Practice Essentials, Gestational Diabetes, Maternal- Fetal Metabolism in Normal Pregnancy. Patients with preexisting diabetes require modification of their pharmacologic regimen to meet the changing metabolic demands of pregnancy. In gestational diabetes, early intervention with insulin or an oral agent is key to achieving a good outcome when diet therapy fails to provide adequate glycemic control. Determine the choice of insulin and regimen based on the patient's individual glucose profile. The goal of insulin therapy during pregnancy is to achieve glucose profiles similar to those of nondiabetic pregnant women. Given that healthy pregnant women maintain their postprandial blood sugar excursions within a relatively narrow range (7. L), reproducing this profile requires meticulous daily attention by both the patient and clinician. Insulins lispro, aspart, regular, and neutral protamine hagedorn (NPH) are well- studied in pregnancy and regarded as safe and effective. Insulin glargine is less well- studied, and given its long pharmacologic effect, may exacerbate periods of maternal hypoglycemia. Upward adjustment of short- acting insulin doses to control postprandial glucose surges within the target band only exacerbates the tendency to interprandial hypoglycemia. Thus, any insulin regimen for pregnant women requires combinations and timing of insulin injections quite different from those that are effective in the nonpregnant state. Further, the regimens must be continuously modified as the pregnancy progresses from the first to the third trimester and insulin resistance rises. Strive to stay ahead of the rising need for insulin, and increase insulin dosages preemptively. When more than 2. L, administer lispro insulin (4- 8 U subcutaneously . If more than 1. 0 U of regular insulin is needed before the noon meal, adding 8- 1. U of NPH insulin before breakfast helps achieve control. When more than 1. L, initiate 6- 8 U NPH insulin at bedtime (hs). Titrate doses as needed according to blood glucose levels. It is largely accounted for by slower glucose disposal. These devices can be programmed to infuse varying basal and bolus levels of insulin, which change smoothly even while the patient sleeps or is otherwise preoccupied. The effectiveness of continuous subcutaneous insulin infusion in pregnancy is well established. Nevertheless, the oral agents glyburide and metformin are gaining popularity. Trials have shown these agents to be effective and no evidence of harm to the fetus has been found, although the potential for long- term adverse effects remains a concern. This is probably largely due to the high plasma protein binding coupled with a short half- life. Only 4% of patients in the glyburide study arm required addition of insulin to achieve glucose control. All studies comparing glyburide to traditional insulin have demonstrated similar levels of glycemic control. Most studies show no differences in maternal or neonatal outcomes with glyburide. Studies evaluating predictors of failure with glyburide cite the following risk factors . Research in this area, although needed, has been difficult given the known teratogenic effects of first- generation sulfonylurea, which readily crossed the placenta. Anderson PhD, MPH Professor & Associate Dean for Learning Systems & Student Affairs, Epidemiology & Community Health. Figure 2 Relationships between Changes in Diet and Physical Activity and Weight Changes within Each 4-Year Period in the Three Cohorts. In a multivariable-adjusted. Amenorrhea is a normal feature in prepubertal, pregnant, and postmenopausal females. Find patient medical information for FISH OIL on WebMD including its uses, effectiveness, side effects and safety, interactions, user ratings and products that have it. Leptin-Replacement Therapy for Lipodystrophy. Elif Arioglu Oral, M.D., Vinaya Simha, M.D., Elaine Ruiz, N.P., Alexa Andewelt, B.S., Ahalya Premkumar. Glyburide has been shown to be safe in breastfeeding, with no transfer into human milk. Metformin. Metformin is a biguanide, which functions mainly by decreasing hepatic glucose output. Metformin crosses the placenta, and umbilical cord levels have been shown to be even higher than maternal levels. Since this initial study, however, several other prospective and retrospective studies involving over 3. Between the 2 groups, patients who achieved glycemic control did not differ with regard to mean fasting and 2- hour postprandial blood glucose level. However, the percentage of women who did not achieve glycemic control and required insulin was 2. Monitoring fetal growth is essential to select the proper timing and route of delivery. This is accomplished by frequent testing for fetal well- being and serial ultrasonographic examinations to follow fetal size. Various fetal biophysical tests are available to the clinician to ensure that the fetus is well oxygenated, including fetal heart rate testing, fetal movement assessment, ultrasonographic biophysical scoring, and fetal umbilical Doppler ultrasonographic studies (see the table below). If applied properly, most of these tests can be used with confidence to provide assurance of fetal well- being while awaiting fetal maturity. Table 3. Biophysical Tests of Fetal Well- Being for Diabetic Pregnancy (Open Table in a new window). TEST< < P> Test. Frequency. Reassuring Result. Comment. Fetal movement counting. Every night from 2. Performed in all patients. Nonstress test (NST)Twice weekly. Begin at 2. 8- 3. GDM. Contraction stress test. Weekly. No heart rate decelerations in response to 3 contractions in 1. Same as for NSTUltrasonographic biophysical profile. Weekly. Score of 8 in 3. Initiate testing early enough to avoid significant stillbirth but not so early that a high rate of false- positive test results is encountered. In patients with poor glycemic control, intrauterine growth restriction, or significant hypertension, begin formal biophysical testing as early as 2. In patients who are at lower risk, most centers begin formal fetal testing by 3. Fetal movement counting is performed in all pregnancies from 2. There is no consensus regarding antenatal testing in patients with gestational diabetes that is well controlled with diet. Assessing fetal growth. Monitoring fetal growth continues to be a challenging and imprecise process. Although currently available tools (serial plotting of fetal growth parameters based on ultrasonographic measurement) are superior to those used previously for clinical estimations, accuracy is still only within . In 1. 99. 2, Bernstein and Catalano reported that significant correlation exists between the degree of error in the ultrasonogram- based estimation of fetal weight and the percentage of body fat on the fetus. Estimate fetal size once or twice at least 3 weeks apart in order to establish a trend. Time the last examination to be at 3. Timing and route of delivery. Select the timing of delivery to minimize morbidity for the mother and fetus. Delaying delivery to as near as possible to the expected date of confinement helps maximize cervical maturity and improves the chances of spontaneous labor and vaginal delivery. However, the risks of advancing fetal macrosomia, birth injury, and in utero demise increase as the due date approaches. Although delivery as early as 3. Because fetal growth from 3. By comparing the outcomes associated with labor induction in patients with gestational diabetes at 3. Kjos et al found that expectant management increased the gestational age at delivery by 1 week, but it did not significantly reduce the cesarean delivery. This suggests that routine induction of women with diabetes on or before 3. The investigators found that in women with insulin- controlled gestational diabetes mellitus, there was no significant difference in the rate of large for gestational age newborns associated with those who had labor induced at 3. In addition, the rate of neonatal hypoglycemia appeared to increase in association with induction at 3. In patients with gestational diabetes mellitus and superb glycemic control, continued fetal testing and expectant management can be considered until 4. In the fetus with an abdominal circumference significantly larger than the head circumference or an estimated fetal weight above 4. After 4. 0 or more weeks, the benefits of continued conservative management are likely to be outweighed by the danger of fetal compromise. Induction of labor before 4. An optimal time for delivery of most diabetic pregnancies is typically on or after the 3. Deliver a patient with diabetes before 3. For elective induction before 3. Because the risk of shoulder dystocia and fetal injury in labor is increased 3- fold in diabetic pregnancy, elective cesarean section should be considered if the fetus is suspected to be significantly obese. The American College of Obstetricians and Gynecologists recommends offering cesarean delivery to diabetic patients if the fetal weight is estimated to be 4. Prevention of Shoulder Dystocia. Although ultrasonographic measurements of the fetus have proven to be poor predictors of the risk of shoulder dystocia, this technique continues to be the mainstay for assessing risk in pregnancy for women with diabetes. The commonly used formulas derived from a multivariate regression multiply multiple coefficients together, with the resultant product (estimated fetal weight) typically having an accuracy that is seldom less than within 1. Fetuses predicted to weigh 4. In a study involving more than 3. However, a sensitivity of approximately 8. This means a false- positive rate of 3. Erb palsy. Thus, current data do not support a policy of early induction of labor in cases of possible fetal macrosomia. If one accepts that 8- 2. However, if fetal weight is estimated to be 4. Intrapartum glycemic management. Maintenance of intrapartum metabolic homeostasis optimizes postnatal infant transition by reducing neonatal hyperinsulinemia and subsequent hypoglycemia. The use of a combined insulin and glucose infusion during labor to maintain maternal blood sugars in a narrow range (8. L) is a common and clinically efficient practice. Typical infusion rates are 5% dextrose in Ringer lactate solution at 1. L/h and regular insulin at 0. U/h. Capillary blood sugar levels are monitored hourly in these patients. For patients with diet- controlled gestational diabetes mellitus or mild type 2 diabetes, avoiding dextrose in intravenous fluids normally maintains excellent blood glucose control. After 1- 2 hours of monitoring, no further assessments of capillary blood sugar typically are necessary.
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