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Management of Diabetes during Pregnancy

1.5 Contact Hours - 1.5 Pharmacology Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Wednesday, July 20, 2022
Course Description
This course will discuss the current guidelines when caring for pregnant women with diabetes.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Outcomes

≥90% of participants will understand evidence-based guidelines for caring for pregnant women with diabetes.

Objectives

After completing this continuing education course, the participant will be able to complete the following objectives:

  1. Identify the difference between gestational diabetes and pre-existing diabetes.
  2. List five risk factors for developing gestational diabetes.
  3. Describe three ways to prevent gestational diabetes.
  4. Identify three complications of diabetes.
  5. Plan how to care for a woman with diabetes in labor and delivery.

Gestational Diabetes

Background

The American Diabetes Association defines gestational diabetes as diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation.1 The occurrence of gestational diabetes in the United States is approximately 6% of all pregnant women.2 This rate has been increasing, likely due to changes in maternal age and obesity. African American, Hispanic American, Native American, Pacific Islander, and South or East Asian women have higher rates than do white women. The American College of Obstetricians and Gynecologists (ACOG) states that a diagnosis of gestational diabetes mellitus generally requires that two or more values meet or exceed glucose thresholds, but clinicians may choose to make the diagnosis based on one elevated value.3

Risk Factors

There are numerous risk factors for gestational diabetes. Some of these risks include:

  • History of impaired glucose tolerance
  • Impaired fasting glucose
  • Gestational diabetes mellitus in a previous pregnancy
  • Family history of diabetes
  • Prepregnancy BMI >30 kg/m2
  • Excessive gestational weight gain during the first 18 to 24 weeks
  • Maternal age >30 years of age
  • Previous unexplained perinatal loss or birth of a malformed infant

Additional risks include:

  • Glycosuria at the first prenatal visit
  • Previous birth of an infant 4500 g
  • Elevated LDL or triglycerides
  • Medical condition associated with the development of diabetes, such as metabolic syndrome, polycystic ovary syndrome, current use of glucocorticoids, hypertension or cardiovascular disease, acanthosis nigricans, or a multiple gestation pregnancy3

However, 20% of women with gestational diabetes do not have any risk factors.

For women who are obese, losing more than 10 pounds may decrease the risk of gestational diabetes. Regular exercise, a healthy diet, and smoking cessation may all improve health and decrease the risk of diabetes.4

Diagnosis

All women should undergo a glucose tolerance test. This test may be done as early as the first prenatal visit if there is a high risk of having diabetes. If early screening is not done or is negative, a woman should be screened at 24 to 28 weeks gestation. There are two different ways to test for gestational diabetes. The one-step approach is when the woman is given a 75-gram dose of glucose, then her blood glucose level is tested 2 hours later. The woman also must be fasting. The two-step approach is most often used. The woman does not have to be fasting. She gets a 50-gram dose of glucose and has her glucose tested 1 hour later. If her sugar is abnormal, she will need a 2nd test. The 2nd test is a 3-hour glucose tolerance test where the woman has a fasting blood sugar drawn, then takes a 100-gram dose of glucose and has her blood sugar drawn every hour for 3 hours. Two or more abnormal results would diagnose the woman with gestational diabetes. Glycated hemoglobin (A1C) is not a good indicator when diagnosing gestational diabetes. It may be used in early pregnancy to determine if the woman has pre-existing diabetes.3

Treatment

The first line of treatment for gestational diabetes is diet. The American Diabetes Association (ADA) recommends a nutrition plan that provides adequate nutrition for mom and fetus while achieving normoglycemia. Caloric intake is important to ensure that the woman and fetus get enough nutrition, but monitoring carbohydrate intake is important to keep glucose levels normal. Appropriate weight gain is important and varies depending on the woman’s BMI. Moderate exercise is also recommended as part of a treatment plan for gestational diabetes.5

Glucose monitoring in pregnancy is important to determine the need for medications and prevent complications. Generally, fasting and postprandial glucose monitoring are recommended. The postprandial sugars may be done at 1 or 2 hours after the meal, depending on providers. Target glucose levels are fasting blood glucose values < 95 mg/dL and postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2 hours.3

Medications used to treat gestational diabetes are insulin, metformin, or glyburide. ACOG recommends insulin as the treatment of choice. Many patients who begin oral therapy will require insulin. Insulin dose should be started at 0.7-1.0 units/kg daily, and the dosage should be divided long-acting or intermediate-acting insulin.3 The Society for Maternal-Fetal Medicine (SMFM) believes that metformin is a safe and reasonable first line of treatment.6

Fetal Monitoring

For all women with poor glucose control on medication without co-morbidities, weekly fetal monitoring should begin at 32 weeks or earlier if other co-morbidities exist. There is no consensus for fetal monitoring for women who are well controlled through diet, but should start at > 32 weeks and include amniotic fluid volume assessment due to the risk of polyhydramios.3

Delivery

Women with gestational diabetes whose glucose is well controlled by diet should be delivered after 39 weeks and can wait up to 40 weeks 6 days with antepartum testing. A woman who is well controlled on medication should deliver at 39 weeks 0 days to 39 weeks 6 days. A woman with poorly controlled diabetes may be recommended to deliver between 37 weeks 0 days and 38 weeks 6 days with delivery between 34 weeks 0 days and 36 weeks 6 days reserved for failure of in-hospital glycemic control or abnormal fetal testing. A patient with an estimated fetal weight ≥ 4500 should be counseled regarding the risks and benefits of a scheduled cesarean section.3 During labor, women with gestational diabetes should be monitored and maintain good glycemic control to prevent newborn hypoglycemia after delivery.

Complications

Gestational diabetes can have serious consequences for the mother and the fetus. There is an increased risk of preeclampsia, polyhydramnios, macrosomia, maternal and infant birth trauma, operative delivery (cesarean, instrumental), and hypoglycemia.7 Good glycemic control can help to prevent these complications. Women with gestational diabetes also have an increased risk of developing diabetes later in life.

Pregestational Diabetes

Early Pregnancy

Women with pregestational diabetes should be well-controlled prior to getting pregnant with a planned pregnancy. Women with an unplanned pregnancy should regulate their glucose as soon as possible. Women who have hemoglobin A1C levels of < 6 to 6.5 percent early in pregnancy have the lowest rates of fetal complications, such as miscarriage and congenital anomalies.8

Glucose Monitoring

Glucose monitoring for these women is similar to the gestational diabetic. Fasting sugars, pre-prandial and/or postprandial sugars, as well as hemoglobin A1C levels are important for these women. Women with pregestational diabetes who are on oral treatment should be switched to insulin treatment, and women who were already on insulin will need a modification to their regimen.8

Complications

Women with pregestational diabetes should have renal function assessed throughout the pregnancy. These women are also at risk for thyroid dysfunction. Cardiac function may need to be monitored, as well as eye exams to monitor for retinopathy. Preeclampsia is also a concern, and low dose aspirin may be prescribed to try to prevent it. 

Fetal risks include miscarriage and congenital malformations early in pregnancy. Neural tube defects and congenital heart disease are higher in this population. Fetal demise is rare due to increased surveillance and improved glycemic control for these women. Polyhydramnios is another risk for the fetus. An increased amount of amniotic fluid could cause complications such as a cord prolapse if the woman’s water breaks. 

Diabetic ketoacidosis is a life-threatening emergency that may occur probably due to increased insulin resistance. Symptoms of diabetic ketoacidosis may include abdominal pain, nausea and vomiting, and altered sensorium. Treatment includes hydration and intravenous insulin.8

Fetal Monitoring

Usually, monitoring is weekly beginning at 32 weeks, although this may begin earlier, and increased to twice weekly at 36 weeks gestation. Fetal growth is monitored closely because these fetuses may grow large for gestational age (LGA). LGA fetuses increase the risk of a long labor, shoulder dystocia, operative delivery, maternal and infant birth trauma, and perinatal death.8 The newborn is at risk for hypoglycemia. Preterm labor is also a higher risk. Fetuses born prior to 34 weeks, whether due to preterm labor or a planned early delivery, should received glucocorticoids to promote fetal lung maturity.

Delivery

ACOG recommends delivery at 39 weeks 0 days to 39 weeks 6 days. A woman with poorly controlled diabetes or vascular disease should deliver between 36 weeks 0 days and 38 weeks 6 days.8 Women with pregestational diabetes also require strict glycemic control during labor. A titratable insulin drip with frequent glucose monitoring is usually recommended for good control.

Conclusion

Diabetes is a serious medical condition that can occur before or during pregnancy and cause complications for the woman and the fetus. It is important that pregnant women with gestational or pregestational diabetes receive close monitoring, both for the woman’s glucose and for the fetus.

Case Study

A.K. is a 23-year-old diabetic woman with an unplanned pregnancy who does not receive prenatal care until 28 weeks gestation. When she sees her doctor, her hemoglobin A1C result is 8.5%, revealing that she has had poor glycemic control. Her BP is 138/92, pulse 88, Resp 18. She has felt the baby moving and denies any other complications, such as bleeding. She does complain of bilateral foot neuropathy. 

  • What complications is she at risk for?
    • A.K. is at an increased risk for preeclampsia. Her BP is elevated, and she is diabetic. She is also at increased risk for kidney disease because of diabetes and elevated BPs. Her diabetes is also poorly controlled, complicating things further.
  • What complications is the fetus at risk for?
    • The fetus is at risk for congenital anomalies and cardiac anomalies. She has passed the stage of miscarriage, but with poorly controlled sugars and the lack of prenatal care, she is also at risk for intrauterine fetal demise.
  • What testing does the fetus need?
    • This woman needs an ultrasound and fetal echocardiogram to look for anomalies. This woman also needs fetal monitoring to assess fetal well-being.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care 2019; 42:S13.
  2. Deputy NP, Kim SY, Conrey EJ, Bullard KM. Prevalence and Changes in Preexisting Diabetes and Gestational Diabetes Among Women Who Had a Live Birth - United States, 2012-2016. MMWR Morb Mortal Wkly Rep 2018; 67:1201.
  3. Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstet Gynecol 2018; 131:e49. Reaffirmed 2019.
  4. Zhang C, Tobias D, Chavarro J, et al. Adherence to Healthy Lifestyle and Risk of Gestational Diabetes Mellitus. Obstetric Anesthesia Digest. 2015;35(3):161. doi:10.1097/01.aoa.0000469500.73740.44.
  5. Lebrun C. Exercise and Type 2 Diabetes: American College of Sports Medicine and the American Diabetes Association: Joint Position Statement. Yearbook of Sports Medicine. 2011;2011:162-163. doi:10.1016/j.yspm.2011.03.038.
  6. SMFM Statement: Pharmacological treatment of gestational diabetes. American Journal of Obstetrics and Gynecology. 2018;218(5). doi:10.1016/j.ajog.2018.01.041.
  7. Gestational Diabetes and Pregnancy | CDC. Updated February 27, 2020. Accessed December 15, 2019. Visit Source.
  8. Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 201: Pregestational Diabetes Mellitus. Obstet Gynecol 2018; 132:e228-e248. doi:10.1097/AOG.0000000000002960.