Diabetes in Pregnancy

Screening

Gestational Diabetes Mellitus Screening Guidelines

1. AACE. Endocr Pract. 2011;17(2):1-53. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.

Diabetes risk assessment

High risk

Screen at confirmation of pregnancy

Positive for GDM

Negative for GDM

Average to low risk

Screen at 24 to 28 weeks

gestation

Positive for GDM

Treat

Negative for GDM

PostpartumScreen for

diabetes at 6-12 weeks1,2

Lifelong screening for

diabetes every 3 years3

Prediabetes

Diabetes

Normoglycemia

Treat3

Diabetes in Pregnancy: Risk Factors

Criteria for Early Prenatal Diabetes Testing1,2,3

(screen patients at pregnancy confirmation)

• Inactive/sedentary lifestyle

• First-degree relative (parent or sibling) with diabetes

• High-risk race/ethnicity (eg, African American, Latino, Native American, Asian American, Pacific Islander)

• History of gestational diabetes mellitus or previous delivery of a large baby (>9 lbs)

• Hypertension (blood pressure ≥140/90 mmHg)

• HDL cholesterol level <35 mg/dL and/or triglyceride levels >250 mg/dL

• History of polycystic ovary syndrome (PCOS)

• A1C ≥5.7%, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT) on a previous diabetes screening test

• Other clinical conditions associated with insulin resistance (eg, severe obesity, acanthosis nigricans)

• History of cardiovascular disease

• Low maternal birth weight (<4 lbs 7 oz)

1. AACE. Endocr Pract. 2011;17(2):1-53. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.3. Innes et al. JAMA. 2002;287(19):2534-2541.

GDM Diagnosis

2 Approaches for Diagnosing Gestational Diabetes Mellitus (GDM)

AACE- and ADA- recommended

1-step 75-g 2-hour oral glucose tolerance test (OGTT) 1,2 or

ACOG- recommended

2 steps: a 50-g 1-hour glucose challenge test (GCT), followed by a 100-g 3-hour OGTT (if necessary)3

GDM Diagnostic Criteria for OGTT Testing

75-g 2-hour† 100-g 3-hour*

Fasting plasma glucose (FPG)

≥92 mg/dL (5.1 mmol/L)2 ≥95 mg/dL (5.3 mmol/L)2

1-hour post-challenge glucose

≥180 mg/dL (10.0 mmol/L)2 ≥180 mg/dL (10.0 mmol/L)2

2-hour post-challenge glucose

≥153 mg/dL (8.5 mmol/L2 ≥155 mg/dL (8.6 mmol/L)2

3-hour post-challenge glucose

≥140 mg/dL (7.8 mmol/L)2

†A positive diagnosis requires that test results satisfy any one of these criteria*A positive diagnosis requires that ≥2 thresholds are met or exceeded

1. AACE. Endocr Pract. 2011;17(2):1-53. 2. ADA. Diabetes Care. 2013;36(suppl 1):11-66.

3. Committee on Obstetric Practice. ACOG. 2011;504:1-3.

Diabetes in Pregnancy: Established Diabetes

• All women of childbearing age diagnosed with T1DM or T2DM should receive: – Preconception diabetes counseling, including information on the risks

of uncontrolled diabetes during pregnancy1

– Preconception evaluation and treatment of diabetes-related complications1

– Counseling on medications contraindicated during pregnancy1,2

• These include statins, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and most non-insulin antihyperglycemic agents

– Counseling on effective contraception for all who wish to avoid pregnancy1

1. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 2. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.

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Diabetes in Pregnancy: Established Diabetes

• All women of childbearing age diagnosed with T1DM or T2DM should receive: – Intensive pre- and post-conception A1C monitoring

• 50% risk reduction in adverse pregnancy outcomes for every 1% decrease in A1C prior to conception1

• Weekly A1C testing after conception can greatly improve glycemic monitoring2

– ADA recommends preconception A1C <7.0%3 – AACE recommends preconception A1C <6.1%4

– Potential contraindications to pregnancy: • Ischemic heart disease, untreated active proliferative retinopathy, renal insufficiency, and

severe gastroenteropathy5

1. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738. 2. Jovanovic L. Diabetes Care. 2011;34(1):53-54.

3. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 4. AACE. Endocr Pract. 2011;17(2):1-53.

5. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.

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