pre-existing
L U
A
diabetes as an alternative to NPH and is
N perinatal outcomes
O
associated with similar
S
R
PE
PERSONAL USE ONLY

2018
Recommendation 13
L Y
13. Women with pre-existing diabetes
O N should start
SE
ASA 81 mg daily at 12-16 weeks gestation to
L U
NA
reduce the risk of preeclampsia [Grade D, Level 4]
SO
R
PE
PERSONAL USE ONLY

2018
Recommendation 14
L Y
O N
14. Women with type 1 and insulin-treated type 2
SE corticosteroids
diabetes who receive antenatal
L U
NA
to improve fetal lung maturation should follow a
SO
protocol which increases insulin doses proactively
E R
P
to prevent hyperglycemia [Grade D, Level 4] and DKA
[Grade D, Consensus]
DKA, diabetic ketoacidosis

PERSONAL USE ONLY
2018
Recommendation 15
L Y
15. Women with type 1 diabetes O inNpregnancy should
SE
be offered use of CGM to improve glycemic
L U complications [Grade
A
control and reduce neonatal
N
B, Level 2]
SO
E R
P
CGM, continuous glucose monitoring

PERSONAL USE ONLY
2018
Recommendation 16
Fetal surveillance and timing of delivery
L Y
O N
16. In women with pre-existing diabetes, assessment
S
of fetal well-being should be Eperformed at 30-32
L U
NA
weeks gestation and performed weekly starting
SO
at 34-36 weeks gestation and continued until
E RConsensus]. Earlier onset and/or
P
delivery [Grade D,
more frequent fetal health surveillance is
recommended in those considered at highest risk
PERSONAL USE ONLY

2018
Recommendation 17
L
17. In women with uncomplicated pre-existing
Y
N
diabetes, induction shouldSE beOconsidered
between 38-39 weeks of L Ugestation to reduce risk
N A
of stillbirth [Grade D,
O Consensus]. Induction prior to
R S
PE
38 weeks of gestation should be considered when
other fetal or maternal indications exist such as
poor glycemic control [Grade D, Consensus]. The
potential benefit of early term induction needs to
be weighed against the potential for increased
neonatal complications
PERSONAL USE ONLY


Phases

1. Prevention,
O N
S E
Diagnosis
U
L 2. Management during
2. Management during A
N Pregnancy
pregnancy SO
E R
P


existing Diabetes:
Intrapartum Glucose Management
L Y 4.0-7.0
• Monitor closely. Keep blood glucose
O N
mmol/L to reduce neonatal Ehypoglycemia
US
inL women who choose to
• CSII can be continued A
stay on their pump,O N they or their partner
and
R S
PE manage the pump
can independently
CSII, continuous subcutaneous insulin infusion

Recommendation 18
Intrapartum glucose management
L Y
18. Women should be closely monitored
O N during
SE
labour and delivery, and maternal blood glucose
L U
A
levels should be kept between 4.0-7.0 mmol/L in
N risk of neonatal
order to minimize SOthe
R
hypoglycemia PE[Grade D, Consensus]
PERSONAL USE ONLY

2018
Recommendation 19
L Y
19. CSII may be continued in women ON with pre-
existing diabetes during labourSE and delivery if the
L U
women or their partners
N A can independently and
safely manage the SO insulin pump [Grade C, Level 3 for
E R D, Consensus for type 2 diabetes]
P
type 1 diabetes; Grade
CSII, continuous subcutaneous insulin infusion

PERSONAL USE ONLY

Phases

1. Prevention,
O N
S E
Diagnosis
U
N Pregnancy
pregnancy SO
E R
P

Postpartum care for pre-existing

diabetes
1. Adjust insulin  at risk of hypoglycemia
L Y
2. Encourage women to breastfeed:
O N
SE offspring obesity
U
• Reduce neonatal hypoglycemia,
L
3. NA may be used during
Metformin and glyburide
S O
breast-feedingER no long term data but appears
P
safe
4. Screen for postpartum thyroiditis in type 1
diabetes  check TSH at 2-4 months postpartum
TSH, thyroid stimulating hormone

2018
Recommendation 20
Postpartum
L Y
20. Insulin doses should be decreased
O N immediately
SE
after delivery below prepregnant doses and
L U
NA
titrated as needed to achieve good glycemic
O
control [Grade D, Consensus]
S
R
PE
PERSONAL USE ONLY

2018
Recommendation 21
Postpartum
L Y
21. Women with pre-existing diabetes
O N should have
SE
frequent blood glucose monitoring in the first
L U
A
days postpartum, as they have a high risk of
ND, Consensus]
O
hypoglycemia [Grade
S
R
PE
PERSONAL USE ONLY

Pre-existing Diabetes: Postpartum

22. For women with pre-existing diabetes, early
neonatal feeding should be encouraged L Y
ON
immediately postpartum to E reduce neonatal
hypoglycemia [Grade C, Level U SBreast feeding should
A L 3] .
be encouraged forOaNminimum of 4 months to
reduce offspring R Sobesity [Grade D, Consensus] and later risk
P E
of developing diabetes [Grade C, Level 3]. Women with
pre-existing diabetes should receive assistance and
counseling on the benefits of breastfeeding, in
order to improve breastfeeding rates, especially in
the setting of maternal obesity [Grade D, Consensus]
PERSONAL USE ONLY

Recommendation 23
Postpartum
L Y
23. Women with type 1 diabetes O N
should be screened
S
for postpartum thyroiditisEwith a TSH test at 2-4
L U
months postpartumA[Grade D, Consensus]
O N
R S
PE
TSH, thyroid stimulating hormone

PERSONAL USE ONLY
2018
Recommendation 24
Postpartum
L Y
24. Metformin and/or glyburide O N be used during
may
breastfeeding [Grade C, Level SE3 for metformin; Grade D,
L U
NA
Level 4 for glyburide]. Other non-insulin
antihyperglycemic SOagents should not be used
E R
P
during breastfeeding as safety data do not exist
for these agents [Grade D, Consensus]
PERSONAL USE ONLY

Diabetes in Pregnancy: Consider Phases


1. Prevention,
O N
S E
Diagnosis
U
N Pregnancy
pregnancy SO
E R
P
PERSONAL USE ONLY

Gestational Diabetes (GDM)

Prevention
• In women at high risk for GDM based on pre-
L Y
Ncounseling
existing risk factors, nutritional
O
S
should be provided re: healthyE eating and
L U
A
prevention of excessNweight gain to reduce risk
SO
ER
of developing GDM
P
Gestational Diabetes (GDM)

Screening
L Y
Universal screening ONfor GDM
SE
U
@ 24-28 weeks NAL gestational age
SO
R
PE
Screen earlier if risk factors for
GDM (see next slide)
PERSONAL USE ONLY

Early Screening for Women

at High Risk for Type 2
Diabetes
Women at high risk of type 2 diabetes
L Y
ON
S E
Screen with A1C (or FPG U if A1C unreliable)
A L
in first
O Ntrimester
R S
P E
A1C ≥6.5% or FPG ≥7.0 mmol/L  treat like
type 2 diabetes
Confirm diagnosis post-partum

FPG, fasting plasma glucose
Why Diagnose and Treat GDM?
• Macrosomia • Caesarian section

• Shoulder dystocia Y obesity
• Offspring
L
and nerve injury ON
E
•SOffspring diabetes
• Neonatal L U
NA
hypoglycemia SO
E R
P
• Preterm delivery
• Hyperbilirubinemia
PERSONAL USE ONLY

Benefits of Treatment of Gestational Diabetes
L Y
ON
SE
L U
NA
SO
R
PE
Horvath K et al. BMJ 2010;340:c1935

Diagnosis of Gestational
Diabetes
LY glucose
Are there clear threshold
N
O
E the risk of
levels above whichUS
AL
O N
adverse neonatal or maternal
R S
PE outcomes increases?
PERSONAL USE ONLY

HAPO: Incidence of Adverse Outcomes Increases

Along Continuum – No Threshold
L Y
ON
SE
L U
NA
SO
R
PE
Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.

HAPO: Incidence of Adverse Outcomes for Glucose

Categories (OR 1.75 or OR 2.0 )
L Y
ON
SE
L U
NA
SO
R
PE
Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.

Considerations for Diabetes Canada

Adopting the OR 1.75 (IADPSG) vs OR 2.0
Thresholds
• How can we select an odds ratio threshold in the
Y
absence of a true threshold in theLdata?
O N
SE
• What is the impact on the patient and workload of
L U
NA
increasing the prevalence of gestational diabetes?
O
S evidence with respect to
R
• Do we have sufficient
PE
treatment benefit at the various thresholds to make
an informed decision?
• In the absence of clear benefit, should the diagnostic
criteria be changed from 2013?
2018 GDM Diagnosis: Two Approaches
L Y
ON
SE
L U
NA
SO
R
PE
Odds Ratio (OR) of 1.75 vs. 2.0 for Primary

Outcome in HAPO
Threshold OR 1.75 OR 2.0
glucose levels
(mmol/L) after a
L Y
75g OGTT
ON
Fasting plasma 5.1 SE 5.3
glucose L U
NA
1-h plasma
SO 10.0 10.6
glucose R
2-h plasma PE 8.5 9.0
glucose
% of cohort that 16.1% 8.8%
met ≥ 1 threshold
above
OGTT, Oral Glucose Tolerance Test

HAPO, Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
2018
Recommendation 25
Gestational Diabetes
Prevention
L Y
25. In women at high risk for GDM O Nbased on pre-
SE counseling should
existing risk factors, nutrition
L U
be provided on healthy A eating and prevention of
Nweight gain in early
O
excessive gestational
S
R
PE before 15 weeks of gestation, to
pregnancy, ideally
reduce the risk of GDM [Grade B, Level 2]
GDM, gestational diabetes

PERSONAL USE ONLY
Recommendation 26
Diagnosis
L Y
26. All pregnant women not known O Nto have pre-
existing diabetes should beSE
screened for GDM at
L U
NA
24-28 weeks of gestation [Grade C, Level 3]
SO
R
PE

PERSONAL USE ONLY
Recommendation 27
Gestational Diabetes: Diagnosis
27. The preferred approach for the screening and diagnosis of
GDM at 24-28 weeks is the following [GradeYD, Consensus]:
NL
•
E O
Screening for GDM should be conducted using the 50 g GCT
S
administered in the nonfasting state with PG glucose measured
U
L
1 hour later [Grade D, Level 4]. A PG >7.8 mmol/L at 1 hour is a
A
N
positive screen and is an indication to proceed to the 75 g OGTT
O
RS
[Grade C, Level 2]. A PG >11.1 mmol/L is diagnostic of
PE
gestational diabetes and does not require a 75 g OGTT for
confirmation [Grade D, Level 4]
• If the GCT screen is positive, a 75 g OGTT should be performed
as the diagnostic test for GDM using the 1 of the following
criteria:
• Fasting PG >5.3 mmol/L OR
• 1 hour PG >10.6 mmol/L OR
• 2 hours PG >9.0 mmol/L [Grade B, Level 1]
GCT, glucose challenge test; GDM, gestational diabetes; OGTT, oral glucose tolerance test; PG,
plasma glucose PERSONAL USE ONLY
Recommendation 28
Diagnosis
L Y
N and diagnose
28. An alternative approach to screen
O
GDM is the 1-step approach:SE a 75 g OGTT should
L U
be performed (with noAprior screening 50 g GCT)
ONfor GDM using the 1 of the
as the diagnosticStest
E R:
P
following criteria
• Fasting PG >5.1 mmol/L OR
• 1 hour PG >10.0 mmol/L OR
• 2 hours PG >8.5 mmol/L [Grade B, Level 1]
GCT, glucose challenge test; GDM, gestational diabetes; OGTT, oral glucose tolerance test; PG,
plasma glucose PERSONAL USE ONLY
2018
Recommendation 29
Gestational Diabetes: Diagnosis
Y
29. Women identified as being at high risk for type 2 diabetes should
L
N
be offered earlier screening with an A1C test at the first
O
E
antenatal visit to identify diabetes which may be pre-existing
S
U
[Grade D, Consensus]. For those women with a hemoglobinopathy or
L
A
renal disease, the A1C test may not be reliable and screening
N
O
should be performed with a FPG [Grade D, Consensus]. If the A1C is
S
R
PE
≥6.5% or the FPG is ≥7.0 mmol/L, the woman should be
considered to have diabetes in pregnancy and the same
management recommendations for pre-existing diabetes should be
followed [Grade D, Consensus]
If the initial screening is performed before 24 weeks of gestation
and is negative, the woman should be rescreened as outlined in
recommendation 27 or 28 between 24-28 weeks of gestation [Grade
D, Consensus]
FPG, fasting plasma glucose

PERSONAL USE ONLY

Phases

1. Prevention,
O N
S E
Diagnosis
U
N Pregnancy
pregnancy SO
E R
P

GDM: Management During Pregnancy

• Receive nutrition counseling by registered dietician
to achieve their nutrition, weight and blood
glucose goals
L Y
O N
• Eat healthy diet and Replace high-Glycemic Index
foods with low-Glycemic Index SE foods to reduce
L U
A and decrease
need for insulin initiation
N
birthweight SO
E R
P
• Discuss appropriate weight gain and healthy
lifestyle interventions throughout pregnancy
• Recommend weight gain according to IOM
recommendations based on prepregnancy BMI
interventions to reduce LGA, C-section
BMI, body mass index; IOM, Institute of Medicine; LGA, large for gestational age
Institute of Medicine Guidelines for

Gestational Weight Gain
Pre-Pregnancy BMI Recommended Recommended
(kg/m2) range of total range of total
weight gain (Kg)
L Y weight gain (lb)
ON
BMI <18.5 E
12.5 – 18.0
S
28 – 40
BMI 18.5 - 24.9 11.5L– U
16.0 25 – 35
N A – 11.5
SO
BMI 25.0 - 29.9 7.0 15 – 23
E R
BMI >30
P 5.0 – 9.0 11 – 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus
Report. May 2009. The National Academies Press. Washington, DC.

• Perform SMBG fasting and postprandially
• Glycemic targets during pregnancy:
L Y
Target BG valuesON
SE
L U
Fasting and preprandial BG <5.3 mmol/L
A
N BG <7.8 mmol/L
O
1h postprandial
S
R
PE
2h postprandial BG <6.7 mmol/L
• If glycemic targets not achieved within 1-2 weeks,

initiate pharmacologic therapy
BG, blood glucose; SMBG, self-monitoring of blood glucose


• Insulin first-line
• May use aspart, lispro, glulisine: perinatal outcomes similar
LY
• Metformin may be used as an alternative to insulin
N
• Good safety data in pregnancyE O
US gain, less large-for-
• Evidence of less maternalLweight
N A
gestational-age, less neonatal hypoglycemia
S O
• Women should Ebe R informed that it crosses the placenta
P
• Safety data in offspring postpartum up to 2 years
• Insulin necessary in 40% on metformin
• Glyburide may be used in women who refuse
insulin and not well controlled on metformin
GDM: Fetal Surveillance

• Increased surveillance should be considered in
women poorly controlled and/orLwith Y
comorbidities ON
SE
• Offer induction 38-40 A L U GA to potentially
weeks
reduce stillbirth and O NC-section
R S
• Earlier or laterPE
induction should be considered
based on glycemic control and presence of
other comorbidities
GA, gestational age; GDM, gestational diabetes

2018
Recommendation 31
Management during pregnancy
L Y
O N
31. Health-care providers should discuss appropriate
SE
weight gain and healthy lifestyle interventions
L U
regularly throughout pregnancy
NA [Grade D,
SO
Consensus]. Recommendations for weight gain for
women with P ER should be individualized based
GDM
on Institute of Medicine guidelines by pre-
pregnancy BMI to prevent excessive gestational
weight gain and reduce the risk of LGA [Grade B,
Level 2], macrosomia and caesarean sections [Grade
B, Level 2]
BMI, body mass index; LGA, large for gestational age

PERSONAL USE ONLY
2018
Recommendation 32
L Y
ON
32. Nutritional counseling by a registered dietitian
should be provided to women S E with GDM to help
L U
NA
them achieve their nutrition, weight and blood
SO
glucose goals [Grade D, Level 4]. Women with GDM
E R
P
should be encouraged to eat a healthy diet for
pregnancy and to replace high GI foods with low
GI foods to reduce the need for insulin initiation
and decrease birth weight [Grade C, Level 3]
GDM, gestational diabetes; GI, glycemic index

PERSONAL USE ONLY
Recommendation 33
2018
Gestational Diabetes: Management during pregnancy

33. If women with GDM do not achieve glycemic targets within 1-2
Y
weeks with nutritional therapy and physical activity,
NL [Grade D, Consensus].
pharmacologic therapy should be initiated
O
•
SE
Insulin in the form of basal-bolus injection therapy may be used as
L U
first line therapy [Grade A, Level 1 for insulin]
• NA
Rapid-acting analogue insulin aspart, lispro or glulisine may be
O
RS
used over regular insulin for postprandial glucose control,
E
P
although perinatal outcomes are similar [Grade B, Level 2 for aspart and
lispro; Grade D, Consensus for glulisine]
• Metformin may be used as an alternative to insulin [Grade A, Level 1A
for metformin]; however, women should be informed that metformin
crosses the placenta, longer-term studies are not yet available, and
the addition of insulin is necessary in approximately 40% to
achieve adequate glycemic control [Grade D, Consensus]

PERSONAL USE ONLY
2018
Recommendation 34
L Y
34. In women with GDM who decline
O N insulin and do
SE
not tolerate or are inadequately controlled on
L U
metformin, glyburide
NA may be used [Grade B, Level
2]
SO
R
PE

PERSONAL USE ONLY
2018
Recommendation 35
Y in GDM
N L
E O
35. Increased frequency of fetal assessment should be
considered in women with U S
GDM that is poorly
AL
O N
controlled and/or associated with comorbid
S
R D, Consensus]
conditions [Grade
PE

PERSONAL USE ONLY
2018
Recommendation 36
Fetal surveillance and timing of delivery in GDM
L Y
36. Women with GDM can be offered O N induction of
labour between 38-40 weeks SE gestation to
L U
potentially reduce theArisk of stillbirth [Grade D,
Consensus] and the O N of caesarean section [Grade
risk
R S
PE or later induction of labour should
C, Level 2]. Earlier
be considered based on glycemic control and the
presence or absence of other comorbid conditions

PERSONAL USE ONLY

Phases

1. Prevention,
O N
S E
Diagnosis
U
N Pregnancy
pregnancy SO
E R
P

GDM: Glycemic Management During

Labour and Delivery
• Keep maternal blood glucose between 4.0 and
L Y
7.0 mmol/L  reduce risk of ON
neonatal
S E
hypoglycemia U L
NA
O
RS
PE
Recommendation 37
L Y
37. Women with GDM should be monitored
O N during
SE
labour and delivery, and maternal blood glucose
L U
A
levels should be kept between 4.0-7.0 mmol/L in
N risk of neonatal
order to minimize SOthe
R
hypoglycemia PE[Grade D, Consensus]

PERSONAL USE ONLY

Phases

1. Prevention,
O N
S E
Diagnosis
U
N Pregnancy
pregnancy SO
E R
P

GDM: Postpartum Management

1. Encourage Breastfeeding
L Y
• Reduce neonatal hypoglycemia, childhood obesity &
diabetes, AND maternal risk of O N
diabetes &
SE
hypertension
L U
NA
SO
R
2. 75 g OGTT between 6 weeks - 6 months
PE
postpartum to detect prediabetes or
diabetes. Suggest phone calls/email
reminders to improve testing rates
GDM: Postpartum OGTT

75 g oral glucose tolerance test
• 6 weeks to 6 months
L Y in
• If diagnosed with diabetes early
pregnancy, do FPG or OGTTOatN6-8 weeks
SE
postpartum
U
A L
Normal N
O glucose
Impaired Type 2
S
R tolerance
PE diabetes
Healthy Healthy behaviour Healthy behaviour

behaviour interventions +/- interventions +/-
interventions metformin metformin +/- insulin
FPG, fasting plasma glucose; OGTT, oral glucose tolerance test

PERSONAL USE ONLY
2018
Recommendation 38
Postpartum Y
N L
E O
38. Women with GDM should be encouraged to
S
breastfeed immediatelyUafter delivery in order to
A L
O N
avoid neonatal hypoglycemia [Grade D, Consensus]
and to continue S
Rfor at least 3-4 months
PE
postpartum in order to prevent childhood obesity
[Grade C, Level 3] and diabetes in the offspring [Grade
D, Level 4] and to reduce risk of type 2 diabetes and
hypertension in the mother [Grade C, Level 3]

PERSONAL USE ONLY
2018
Recommendation 39
Postpartum
L Y
39. Women should be screened O N a 75 g OGTT
with
SE
L U
between 6 weeks to 6 months postpartum to
N
detect prediabetes andA diabetes [Grade D,
SO
E R
Consensus]. Methods to improve postpartum
P
testing such as phone calls or email reminders to
women with a history of GDM should be employed
to improve screening rates [Grade C, Level 3]
GDM, gestational diabetes; OGTT, oral glucose tolerance test

PERSONAL USE ONLY
2018
Recommendation 40
Postpartum
L Y
40. In women who were diagnosed O Nwith diabetes in
SE
early pregnancy based on
L U A1C (see recommendation
NA
29), if ongoing hyperglycemia is not evident
SO
R
postpartum, aEconfirmatory test for diabetes with
P
a FPG or 75 g OGTT should be done at 6 to 8
weeks postpartum [Grade D, Consensus]
FPG, fasting plasma glucose; OGTT, oral glucose tolerance test

PERSONAL USE ONLY
2018
Recommendation 41
Postpartum
L Y
41. Women with prior GDM should O N
receive counseling
regarding healthy behaviour SE interventions to
L U in subsequent
reduce the recurrenceArate
ON their increased risk of
pregnancies and Sreduce
E R[Grade C, Level 3]
P
type 2 diabetes

PERSONAL USE ONLY
2018
Recommendation 42
Postpartum
L Y
42. In women with prior GDM who ON IGT on
has
S
postpartum screening, healthyE behaviour
LU
interventions with orAwithout metformin can be
used in women to O N
prevent/delay the onset of
S
R Level 2]
PE
diabetes [Grade B,
GDM, gestational diabetes; IGT, impaired glucose tolerance

PERSONAL USE ONLY
Visit guidelines.diabetes.ca
L Y
ON
SE
L U
NA
SO
R
PE
PERSONAL USE ONLY

Or download the App
L Y
ON
SE
L U
NA
SO
R
PE
PERSONAL USE ONLY

Diabetes Canada Clinical
Practice Guidelines
www.guidelines.diabetes.ca – for L Y
health-care
O N
providers
S E
L U
NA
SO
1-800-BANTING (226-8464)
R
PE
www.diabetes.ca – for people with diabetes
PERSONAL USE ONLY

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L Y

2018 Clinical Practice Guidelines

All Content contained on this slide deck is the property of Diabetes

Diabetes in Pregnancy: Consider

1. Preconception counseling L Y Screening &

4. Postpartum considerations 4. Postpartum considerations

Diabetes in Pregnancy: Consider

1. Preconception counseling L Y Screening &

4. Postpartum considerations 4. Postpartum considerations

Dysglycemia in Pregnancy can Result

Risk of Fetal Anomaly Relative to

Guerin A et al. Diabetes Care 2007;30:1-6.

Preconception Counseling for

PCOS, polycystic ovary syndrome

Screen for Complications:

Preconception Checklist for 2018

Women with Pre-existing Diabetes

BMI, body mass index

PCOS, polycystic ovary syndrome; TZD, thiazolidinedione

PERSONAL USE ONLY

• Stillbirth [Grade C, Level 3]

PERSONAL USE ONLY

PERSONAL USE ONLY

• upon detection of pregnancy in women with CKD [Grade

ii. Statins [Grade D, Level 4]

ACE, angiotensin converting enzyme; CKD, chronic kidney disease

PERSONAL USE ONLY

PERSONAL USE ONLY

CKD, chronic kidney disease

Diabetes in Pregnancy: Consider Phases

1. Preconception counseling L Y Screening &

4. Postpartum considerations 4. Postpartum considerations

PERSONAL USE ONLY

Pregnancy Management for Pre-

Pregnancy Management for Pre-

• Aim for A1C ≤6.5% (≤6.1% if possible)

Pregnancy Management for Pre-

CONCEPTT trial, Lancet 2017;390:2347-2359.

Institute of Medicine Guidelines for

Pregnancy Management for Pre-

Management of pregnant women

Day 5 Increase all insulin doses by 10 to 20%

Days 6 & 7 Gradually taper insulin doses to pre-

Mathiesen et al Acta Obstet Gynecol Scand 2002;1:835-839

Pregnancy Management for Pre-

PERSONAL USE ONLY

PERSONAL USE ONLY

BMI, body mass index; LGA, large for gestational age

BG, blood glucose

PERSONAL USE ONLY

PERSONAL USE ONLY

DKA, diabetic ketoacidosis

CGM, continuous glucose monitoring

PERSONAL USE ONLY

PERSONAL USE ONLY

Diabetes in Pregnancy: Consider

1. Preconception counseling L Y Screening &

4. Postpartum considerations 4. Postpartum considerations