In patients with preexisting diabetes, nutritional and metabolic intervention must be initiated well before pregnancy begins, because birth defects occur during the critical 3-6 weeks after conception.
Insulin remains the standard medication for treatment of diabetes during pregnancy, but the oral agents glyburide and metformin are increasingly used.
A study by Goh et al found that, in routine practice, metformin use in gestational diabetes was associated with fewer adverse outcomes compared with insulin.
Proper management can minimize the risks posed by glucose intolerance during pregnancy, but vigilance and meticulous monitoring is necessary. Therapeutic goals are best achieved through a team approach.
To reduce diabetes-associated neonatal morbidity, counsel the patient before conception and perform a medical risk assessment in all women with overt diabetes and those with a history of gestational diabetes mellitus during a previous pregnancy.
Key features of an effective diabetes management program include performing a thorough assessment of cardiovascular, renal, and ophthalmologic status; and instituting a regimen of frequent and regular monitoring of both preprandial and postprandial capillary glucose levels.
Controversy exists as to whether the target glucose levels to be maintained during diabetic pregnancy should be designed to limit macrosomia or to closely mimic nondiabetic pregnancy profiles. The Fifth International Workshop Conference on Gestational Diabetes recommends the following :
Fasting plasma glucose 90-99 mg/dL (5.0–5.5 mmol/L)
- One-hour postprandial plasma glucose less than 140 mg/dL (7.8 mmol/L)
- Two-hour postprandial plasma glucose less than 120-127 mg/dL (6.7–7.1 mmol/L)
The insulin regimen should result in a smooth glucose profile throughout the day, with no hypoglycemic reactions between meals or at night. Initiate the regimen early enough before pregnancy so that the glycohemoglobin level is lowered into the reference range for at least 3 months before conception.
Patients should take a prenatal vitamin containing at least 1.0 mg of folic acid daily for at least 3 months before conception to minimize the risk of neural tube defects in the fetus.
The development of family, financial, and personal resources necessary to achieve successful pregnancy is important. Pay particular attention to support systems that permit extended bedrest in the third trimester if necessary.
Preemptive outreach is helpful. In many perinatal centers, diabetes-in-pregnancy programs focus on outreach to nonpregnant reproductive-aged women with diabetes in order to minimize the morbidity attendant to poor periconceptional control. Urge nonpregnant women to avoid pregnancy until their HbA1C value is in within the reference range (< 6.5%).
Hone and Jovanovic have summarized a convenient and structured method of managing diet and insulin therapy to optimize glycemic control. These principles are outlined in the subsequent sections.
Most large programs for treating women with diabetes during pregnancy have a staff that includes a registered nurse, a certified diabetes educator, a dietitian knowledgeable about pregnancy, and a social worker. Successful management of diabetic pregnancy is optimized when this type of team care is available.
The diabetes-in-pregnancy team is also able to help the patient during the puerperal period with the challenges of lactation, diet, sleep, and glycemic control. This team is also most effective in providing a smooth return to nonpregnant metabolic management.
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