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12. Management Of Diabetes In Pregnancy

12. Management Of Diabetes In Pregnancy

For guidelines related to the diagnosis of gestational diabetes mellitus, please refer to Section 2 “Classification and Diagnosis of Diabetes.” Pregestational Diabetes Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. B Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. A Preferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. A General Principles for Management of Diabetes in Pregnancy Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B Fasting, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and pregestati Continue reading >>

Dka In Pregnancy Acog

Dka In Pregnancy Acog

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Diabetes Management Guidelines

Diabetes Management Guidelines

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page Diabetes in Pregnancy (Gestational Diabetes) Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM) Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L) 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L) 2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L) A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses Achieve without hypoglycemia Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM Spontaneous abortion Fetal anomalies Preeclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes Counsel on the risk of development and/or progression of diabetic retinopathy Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pre Continue reading >>

Diabetes In Pregnancy: Managementdiabetes In Pregnancy: Management From Preconception To The Postnatalfrom Preconception To The Postnatal Periodperiod

Diabetes In Pregnancy: Managementdiabetes In Pregnancy: Management From Preconception To The Postnatalfrom Preconception To The Postnatal Periodperiod

© NICE 2017. All rights reserved. Subject to Notice of rights (rights). YYour responsibilityour responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Diabetes in pregnancy: management from preconception to the postnatal period (NG3) © NICE 2017. All rights reserved. Subject to Notice of rights (conditions#notice-of-rights). Page 2 of 67 ContentsContents Overview ..................................................................... Continue reading >>

Diabetes Mellitus And Pregnancy

Diabetes Mellitus And Pregnancy

Practice Essentials Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy. A study by Stuebe et al found this condition to be associated with persistent metabolic dysfunction in women at 3 years after delivery, separate from other clinical risk factors. [1] Infants of mothers with preexisting diabetes mellitus experience double the risk of serious injury at birth, triple the likelihood of cesarean delivery, and quadruple the incidence of newborn intensive care unit (NICU) admission. Gestational diabetes mellitus accounts for 90% of cases of diabetes mellitus in pregnancy, while preexisting type 2 diabetes accounts for 8% of such cases. Screening for diabetes mellitus during pregnancy Gestational diabetes The following 2-step screening system for gestational diabetes is currently recommended in the United States: Alternatively, for high-risk women or in areas in which the prevalence of insulin resistance is 5% or higher (eg, the southwestern and southeastern United States), a 1-step approach can be used by proceeding directly to the 100-g, 3-hour OGTT. The US Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus after 24 weeks of pregnancy. The recommendation applies to asymptomatic women with no previous diagnosis of type 1 or type 2 diabetes mellitus. [2, 3] The recommendation does not specify whether the 1-step or 2-step screening approach would be preferable. Type 1 diabetes The disease is typically diagnosed during an episode of hyperglycemia, ketosis, and dehydration It is most commonly diagnosed in childhood or adolescence; the disease is rarely diagnosed during pregnancy Patients diagnosed during pregnancy most often present with unexpected Continue reading >>

Normoglycemic Diabetic Ketoacidosis In Pregnancy

Normoglycemic Diabetic Ketoacidosis In Pregnancy

The clinical presentation of diabetic ketoacidosis in pregnancy is usually the same as in nonpregnant women, although the blood glucose may not be as high as in the nongravid state. We report a case of a pregnant woman who developed diabetic ketoacidosis with a normal blood glucose and review the pertinent medical literature. A 29-year-old woman with type I diabetes developed diabetic ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100 ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l−1. Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but can occur with relatively low, or even normal, blood sugars and necessitates prompt recognition and treatment. In this case, the combination of an initial episode of hypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml led to a prolonged delay in the initiation of a planned insulin infusion for insulin coverage during the induction of labor. A significant ketoacidosis consequently developed, despite the absence of even a single elevated blood glucose measurement. This case illustrated the importance of not withholding insulin in a patient with type I diabetes for more than a few hours even if the blood glucose is normal. Normal pregnancy is characterized by a state of decreased insulin sensitivity, as well as accelerated lipolysis and ketogenesis.1, 2, 3, 4 The concentration of serum ketones has been estimated to be two to four times greater than in the nonpregnant state.1, 5 In addition, pregnant women have a respiratory alkalosis, lowering the serum bicarbonate concentration, thus reducing the capacity to buffer hydrogen ions. Despite these changes, the incidence of diabetic ketoacidosis (DKA) in pregnant diabetic women is only 1 to 3%.6, 7 K Continue reading >>

Insulin Therapy For The Treatment Of Type 1 Diabetes During Pregnancy

Insulin Therapy For The Treatment Of Type 1 Diabetes During Pregnancy

Pregnancies affected by type 1 diabetes (T1D) carry a major risk for poor fetal, neonatal and maternal outcomes. Achieving normoglycemia while minimizing the risk of hypoglycemia is a major goal in the management of T1D as this can greatly reduce the risk of complications. However, maintaining optimal glucose levels is challenging because insulin requirements are not uniform throughout the course of the pregnancy. Over the past decade, there has been significant improvement in the methods for glucose monitoring and insulin administration, accompanied by an increase in the number of treatment options available to pregnant patients with T1D. Through study of the scientific literature and accumulated evidence, we review advances in the management of T1D in pregnancy and offer advice on how to achieve optimal care for the patient. Introduction Diabetes is one of the most common chronic diseases among women of reproductive age, observed in about 10% of pregnancies in the US and approximately 0.2–0.5% of these are in women with type 1 diabetes (T1D). T1D pregnancies are associated with an increased rate of complications, including late intrauterine death or major congenital malformations, which can lead to increased fetal morbidity and mortality compared to non-diabetic pregnancies. Maternal complications are also more frequent, with increased rates of preeclampsia, cesarean section and maternal mortality. Poor glycemic control at the time of conception and organogenesis during the first trimester is a major cause for an increased risk of birth defects and pregnancy complications. It has been recognized that a positive correlation exists between hemoglobin A1c (HbA1c) levels during early pregnancy and the incidence of fetal malformations. Therefore, good glycemic control co Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence in pregnancy compromises both the fetus and the mother profoundly. Although predictably more common in patients with type 1 diabetes, it has been recognised in those with type 2 diabetes as well as gestational diabetes, especially with the use of corticosteroids for fetal lung maturity and β2-agonists for tocolysis.1–3 Diabetic ketoacidosis usually occurs in the second and third trimesters because of increased insulin resistance, and is also seen in newly presenting type 1 diabetes patients. With increasing practice of antepartum diabetes screening and the availability of early and frequent prenatal care/surveillance, the incidence and outcomes of diabetic ketoacidosis in pregnancy have vastly improved. However, it still remains a major clinical problem in pregnancy since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. The purpose of this article is to illustrate a typical patient who may present with diabetic ketoacidosis in pregnancy and review the literature on this relatively uncommon condition and provide an insight into the pathophysiology and management. MAGNITUDE OF THE PROBLEM In non-pregnant patients with type 1 diabetes, the incidence of diabetic ketoacidosis is about 1–5 episodes per 100 per year with mortality averaging 5%–10%.4 The incidence rates of diabetic ketoacidosis in pregnancy and the corresponding fetal mortality rates from different retrospective studies5–8 are summarised in the table 1. As is evident from the table, both the incidence and rates of fetal loss in pregnancies have fallen in recent times compared with those before. In 1963 Continue reading >>

Successful Management Of Diabetic Ketoacidosis In Pregnancy

Successful Management Of Diabetic Ketoacidosis In Pregnancy

(* Assistant Professor, **Registrar, *** Second Year Resident, **** Additional Professor Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.) Diabetic ketoacidosis (DKA) is a complication seen in type 1 diabetes mellitus (DM) but can also occur in pregnancies complicated by type 2 DM or gestational diabetes mellitus (GDM). DKA is a medical emergency with high maternal and fetal mortality, and requires treatment in an intensive care setting. Prompt recognition and resuscitative therapy improves medical and obstetric outcomes. This report of DKA in a case of GDM provides insight into pathophysiology and successful management. Normal pregnancy is characterized by a state of decreased insulin sensitivity, accelerated lipolysis and ketogenesis.[1, 2, 3, 4] The concentration of serum ketones is estimated to be two to four times greater than in nonpregnant state.[1, 5] Despite these changes, the incidence of DKA in pregnant diabetics is only 1 to 3%.[2, 3] Fetal mortality rates of 30 to 90% in the past have now decreased to 9% due to improvements in neonatal and diabetic management.[2, 3] A 22 year old primigravida with 34+6 weeks of gestation was referred to our tertiary care center with giddiness, polyuria, polydipsia, candidial vagina discharge and deranged blood sugars (fasting blood glucose 280 mg/dl and post-meal value 410 mg/dl a few days back). She had stable vital signs, 34 weeks’ sized relaxed gravid uterus with cephalic presentation and normal fetal heart sounds. She had been diagnosed by her primary care obstetrician as GDM one month earlier and referred to us; however she did not report nor was she on any treatment. Recent sonography revealed oligohydramnios (amniotic fluid index 7 cm) but no fetal malformations. Continue reading >>

Managing Severe Preeclampsia And Diabetic Ketoacidosis In Pregnancy

Managing Severe Preeclampsia And Diabetic Ketoacidosis In Pregnancy

US Pharm. 2010;35(9):HS-2-HS-8. Pregnancy is associated with increased levels of emotional and physical stress. Women with preexisting conditions such as hypertension and diabetes require intense prenatal monitoring by health care professionals. Pharmacists in direct contact with patients can play an integral role in identifying signs and symptoms that require immediate care. Two conditions that require emergent treatment in pregnant women are severe preeclampsia and diabetic ketoacidosis. SEVERE PREECLAMPSIA Hypertensive disorders can affect 6% to 8% of women and increase the risk of morbidity and mortality in both the expectant mother and the unborn child.1,2 Hypertension in pregnancy is divided into four categories: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. The focus in this article is on severe preeclampsia, but a brief discussion of preeclampsia is warranted. Preeclampsia, a pregnancy-specific syndrome of unknown etiology, is a multiorgan disease process characterized by the development of hypertension and proteinuria after 20 weeks' gestation.1,2 See TABLE 1 for diagnostic criteria.1,2 History of antiphospholipid antibody syndrome, chronic hypertension, chronic renal disease, elevated body-mass index, age 40 years or older, multiple gestation, nulliparity, preeclampsia in a previous pregnancy, and pregestational diabetes mellitus increase a woman's risk of preeclampsia.1 Preeclampsia is classified as mild or severe based on the degree of hypertension, the level of proteinuria, and the presence of symptoms resulting from the involvement of the kidneys, brain, liver, and cardiovascular system. The incidence of severe preeclampsia is 0.9% in the United States.3 Severe preeclampsia is associate Continue reading >>

Pregestational Diabetes Mellitus: Obstetrical Issues And Management

Pregestational Diabetes Mellitus: Obstetrical Issues And Management

INTRODUCTION The key elements in management of pregnancies complicated by diabetes are: Achieving and maintaining excellent glycemic control Screening, monitoring, and intervention for maternal medical complications (eg, retinopathy, nephropathy, hypertension, cardiovascular disease, ketoacidosis, thyroid disease) Monitoring of, and intervention for, fetal and obstetrical complications (eg, congenital anomalies, preeclampsia, macrosomia) Most issues related to the obstetrical management of a pregnant diabetic woman (type 1 or type 2) will be reviewed here. The obstetrical management of these pregnancies is largely based upon clinical experience, data from observational studies, and expert opinion [1,2]. There is virtually no evidence from randomized trials. Continue reading >>

Diabetic Ketoacidosis During Pregnancy

Diabetic Ketoacidosis During Pregnancy

​ During pregnancy the most common metabolic complication is diabetes [1]. The American College of Obstetrics and Gynecology (ACOG) has recommended that each pregnancy be tested at 24 – 28 weeks for gestational diabetes by a two-step method (1-hour glucose assessment followed by a 3-hour glucose tolerance test (GTT) when necessary) [2]. The standard of care for those with an elevated 1-hour test involves a 3 hour GTT using either of the two widely accepted criteria (Carpenter/Coustan or National Diabetes Data Group) [2, 3]. Assessment by one of these criteria is important [1, 4]. Traditionally we have tightly controlled our insulin dependent diabetic patient population (Type 1) and hoped that lowering the threshold for the diagnosis of gestational diabetes along with rigorous glycemic control might offer the same salutary results to gestational diabetic women and their babies [5]. In the comparing, the two diagnostic methods of 3hr GTT assessment, we did identify about 20% more patients with the Carpenter/Coustan criteria compared to the National Diabetes Data Group levels [2, 3]. However, there were no differences in patient outcome, so we, like the majority of other institutions, have employed the National Diabetic Data Group Criteria [5]. Regardless of methodology, one needs to perform this two-step testing as glucose intolerance during pregnancy does impact outcome regardless of the method used [1, 6]. In a retrospective analysis of diabetic ketoacidosis (DKA) complicating pregnancy at our institution, we compared two times periods; 1976-81 and 1986-91. The incidence DKA fell from 22% to 3% as we identified diabetes at 24-28 weeks and tightly controlled maternal glucose excursions [7]. This as well as other maternal therapy resulted in a significant decrease in Continue reading >>

A Case Of Diabetic Ketoacidosis In Gestational Diabetes Mellitus

A Case Of Diabetic Ketoacidosis In Gestational Diabetes Mellitus

Myung Hwan Kim, Eui Dal Jung, Seung Pyo Hong, Gyu Hwan Bae, Sun Young Ahn, Eon Ju Jeon, Seong Yeon Hong,1 Ji Hyun Lee and Ho Sang Son Department of Internal Medicine, Catholic University of Daegu, Korea. 1Department of Obstetrics and Gynecology, Catholic University of Daegu, Korea. Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variant severity with onset or first recognition during present pregnancy. Recently the prevalence of GDM in Korean has reported as 1.7~4.0%. Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence is very rare in gestational diabetes patients, but is harmful to fetal and maternal health. A 26 years-old pregnant woman was admitted at 37 weeks gestation because of progressive generalized weakness, anorexia and weight loss. Initial physical examination reveals that she had been dehydrated, and blood pressure 130/80 mmHg, pulse rate 100/min, respiratory rate 20/min, and body temperature was 36.9℃. Serum glucose was 545 mg/dL, pH 7.282, HCO3- 10.5 mmol/L, urine ketone 3+, urine glucose 2+ when initial laboratory work was done. She was treated with intravenous fluid and insulin under the impression of diabetic ketoacidosis. Her delivery was performed after 24 hours from admission because of suggestive fetal distress. After recovery, she is being treated with insulin at outpatient department. We experienced a appropriately treated case of diabetic ketoacidosis in pregnant woman with GDM, and report it with a literature review. Continue reading >>

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

1. Management of diabetic ketoacidosis in pregnancy Dr/ Ahmed Walid Anwar Morad Assistant professor of OB/GYN Benha University 2017 2. This talk spotlights on • Definition • Epidemiology • Pathophysiology • Diagnosis • Differential diagnosis • Prevention • Treatment • Pitfalls in DKS 3. Epidemiology • DKA is an acute medical emergency associated with: - Fetal loss rates more than 50%. - Maternal mortality rates less than 1%. 4. Epidemiology • DKA in pregnancy most commonly occurs in women with: - Poorly controlled : *T1DM *T2DM or GDM under - Glucocorticoids - B-agonists / tocolytics - First presentation of T1DM in pregnancy 6. Glucose Homeostasis 7. DKA is common during pregnancy WHY? • Pregnancy is a stat of Relative insulin resistance especially in 2nd & 3rd trimesters. • Increased levels of HPL ,E, P & Cortisol act as insulin antagonists& impair maternal insulin sensitivity. • Pregnancy is a state of respiratory alkalosis associated with a compensatory drop in bicarbonate levels; this impairs the renal buffering capacity. 8. Precipitating factors of DKA in pregnancy • Insufficient or no insulin • Protracted vomiting • Hyperemesis gravidarum • Starvation • Infections • Medications precipitating DKP • Conditions such as diabetic gastroparesis 9. Diagnosis of DKA in pregnancy • DKP may be the first presentatio n of diabetes in pregnancy 10. Laboratory confirmation of DKA in pregnancy 11. Pitfalls in DKA • Potassium level may be falsely normal/elevated. • High – WBC count without infection. – Blood urea with prerenal azotemia due to dehydration. – Creatinine in absence of true impairment of renal function. – Serum amylase even in absence of pancreatitis. 12. What is different in pregnancy? • DKA occurs at lower blo Continue reading >>

A Case Of Diabetic Ketoacidosis In Gestational Diabetes Mellitus

A Case Of Diabetic Ketoacidosis In Gestational Diabetes Mellitus

J Korean Diabetes Assoc. 2007 Jul;31(4):368-371. Korean. Copyright © 2007 Korean Diabetes Association Eui Dal Jung, Seung Pyo Hong, Gyu Hwan Bae, Sun Young Ahn, Eon Ju Jeon, Seong Yeon Hong,1 Ji Hyun Lee and Ho Sang Son Department of Internal Medicine, Catholic University of Daegu, Korea. 1Department of Obstetrics and Gynecology, Catholic University of Daegu, Korea. Received April 24, 2007; Accepted June 18, 2007. Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variant severity with onset or first recognition during present pregnancy. Recently the prevalence of GDM in Korean has reported as 1.7~4.0%. Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence is very rare in gestational diabetes patients, but is harmful to fetal and maternal health. A 26 years-old pregnant woman was admitted at 37 weeks gestation because of progressive generalized weakness, anorexia and weight loss. Initial physical examination reveals that she had been dehydrated, and blood pressure 130/80 mmHg, pulse rate 100/min, respiratory rate 20/min, and body temperature was 36.9℃. Serum glucose was 545 mg/dL, pH 7.282, HCO3- 10.5 mmol/L, urine ketone 3+, urine glucose 2+ when initial laboratory work was done. She was treated with intravenous fluid and insulin under the impression of diabetic ketoacidosis. Her delivery was performed after 24 hours from admission because of suggestive fetal distress. After recovery, she is being treated with insulin at outpatient department. We experienced a appropriately treated case of diabetic ketoacidosis in pregnant woman with GDM, and report it with a literature review. Continue reading >>

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