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diabetics who become pregnant

Special laboratory: - funduscopic examination by ophthalmologist - during preconception planning [1] - each trimester; continue for 1 year postpartum* [1] * postpartum frequency not specified [1] Complications: 1) maternal risks - pre-eclampsia - polyhydramnios - preterm labor - progression of existing diabetic retinopathy > diabetic nephropathy [9] - tight glycemic control may increase risk for diabetic retinopathy [1,9] 2) fetal risks - increased risk of major fetal malformations in the 1st 12 weeks of gestation - intrauterine death - acute respiratory distress syndrome - hypoglycemia - hypocalcemia - polycythemia - hyperviscosity - hyperbilirubinemia - cardiomyopathy - macrosomia - increased risk of early-onset cardiovascular disease in offspring (RR=1.3) [6] Management: 1) aggressive control of blood glucose - HgbA1c < 6.0% is optimal - continuous glucose monitoring in pregnant women with type 1 diabetes is associated with better neonatal outcomes [5] 2) type 2 diabetes a) switch from oral agents to insulin b) metformin & glyburide OK (pregnancy catergory B)* c) metformin appears to be a reasonably safe alternative to insulin for patients who refuse insulin [7] d) sulfonylureas, GLP-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, or flozins not associated with increased risk of birth defects [8] 3) use bile acid sequestrant (colesevelam) for treatment of hypercholesterolemia [1] - statin contraindicated * oral hypoglycemic agents formerly contraindicated during pregnancy [1,2,3]

Related

gestational diabetes

General

pregnancy disorder; obstetric disorder; pregnancy complication diabetes mellitus

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018.
  2. Prescriber's Letter 7(12):71 2000
  3. Prescriber's Letter 14(9): 2007 Treatment of diabetes in women who are pregnant Detail-Document#: 230913 (subscription needed) http://www.prescribersletter.com
  4. Berghella V, Buchanan E, Pereira L, Baxter JK. Preconception care. Obstet Gynecol Surv. 2010 Feb;65(2):119-31. PMID: 20100361
  5. Feig DS, Donovan LE, Corcoy R et al Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet. Sept 15, 2017 PMID: 28923465 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32400-5/fulltext
  6. Yu Y, Arah OA, Liew Z et al Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up. BMJ 2019;367:l6398 PMID: 31801789 https://www.bmj.com/content/367/bmj.l6398
  7. Boggess KA et al. Metformin plus insulin for preexisting diabetes or gestational diabetes in early pregnancy: The MOMPOD randomized clinical trial. JAMA 2023 Dec 12; 330:2182. PMID: 38085312 PMCID: PMC10716718 (available on 2024-06-12) https://jamanetwork.com/journals/jama/fullarticle/2812641 - Dunne F et al. Early metformin in gestational diabetes: A randomized clinical trial. JAMA 2023 Oct 24; 330:1547. PMID: 37786390 PMCID: PMC10548359 (available on 2024-04-03) https://jamanetwork.com/journals/jama/fullarticle/2810387 - Feig DS. Metformin for diabetes in pregnancy: Are we closer to defining its role? JAMA 2023 Dec 12; 330:2167. PMID: 38085322 https://jamanetwork.com/journals/jama/fullarticle/2812667
  8. Cesta CE et al. Safety of GLP-1 receptor agonists and other second-line antidiabetics in early pregnancy. JAMA Intern Med 2023 Dec 11; [e-pub] PMID: 38079178 PMCID: PMC10714281 Free PMC article https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2812743
  9. NEJM Knowledge+ - ElSayed NA, Aleppo G, Aroda VR et al 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S254-S266. PMID: 36507645 PMCID: PMC9810465 Free PMC article. Review. - Morrison JL, Hodgson LA, Lim LL, Al-Qureshi S. Diabetic retinopathy in pregnancy: a review. Clin Exp Ophthalmol. 2016 May;44(4):321-34. PMID: 27062093 Review.
  10. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Pregnancy if You Have Diabetes https://www.niddk.nih.gov/health-information/diabetes/diabetes-pregnancy