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29/01/2014
1
Canadian Diabetes Association
Clinical Practice Guidelines
Pregnancy
Chapter 36
David Thompson, Howard Berger,
Denice Feig, Robert Gagnon, Tina Kader,
Erin Keely, Sharon Kozak, Edmond Ryan,
Mathew Sermer, Christina Vinokuroff
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
In collaboration with …
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Diabetes in Pregnancy: 2 Categories
Pregestational diabetes Gestational diabetes
Pregnancy in
pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Diabetes diagnosed in
pregnancy
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Copyright © 2013 Canadian Diabetes Association
Need a Preconception Checklist for
Women with Pre-existing Diabetes
1. Attain a preconception A1C of ≤7.0% (if safe)
2. Assess for and manage any complications
3. Switch to insulin if on oral agents
4. Folic Acid 5 mg/d: 3 months pre-conception to 12
weeks post-conception
5. Discontinue potential embryopathic meds:
Ace-inhibitors/ARB (prior to or upon detection of pregnancy)
Statin therapy
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendations 1-2: Preconception Care
1. All women of reproductive age with type 1 or type 2
diabetes should receive advice on reliable birth control,
the importance of glycemic control prior to pregnancy,
impact of BMI on pregnancy outcomes, need for folic
acid and the need to stop potentially embyropathic
drugs prior to pregnancy [Grade D, Level 4].
2. Women with type 2 diabetes and irregular
menses/PCOS who are started on metformin or a
thiazolidinedione should be advised that fertility may
improve and be warned about possible pregnancy [Grade D,
Consensus].
2013
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Copyright © 2013 Canadian Diabetes Association
Recommendation 3: Preconception Care
3. Before attempting to become pregnant, women
with type 1 or type 2 diabetes should:
a) Receive preconception counseling that
includes optimal diabetes management and
nutrition, preferably in consultation with an
interdisciplinary pregnancy team to optimize
maternal and neonatal outcomes [Grade C, Level 3]
29/01/2014
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Recommendation 3: Preconception Care
(continued)
b) Strive to attain a preconception A1C of ≤7.0% (or
A1C as close to normal as can safely be achieved)
to decrease the risk of:
– Spontaneous abortion [Grade C, Level 3]
– Congenital anomalies [Grade C, Level 3]
– Pre-eclampsia [Grade C, Level 3]
– Progression of retinopathy in pregnancy [Grade A, level
1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]
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Copyright © 2013 Canadian Diabetes Association
c) Supplement their diet with multivitamins containing
5 mg of folic acid at least 3 months pre-
conception and continuing until at least 12 weeks
post-conception [Grade D, Level 4]. Supplementation
should continue with a multivitamin containing 0.4-
1.0 mg of folic acid from 12 weeks
postconception through to 6 weeks postpartum
or as long as breastfeeding continues [Grade D,
Consensus].
Recommendation 3: Preconception Care
(continued)
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Copyright © 2013 Canadian Diabetes Association
d) Discontinue medications that are potentially
embryopathic, including any from the following
classes:
• ACE inhibitors and ARBs prior to conception
or upon detection of pregnancy [Grade C, Level 3]
• Statins [Grade D, Level 4]
2013
Recommendation 3: Preconception Care
(continued)
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
4. Women with type 2 diabetes who are planning a
pregnancy should switch from non-insulin
antihyperglycemic agents to insulin for glycemic
control [Grade D, Consensus].
Women with pregestational diabetes who also
have PCOS may continue metformin for
ovulation induction [Grade D, Consensus].
Recommendation 4: Preconception Care
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Recommendations 5 and 6: Preconception
and Complications
5. Women should undergo an ophthalmological
evaluation by an eye care specialist [Grade A, Level 1, for
type 1; Grade D, Level 4 for type 2].
6. Women should be screened for chronic kidney
disease prior to pregnancy [Grade D level 4 for type 1 diabetes
Grade D, consensus for type 2 diabetes]. Women with
microalbuminuria or overt nephropathy are at
increased risk for the development of HTN and
preeclampsia [Grade A level 1]; and should be followed
closely for these conditions [Grade D, Consensus]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 7: Management in
Pregnancy for Pregestational Diabetes
7. Pregnant women with type 1 or type 2 diabetes
should:
a) Receive an individualized insulin regimen and
glycemic targets typically using intensive insulin
therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2]
b) Strive for target glucose values [Grade D consensus]:
• Fasting PG below 5.3 mmol/L
• 1h postprandial below 7.8 mmol/L
• 2h postprandial below 6.7 mmol/L
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Recommendation 7: Management in Pregnancy
for Pre-gestational Diabetes (continued)
c) Be prepared to raise these targets if need be
because of the increased risk of severe
hypoglycemia during pregnancy [Grade D, Consensus]
d) Perform SMBG, both pre- and postprandially
to achieve glycemic targets and improve
pregnancy outcomes [Grade C, Level 3]
2013
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Copyright © 2013 Canadian Diabetes Association
10.Women should be closely monitored during labour
and delivery and maternal blood glucose levels
should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia [Grade D, Consensus]
11.Women should receive adequate glucose during
labour in order to meet the high energy requirements [Grade D, Consensus]
Recommendation 10 and 11: Intrapartum
Glucose Management
2013
2013
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Copyright © 2013 Canadian Diabetes Association
Recommendations 12 and 13: Postpartum
Glucose Management
12.Women with pregestational diabetes should be
carefully monitored postpartum as they have a
high risk of hypoglycemia [Grade D, Consensus].
13.Metformin and glyburide may be used during
breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for
glyburide].
2013
2013
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Recommendation 14 and 15: Postpartum
Glucose Management
14.Women with type 1 diabetes in pregnancy should
be screened for postpartum thyroiditis with a TSH
test at 6-8 weeks postpartum [Grade D, Consensus].
15.All women should be encouraged to breast-feed,
since this may reduce offspring obesity, especially in
the setting of maternal obesity [Grade C level 3-]
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Copyright © 2013 Canadian Diabetes Association
Gestational Diabetes (GDM) Diagnosis
• Universal screening for GDM @ 24-28 weeks
Gestational Age (GA)
• Screen earlier if risk factors for GDM:
Previous GDM BMI ≥30 kg/m2
Prediabetes Polycystic ovarian syndrome
High risk population
(Aboriginal, Hispanic, South
Asian, Asian, African)
Current fetal macrosomia or
polyhydramnios
Age ≥35 years History of macrosomic infant
Corticosteroid use
Acanthosis nigricans
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Why Diagnose and Treat GDM?
• Macrosomia
• Shoulder dystocia and
nerve injury
• Neonatal hypoglycemia
• Preterm delivery
• Hyperbilirubinemia
• Caesarian section
• Offspring obesity (?)
• Offspring diabetes (?)
29/01/2014
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Benefits of Treatment of GDM
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Copyright © 2013 Canadian Diabetes Association
Benefits of Treatment of GDM
Horvath K et al. BMJ 2010;340:c1935
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Copyright © 2013 Canadian Diabetes Association
Are there clear threshold glucose levels
above which the risk of adverse neonatal
or maternal outcomes increases?
Diagnosis of GDM
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Are there clear threshold glucose levels
above which the risk of adverse neonatal
or maternal outcomes increases?
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Copyright © 2013 Canadian Diabetes Association
Threshold glucose
levels (mmol/L) after
a 75g OGTT
OR 1.75 OR 2.0
Fasting plasma
glucose 5.1 5.3
1-h plasma glucose 10.0 10.6
2-h plasma glucose 8.5 9.0
% of cohort that met
≥ 1 threshold above 16.1% 8.8%
Odds Ratio (OR) of 1.75 vs. 2.0 for Primary
Outcome in HAPO
OGTT = Oral Glucose Tolerance Test
HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
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Copyright © 2013 Canadian Diabetes Association
Considerations for the CDA Adopting the
IADPSG Thresholds
• How can we select an odds ratio threshold in the
absence of a true threshold in the data?
• What is the impact on the patient and workload of
increasing the prevalence of GDM?
• Do we have sufficient evidence with respect to
treatment benefit at the various thresholds to make
an informed decision?
• In the absence of clear benefit, should the diagnostic
criteria be changed from 2008?
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
2013 GDM Diagnosis: Two Approaches 2013
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Copyright © 2013 Canadian Diabetes Association
Recommendations 16-17: Diagnosis of GDM
16.All pregnant women should be screened for GDM
at 24-28 weeks of gestation [Grade C, Level 3].
17.If there is a high risk of GDM based on multiple
clinical factors, screening should be offered at any
stage in the pregnancy [Grade D, Consensus]. If the initial
screening is performed before 24 weeks of
gestation and is negative, rescreen between 24-28
weeks of gestation. (see next slide)
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Copyright © 2013 Canadian Diabetes Association
Recommendation 17: Risk Factors for GDM
(continued)
• Age ≥35 years
• Previous GDM
• Prediabetes
• High risk population
– Aboriginal, Hispanic, South
Asian, Asian, African
• BMI ≥30 kg/m2
• Polycystic ovarian
syndrome
• Acanthosis nigricans
• Corticosteroid use
• History of macrosomic
infant
• Current fetal macrosomia
or polyhydramnios
[Grade D, Consensus]
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Recommendation 18: Diagnosis of GDM
18.The preferred approach for the screening and
diagnosis of GDM is the following [Grade D, Consensus]:
a) Screening for GDM should be conducted using the 50 g
glucose challenge test (GCT) administered in the non-
fasting state with plasma glucose measured one hour later
[Grade D, Level 4]. A plasma glucose value ≥7.8 mmol/L at
one hour will be considered a positive screen and will be
an indication to proceed to the 75 gram OGTT [Grade C, Level
2]. A plasma glucose value >11.1 mmol/L can be
considered to be diagnostic of gestational diabetes and
does not require a 75 gram OGTT for confirmation [Grade C,
Level 3].
2013
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Copyright © 2013 Canadian Diabetes Association
Recommendation 18: Diagnosis of GDM
(continued)
b) If the GCT screen is positive, a 75 gram OGTT
should be performed as the diagnostic test for
GDM using the following criteria: >1 of the
following values:
– Fasting >5.3 mmol/L,
– 1h >10.6 mmol/L,
– 2h >9.0 mmol/L
[Grade B, Level 1]
2013
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GDM: Glycemic Management During Pregnancy
• Perform SMBG, both fasting and postprandially
• Glycemic Targets during pregnancy:
• Receive nutrition counseling
– Moderate carbohydrate restriction: 3 meals + 3 snacks
– Targets not met within 2 weeks start insulin
– Avoid hypocaloric diet weight loss + ketosis
Target glucose values
Fasting PG <5.3 mmol/L
1h postprandial PG <7.8 mmol/L
2h postprandial PG <6.7 mmol/L
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Pre-Pregnancy BMI Recommended range
of total weight gain
(Kg)
Recommended range
of total weight gain
(lb)
BMI <18.5 12.5 – 18.0 28 – 40
BMI 18.5 - 24.9 11.5 – 16.0 25 – 35
BMI 25.0 - 29.9 7.0 – 11.5 15 – 23
BMI > or = 30 5.0 – 9.0 11 – 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
IOM Guidelines for Gestational Weight Gain
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus
Report. May 2009. The National Academies Press. Washington, DC.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Postpartum GDM Management Checklist
1. Encourage Breastfeeding
2. 75g OGTT between 6 weeks - 6 months
postpartum to detect prediabetes or diabetes
3. Discuss increased long-term risk of diabetes –
Importance of returning to pre-pregnancy weight
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Copyright © 2013 Canadian Diabetes Association
Recommendation 20: Management During
Pregnancy (GDM)
20.Women with GDM should:
a. Strive for target glucose values:
– Fasting PG below 5.3 mmol/L [Grade B, Level 2]
– 1h postprandial below 7.8 mmol/L [Grade B, Level 2]
– 2h postprandial below 6.7 mmol/L [Grade B, Level 2]
b. Perform SMBG, both fasting and postprandially to
achieve glycemic targets and improve pregnancy
outcomes [Grade B, Level 2]
c. Avoid ketosis during pregnancy [Grade C, Level 3]
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Recommendation 21: Management During
Pregnancy (GDM)
21.Receive nutrition counseling from a registered
dietitian during pregnancy [Grade C, Level 3] and
postpartum [Grade D, Consensus]. Recommendations for
weight gain during pregnancy should be based on
pregravid BMI [Grade D, Consensus].
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Copyright © 2013 Canadian Diabetes Association
Recommendation 22 and 24: Management
During Pregnancy (GDM)
22.If women with GDM do not achieve glycemic targets
within 2 weeks from nutritional therapy alone,
insulin therapy should be initiated [Grade D, Consensus].
23.Insulin therapy in the form of multiple injections
should be used [Grade A, Level 1].
24.Rapid-acting bolus analog insulin may be used
over regular insulin for postprandial glucose control
although perinatal outcomes are similar [Grade B, Level 2].
2013
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Copyright © 2013 Canadian Diabetes Association
Recommendation 25: Management During
Pregnancy (GDM)
25.For women who are non-adherent to or who refuse
insulin, glyburide [Grade B, Level 2] or metformin [Grade B,
Level 2] may be used as alternative agents for
glycemic control. Use of oral agents in pregnancy is
off-label and this should be discussed with the
patient [Grade D, Consensus].
29/01/2014
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Copyright © 2013 Canadian Diabetes Association
Recommendation 26: Intrapartum
Management (GDM)
26.Women should be closely monitored during labour
and delivery and maternal blood glucose levels
should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia. [Grade D, Consensus]
26.Women should receive adequate glucose during
labour in order to meet the high energy requirements [Grade D, Consensus].
2013
2013
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Copyright © 2013 Canadian Diabetes Association
Recommendation 28: Postpartum (GDM)
28.Women with GDM should be encouraged to
breastfeed immediately after delivery in order to
avoid neonatal hypoglycemia [Grade D, Level 4] and to
continue for at least three months postpartum in
order to prevent childhood obesity [Grade C, Level 3] and
reduce risk of maternal hyperglycemia [Grade C, Level 3].
29.Women should be screened with a 75g OGTT
between 6 weeks and 6 months postpartum to
detect prediabetes and diabetes [Grade D, Consensus].
2013
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Copyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients