1. Diabetes and Pregnancy
Karen Playforth, MFM
Associate Professor, Department of OB/GYN
September 14th, 2018

2. I have no conflicts of interest to disclose.
Karen Playforth, MD, MFM
I have no conflicts of interest to disclose.

3. St. Luke’s-Roosevelt Hospital:
Residency
Generalist OB/GYN Attending
MFM Fellowship

5. Overarching Objective
Upon completion of this activity, participants will be able to:
Explain the potential impact of metabolic syndrome or diabetes on the reproductive health of females

6. Specific Objectives
Upon completion of this activity, participants will be able to:
Recognize the importance of preconception counseling in patients with preexisting diabetes mellitus and of post-partum testing and counseling of patients with gestational diabetes mellitus;
List the complications of pregnancy associated with poorly controlled preexisting diabetes mellitus in the first trimester of pregnancy;
Name the complications of pregnancy common to both preexisting and gestational diabetes mellitus;
Describe the baseline lab work and evaluations done in pregnancy for preexisting and gestational diabetes mellitus patients and why;
Recall the goals for blood glucose control in pregnancy and why;
Restate the recommendations for monitoring and delivery timing for pregnancies complicated by diabetes;
Explain the bigger picture of diabetes and the reproductive health of women.

7. Epidemiology

8. Epidemiology
Approximately 7% of pregnancies are affected by ANY TYPE of diabetes
Preexisting diabetes complicates ~1 % of pregnancies in US
Type 1 DM accounts for 5-10% of patients diagnosed with diabetes in the general population
Incidence of Type 2 DM is very dependent on the population studied
Gestational diabetes (GDM) accounts for 86% of diabetes in pregnancy
The incidence depends on the baseline prevalence of Type II of the population, which can vary between 1 – 14%.
However, type 1 diabetes may represent a slightly greater fraction of women in the reproductive age group because of the relatively earlier age of onset of type 1 diabetes compared with type 2 diabetes
Yang JE, Cummings EA, O'Connell C, Jangaard K: Fetal and neonatal outcomes of diabetic pregnancies. Obstet Gynecol
ACOG Practice Bulletin Number 190, February 2018.
ACOG Practice Bulletin Number 60, March 2005.

9. Epidemiology
Total of 30.2 million people, or 12.2% of the U.S. population, have diabetes
23 million people with diagnosed diabetes
7.2 million people with undiagnosed diabetes
14.9 million, or 11.7 %, of all women age 18 years or older have diabetes
11.7% of women > 18yo are diagnosed
3.1% of women > 18yo are undiagnosed
Data source: 2011–2014 National Health and Nutrition Examination Survey and 2015 U.S. Census Bureau data.

10. 11.1% of Kentucky women are diagnosed with diabetes
Data source: 2011–2014 National Health and Nutrition Examination Survey and 2015 U.S. Census Bureau data.

11. Epidemiology Risk Factors for Diabetes Obesity Sedentary lifestyle
Family history
Genetics
Ethnicity
Age
INTRAUTERINE ENVIRONMENT

12. Epidemiology
Exponential rise in numbers of pregnancies affected by diabetes mellitus
 “Diabesity”
 infants of mothers with diabetes (Type 1)
 diabetes/prediabetes in reproductive age women
5% to 10% of women with GDM develop Type 2 immediately after pregnancy
35% to 60% of women with GDM develop Type 2 within the 10–20 years
Among Hispanic women, approximately 50% develop Type 2 within 2 years
2009 CDC Data

14. Complications and Interventions

15. Complications in Pregnancy

16. Complications in First Trimester

17. Complications in 1st Trimester
Uncontrolled preexisting DM in first trimester of pregnancy = Maternal hyperglycemia
Miscarriage
Congenital anomalies
Open neural tube defects
Heart defects

18. Teratogens
MAJOR POINT– Most sensitive time for majority of organs is the EMBRYONIC PERIOD. 3-8 WEEKS.

19. Interventions in First Trimester (or before)
Preconception counseling
Risk to fetus for congenital malformations highest often before they know they are pregnant
HgbA1c > 8% risk of miscarriage is 26 times baseline risk
HgbA1c > 10% confers 25% risk of congenital malformation
The pivotal time is 3-6 weeks post-conception, OR 5-8 weeks from LMP.

20. Interventions in 1st Trimester
Diabetes Re-Education  Different rules in pregnancy
First trimester
Ultrasound to establish dates
Baseline labs and evaluations
24 hour urine protein, preeclampsia labs, TSH, maternal echo, ophthalmology exam
Start daily low dose aspirin between weeks of pregnancy and continue until delivery

21. Complications in 2nd and 3rd Trimester

22. Complications in 2nd and 3rd Trimester
Uncontrolled DM in second and third trimester of pregnancy = Hyperglycemia and Hyperinsulinemia
Premature delivery
Preeclampsia
Stillbirth
Macrosomia
Shoulder dystocia
Operative delivery
Maternal or fetal trauma
NICU admission
Childhood obesity and diabetes mellitus

23. Fractured clavicle
Erb’s Palsy

25. In a study done on mothers and infants born at The Ohio State University Hospitals from 1994-1996,
36% of A1 diabetes patient went to the NICU
68% of class D-R diabetics
36% of those going to the NICU for RDS had mechanical ventilation
HMD=hyaline membrane disease
PPHNB=persistent pulmonary hypertension
Arch Pediatr Adolesc Med. 1998;152(3): doi: /archpedi

26. Interventions in 2nd and 3rd Trimester
Strict blood glucose control
Fasting < 95mg/dl (I prefer <90mg/dl)
Pre-prandial <100mg/dl
Post-prandial <120mg/dl
Bedtime <100mg/dl
Close follow-up
Nutritional Counseling and Diabetes Self-Management Education
Serial ultrasounds for anatomic survey and then for growth q 4 weeks
Antenatal testing
Delivery timing

27. Antepartum Testing Ultrasounds Fetal echocardiogram
For dating
To assess for congenital malformations
Growth assessment
Fetal echocardiogram
Non-Stress Tests – begun generally between weeks, but individualized based on underlying risk

28. Delivery Timing Balance the risk of IUFD with risks of preterm birth
Poorly controlled – delivery between weeks
Evidence of compromise/elevated risk profile – consider delivery before 39 weeks
Well-controlled, A1’s may go to EDC
Expectant management beyond is not recommended

29. PREGNANCY = TEACHABLE MOMENT

31. Questions?