Diabetes and Pregnancy

Abstract

All women with pre-existing type 1 or type 2 diabetes should receive preconception care to optimize glycemic control, assess complications, review medications and begin folate supplementation. Care by an interdisciplinary diabetes healthcare team composed of diabetes nurse educators, dietitians, obstetricians and diabetologists, both prior to conception and during pregnancy, has been shown to minimize maternal and fetal risks in women with pre-existing type 1 or type 2 diabetes. Gestational Diabetes MellitusThe diagnostic criteria for gestational diabetes mellitus (GDM) remain controversial; however, the committee has chosen a preferred approach and an alternate approach. The preferred approach is to begin with a 50 g glucose challenge test and, if appropriate, proceed with a 75 g oral glucose tolerance test, making the diagnosis of GDM if !1 value is abnormal (fasting !5.3 mmol/L, 1 hour !10.6 mmol/L, 2 hours !9.0 mmol/L). The alternate approach is a 1-step approach of a 75 g oral glucose tolerance test, making the diagnosis of GDM if !1 value is abnormal (fasting !5.1 mmol/L, 1 hour !10.0 mmol/L, 2 hours !8.5 mmol/L). Untreated GDM leads to increased maternal and perinatal morbidity, while treatment is associated with outcomes similar to control populations. Preconception carePreconception care for women with pregestational diabetes is associated with better outcomes (10,11). Although multidisciplinary clinics improve outcomes, <50% of women receive such care. Women who are heavier, younger and smokers, and who have a lower socioeconomic status, lower health literacy and a poor relationship with their healthcare provider, are less likely to receive preconception care (11e14). Some, but not all, have shown that women with type 2 diabetes are also less likely to receive preconception care (7,15). Higher glycated hemoglobin (A1C) levels are associated with poorer outcomes, but even women who achieve tight glycemic control (A1C <7.0%) have an increased risk of complications, which may be caused, in part, by maternal obesity (16,17). By discussing pregnancy prior to conception, healthcare providers may be able to improve outcomes by educating women Contents lists available at SciVerse ScienceDirect Canadian Journal of Diabetes j o u r n a l h o m e p a g e : w w w . c a n a d ia n j o u r n a l o f d i a b e t e s . c o m

Large‐for‐gestational‐age (LGA) neonate predicts a 2.5‐fold increased odds of neonatal hypoglycaemia in women with type 1 diabetes

“…Our study has important implications for how clinicians discuss the need for good glycaemic control in pregnancy with their patients [30][31][32]. It may be helpful to inform patients that improved glycaemic control preconception and in the first trimester of pregnancy reduces risk for serious complications such as congenital malformations and stillbirth but does not necessarily reduce the risk of other complications of pregnancy in women with pre-existing diabetes such as neonatal hypoglycaemia and LGA [1,33].…”

Early prediction of gestational diabetes: a practical model combining clinical and biochemical markers

“…Finally, soft drink intake before pregnancy was higher in women with GDM and was retained in all risk models, which deserves further investigation. National Institute for Health and Care Excellence (NICE) and CDA guidelines suggest that women with risk factors should be screened earlier in pregnancy with glucose measurements [6,39]. However, the sensitivity of clinical information alone to detect women who will develop GDM remains limited [40].…”

“…After delivery, the medical record of each participant was reviewed to complete clinical information, including the need for insulin therapy in women who developed GDM. According to practice guidelines [6], insulin therapy was initiated if, within 2 weeks, nutrition therapy alone did not allow to attain the following glycemic targets: fasting glucose < 5.3 mmol/L, 1-h post-prandial glucose < 7.8 mmol/L and 2-h post-prandial glucose < 6.7 mmol/L.…”

“…Prevalence of GDM is generally estimated between 2% and 6% in most developed countries using traditional approaches, but is highly dependent on the diagnostic criteria used [2]. Screening and diagnostic strategies vary widely [3] and, despite a recent suggestion by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) [4], there is no definitive consensus [5][6][7][8].…”

“…Moreover, there is accumulating evidence suggesting that lifestyle interventions implemented before 20 weeks of gestation in high-risk women reduce the risk of developing GDM and its complications [16][17][18]. Unfortunately, current screening procedures, that usually take place between 24 and 28 weeks of gestation [6,7] leading to a diagnosis in the third trimester, are not optimal for initiating targeted measures early in pregnancy.…”