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Insulin therapy: Insulin in pregnancy
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There are different categories of patients in this situation: Patients that develop resolvable diabetes during pregnancy, patients not diagnosed prior to pregnancy, and diabetic patients that are on antidiabetic medication.

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The essential clinical questions are:
When should we intervene? What should we do?

In good clinical practice, all at-risk pregnant women should be screened for gestational diabetes in weeks 24-28 of pregnancy, using an oral glucose tolerance test (OGTT).

PCOS: polycystic ovary syndrome

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The diagnostic criteria are well-defined and include women with a fasting blood glucose (FBG) >5.1-6.9mmol/L, a 1-hour OGTT level of >10.0mmol/L and a 2-hour level of >8.5-11.0mmol/L.
One or more of these criteria must be met for the diagnosis of gestational diabetes.

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As can be seen, the diagnostic criteria for GDM are much tighter than those of DM.

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The metabolic situation of the mother has a complex relationship with the baby in utero.

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Many factors will affect the baby at various stages of his/her development. Foetal glycaemia and insulinaemia develop in early gestation.

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It is important to note that a recent study has shown that the children of women with GDM have a greater risk of developing diabetes and an increased risk of obesity in later life.

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The clinician’s challenge is to manage the hyperglycaemia/diabetes properly to ensure that the baby is minimally/not affected at all.
The picture on the left indicates failure!

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Poorly managed diabetes leads to severe complications that affect the mother, foetus and neonate adversely.

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Insulin resistance develops mainly in the 2nd and 3rd trimester, leading to maternal complications.

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In known diabetic pregnancies, early diabetic control is vital.

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At birth, there is frequently a problem with trauma due also to the macrosomia of the baby of a poorly controlled DM/GDM mother.

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Tight glycaemic control and pre-conception counselling is essential for women with diabetes who are planning a pregnancy.

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In planning for a pregnancy, these criteria should ideally be met to optimise neonatal outcomes.

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Insulin is preferred therapy, but metformin can also be considered. GDM patients should be monitored for 5 years post-delivery.

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Foetal evaluation in DM mothers should be undertaken early (16-20 weeks). Ultrasound is a very valuable tool in ongoing foetal evaluation.

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Glibenclamide can still be used in some circumstances but does lead to an increased risk of neonatal hypoglycaemia and slightly increased risk of macrosomia.

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Metformin is the preferred oral agent. If you and the patient prefer an oral agent, it can still be used with insulin.

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  1. Analogue insulins are recommended
  2. Check insulin package inserts carefully – glargine is not registered
  3. Use small insulin doses frequently to improve control.
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Home glucose monitoring (HGM) is important to avoid postprandial peaks.

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Continuous glucose monitoring (CGM) can be very valuable in diabetic pregnancies.

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There is a difference in insulin response during pregnancy in T1DM, including an increased vulnerability to hypoglycaemia.

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Weight maintenance is critical in T2DM.

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This must be avoided, as the baby is at risk.
Control of hyperglycaemia makes a real difference to clinical outcomes.

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There is a need for a multidisciplinary approach, involving the gynaecologist/ obstetrician and antenatal nurses and dietitians.

CPD: cephalopelvic disproportion

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NOTE: This article was made possible by an unrestricted educational grant from Sanofi, which had no control over content.

References

  1. American Diabetes Association. Standards of medical care in diabetes – 2017. Diabetes Care 2017; 40(S1): S114-S119.
  2. The 2017 SEMDSA Guidelines for the Management of Type 2 Diabetes. JEMDSA 2017; 22(1): S99-103.
  3. Hebert MF, Ma X, Naraharisettti SB, et al. Are we optimizing gestational diabetes treatment with glyburide? The pharmacologic basis for better clinical practice. Clin Pharmacol Ther 2009; 85(6): 607-614.
  4. Balsells M, Garcia-Patterson A, Sola I, et al. Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. BMJ 2015; 350: h102.
  5. Jiang YF, Chen XY, Ding T, et al. Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials. J Clin Endocrinol Metab 2015; 100(5): 2071-2080.
  6. Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum 2016; 29(2): 92-97.
  7. Daniels M, Grobbelaar L. Nutrition in pregnancy. SA J of Diabetes 2015; 8: 19-23.
  8. The 2017 SEMDSA Guidelines for the Management of Type 2 Diabetes. JEMDSA 2017; 22(1): S103-106.

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