10 Diabetes and Pregnancy
Chapter 10 / Diabetes and Pregnancy 149
10.11.5.2.4 Medication. Insulin therapy is used concurrently with MNT if normogly-cemia is not consistently maintained with diet only. There is no consensus of opinion as to when insulin therapy should be instituted. The nutrition practice guidelines recom-mend beginning insulin therapy 2 weeks after MNT is implemented [61]. The American Diabetes Association and the American College of Obstetricians and Gynecologists use different glycemic cut-offs for initiating insulin (Table 10.6). Ultrasound measurement of the fetal abdominal circumference to determine macrosomic growth is also used to determine initiatiation of insulin therapy [70].
Human-based insulin is preferred over animal-based because it is less allergenic. The type, dosage, and regimen vary but are usually a combination of short-acting and intermedi-ate-acting insulin. Calculation of the starting dose uses an approach that is similar to that employed for preexisting diabetes, and self-monitoring of blood glucose is used to guide the dose and timing of the regimen and subsequent adjustments. Insulin analogs are not yet approved by the Food and Drug Administration for use in GDM. Studies using insulin Lispro and insulin Aspart in GDM were not associated with adverse effects [71, 72].
Prior to 2000, oral antidiabetic agents were contraindicated during pregnancy. First-generation sulfonylureas crossed the placenta and were thought to cause fetal hyper-insulinemia or teratogenicity. A randomized trial by Langer et al. in which Glyburide, a second-generation sulfonylurea, was compared to insulin and reported no difference in the incidence of maternal or fetal complications, including preeclampsia, cesarean sections, macrosomia, or fetal anomalies [73]. Glyburide was also not detected in the cord serum. Four percent of the women on Glyburide did require insulin therapy. The American Diabetes Association and the American College of Obstetricians and Gynecolo-gists have not recommended Glyburide in pregnancy, although both organizations have acknowledged its use in controlling blood glucose levels in GDM. The advantages of Glyburide in pregnancy, according to healthcare providers who advocate its use, are that it is cost-effective, non-invasive, and may result in better compliance than insulin injec-tions [74]. Recent research in Glyburide therapy use in pregnancy demonstrated a failure rate of 12–20% [75, 76]. Women with high fasting blood glucose levels (≥110 mg/dl) were more likely to be switched to insulin therapy [76]. Further research is needed to determine the safety of other oral antidiabetic agents in pregnancy.
10.11.6 Postpartum
Women with GDM are at increased risk for developing type 2 diabetes after preg-nancy and should be screened 6–12 weeks postpartum [3, 58]. The American Diabetes Association recommends a 75-g, 2-h oral glucose tolerance test to identify women with possible undiagnosed diabetes before conception, impaired glucose tolerance, or risk for
Table 10.6
Criteria for Initiating Insulin in GDM
American Diabetes American College of Association Obstetricians and Gynecologists Fasting ≤ 105 mg/dl (5.8 mmol/l) < 95 mg/dl (5.2 mmol/l) 1 h postprandial ≤ 155 mg/dl (8.6 mmol/l) < 130 mg/dl (7.2 mmol/l) 2 h postprandial ≤ 130 mg/dl (7.2 mmol/l) < 120 (6.6 mmol/l)
From [3, 58]
future diabetes (Table 10.7) [3]. If the oral glucose tolerance test is normal at 6–12 weeks postpartum, the woman should be reassessed every 3 years. Women with impaired fasting glucose or impaired glucose tolerance need to be tested annually for diabetes.
Breastfeeding, unless contraindicated, is recommended for women with GDM [3].
Lactation may improve glucose control, mobilize fat stores, promote weight loss, and protect against future risk of developing diabetes [36, 77]. Gradual weight loss (1–2 kg/
month) is encouraged.
Oral contraceptive use in women with previous GDM is associated with thromboem-bolism, myocardium infarction, stroke, and increased insulin resistance [78, 79]. If an oral contraceptive agent is desired, a low potency dose of progestin and estrogen is prescribed to minimize the adverse effects of glucose intolerance and increased serum lipids [51].
Women with previous histories of GDM are also at risk of developing GDM in recurring pregnancies. Factors that increase the risk of GDM in a subsequent pregnancy are hip-to-waist ratio >0.84, weight gain >11 lb (5.0 kg) between pregnancies, and a fat intake >40%
of the total calorie intake [80]. Women should be encouraged to adopt healthy lifestyles to lessen their risk of developing type 2 diabetes or GDM in subsequent pregnancies. Recom-mended lifestyle modifications include achieving and maintaining normal body weight, healthy eating habits, and consistent physical activity [61].
10.12 CONCLUSION
Advances in diabetes management have greatly improved pregnancy outcomes. For the woman with preexisting diabetes, optimal maternal blood glucose control must begin before conception and continue throughout the pregnancy. All women with type 1 diabetes and type 2 diabetes of childbearing age should be referred for preconceptional care to incorporate self-management strategies that can decrease perinatal morbidity and mortality. Self-management care includes MNT, self-monitoring of blood glucose, and if necessary, ketone testing, insulin therapy, and physical activity.
MNT is a key component in the management of GDM. An individualized meal plan should be designed to provide adequate energy and nutrients for maternal and fetal Table 10.7
Criteria for Diagnosis of Diabetes Mellitus using a 75 g OGTT
Normal values mg/dl (mmol/l)
Impaired fasting glucose mg/dl (mmol/l)
Impaired glucose tolerance mg/dl (mmol/l)
Diabetes mellitus mg/dl (mmol/l) Fasting plasma
glucose
<100 mg/dl (5.6 mmol/l)
≥100 to <126 mg/dl (≥ 5.6–7.8 mmol/
l)
<100 mg/dl (<
5.6 mmol/l)
≥ 126 mg/dl (≥
7.0 mmol/l) 75 g OGTT <140 mg/dl
(7.8 mmol/l)
<140 mg/dl (7.8 mmol/l)
≥140 to <200 mg/
dl (≥ 7.8–
11.1 mmol/l)
≥200 mg/dl 11.8 mmol/l) From American Diabetes Association (2004) Screening for type 2 diabetes. Diabetes Care 27(Suppl 1):
S11–S14, OGTT: Oral Glucose Tolerance Test
Chapter 10 / Diabetes and Pregnancy 151 health and promote appropriate weight gain based on prepregnancy BMI. The registered dietitian will use food, blood glucose and, if necessary, ketone records to adjust the meal plan. After delivery, lifestyle modifications will be necessary to reduce the long-term risk of developing type 2 diabetes. These modifications should focus on diet, physical activity and achieving and maintaining a healthy weight.
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