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      Josephine OgunsolaJosephine Ogunsola

      Organization of preconception and pregnancy care

      -Women with diabetes and childbearing potential should be educated about the need for good glucose control before pregnancy and should participate in effective family planning.

      -Whenever possible, organize multidiscipline patient-centered team care for women with preexisting diabetes in preparation for pregnancy.

      -Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic nephropathy, neuropathy, and retinopathy, as well as cardiovascular disease (CVD), hypertension, dyslipidemia, depression, and thyroid disease.

      -Medication use should be evaluated before conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, angiotensin II receptor blockers (ARBs), and most noninsulin therapies.

      -Continue multidiscipline patient-centered team care throughout pregnancy and postpartum.

      -Regular follow-up visits are important for adjustments in the treatment plan related to stage of pregnancy, glycemic and blood pressure control, weight gain, and individual patient needs.

      -Educate pregnant diabetic women about the strong benefits of 1) long-term CVD risk factor reduction, 2) breastfeeding, and 3) effective family planning with good glycemic control before the next pregnancy.

      At the onset of preconception care, or in its absence, early in pregnancy, a complete medical evaluation should be performed to:

      -classify the patient and detect the presence of diabetic, cardiovascular, thyroid, or obstetrical complications

      -review history of eating patterns, physical activity/exercise, and psychosocial problems

      -counsel the patient on prognosis

      -set expectations for patient participation

      -assist in formulating a management plan with team care members

      -provide a basis for continuing care and laboratory tests

      The evaluation should review the history of prior pregnancies and comorbidities such as dyslipidemias and other cardiac risk factors, hypertension, albuminuria, variant symptoms of cardiac ischemia or failure, and peripheral vascular disease, symptoms of neuropathies, hypoglycemia awareness and severe hypoglycemic episodes, bowel symptoms, celiac disease, thyroid disorders, and infectious diseases, as well as previous diabetes education, treatment, and past and present degrees of glycemic control.

      In addition to appropriate obstetrical examination, physical examination should include sitting blood pressure determination, orthostatic heart rate and blood pressure responses when indicated; thyroid palpation; auscultation for carotid and femoral bruits, palpation of dorsalis pedis and posterior tibial pulses; presence/absence of Achilles reflexes and determination of vibration and monofilament sensation in the feet; and visual inspection of both feet.

      Glycemic control
      -Before pregnancy, in order to prevent excess spontaneous abortions and major congenital malformations, target A1C is as close to normal as possible without significant hypoglycemia.

      -Ensure effective contraception until stable and acceptable glycemia is achieved.

      -Excellent glycemic control in the first trimester continued throughout pregnancy is associated with the lowest frequency of maternal, fetal, and neonatal complications. Develop or adjust the management plan to achieve near-normal glycemia, while minimizing significant hypoglycemia.

      +Throughout pregnancy, optimal glycemic goals are premeal, bedtime, and overnight glucose 60–99 mg/dl, peak postprandial glucose 100–129 mg/dl, mean daily glucose <110 mg/dl, and A1C <6.0.

      -Higher glucose targets may be used in patients with hypoglycemia unawareness or the inability to cope with intensified management.

      Assessment of metabolic control
      -Self-monitoring of blood glucose (SMBG) is a key component of diabetes therapy during pregnancy and should be included in the management plan. Daily SMBG both before and after meals, at bedtime, and occasionally at 2:00 a.m.–4:00 a.m. will provide optimal results in pregnancy.

      -Fingerstick SMBG is best in pregnancy, since alternate site testing may not identify rapid changes in glucose concentrations characteristic of pregnant women with diabetes.

      -Postprandial capillary glucose measured 1-h after beginning the meal on average best approximates postmeal peak glucose measured continuously, but due to individual differences it may be useful for each patient to determine her own peak postprandial testing time.

      -Continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness.

      -Teach the pregnant patient to perform urine ketone measurements at times of illness or when the blood glucose reaches 200 mg/dl. Positive values should be reported promptly to the health care professional.

      -Develop the food plan (daily meal and snack pattern) based on individual preferences to include 1) appropriate calorie level, 2) adequate consumption of protein (1.1 g · kg−1 · day−1), fats, and micronutrients, 3) consumption of 175 g/day digestible carbohydrate, and 4) a distribution of carbohydrate intake that will promote optimal glycemic control and avoidance of hypoglycemia and ketonemia.

      -Promote consumption of a wholesome, balanced diet consistent with ethnic, cultural, and financial considerations. Maintain the pleasure of eating by selecting food choices according to scientific evidence, weight gain, and postprandial glucose responses.

      -Instruct the woman with diabetes to estimate the quantity of carbohydrate per serving and meal/snack and to select the type of carbohydrates that will contribute to postprandial glucose control; encourage fiber intake (28 g/day) by use of whole grains, fruits, and vegetables.

      -Emphasize consistent timing of meals and snacks on a daily basis to minimize hypoglycemia and in proper relation to insulin doses to prevent hyperglycemia.

      -Encourage patients to record all food and beverage intake continuously or for at least 1 week before each visit for assessment of adequacy of nutrient intake and comparison of carbohydrate intake with SMBG records.

      Insulin therapy
      -For optimal glycemic control in pregnancy in women with preexisting diabetes, provision of basal and prandial insulin needs with intensified insulin regimens (multiple dose regimens of subcutaneous long- and short-acting insulins or continuous subcutaneous insulin infusion [CSII]) usually gives the best results.

      -Patients who are taking insulins detemir or glargine should be transitioned to NPH insulin twice or three times daily, preferably before pregnancy or at the first prenatal visit, pending clinical trials proving efficacy and safety with these analogs.

      -Match prandial insulin doses to carbohydrate intake, premeal blood glucose, and anticipated activity.

      -Rapid-acting insulin analogs such as lispro or aspart may produce better postprandial control with less hypoglycemia compared with the use of premeal regular insulin.

      -Injections should be given in the abdomen or hips for consistency of absorption.

      -Because of the heightened risks of ketosis in pregnancy, patients using CSII should be well trained in the detection and treatment of unexplained hyperglycemia due to insulin under-delivery (pump or infusion site problems). (
      enomenon (increased insulin requirement between 4:00 a.m. and 8:00 a.m.). The disadvantages of CSII are cost and the potential for marked hyperglycemia and risk of DKA as a consequence of insulin delivery failure (usually due to kinking of the catheter or other infusion site issues), so patient training is very important.

      Oral antihyperglycemic agents for type 2 diabetes

      -Oral medications for treatment of type 2 diabetes should be stopped and insulin started and titrated to achieve acceptable glucose control before conception.

      -Women who become pregnant while taking oral medications should start insulin as soon as possible. It may be inferred from limited first trimester data that metformin and glyburide can be continued until insulin is started, in order to avoid severe hyperglycemia, a known teratogen.

      -Controlled trials are needed to determine whether glyburide treatment of women with type 2 diabetes (alone or in combination with insulin) is safe in early pregnancy or effective later in gestation.

      -Metformin should be used only in the setting of properly controlled trials during pregnancy until there is ample evidence of efficacy and safety. Such trials should include a focus on long-term development and metabolic function of the infants.


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