Management Of Diabetes In Pregnancy Research Articles

Diabetes in Pregnancy

ABSTRACT Gestational diabetes mellitus is carbohydrate intolerance with onset or first recognition during pregnancy. Pregnancy could also occur in a woman with pre-existing diabetes. Congenital anomalies, macrosomia, birth injuries, obstetric and neonatal complications are associated with diabetes in pregnancy. The long-term implications in both mother and offspring include the development of obesity, metabolic syndrome and diabetes. Screening would identify patients and many guidelines exist for the same. Universal screening is advocated. The glycemic goals are stringent, although data indicate that thresholds should be lowered further. Nutritional therapy is the mainstay of treatment. Insulin is the agent of choice if glycemic goals are not met. Newer insulin analogs are advantageous. Oral antidiabetic agents show promise for the future, although more long-term trials are needed. Self monitoring of glucose is an important tool in the management of diabetes in pregnancy. Rates of cesarean section are high in diabetic pregnancies. If macrosomia occurs, other obstetric complications ensue. Maternal hyperglycemia can lead to neonatal hypoglycemia. Postpartum, maternal glycemic status should be reassessed and treatment modified accordingly. In the long-term, both mother and offspring are ideal candidates for lifestyle modification for the prevention of type 2 diabetes. Preconception care in women with pre-existing diabetes and/or its complications is desirable to minimize complications and congenital anomalies.

Morbidity and mortality amongst infants of diabetic mothers admitted into a special care baby unit in Port Harcourt, Nigeria

BackgroundInfants born to diabetic women have certain distinctive characteristics, including large size and high morbidity risks. The neonatal mortality rate is over five times that of infants of non diabetic mothers and is higher at all gestational ages and birth weight for gestational age (GA) categories.The study aimed to determine morbidity and mortality pattern amongst infants of diabetic mothers (IDMS) admitted into the Special Care Baby Unit of University of Port Harcourt Teaching Hospital.MethodsThis was a study of prevalence of morbidity and mortality among IDMs carried out prospectively over a two year period. All IDMs (pregestational and gestational) admitted into the Unit within the period were recruited into the study.Data on delivery mode, GA, birth weight, other associated morbidities, investigation results, treatment, duration of hospital stay and outcome were collated and compared with those of infants of non diabetic mothers matched for GA and birth weight admitted within the same period. Maternal data were reviewed retrospectively. Data were analyzed using SPSS 16.0.ResultsSixty percent of the IDMs were born to mothers with gestational diabetes, while 40% were born to mothers with pregestational DM. 38 (74.3%) were born by Caesarian section (CS), of which 20 (52.6%) were by emergency CS. There was no significant difference in emergency CS rates, when compared with controls, but non-IDMs were more likely to be delivered vaginally. The mean GA of IDMs was 37.84 weeks ± 1.88. 29 (61.7%) of them were macrosomic. The commonest morbidities were Hypoglycemia (significantly higher in IDMs than non-IDMs) and hyperbilirubinaemia in 30 (63.8%) and 26 (57.4%) respectively.There was no difference in morbidity pattern between infants of pre- gestational and gestational diabetic mothers. Mortality rate was not significantly higher in IDMsConclusionsThe incidence of macrosomia in IDMs was high but high rates of emergency CS was not peculiar to them. Hypoglycaemia and hyperbilirubinaemia were the commonest morbidities in IDMs.Referring women with unstable metabolic control to specialized centers improves pre- and post- natal outcomes. Maternal-Infant centers for management of diabetes in pregnancy are advocated on a national scale to reduce associated morbidity and mortality

I326 The value of information technology in the management of diabetes in pregnancy

I326 The value of information technology in the management of diabetes in pregnancy

Continuous Glucose Monitoring During Pregnancy

Diabetes throughout gestation presents challenges that greatly influence maternal and fetal outcomes. Since the degree of maternal hyperglycemia is the most deterministic of these risks, glucose monitoring has become a fundamental tool in the management of diabetes in pregnancy. While most patients with diabetes are in need of improved glucose control, certain circumstances beg for more detailed glucose information than is available by conventional methods alone. In this article, we will review the state of diabetes during pregnancy and the serious outcomes that persist despite the overall improvement in glycemic control today. We will discuss the advantages of incorporating continuous glucose monitoring (CGM), specifically in the treatment of pregnancies complicated by diabetes. In addition to its clinical utility, CGM can advance our understanding and classification of normoglycemia during pregnancy. Demarcation of the normal glucose profile that is present during gestation better defines the therapeutic goals for women with diabetes and ultimately promotes success in pregnancy.

Management of diabetes in pregnancy

AbstractPregnancy in women with diabetes is associated with significantly increased risks. The authors look at the factors that influence outcome and how these can be addressed through advanced planning. Copyright © 2008 Wiley Interface Ltd

Management of Diabetes in Pregnancy: Comparison of Guidelines with Current Practice at Austrian and Australian Obstetric Center

To compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and estimate the level to which physicians comply with their country's guidelines. Austrian (ODG, Austrian Diabetes Society) and Australian guidelines (ADIPS, Australasian Diabetes in Pregnancy Society) for the treatment of gestational diabetes and pre-gestational diabetes were systematically reviewed. Current practices in two obstetric centers in Austria and Australia were assessed by interviewing key stakeholders through questionnaires assessing different components of diabetes care. For gestational diabetes, these components were screening, abnormal oral glucose tolerance test values (mmol/L), abnormal values for diagnosis, further management when abnormal values are detected, monitoring/glucose targets (mmol/L), further management and indications for insulin therapy, route and timing of delivery, and postpartum management and counseling. For pre-gestational diabetes, the components were management during the preconceptional period, glucose target values, medical surveillance, obstetric surveillance, medication used, route and timing of delivery, and postpartum management and counseling. More variation was found in the management of gestational than pre-gestational diabetes. There were differences in oral glucose tolerance test and cut-off levels for diagnosing gestational diabetes in both centers and guidelines. Australian guidelines recommended two-stage screening for gestational diabetes, while Austrian guidelines recommended one-stage screening. At the Austrian obstetric center, amniocentesis was recommended for determining the start of insulin treatment in pregnant women with gestational diabetes. This approach was neither used at the Australian obstetric center nor recommended by any of the two guidelines. Our study showed that it was difficult to standardize screening criteria and diagnostic methods for gestational and pre-gestational diabetes. National and international consensus has yet to be achieved in the management of diabetes in pregnancy.

Epidemiology of childhood type 2 diabetes and obesity

Over the last decade, it has become apparent that type 2 diabetes extends not only into the young adult population but is also found in adolescents and even, occasionally, in children. The limited data that are currently available present a rather uncertain picture, with a rather wide range of prevalences and incidences of type 2 diabetes in children and adolescents. Not surprisingly, the majority of the cases, and the highest prevalences, have been found among ethnic groups known to be at high risk of adult type 2 diabetes. Nevertheless, even in European populations, where the prevalence of type 2 diabetes remains very low among children and adolescents and certainly is considerably smaller than type 1 diabetes, there are several cases reported. The risk factors for type 2 diabetes in children and adolescents are, as expected, similar to those seen in adults, with obesity being almost always present. In utero exposure to hyperglycemia now appears to be an additional risk factor to having a family history of diabetes and suggests that better management of diabetes in pregnancy and prevention of gestational diabetes may reduce the risk of diabetes developing in the offspring.

Diabetes management in pregnancy

Diabetes in pregnancy is associated with significant morbidity and mortality and its prevalence is rising. The management of this condition involves the co-ordinated care of a multi-disciplinary team consisting of endocrinologists, obstetricians, midwives and dieticians. This review concentrates on the control of diabetes in pregnancy, by which both maternal and fetal complications can be minimised. The management of gestational diabetes centres on self-monitoring of blood glucose, diet control and if necessary, insulin treatment. Women with gestational diabetes have a high risk of developing type 2 diabetes later in life and should be counselled on the importance of lifestyle modification. In patients with pre-existing type 1 and 2 diabetes, pre-conception counselling is important to optimise pregnancy outcome. Such counselling also provides an opportunity to screen for pre-existing vascular complications such as retinopathy (which may worsen during pregnancy) and measure baseline markers of glycaemic control such as HbA 1C. Insulin requirements vary during pregnancy and hence daily assessment of blood glucose levels should be performed and the insulin dose adjusted accordingly. Conventional injections of insulin or insulin pumps are both effective in optimising glycaemic control, although the latter is generally used in patients for whom achieving normoglycaemia is challenging. Blood pressure should be regularly monitored and hypertension treated. The evidence for the efficacy of various treatment modalities has been examined in this review. By optimising diabetes management in pregnancy, it is hoped that the pregnant diabetic patient can look forward to a similar pregnancy outcome as that of a normal woman.

Ultrasound biometry evolves in the management of diabetes in pregnancy

Ultrasound biometry evolves in the management of diabetes in pregnancy

The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in relation to pregnancy

Strict control of blood glucose levels should be pursued before conception and maintained throughout the pregnancy (glycohaemoglobin [HbA(1c)] level as close as possible to the reference range). Before conception: high-dose (5 mg daily) folate supplementation should be commenced; oral hypoglycaemic agents should be ceased; and diabetes complications screening should take place. Management should be by a multidisciplinary team experienced in the management of diabetes in pregnancy. Blood glucose monitoring is mandatory during pregnancy, and targets are: fasting 4.0-5.5 mmol/L; postprandial < 8.0 mmol/L at 1 hour; < 7 mmol/L at 2 hours. A first trimester nuchal translucency (possibly with first trimester biochemical screening with pregnancy-associated plasma protein A and beta-human chorionic gonadotropin) should be offered. Ultrasound should be performed for fetal morphology at 18-20 weeks, if required, for cardiac views at 24 weeks and for fetal growth at 28-30 and 34-36 weeks. Induction of labour or operative delivery should be based on obstetric and/or fetal indications. Level 3 neonatal nursing facilities may be required and should be anticipated when birth occurs before 36 weeks, or if there has been poor glycaemic control. Insulin requirements fall rapidly during labour and in the puerperium. At this time, close monitoring and adjustment of insulin therapy is necessary.

Maternity services for women with diabetes in the UK

Diabetic pregnancy is high risk in those regions within the UK that have reported on such an outcome. There is a paucity of information about diabetic pregnancy outcome in the rest of the UK but it seems appropriate to assume that poor outcome is widespread. Previously reports have highlighted problems with the delivery of preconception care and the lack of agreement about the screening and diagnosis of gestational diabetes. The provision of maternity services for women with diabetes in the UK is reviewed. Service development is traced from the 1980s to more recent surveys from Scotland and the former Northern region of England. Service provision has improved over the years in those regions that have agreed and audited standards for provision of care. There is a lack of information about current services within the UK but this will be partly addressed by the forthcoming survey of organization of services co-ordinated by the Confidential Enquiry into Stillbirths and deaths in Infancy (CESDI), which will survey England, Wales and Northern Ireland. In Scotland the Scottish Intercollegiate Guidelines 'Management of diabetes in pregnancy' has been implemented and audited. A similar guideline of agreed standards of care is needed for the rest of the UK.

Management of diabetes in pregnancy.

Management of diabetes in pregnancy.

Twenty years of management of diabetic pregnancy what was achieved? What must be improved?

Twenty years of management of diabetic pregnancy what was achieved? What must be improved?

A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy.

Seeks to assess maternity care for women with Type 1 diabetes in relation to recommendations in a national clinical guideline using a criterion-based clinical audit. The audit covered all 22 consultant-led maternity units in Scotland, focusing on 268 completed pregnancies in women with Type 1 diabetes. Results are presented and discussed. Concludes that a national audit to monitor the impact of clinical guidelines proved feasible. Antenatal care is organised in line with guideline recommendations but there is lower provision of formal prepregnancy care. Pregnancy planning and periconceptual care fall short of recommendations but care during pregnancy is meticulous. Adverse pregnancy outcomes remain commoner than in non-diabetic pregnancies.

Erratum

This article has been withdrawn as it was published elsewhere and accidentally duplicated. The original article can be seen here: 10.1108/14664100010332991. When citing the article, please cite: Gillian C. Penney, Donald Pearson, (2000), “A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy”, British Journal of Clinical Governance, Vol. 5 Iss 1 pp. 28 - 34.

Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.

To provide a concise review of current practices regarding prenatal diagnosis of excess fetal growth in pregnancies complicated by diabetes mellitus. A literature review of relevant publications. Sonographic estimation of fetal size at term is frequently undertaken in the management of diabetic pregnancy. Considerable error in fetal weight estimations, particularly in asymmetrically enlarged fetuses, may limit the accuracy and clinical utility of these measurements. The limitations and potential inaccuracy of current sonographic methods to detect the large-for-gestational age fetus of a diabetic mother are acknowledged. Customized formulae are of limited benefit so that further study of techniques aimed at assessing fetal fat content and distribution should be undertaken. These methods may improve detection of the large fetus and aid in clinical decision making.

Management of diabetic pregnancies in the United Kingdom

The aim of this postal questionnaire survey was to identify facilities currently available for the care of pregnant diabetic women in the United Kingdom and determine how closely these reflect the standards recommended by The St Vincent Declaration Action Programme. A questionnaire was sent to a physician and an obstetrician in each of the 255 obstetric hospitals in the UK. Two hundred and forty-five (96.1%) hospitals replied, with most of these managing 20 or less insulin dependent diabetics per year. Of the hospitals, 58.4%, had a special combined diabetic antenatal clinic; 86.6% of the units had a single physician responsible for diabetic care, whilst more than one obstetrician was involved in 50.6% of the units. Prepregnancy counselling was provided in 87.4% of the hospitals. Home blood glucose monitoring was used in 97.9% of the units. Ideal mean pre- and postprandial blood glucose concentrations were 6.0 mmol/1 (SD 0.82) and 7.9 mmol/l (SD 0.91), respectively. Ultrasound was routinely used to assess fetal growth in 98.7% of the units. The mean gestational age for elective caesarean section was 38.2 weeks (SD 0.55), compared with 39.0 weeks (SD 0.35) for planned vaginal delivery. During labour, 98% of the units used a dextrose and insulin infusion, but only 53.7% of the units maintained an intrapartum maternal blood glucose of between 4 and 6 mmol/l. We conclude that there is widespread variation in the management of the pregnant diabetic patient, and much practice is suboptimal. Many of the recommendations of the St Vincent Declaration are not being met by current UK practice.

Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus

Objective: To provide a concise review of current practices regarding prenatal diagnosis of excess fetal growth in pregnancies complicated by diabetes mellitus. Methods: A literature review of relevant publications. Results: Sonographic estimation of fetal size at term is frequently undertaken in the management of diabetic pregnancy. Considerable error in fetal weight estimations, particularly in asymmetrically enlarged fetuses, may limit the accuracy and clinical utility of these measurements. Conclusions: The limitations and potential inaccuracy of current sonographic methods to detect the large-for-gestational age fetus of a diabetic mother are acknowledged. Customized formulae are of limited benefit so that further study of techniques aimed at assessing fetal fat content and distribution should be undertaken. These methods may improve detection of the large fetus and aid in clinical decision making. J. Matern.-Fetal Med. 2000; 9:52–54. © 2000 Wiley-Liss, Inc.

Diabetes and pregnancy

Preexisting type-I-diabetes (incidence 0.8%) and gestational diabetes (3-5%) are the two manifestations of disturbed carbohydrate metabolism in pregnancy. Maternal hyperglycemia and the resulting excessive glucose supply for the fetus leads to fetal hyperinsulinism which is responsible for the complications in the offspring. The most important clinical manifestations are the excessive growth of the fetus (macrosomia), the risk of intrauterine death and the neonatal morbidity caused by hypoglycemia and the delay of maturation of lungs and liver. Women with type-I-diabetes require preconception counseling and optimizing of glucose control to reduce the rate of abortion and of congenital anomalies of the offspring. Furthermore kidney function and retinopathia should be evaluated preconceptionally. The management of diabetic pregnancies requires a tight cooperation of obstetricians and diabetologists. Blood glucose levels have to be lower than outside pregnancy. Gestational diabetes is diagnosed by a screening test with 50 g glucose for all women followed by a regular 75 g oGTT when the glucose value is > or = 140 mg%. In most of the women euglycemia can be achieved by diet and exercise. Women after pregnancies with gestational diabetes should be retested postnatally and counseled about their increased risk to develop diabetes in later life.

The management of diabetes in pregnancy.

The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.