Oral medication options for gestational diabetes -
Preconception care should also include advice regarding folic acid supplementation. In 1 case-control study in the United States, women with diabetes who did not take folic acid containing vitamins were at a 3-fold higher rate of congenital anomalies compared to women with diabetes who did Obesity, which is more common in women with type 2 diabetes, is associated with lower serum folate levels for the same intake, lower intake of folate rich foods and increased risk of neural tube defects independent of glycemic control 15— A higher dose of folic acid may be considered in women with obesity, although there is no clinical evidence that this higher dose reduces congenital anomalies.
Measurement of red blood cell RBC folate may also be useful to guide adjustment of folic acid dosage in women with obesity or women who have had bariatric surgery.
Additionally, some studies have shown that women with type 2 diabetes are less likely to receive preconception care compared to women with type 1 diabetes 19, Women with type 1 24,25 and type 2 diabetes 26 should ideally have ophthalmological assessments before conception, during the first trimester, as needed during pregnancy, and within the first year postpartum 27, The risk of progression of retinopathy is increased with poor glycemic control during pregnancy, and progression may occur for up to 1 year postpartum 25, Additional risk factors for retinopathy progression include: chronic and pregnancy-induced hypertension, preeclampsia, more severe pre-existing diabetic retinopathy 24,29—31 , and a greater decrease in A1C between the first and third trimester of pregnancy Closer retinal surveillance is recommended for women with more severe pre-existing retinopathy, those with poor glycemic control or women with greater reductions in A1C during pregnancy 27, Laser photocoagulation for severe nonproliferative or proliferative retinopathy prior to pregnancy reduces the risk of visual impairment in pregnancy 34 ; if not performed prior to pregnancy, it is still considered safe to receive during pregnancy.
There is insufficient evidence to confirm safety or harm from the use of intravitreal antivascular endothelial growth factor anti-VEGF injections for diabetic macular edema or proliferative diabetic retinopathy during pregnancy Potential side effects include hypertension, proteinuria, defective embryogenesis and fetal loss 36, It is not known if these medications cross the placenta or if they are secreted in breastmilk.
Gestational timing of exposure needs to be considered in situations where potential benefit to the woman justifies the potential fetal risk. Until more safety information is available, we support the recommendations of others: a to ensure a negative pregnancy test and contraception use during intravitreal anti-VEGF therapy, and b to consider delaying conception for 3 months after the last intravitreal injection 38, Intravitreal anti-VEGF therapy in pregnancy should be avoided especially in the first trimester.
Second and third trimester use should occur only if absolutely necessary after discussion of the potential risks and benefits. Diabetic macular edema may often regress after pregnancy without specific therapy. Data are lacking to guide treatment recommendations for diabetic macular edema during pregnancy.
One retrospective study of women with type 1 diabetes, 63 with an active second-stage delivery 3 with proliferative diabetic retinopathy found no impact of expulsive efforts in the active second stage of labour on retinopathy progression in women with stable retinopathy Data from the Diabetes Control and Complications Trial DCCT has suggested that pregnancy does not affect the long-term outcome of mild-to-moderate retinopathy More recently, preeclampsia and pregnancy-induced hypertension in women with type 1 diabetes has been shown to be associated with an increased risk of severe diabetic retinopathy later in life A systematic review of risk factors for preeclampsia demonstrated a 3.
Type 1 diabetes is more often associated with preeclampsia whereas type 2 diabetes is more often associated with chronic hypertension. In the general population, the risk of preeclampsia is highest in nulliparous women and lower in multiparous women. However, in women with type 1 diabetes, the risk of preeclampsia is similar in nulliparous and multiparous women Other risk factors for hypertension, such as poor glycemic control in early pregnancy, are potentially modifiable.
Some studies 44,45 , but not all 46 , have found that increased urinary protein excretion in early pregnancy is associated with an increased risk of hypertension.
Any type and degree of hypertension is associated with adverse outcomes. Finally, a number of antihypertensive medications are safe and effective in pregnancy, including calcium channel blockers, labetalol and methyldopa.
Although there are no intervention trials for ASA prophylaxis for the prevention of preeclampsia specific to women with pre-existing diabetes, ASA prophylaxis started between 12 to 16 weeks of gestation is likely to be beneficial, given the evidence of benefit in other high-risk populations, Chronic kidney disease.
Prior to conception, women should be screened for chronic kidney disease CKD. Albuminuria and overt nephropathy are associated with increased risk of maternal and fetal complications 50— An estimated glomerular filtration rate eGFR should be used prior to pregnancy to determine risk of adverse outcomes.
However, inadequate BP control in pregnancy may account for this observed difference in this study. During pregnancy, serum creatinine not eGFR should be used, as eGFR will underestimate GFR in pregnancy 57, Proteinuria increases during pregnancy, but, in women with a normal GFR, pregnancy has no adverse effects on long-term renal function as long as BP and blood glucose BG are well controlled 50—53,56,59, First trimester BP elevations and protein excretion are associated with delivery before 37 weeks, usually due to preeclampsia There is conflicting information on whether first-trimester exposure to angiotensin-converting enzyme ACE inhibitors and angiotensin receptor blockers ARBs is associated with an increased risk of congenital malformations 65, Fetal exposure in the second and third trimesters is clearly associated with a fetal renin angiotensin aldosterone system RAAS blockade syndrome, which includes renal failure, oligohydramnios, hypotension, intrauterine growth restriction and death The decision to discontinue an ACE inhibitor or ARB prior to pregnancy should be discussed with the woman and may depend on the indication for use and availability of an effective alternative medication.
However, once a woman is pregnant, ACE inhibitors and ARBs should be discontinued. Painful peripheral neuropathy management. As with all medications used in pregnancy, benefits need to be weighed against risk.
Cardiovascular disease. Although rare, cardiovascular disease CVD can occur in women of reproductive age with diabetes. Myocardial infarct MI in pregnancy is associated with poor maternal and fetal outcomes 71, Women with known CVD should be evaluated and counselled about the significant risks associated with pregnancy.
An early working relationship should be established between the woman and the DHC team to optimize care, facilitate the planning of pregnancy, ensure adequate self-care practices and to discuss the need for social support during pregnancy.
Elevated BG levels have adverse effects on the fetus throughout pregnancy. At conception and during the first trimester, hyperglycemia increases the risk of fetal malformations and intrauterine fetal demise Later in pregnancy, it increases the risk of macrosomia, fetal and infant death 77 as well as metabolic and obstetrical complications at birth 78, As a result, meticulous glycemic control throughout pregnancy is required for optimal maternal and fetal outcomes.
An important first step in achieving optimal glycemic control is to set target BG levels 74, However, optimal targets for fasting, preprandial and postprandial BG levels in women with pre-existing diabetes have not been examined in randomized controlled trials; and a variety of BG targets are used in clinical practice.
In women with type 1 diabetes and good glycemic control during pregnancy with an A1C of 4. In the absence of comparative studies of specific BG targets for women with pre-existing diabetes, use of the mean BG plus 2 standard deviation SD of pregnant women without diabetes appears to be appropriate.
However, since the hypoglycemia level is often individualized to each person with diabetes, with consideration of symptoms, therapy, medical condition and associated risk; the official lower limit of BG level during pregnancy is difficult to clearly establish. Overall, it is understood that pregnant women have lower BG values that can be judged as normal even if below the traditional level of 4.
Hypoglycemia is generally considered to be without risk for the fetus, as demonstrated in women with pre-existing diabetes 79,92—94 , as long as it is not sustained and maternal loss of consciousness, convulsion, and fall or trauma is avoided during the episode However, repeated hypoglycemia and associated loss of glycemic control have been associated with macrosomia The limiting factor when targeting euglycemia in women with pre-existing diabetes is the increased risk of hypoglycemia during pregnancy, particularly in the first trimester 96— , for both type 1 and type 2 diabetes The latter may relate, in part, to the loss of counterregulatory hormones reported in women with pre-existing diabetes during pregnancy, particularly growth hormone and epinephrine 95,— This risk of hypoglycemia may be ameliorated if efforts are made to achieve good glycemic control preconception and by the use of analogue insulins ,, see Hypoglycemia chapter, p.
Health-care providers should ensure that pregnant women with diabetes: a have a glucagon kit; b are advised regarding effective interventions if a severe hypoglycemic event occurs; and c are encouraged to inform close relatives and co-workers of this increased risk, especially in the first and early second trimester.
Frequent self-monitoring of blood glucose SMBG in pregnant women with type 1 diabetes is essential during pregnancy in order to achieve the glycemic control associated with better outcomes Preprandial testing to guide mealtime insulin dose adjustment and postprandial testing to meet postprandial targets are associated with less macrosomia in observational studies and reduced preeclampsia 81,, Due to the increased risk of nocturnal hypoglycemia with any intensive insulin therapy, SMBG during the night is often necessary in pregnant women with diabetes receiving insulin SMBG 4 to 7 times per day is also recommended for pregnant women with type 2 diabetes i.
fasting, preprandial and 1 or 2 hours postprandially to achieve good glycemic control. CGM may help identify periods of hyper- or hypoglycemia , and can confirm glycemic variability, especially in women with type 1 diabetes Evidence for the use of CGM to improve glycemic control, and maternal and fetal outcomes is conflicting.
One study using blinded, intermittent CGM with review of results with a clinician showed that CGM improved A1C and rates of macrosomia compared to standard care However, a study of intermittent real-time CGM did not demonstrate benefit Finally, a study examining CGM use to prevent episodes of severe hypoglycemia early in pregnancy in women with a history of episodes in the year prior to pregnancy did not demonstrate benefit.
The Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy CONCEPTT trial randomized women pregnant and planning pregnancy to capillary blood glucose CBG monitoring with CGM or without.
Neonatal health outcomes were significantly improved, with lower incidence of LGA OR 0. No benefit was observed for women planning a pregnancy Whether closed-loop systems will be beneficial for use in pregnancy remains to be seen One study of pregnant women with type 1 diabetes showed overnight closed-loop therapy resulted in better glycemic control than sensor-augmented pump therapy Women with pre-existing diabetes during pregnancy should have A1C levels measured during pregnancy to assist in management.
A1C levels can also be helpful predictors of adverse pregnancy outcomes , The optimal frequency of A1C measurement is not known; however, testing more than the usual every 3 months may be appropriate see Monitoring Glycemic Control chapter, p.
Institute of Medicine IOM guidelines for weight gain in pregnancy were first established in based on neonatal outcomes. Results of a systematic review of studies examining the IOM recommendations for maternal weight gain in women without diabetes, showed that those who followed guidelines were more likely to have good infant birthweight and fetal growth, and decreased the amount of weight loss required postpartum The IOM revised their recommendations in due to increasing rates of obesity and to take into consideration maternal obesity; however, IOM recommendations do not take into account pre-existing medical conditions Cohort studies of various body mass index BMI classes of women with pre-existing diabetes showed that excessive gestational weight gain GWG is characterized by higher birth weight infants independent of pre-pregnancy BMI and glycemic control , The researchers suggest that aiming for the lower weight gain range based on BMI category may be useful in the management of women with pre-existing diabetes.
Furthermore, prepregnancy overweight and obesity are risk factors for adverse maternal and neonatal outcomes. Findings of cohort studies with pregnant women with type 2 diabetes who had overweight or obesity showed that weight gain greater than the IOM recommendations was associated with increased macrosomia — , LGA , adverse neonatal outcomes and higher rates of caesarean deliveries , Studies investigating weight gain below the IOM guidelines in women with obesity and type 2 diabetes have produced conflicting results ranging from: no evidence of worsened perinatal outcomes ; increased risk of SGA ; and lower birth weight, LGA and less perinatal morbidity with no increased risk of SGA Prepregnancy BMI, glycemic control and GWG can have independent and additive effects on fetal growth.
Therefore, diabetes education and management for this group of women in preconception and regularly throughout pregnancy should be inclusive of both optimal glycemic control, healthy preconception weight and weight gain through pregnancy.
Until additional data on specific weight gain recommendations for women with pre-existing diabetes becomes available, these women should be advised to gain weight as per the IOM guidelines based on their prepregnancy BMI category to lower the risk of LGA, macrosomia and caesarean deliveries.
Insulin therapy must be individualized and regularly adapted to the changing needs of pregnancy — Intensive insulin therapy with basal-bolus therapy or continuous subcutaneous insulin infusion CSII or insulin pump therapy is recommended to achieve glycemic targets prior to pregnancy and during pregnancy.
Women using CSII should be educated about the possible increased risk of diabetic ketoacidosis DKA in the event of insulin pump failure. However, recent studies using pumps have not demonstrated an increase in DKA compared to multiple daily injections MDI Rapid-acting bolus analogues e.
aspart, lispro appear safe for use in pregnancy, with some studies showing improvement in postprandial glycemia and reduced maternal hypoglycemia compared to regular insulin — A meta-analysis of observational studies women with pre-existing diabetes and GDM found that lispro compared to regular insulin was associated with decreased rates of severe maternal hypoglycemia and neonatal jaundice, but increased rates of LGA infants A randomized trial of women with type 1 diabetes randomized to insulin aspart vs.
human regular insulin, showed a trend toward reduced episodes of major hypoglycemia, with improved postprandial BG levels but similar overall glycemic control In a smaller, underpowered study, perinatal outcomes were similar using insulin aspart and human insulin A meta-analysis of randomized trials of 1, women with gestational or pre-existing diabetes assessing the use of insulin aspart or premixed biphasic insulin aspart 30 compared to human regular insulin or premixed biphasic insulin aspart during pregnancy found similar rates of caesarean section and macrosomia Finally, a case series of women exposed to glulisine during pregnancy showed no noted pattern of few birth defects There are no data to date on faster-acting insulin aspart.
Long-acting insulin analogues, glargine and detemir, appear safe with similar maternal and fetal outcomes compared to neutral protamine hagedorn NPH insulin.
Both glargine and detemir do not cross the placenta at therapeutic doses, although glargine does cross at very high doses Notably, 2 randomized trials of detemir use compared with NPH in women with type 1 diabetes showed a lowering of FBG, but similar A1C, maternal hypoglycemia, and other maternal and fetal outcomes ; another trial found less hypoglycemia with detemir compared with NPH The research evidence for glargine are more limited cohort and case control studies ; however, in a meta-analysis of cohort studies comparing glargine to NPH, maternal and fetal outcomes were similar and no adverse maternal or fetal effects have been described to date.
Finally, there are no benefit or harms data on the use of glargine insulin U, lispro insulin U, degludec insulin U and U, or glargine biosimilar in pregnancy.
CSII therapy during pregnancy. While the use of CSII may be preferred by some women with type 1 diabetes, older randomized studies have not demonstrated superiority over basal-bolus regimen ,— A meta-analysis of observational studies comparing the use of CSII with insulin analogs to MDI found no differences in maternal or fetal outcomes However, recent studies not included in the meta-analysis suggest improved glycemic control with CSII — , while other studies found no difference Overall, studies show no difference in maternal or fetal outcomes with CSII, but also no increase in harms, such as maternal hypoglycemia, DKA or weight gain.
More randomized trials are needed with current CSII technology to better assess the utility of CSII during pregnancy. Noninsulin antihyperglycemic agents and pregnant women with type 2 diabetes.
A meta-analysis of first-trimester use of either glyburide or metformin, and a meta-analysis of metformin alone in women with polycystic ovary syndrome PCOS showed no increased incidence of congenital anomalies , Women with type 2 diabetes who conceive on metformin or glyburide can continue these agents until insulin is initiated.
Three smaller randomized trials have examined the use of metformin in pregnant women with type 2 diabetes.
However, given the small sample sizes in the study and other methodological challenges, the findings from these studies offer limited generalizability.
Currently, a large, double-blind randomized trial is underway to determine whether adding metformin to insulin will benefit mothers with type 2 diabetes and their infants Metformin in Women with Type 2 Diabetes in Pregnancy [MiTy] and Metformin in Women with Type 2 Diabetes in Pregnancy Kids [MiTy Kids] trials.
In conclusion, some studies indicate a possible benefit to adding metformin to insulin in women with type 2 diabetes; however, due to limitations in the research, there is insufficient evidence to recommend the addition of metformin to insulin in pregnant women with type 2 diabetes.
Pregnant women with diabetes receiving steroids. In women suspected of preterm delivery, 2 doses of betamethasone is often given to aid in the maturation of the fetal lungs.
The algorithm in Table 1 has been shown to prevent severe hyperglycemia, DKA and severe hypoglycemia in women with type 1 diabetes Despite health care advances, including NICU, accurate ultrasound dating, SMBG and antenatal steroids for fetal lung maturity, perinatal mortality rates in women with pre-existing diabetes remain increased 1- to fold compared to women without diabetes, and is influenced by glycemic control 1, In women with pre-existing diabetes, the risk of stillbirth is higher at all gestations after 32 weeks Perinatal mortality is increased in pregnancies of women with pre-existing diabetes, particularly in those with poor glycemic control It has been hypothesized that a marked or rapid decrease in insulin requirements could be a harbinger of placental insufficiency.
The relationship between falling insulin requirements and pregnancy outcomes has been explored in 4 retrospective studies — Therefore, not surprisingly, those with the greater decrease in insulin requirements compared to those without, were admitted more frequently to the NICU Although care was taken not to include the period within 5 days of antenatal steroid administration when calculating the percent fall in insulin dosing in this study, the substantially higher antenatal steroid use in the pregnancies with falling insulin requirements However, caution is required in the interpretation of these retrospective studies since decreasing insulin requirements may impact decisions regarding timing of delivery which may, in turn, impact pregnancy outcomes.
In contrast, results from other studies found no association with decreasing insulin requirements and birthweight, and neonatal weight distribution i. SGA to LGA However, 1 study observed a trend for greater LGA neonates in women with decreasing insulin requirements Caution is required when interpreting the findings as researchers used differing calculation methods to indicate fall in insulin requirements or perhaps due to heterogeneity in the population of women with type 2 diabetes included in the studies.
The use of advanced sonographic and fetal doppler assessment in the surveillance of the fetus at risk, as in other high-risk pregnancies, may allow further stratification of risk in this population, but the optimal indicator of feto-placental compromise, particularly in women with diabetes, remains unclear.
In summary, the impact of decreasing insulin requirements is still not certain. While fetal monitoring in this situation can provide reassurance of current fetal well-being, it should not be viewed as a substitute for a well thought out plan for timing of delivery that takes into consideration other risks for perinatal mortality, such as gestational age, maternal glycemic control both periconception and in later pregnancy , prepregnancy retinopathy 77 , maternal age, obesity and smoking history.
The goal of fetal surveillance and planned delivery in women with pre-existing diabetes in pregnancy is the reduction of preventable stillbirth. However, not all stillbirths can be avoided due to the fact that many stillbirths in pre-existing diabetes occur prior to 36 weeks of gestation and that in a large number of cases no obvious cause is noted Despite this, it is reasonable to apply surveillance strategies to pre-existing diabetes pregnancies that are similar to those in other pregnancies at high risk of fetal complications, such as intrauterine growth restriction IUGR , chronic hypertension, and systemic lupus erythematosis Although there is no single strategy for antenatal surveillance for pre-existing diabetes pregnancies, the initiation of some form of fetal surveillance in all women with pregnancies complicated by pre-existing diabetes while applying more intensive protocols for fetal surveillance in pregnancies with additional risk factors is required.
These risk factors include: evidence of poor glycemic control, prepregnancy retinopathy 77 , LGA, polyhydramnios or the presence of other comorbidities or high-risk conditions hypertension, obesity, late maternal age, IUGR, previous stillbirth.
As a general rule, intensified fetal surveillance should begin at a period in gestation when intervention i. delivery is possible and acceptable to both the parents and the neonatal care providers. For GDM, fetal surveillance and timing of delivery are more complex as there is less evidence for increased perinatal mortality in this group.
This is likely due to the fact that the risk for perinatal mortality is probably limited to the subgroup of women with poor glycemic control, inclusion of women with pre-existing diabetes in GDM cohorts, obesity and other comorbidities and the rarity of these events.
However, a large retrospective cohort showed an increased risk of stillbirth in women with GDM between 36 to 39 weeks of gestation unadjusted OR 1.
Based on the large dataset, a relative risk was calculated of expectant management compared with induction of labour, while taking into consideration both the risk of stillbirth expectant management and infant death expectant management and induction of labour and showed a significant increased risk of stillbirth with expectant management at both 39 and 40 weeks of gestation when compared with induction of labour.
As the absolute risk difference was small, the number needed to deliver to prevent 1 excess perinatal death was estimated as 1, at 39 weeks' gestation and 1, at 40 weeks' gestation. However, this study is limited by unadjusted confounders, including adequacy and method of glycemic control as well as obesity, thus limiting the generalizability of the study.
There are additional potential benefits of induction of labour in diabetic pregnancies, including reduction of excess fetal growth, shoulder dystocia and caesarean section rate.
One randomized controlled trial compared induction of labour with expectant management of labour at term In this trial of insulin requiring GDM and pre-existing diabetes in pregnancies, expectant management after 38 weeks of gestation was associated with increased birthweight and macrosomia, but no change in caesarean section rate.
A recent retrospective cohort study from Ontario supports these findings, showing a significant reduction in caesarean section rate at both 38 and 39 weeks of gestation in women with GDM who underwent induction of labour when compared with those that underwent expectant management Conversely, induction of labour at 38 but not 39 weeks was associated with an increase in NICU admission.
Importantly, these results remained significant after adjusting for important confounders, including parity, insulin treatment and BMI.
Two recently published randomized controlled trials shed additional light on this clinical question. The study found no difference in caesarean section rates between groups, but an increase in hyperbilirubinemia was noted in the IOL group.
However, the study was underpowered and discontinued due to recruitment difficulties; thus any extrapolations from the study cannot be made In summary, there is a paucity of quality evidence to guide clinical decisions regarding optimal fetal surveillance and timing of delivery in diabetic pregnancies.
Clinical identification of increased risk of stillbirth should be the target of prenatal care and lead to an individualized approach to defining the appropriate regimen of fetal surveillance and timing of delivery.
In pre-existing diabetes, poorly controlled GDM or pre-existing diabetes in pregnancy associated with comorbidities, initiation of weekly assessment of fetal well-being at 34 to 36 weeks gestation is recommended. Acceptable methods of assessment of fetal well-being near term can include the nonstress test, amniotic fluid index, biophysical profile or a combination of these.
When making decisions regarding timing of delivery before 40 weeks' gestation, the benefits with regards to prevention of stillbirth and a possible decrease in the caesarean rate need to be weighed against the likely increase in neonatal complications.
Planning insulin management during labour and delivery is an important part of care and must be adaptable given the unpredictable combination of work of labour, dietary restrictions and need for an operative delivery. The goal is to avoid maternal hypoglycemia while preventing significant hyperglycemia which, in turn, may increase the risk of neonatal hypoglycemia Options for peripartum BG control include watchful waiting until BG rises above a specified threshold e.
In a retrospective study of consecutive women with type 1 diabetes, women who chose to continue on CSII during labour had better glycemic control than women using CSII during pregnancy but who chose to convert to intravenous insulin infusion during labour. There was no increase in maternal hypoglycemia, suggesting that the continuation of CSII during labour and delivery appears safe and efficacious Similarly, another retrospective study found that women using CSII had excellent glycemic control without hypoglycemia Observational studies comparing the use of CGM to SMBG during labour and delivery identified improved glycemic control with CGM , ; however, neonatal hypoglycemia was comparable between groups , Each centre should establish protocols which include BG targets, monitoring frequency, insulin regimen and intravenous glucose, based on nursing, medical and anaesthesia expertise available, and patient choice , Postpartum care in women with pre-existing diabetes should include counselling on the following issues: 1 rapid decrease in insulin needs and risk of hypoglycemia in the immediate postpartum period; 2 risk of postpartum thyroid dysfunction in the first months; 3 benefits of breastfeeding; 4 contraceptive measures and; 5 psychosocial assessment and support during this transition period.
Diabetes management and insulin sensitivity immediately postpartum. In women with type 1 and type 2 diabetes, insulin requirements decrease rapidly immediately after the delivery of the placenta — However, a nonsignificant trend toward lower requirements in exclusively breastfeeding mothers compared to partial or full formula feeding was also noted A gradual return to pre-pregnant insulin doses has been noted after 6 to 8 weeks postpartum in some studies , ; however, another study found persistently reduced insulin needs up to 4 months postpartum In some studies, reduced insulin needs have been especially noted in women with type 1 diabetes who were breastfeeding , , although this has not been universally observed Nevertheless, most clinicians advise women with type 1 diabetes who are breastfeeding of the potential increased risk of hypoglycemia, especially during night breastfeeding.
Thus, for women with pre-existing diabetes in pregnancy, a post-delivery plan for reduced prepregnant insulin dosages, pump settings or noninsulin antihyperglycemic agents should be discussed with the woman and recorded before delivery.
Evidence suggests that despite good glycemic control during pregnancy, continuous weight loss, as well as substantial diabetes education and follow up during pregnancy and in the first months postpartum, glycemic control is managed less effectively by mothers with diabetes in the first year postpartum, and A1C levels gradually increase and return to the pre-pregnancy level , Postpartum A1C levels are positively associated with pre-pregnancy BMI and postpartum weight retention in type 1 diabetes In addition, most women are unable to return to prepregnancy weight Improved postpartum care and specific interventions for women with pre-existing diabetes should be developed to help women achieve their target weight postpartum , , to improve glycemic control in the first year postpartum and to increase breastfeeding rates Risk of postpartum thyroid dysfunction.
Women with type 1 diabetes are at high risk for autoimmune thyroid disease and, consequently, postpartum thyroid dysfunction. Screening for thyroid hormonal abnormalities during pregnancy and at approximately 3 months postpartum in women with type 1 diabetes is recommended.
Lower rate and difficulties around delayed lactation in women with diabetes. A Canadian group demonstrated that women with pre-existing diabetes were less likely to initiate breastfeeding compared with noninsulin-treated mothers with diabetes, GDM women and mothers without diabetes Concordant with other studies , , women with all types of diabetes in pregnancy GDM, pre-existing, insulin-treated or noninsulin-treated in this study had also lower rates of exclusive breastfeeding in hospital and on discharge.
However, women with pre-existing diabetes were disproportionately affected and had lower rates of breastfeeding , Lower education and maternal age less than 25 years of age were risk factors associated for lower rates of breastfeeding and exclusive breastfeeding postpartum Women with pre-existing diabetes tend to have delayed milk production.
There is a greater delay in lactation onset in mothers with type 1 diabetes who had poor glycemic control Women with type 1 diabetes also discontinue breastfeeding at a higher rate during the first week postpartum — Overall, women with any form of diabetes during pregnancy have more nursing difficulties with lower milk supply than women without diabetes However, once established, lactation persists and duration is similar in mothers with and without diabetes , There are several pathophysiologic and behavioural explanations for lower breastfeeding rates in women with diabetes.
Poor glycemic control, insulin resistance, obesity and impaired bonding between mother and child caused by obstetrical complications such as NICU admission, prematurity, caesarean section are the major factors associated with delayed lactation It has been demonstrated that ideal glucose and insulin levels are necessary for lactation Good glycemic control enhances maternal serum and milk prolactin concentrations and decreases the delay in the establishment of lactation that has been observed in mothers with type 1 diabetes , Moreover, infants of mothers with diabetes showed poorer and immature sucking patterns contributing to the difficulties to breastfeed for those mothers in the first days postpartum Protective factors associated with both higher rates of intention to breastfeed and exclusive breastfeeding included attending antenatal classes and having antenatal care delivered by a health-care provider other than an obstetrician.
These drugs help insulin work better in the muscle and fat and reduce glucose production in the liver. A benefit of TZDs is that they lower blood glucose without having a high risk for causing low blood glucose. Both drugs in this class can increase the risk for heart failure in some individuals and can also cause fluid retention edema in the legs and feet.
In addition to the commonly used classes discussed above, there are other less commonly used medications that can work well for some people:. Acarbose Precose and miglitol Glyset are alpha-glucosidase inhibitors. These drugs help the body lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine.
By slowing the breakdown of these foods, this slows the rise in blood glucose levels after a meal. These medications should be taken with the first bite of each meal, so they need to be taken multiple times daily. Based on how these medications work, they commonly cause gastrointestinal side effects including gas and diarrhea.
The BAS colesevelam Welchol is a cholesterol-lowering medication that also reduces blood glucose levels in people with diabetes. BASs help remove cholesterol from the body, particularly LDL cholesterol, which is often elevated in people with diabetes.
The medications reduce LDL cholesterol by binding with bile acids in the digestive system. The body in turn uses cholesterol to replace the bile acids, which lowers cholesterol levels. The mechanism by which colesevelam lowers glucose levels is not well understood.
Because BASs are not absorbed into the bloodstream, they are usually safe for use in people who may not be able to use other medications because of liver problems or other side effects.
Because of the way they work, side effects of BASs can include flatulence and constipation, and they can interact with the absorption of other medications taken at the same time.
Bromocriptine Cycloset is a dopamine-2 agonist that is approved by the FDA to lower blood glucose in people with type 2 diabetes. Bromocriptine is taken once daily in the morning.
A common side effect is nausea. Meglitinides are drugs that also stimulate beta cells to release insulin. Nateglinide Starlix and repaglinide Prandin are both meglitinides. They are taken before each meal to help lower glucose after you eat. Because meglitinides stimulate the release of insulin, it is possible to have low blood glucose when taking these medications.
Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together to help meet your individualized diabetes goals. The use of glyburide should be based on evidence-based criteria.
To be considered Level I in the U. Preventive Service Task Force criteria for quality, evidence needs to be the result of a single properly designed, randomized, controlled trial. Clinical experts have consistently applauded and welcomed the results of the glyburide study 21 — 29 as convincing data that glyburide is a safe and effective alternative therapy for use in women with GDM.
The existing body of research should encourage us to rely on evidence-based knowledge and not emotion-based misinformation when considering this medication for use with diabetic pregnant women. Oded Langer, MD, PhD, is a professor and chairman of the Department of Obstetrics and Gynecology at St.
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The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
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There are different types, or classes, of medications optiions work gestatonal different ways medicahion lower blood egstational also known B vitamins for skin health Arthritis and mindfulness practices Oral medication options for gestational diabetes levels. Some options are taken by mouth and others are injected. Ciabetes of the commonly used classes of non-insulin medications include:. Metformin Glucophage is classified as a biguanide medication and is the only available medication in this class. Metformin lowers blood glucose levels primarily by decreasing the amount of glucose produced by the liver. Metformin also helps lower blood glucose levels by making muscle tissue more sensitive to insulin so blood glucose can be used for energy.
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