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		Literature Compendium

Current Concepts in Type 2 Diabetes

Volume 3
Special Considerations in the Management of Diabetes and Its Complications

Chapter 4
Management of Diabetes Mellitus in Pregnancy

Women with pre-existing diabetes are at increased risk of adverse pregnancy outcomes and birth defects. Women with gestational diabetes mellitus are at increased risk for adverse outcomes, including neonatal hypoglycaemia, hyperbilirubinaemia, macrosomia, increased risk of obesity and diabetes in offspring later in life, and increased risk for other maternal comorbidities. Studies have shown that tight glycaemic control before and during pregnancy can decrease the risk of adverse outcomes, congenital malformations, and maternal complications resulting from pre-existing maternal diabetes. In order to optimize outcomes, it is important to identify women with gestational diabetes and provide appropriate perinatal and postnatal care.

While women with diabetes were once discouraged from having children, today’s treatments have made it possible to have a safe and healthy pregnancy. The key to a healthy pregnancy is keeping blood glucose in the target range—both before a woman is pregnant and during her pregnancy. In this chapter, 3 key papers addressing the management of diabetes before, during, and after pregnancy are reviewed.

Mulholland and colleagues¹ have written a thorough review of guidelines for the diagnosis and management of diabetes before, during, and after pregnancy. Their paper compares in table format the most recent guidelines issued by the American College of Obstetricians and Gynecologists, American Diabetes Association, Joslin Diabetes Center, World Health Organization, International Diabetes Center, and US Preventive Services Task Force with regard to preconception examinations and goals, target blood glucose level during pregnancy, monitoring, delivery, and postnatal care. The guidelines reviewed generally agree that it is appropriate to screen women at moderate or high risk of gestational diabetes early in the course of the pregnancy by use of a 50-g, 1-hour glucose tolerance test, but acceptable values vary. There is little agreement in terms of monitoring blood glucose values for women with gestational diabetes. Guidelines for managing women with pre-existing diabetes appear more consistent than those for managing women with gestational diabetes. The major differences among the guidelines for managing pre-existing diabetes during pregnancy include slight variations in the blood glucose levels used to define tight glycaemic control, the specificity of guidelines for labour and delivery, and the tests recommended throughout pregnancy. The authors suggest a convening of experts to strive for more uniformity among guidelines and propose further research to answer remaining questions about best practices.

Singh and Jovanovic² have written a literature review of the safety and efficacy of insulin analogs in pregnancy. They summarize the latest evidence for the use of rapid-acting insulins (insulin lispro, insulin aspart) and long-acting insulins (insulin glargine and detemir) during pregnancy and review the potential risks of insulin analogs in pregnancy. The rapid-acting insulins appear to be as safe and effective as regular human insulin in women with gestational diabetes and appear to achieve better postprandial glucose levels with less postprandial hypoglycaemia. The long-acting insulins do not have as pronounced a peak effect as NPH insulin and therefore cause less nocturnal hypoglycaemia. There are no direct comparisons of rapid- and long-acting insulins in women with gestational diabetes. The authors recommend further research to develop insulins that perfectly match the physiological insulin profiles associated with pregnancy.

In their review paper, Leguizamón and colleagues³ summarize current knowledge regarding the effect of pregestational diabetes on pregnancy outcomes and the impact of pregnancy on the progression of diabetes. The timing and type of interventions in preconception care to prevent pregnancy and maternal complications in women with diabetes are also discussed. The authors state that 'preconception care can significantly reduce pregnancy complications, with a dramatic impact on the diabetic mother and her infant' and provide basic recommendations for preconception care.

It is clear from these papers that there is a growing recognition of the need for glycaemic control before, during, and after diabetes to ensure the optimal health of both the mother and her child. Clinicians can use available guidelines as a basis with which to develop strategies for diabetes screening, prevention, and management but should understand that there is some variability between guidelines with regard to target glucose levels and other parameters.

References

1. Mulholland C, Njoroge T, Mersereau P, Williams J. Comparison of guidelines available in the United States for diagnosis and management of diabetes before, during, and after pregnancy. J Women’s Health (Larchmt). 2007;16:790-801.

2. Singh C, Jovanovic L. Insulin analogues in the treatment of diabetes in pregnancy. Obstet Gynecol Clin North Am. 2007;34:275-291.

3. Leguizamón G, Igarzabal ML, Reece EA. Periconceptional care of women with diabetes mellitus. Obstet Gynecol Clin North Am. 2007;34:225-239.

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The Literature Compendium is funded by an educational grant from Pfizer Inc.

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