Special Populations Preconception and Pregnancycourses.washington.edu/dmelecti/Week10/diabetes in pregancy cornell slides.pdf0.8 g/kg/day during 1st half of pregnancy Same as non-pregnant

Special Populations:Special Populations:Preconception and Preconception and

PregnancyPregnancy

Susan Cornell, BS, Pharm.D., CDE, CDMSusan Cornell, BS, Pharm.D., CDE, CDMMidwestern University Chicago College of PharmacyMidwestern University Chicago College of Pharmacy

Diabetes in PregnancyDiabetes in Pregnancy

Diabetes is one of the most commonly Diabetes is one of the most commonly encountered complications of pregnancyencountered complications of pregnancy

>150,000 pregnancies annually>150,000 pregnancies annuallyCongenital malformations are most notable Congenital malformations are most notable complicationcomplication

~40%~40%--50% of 50% of perinatalperinatal deathsdeathsAssociated with maternal hyperglycemia and the Associated with maternal hyperglycemia and the consequent fetal hyperinsulinemiaconsequent fetal hyperinsulinemia

Homko CJ, Sargrad KR. A Core Curriculum for Diabetes Educators; 2003:99-101

Definition of Diabetes in PregnancyDefinition of Diabetes in Pregnancy

2 groups2 groupsWomen with preWomen with pre--existing diabetes existing diabetes (diabetes (diabetes prior toprior to conception)conception)

~ 0.2%~ 0.2%--0.3% type 10.3% type 1~ 65% type 2~ 65% type 2~ 2% undiagnosed type 2~ 2% undiagnosed type 2

Gestational diabetes (GDM)Gestational diabetes (GDM)(onset (onset duringduring pregnancy)pregnancy)

~ 7% of pregnancies~ 7% of pregnancies


Pregnancy with prePregnancy with pre--existing existing diabetes diabetes

(diabetes (diabetes prior toprior to conception)conception)

PerinatalPerinatal ComplicationsComplications

Complications are related to the level of Complications are related to the level of maternal maternal glycemiaglycemia

Complications in the FirstComplications in the First--Trimester:Trimester:Congenital malformations (~ 6%Congenital malformations (~ 6%––13%)13%)

Cardiovascular, CNS, SkeletalCardiovascular, CNS, Skeletal

Spontaneous abortions (~ 30%Spontaneous abortions (~ 30%––60%)60%)

These complications often occur before a These complications often occur before a woman knows she is pregnantwoman knows she is pregnant

Mills JL et al. Diabetes. 1979; 28:292-293

PerinatalPerinatal complicationscomplications

MacrosomiaMacrosomiaAbnormally large body sizeAbnormally large body size~ 20~ 20--32% of pregnancies with diabetes32% of pregnancies with diabetes

Still birthStill birthRespiratory distress syndrome (RDS)Respiratory distress syndrome (RDS)HypocalcemiaHypocalcemia, , HyperbilirubinemiaHyperbilirubinemia, , polycythemiapolycythemia


Maternal ComplicationsMaternal ComplicationsHypertensionHypertension

Pregnancy inducedPregnancy inducedPreeclampsiaPreeclampsiaChronic hypertensionChronic hypertension

HydramniosHydramniosExcess amniotic fluidExcess amniotic fluid

Possibly due to increased fetal urine productionPossibly due to increased fetal urine production

Infectious postoperative complicationInfectious postoperative complicationPreterm deliveryPreterm delivery

Related to motherRelated to mother’’s blood pressure statuss blood pressure statusCesarean sectionCesarean section

Cousins L. Diabetes Mellitus in Pregnancy. 1995:287-302

Normal MetabolismNormal Metabolism

Early gestation:Early gestation:

The fetus depends on the mother for an The fetus depends on the mother for an uninterrupted supply of fuel or nutritionuninterrupted supply of fuel or nutrition

Increases occurs in:Increases occurs in:Tissue glycogen storageTissue glycogen storagePeripheral glucose utilizationPeripheral glucose utilizationHepatic glucose productionHepatic glucose production


Normal MetabolismNormal Metabolism

Late Gestation:Late Gestation:↑↑ growth of fetusgrowth of fetus↑↑ hormones levelshormones levels

lactogenlactogenestrogenestrogen

↑↑ insulin resistanceinsulin resistance↓↓ in food may result in in food may result in ↑↑ in free fatty in free fatty acids and acids and ketonesketones

↑↑ risk of DKArisk of DKA


First Trimester of Pregnancy with First Trimester of Pregnancy with Preexisting DiabetesPreexisting Diabetes

Hormone changes can result in erratic Hormone changes can result in erratic blood glucose levels blood glucose levels Meal plans should be adjusted to Meal plans should be adjusted to accommodate BG changesaccommodate BG changesCritical to avoid Critical to avoid ketonemiaketonemia and and ketoacidosisketoacidosis

Second and Third Trimesters of Second and Third Trimesters of Pregnancy with Preexisting DiabetesPregnancy with Preexisting Diabetes

Energy requirements will increaseEnergy requirements will increaseInsulin resistance will start to increaseInsulin resistance will start to increase

Especially in second half of pregnancyEspecially in second half of pregnancy

Insulin requirements will increaseInsulin requirements will increase↑↑ dosages of rapid or dosages of rapid or shortshort−−actingacting insulin (bolus insulin (bolus insulin) needed to cover mealsinsulin) needed to cover meals↑↑ dosages of intermediate or longdosages of intermediate or long--acting insulin (basal acting insulin (basal insulin) needed to maintain nocturnal insulin levelsinsulin) needed to maintain nocturnal insulin levels↑↑ risk of DKA in the third trimesterrisk of DKA in the third trimester

Jovanovic L et al. Diabetes Care. 1982:5:24-37

Treatment of Diabetes in Treatment of Diabetes in PregnancyPregnancy

NonPharmacologicalNonPharmacological

DSME educationDSME educationIncluding preconception Including preconception counseling and carecounseling and care

Exercise/ActivityExercise/ActivityMedical Nutrition Medical Nutrition

TherapyTherapySMBGSMBGWeight managementWeight management

PharmacologicalPharmacological

InsulinInsulin

Patient Education Outline for Patient Education Outline for Pregnancy with Preexisting DiabetesPregnancy with Preexisting Diabetes

Preconception CounselingPreconception Counseling

Patient education for pregnancyPatient education for pregnancy

Postpartum educationPostpartum education

Preconception Counseling and Preconception Counseling and CareCare

Begins 3 to 6 months prior to conception and Begins 3 to 6 months prior to conception and continues throughout pregnancycontinues throughout pregnancy

Normalize and stabilize blood glucose levelsNormalize and stabilize blood glucose levelsOptimize diabetes controlOptimize diabetes control

Counseling for:Counseling for:Women with preexisting diabetesWomen with preexisting diabetes

Type 1Type 1Type 2Type 2

Women at risk for type 2 diabetesWomen at risk for type 2 diabetes

Preconception Counseling and Care: Preconception Counseling and Care: Prior to Discontinuing ContraceptionPrior to Discontinuing ContraceptionAssessment of complicationsAssessment of complications

MicrovascularMicrovascularMacrovascularMacrovascular

Discontinue oral Discontinue oral antidiabeticantidiabetic agents (if agents (if applicable)applicable)Nutrition assessment and modificationsNutrition assessment and modifications

Modify meal plans to meet anticipated pregnancy Modify meal plans to meet anticipated pregnancy needsneedsCalcium, iron, folic acid assessment and Calcium, iron, folic acid assessment and supplementationsupplementation


Preconception Counseling and Care: Preconception Counseling and Care: Prior to Discontinuing ContraceptionPrior to Discontinuing ContraceptionSelfSelf−−ManagementManagement skill assessmentskill assessment

Review SMBG techniqueReview SMBG techniqueReview insulin administration techniqueReview insulin administration techniqueReview hypoglycemia prevention, awareness Review hypoglycemia prevention, awareness and treatment skillsand treatment skillsReview glucagon emergency planReview glucagon emergency plan

Continue contraception until glucose goals Continue contraception until glucose goals are attainedare attained


Medical Nutrition in PregnancyMedical Nutrition in Pregnancy

Adequate nutrition is one of the most Adequate nutrition is one of the most important influences on the health of important influences on the health of pregnant women and their infants.pregnant women and their infants.

Recommended Dietary Allowances Recommended Dietary Allowances (RDA) in Pregnancy(RDA) in Pregnancy

ProteinProtein0.8 g/kg/day during 10.8 g/kg/day during 1stst half of pregnancyhalf of pregnancy

Same as nonSame as non--pregnant womenpregnant women1.1 g/kg/day during 21.1 g/kg/day during 2ndnd half of pregnancyhalf of pregnancy

Add 50 g/day for twinsAdd 50 g/day for twins

Carbohydrate (CHO)Carbohydrate (CHO)Same as preconception intakeSame as preconception intake

Minimum of 175 g/day to assure fuel for CNS for fetus and Minimum of 175 g/day to assure fuel for CNS for fetus and mothermotherUse insulinUse insulin--toto--CHO ratios for appropriate insulin dosesCHO ratios for appropriate insulin doses

usually larger at breakfast since CHO is less well tolerated dueusually larger at breakfast since CHO is less well tolerated due to to increase in increase in cortisolcortisol and growth hormones.and growth hormones.

Institute of medicine of the National Academies. Dietary Reference Intakes;2002

Meal Plans in PregnancyMeal Plans in Pregnancy

Eat meals at regular timesEat meals at regular timesSmall, frequent meals and snacksSmall, frequent meals and snacks

every 2 to 4 hoursevery 2 to 4 hoursMinimize hypoglycemia Minimize hypoglycemia

Bedtime snacksBedtime snacksDecreases risk of nocturnal starvation, Decreases risk of nocturnal starvation, ketonuriaketonuria and and ketonemiaketonemia

Match insulin to food consumptionMatch insulin to food consumptionCheck BG levels oftenCheck BG levels often

Recommended Ranges of Total Recommended Ranges of Total Weight Gain for Pregnant WomenWeight Gain for Pregnant Women

BMI < 19.8BMI < 19.8 2828−−40 lb40 lb(underweight)(underweight)

BMI 19.8 BMI 19.8 –– 26.026.0 2525−−35 lb35 lb(normal weight)(normal weight)

BMI 26.0 BMI 26.0 –– 29.029.0 1515−−25 lb25 lb(overweight)(overweight)

BMI > 29BMI > 29 ~15 lb~15 lb(obese)(obese)

National Academy of Sciences. Nutrition during pregnancy; 1990

Recommended Ranges of Total Recommended Ranges of Total Weight Gain for Pregnant WomenWeight Gain for Pregnant Women

(cont.)(cont.)

Twin GestationTwin Gestation 3535−−45 lb45 lb

Triplet GestationTriplet Gestation 4545−−55 lb55 lb

National Academy of Sciences. Nutrition during pregnancy; 1990

SelfSelf--Monitoring Blood GlucoseMonitoring Blood Glucose

Blood Glucose Goals in Diabetic Blood Glucose Goals in Diabetic Pregnancy (Preconception)Pregnancy (Preconception)

PrePre--mealmeal 8080−−110 mg/dl110 mg/dl

22−−hour postprandialhour postprandial < 155 mg/dl< 155 mg/dl

Preconception care of women with diabetes. Diabetes Care. 2003;26:S91-93

Blood Glucose Goals in Diabetic Blood Glucose Goals in Diabetic PregnancyPregnancy

FastingFasting 6565−−100 mg/dl100 mg/dl

PrePre--meal:meal: 6565−−115 mg/dl115 mg/dl

1 hour postprandial1 hour postprandial <145 <145 mg.dlmg.dl

2 hour postprandial2 hour postprandial < 135 mg/dl< 135 mg/dl

22--6 hour postprandial6 hour postprandial 6565−−135 mg/dl135 mg/dl

Preconception care of women with diabetes. Diabetes Care. 2003;26:S91-93

MonitoringMonitoring

KetonesKetonesWhenever BG > 200 mg/dlWhenever BG > 200 mg/dlDuring illness (result of nausea/vomiting)During illness (result of nausea/vomiting)

UrineUrinefirst morning urinefirst morning urine

BloodBlooddailydaily

A1CA1CBlood PressureBlood Pressure

Insulin During PregnancyInsulin During Pregnancy

Insulin regimen should be individualizedInsulin regimen should be individualizedMay require 3 to 4 injections or more dailyMay require 3 to 4 injections or more dailyRapid or short acting at meals (bolus)Rapid or short acting at meals (bolus)Intermediate or long acting at bedtime (basal)Intermediate or long acting at bedtime (basal)

PrePre--meal Regular/ Bedtime NPHmeal Regular/ Bedtime NPH(Bolus/Basal)(Bolus/Basal)

Continuous Subcutaneous Insulin Continuous Subcutaneous Insulin Infusion (CSII)Infusion (CSII)

Insulin pump therapyInsulin pump therapyLowers the amount of basal insulinLowers the amount of basal insulin↓↓ risk of risk of premealpremeal hypoglycemiahypoglycemia↑↑ control over postprandial glucose control over postprandial glucose excursionsexcursions

Ideally started prior to conception, Ideally started prior to conception, however, can be started at any pointhowever, can be started at any point

Especially if suboptimal glucose controlEspecially if suboptimal glucose control

Rudolf MC et al. Diabetes. 1981;30:891-895

Insulin Requirements Throughout Insulin Requirements Throughout GestationGestation

PreconceptionPreconception 0.6 units/kg0.6 units/kgFirst TrimesterFirst Trimester 0.7 units/kg0.7 units/kgSecond TrimesterSecond Trimester 0.8 units/kg0.8 units/kgThird TrimesterThird Trimester 0.90.9−−1.0 units/kg1.0 units/kgPostpartumPostpartum <0.6 units/kg<0.6 units/kg

Women > 150% of ideal body weight Women > 150% of ideal body weight ↑↑ 1.51.5--2.0 units/kg 2.0 units/kg Insulin resistance due to obesityInsulin resistance due to obesity

Jovanovic L et al. Diabetes Care. 1982:5:24-37

Insulin Requirements Throughout Insulin Requirements Throughout GestationGestation

Adjustments may be necessary in first trimester Adjustments may be necessary in first trimester due to due to ↑↑ incidence of hypoglycemiaincidence of hypoglycemia

Most common during sleepMost common during sleepWomen with history of severe hypo events at greater Women with history of severe hypo events at greater riskrisk

Family education on hypoglycemiaFamily education on hypoglycemiaPreventionPreventionAwarenessAwarenessTreatmentTreatment

Glucagon administrationGlucagon administration

Kimmerle R et al. Diabetes Care. 1992;15:1034-1037

Labor and DeliveryLabor and Delivery

Goals of diabetes care during labor:Goals of diabetes care during labor:Adequate CHO intakeAdequate CHO intake

Glucose administer via continuous IVGlucose administer via continuous IV~ 2.0~ 2.0−−2.5 mg/kg/minute2.5 mg/kg/minute

Maintain normal BG levelsMaintain normal BG levelsMeasured every 1Measured every 1−−2 hours2 hoursShortShort−−actingacting insulin insulin

Multiple subcutaneous dosingMultiple subcutaneous dosingCSIICSII

Jovanovic L et al. Am J Med. 1983;75:607-612

PostpartumPostpartumImmediate Immediate ↓↓ insulin requirementsinsulin requirements

Little to no insulin may be required in the first 24Little to no insulin may be required in the first 24−−48 48 hours post deliveryhours post delivery~0.6 units/kg for non~0.6 units/kg for non--lactating womenlactating women~ 0.4 units/kg for lactating women~ 0.4 units/kg for lactating women

(based on current weight)(based on current weight)

Support and educationSupport and educationBalance of motherBalance of mother’’s s selfself−−carecare needs with infant needs with infant needsneedsAssessment for postpartum depressionAssessment for postpartum depression↑↑ risk of hypoglycemiarisk of hypoglycemia

Education on prevention, awareness and treatmentEducation on prevention, awareness and treatmentModification of meal plansModification of meal plans


LactationLactation

Breastfeeding mothers need less insulin Breastfeeding mothers need less insulin ↑↑ expended caloriesexpended caloriesMay need CHO snack before/during nursing May need CHO snack before/during nursing

Increase in hypoglycemiaIncrease in hypoglycemiaOral agents are not approved for use Oral agents are not approved for use during lactationduring lactation

Insulin can be usedInsulin can be used


Key Take Home PointsKey Take Home Points

Preconception care planning is essentialPreconception care planning is essential

Diabetes care and blood glucose control Diabetes care and blood glucose control need to be optimal at least 3need to be optimal at least 3−−6 months 6 months prior to conception.prior to conception.

Contraception use should be emphasized Contraception use should be emphasized until blood glucose goals have been attaineduntil blood glucose goals have been attained

Key Take Home PointsKey Take Home Points

Diabetes care and glucose control need to Diabetes care and glucose control need to be monitored very closely during be monitored very closely during pregnancy pregnancy

Treatment plans should be reviewed Treatment plans should be reviewed regularly for necessary adjustmentsregularly for necessary adjustments

Education and monitoring in the Education and monitoring in the postpartum period.postpartum period.

Gestational Diabetes Mellitus Gestational Diabetes Mellitus (GDM)(GDM)

(onset (onset duringduring pregnancy)pregnancy)

Gestational diabetesGestational diabetes

CHO intolerance with onset or first CHO intolerance with onset or first recognition during pregnancyrecognition during pregnancy

Includes women with undiagnosed type 2 Includes women with undiagnosed type 2 diabetes prior to pregnancy but are diagnosed diabetes prior to pregnancy but are diagnosed during pregnancyduring pregnancyIncludes women using medications or that Includes women using medications or that have medical conditions that affect glucose have medical conditions that affect glucose tolerance.tolerance.

Biastre SA, Slocum J.. A Core Curriculum for Diabetes Educators; 2003:145-146

Metabolic ChangesMetabolic Changes

Similar to the second and third trimesters Similar to the second and third trimesters of pregnancy with preof pregnancy with pre--existing diabetesexisting diabetes↑↑ mobilization of glucosemobilization of glucose↓↓ insulin sensitivityinsulin sensitivity↑↑ circulating hormones circulating hormones ↑↑ basal insulin requirementsbasal insulin requirements↑↑ risk risk ketonesketones (urine & blood)(urine & blood)

Biastre SA, Slocum J.. A Core Curriculum for Diabetes Educators; 2003:145-146

PerinatalPerinatal complicationscomplications

Similar to complications in pregnancy with Similar to complications in pregnancy with preexisting diabetespreexisting diabetes

MacrosomiaMacrosomiaAbnormally large body sizeAbnormally large body size~ 20~ 20--32% of pregnancies with diabetes32% of pregnancies with diabetes

StillbirthStillbirthRespiratory distress syndrome (RDS)Respiratory distress syndrome (RDS)HypocalcemiaHypocalcemia, , HyperbilirubinemiaHyperbilirubinemia, , polycythemiapolycythemia


LongLong−−TermTerm Complications of GDMComplications of GDM

↑↑ risk of developing GDM in future risk of developing GDM in future pregnanciespregnancies

~ 30~ 30--50%50%↑↑ risk of developing type 2 diabetesrisk of developing type 2 diabetes↑↑ risk of obesity in offspringrisk of obesity in offspring↑↑ risk for offspring to develop intellectual risk for offspring to develop intellectual and neurological conditionsand neurological conditions

Metzger BE et al. Diabetes Care. 1998;21

Diagnosis of GDMDiagnosis of GDM

Risk assessment at first prenatal visitRisk assessment at first prenatal visit

Low RiskLow Risk High RiskHigh Risk< 25 years of age< 25 years of age ObesityObesity

Normal weight prior to Normal weight prior to pregnancypregnancy

History of GDMHistory of GDM

No family history of No family history of diabetesdiabetes

Family history of diabetesFamily history of diabetes

No history of glucose No history of glucose intoleranceintolerance

GlycosuriaGlycosuria

Ethnicity of low riskEthnicity of low risk Ethnicity of high riskEthnicity of high risk


Women at low to average risk screened Women at low to average risk screened between weeks 24between weeks 24−−28 of gestation28 of gestation

Women at high risk should be screened as Women at high risk should be screened as early as possibleearly as possible

Gestational Diabetes mellitus. Diabetes Care. 2003;26:S103-S105.


Screening test (step 1)Screening test (step 1)50 g oral glucose load (random)50 g oral glucose load (random)Plasma glucose level > 130 mg/dlPlasma glucose level > 130 mg/dl

1 hour postprandial1 hour postprandial

Proceed to OGTT step 2Proceed to OGTT step 2



Diagnosis criteria (step 2)Diagnosis criteria (step 2)100 g glucose load after overnight fast of no less than 100 g glucose load after overnight fast of no less than 8 hours and no more than 14 hours8 hours and no more than 14 hours33--hour testhour test

Fasting: Fasting: 95 mg/dl95 mg/dl1 hour1 hour 180 mg/dl180 mg/dl2 hour2 hour 155 mg/dl155 mg/dl3 hour3 hour 140 mg/dl140 mg/dl

2 or more exceed limit: GDM diagnosis2 or more exceed limit: GDM diagnosis


Management of GDMManagement of GDM

NonPharmacologicalNonPharmacological

DSME EducationDSME EducationExercise/ActivityExercise/ActivityMedical Nutrition Medical Nutrition

TherapyTherapySMBGSMBGWeight ManagementWeight Management

PharmacologicalPharmacological

InsulinInsulin

Medical Nutrition Therapy for GDMMedical Nutrition Therapy for GDM

Primary treatmentPrimary treatmentCHO controlled meal plansCHO controlled meal plans

Control of BG levelsControl of BG levelsAppropriate weight gainAppropriate weight gain

Avoid maternal ketosisAvoid maternal ketosisMeal plans to deliver appropriate nutrientsMeal plans to deliver appropriate nutrients↓↓ hypoglycemia, nausea, vomitinghypoglycemia, nausea, vomiting


MNT and SMBGMNT and SMBG

SMBG can assist in making appropriate SMBG can assist in making appropriate food adjusts in the meal planfood adjusts in the meal plan

CHO affects postprandial BG levelsCHO affects postprandial BG levelsMinimum of 175 g/day to assure fuel for CNS Minimum of 175 g/day to assure fuel for CNS for fetus and motherfor fetus and motherMonitor fasting, Monitor fasting, preprandialpreprandial, 1, 1−− and/or 2and/or 2−−hour hour postprandial and bedtime BG levelspostprandial and bedtime BG levels


GDM Blood Glucose GoalsGDM Blood Glucose Goals

FastingFasting < 105 mg/dl< 105 mg/dl1 hour postprandial1 hour postprandial < 155 mg/dl< 155 mg/dl2 hour postprandial2 hour postprandial < 130 mg/dl< 130 mg/dl


Exercise and ActivityExercise and Activity

ActivityActivity

Can improve glucose intoleranceCan improve glucose intoleranceShould be encouragedShould be encouragedBest BG lowering effect observed with 1 Best BG lowering effect observed with 1 hour of activityhour of activityObtain medical clearance before starting Obtain medical clearance before starting an exercise program during pregnancyan exercise program during pregnancy

Avoid with HTN, preterm labor history, Avoid with HTN, preterm labor history, persistent bleedingpersistent bleeding

Avery MD et al. Obstet Gynecol. 1997;89:10-15.

Insulin TherapyInsulin Therapy

Only Human insulin used in GDMOnly Human insulin used in GDM↓↓ risk of risk of transplacentaltransplacental transport of antitransport of anti--insulin insulin antibodiesantibodies

Start if BG goals not achievedStart if BG goals not achieved~ 20%~ 20%--25% of women with GDM require 25% of women with GDM require insulin therapyinsulin therapy↓↓ risk risk macrosomiamacrosomia


Insulin TherapyInsulin Therapy

Insulin regimens should be individualizedInsulin regimens should be individualized↑↑ insulin needs thru progression of pregnancyinsulin needs thru progression of pregnancyAdjust dosage accordingly to BG levelsAdjust dosage accordingly to BG levelsObese patients may need large amounts of Obese patients may need large amounts of insulininsulin

Starting dose:Starting dose:StandardizedStandardizedBased on body weightBased on body weight

Jovanovic-Peterson L et al. J Am Coll Nutr. 1992;71:921-927

Oral Oral AntidiabeticAntidiabetic Agents in GDMAgents in GDM

Currently NOT recommended during Currently NOT recommended during pregnancypregnancy

No oral antiNo oral anti--diabetic agents are approved diabetic agents are approved by the FDA for treatment of GDMby the FDA for treatment of GDM

Postpartum CarePostpartum Care

Normal glucose tolerance returns usually Normal glucose tolerance returns usually after deliveryafter deliveryWomen with history of GDM should be Women with history of GDM should be screened for type 2 diabetes regularlyscreened for type 2 diabetes regularlyPreconception planning should be Preconception planning should be emphasized for subsequent pregnanciesemphasized for subsequent pregnanciesContraception choices reviewedContraception choices reviewedNutrition and activityNutrition and activity

Metzger BE et al. Diabetes Care. 1998;21

Key Take Home PointsKey Take Home PointsWomen at high risk should be screened and Women at high risk should be screened and tested for GDM earlytested for GDM early

Diabetes care and glucose control need to be Diabetes care and glucose control need to be monitored very closely during pregnancy monitored very closely during pregnancy

Medical Nutrition Therapy should be the primary and Medical Nutrition Therapy should be the primary and continual treatment.continual treatment.Treatment plans should be reviewed regularly for Treatment plans should be reviewed regularly for necessary adjustmentsnecessary adjustments

Education and monitoring in the postpartum Education and monitoring in the postpartum periodperiod

What Questions Can I Answer What Questions Can I Answer for You ???for You ???

Documents

Special Populations Preconception and Pregnancycourses.washington.edu/dmelecti/Week10/diabetes in pregancy cornell slides.pdf0.8 g/kg/day during 1st half of pregnancy Same as non-pregnant