Preconception Care for Women with Diabetes

1. Preconception CareforWomen with Diabetes

2. Objectives and GoalsTo Understand… • Preconception Care (PCC): definition and purpose • The role that PCC plays for women with diabetes • Identify different aspects of pregnancy readiness • Pregnancy Spacing for better health

3. Preconception Care: Definition • “Preconception care is comprised of interventions that aim to identify and modify • biomedical • behavior and • social risks • to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors to be acted on before conception...”(CDC, 2009)

4. Preconception Care Every woman, every time (MOD, 2001)

5. Sweet Success PCC Goals… • To Prevent excess spontaneous abortions and congenital malformations in infants of diabetic mothers • Achieve A1C levels < 6.5% • Assure effective contraception until stable and acceptable glycemia is achieved • Identify, evaluate, and treat long-term diabetic complications (GFC, in print)

6. Main Elementsin the SS Model of Care… • Physician directed medical assessment, laboratory testing, treatment, maternal and fetal care. • Patient education about interaction of diabetes and pregnancy, and self-care • Educator-directed assessment and education of diabetes self-management skills • Mental health professional counseling when indicated to assess coping, reduce stress and improve adherence to diabetic treatment plan (GFC, in print)

7. Risks to Moms… • Pyelonephritis • Preterm delivery • Traumatic delivery • Operative delivery • Progression of disease • Hypoglycemia • Pregnancy Loss • Pre-eclampsia • Polyhydramnios • Hyperglycemia • Diabetic Ketoacidosis

8. Risks for Babies… • Organogenesis largely completed by week 8 of gestation • Poorly controlled blood glucose in this period of time  risks of anomalies &SAB • Poorly controlled blood glucose  risk and predisposes to chronic diseases including diabetes (Diabetes Care, January 2003)

9. Critical Periods of Development Weeks gestation from LMP 4 5 6 7 8 9 10 11 12 Most susceptible Central Nervous System time for major Heart malformation Arms Eyes Legs Teeth Palate External genitalia Ear Mean Entry into Prenatal Care Missed Period

10. Why Plan and Change? Preconception Care • Identifies risks • Provides interventions tooptimal outcomes • Maximizes maternal health • Builds more effective patient/provider relationship prior to conception • Improves early access to prenatal care • Reduces poor outcomes • Creates rewarding experience for couples

11. The Big PCC Picture…Team-Work! • Readiness for pregnancy • Complete medical examination • Laboratory Evaluation • Normal Blood glucose control • Planned Pregnancy

12. Readiness for Pregnancy…Healthy Coping • General Mental Health • Diabetic Self-Care • High-Risk Factors • Network of Social Support • Resources/consultations

13. Complete Medical Exam…History Assessment • Type of diabetes • Risk for diabetes (previously pre-diabetes) • Age at onset, including duration • Status of medical conditions/treatments • organ involvement • hospitalizations • complications • pregnancy history • Co-morbidities • Current Medications • Alcohol or chemical substance use

14. Medical Exam… Physical Assessment* • Metabolic control • Blood pressure • Cardiovascular examination • Retinal • Renal • Neurological • Dental Evaluation • Foot Exam • Immunological Status • Pelvic exam/pap smear *Thefocus of assessment is to evaluate level of end organ damage, retina, kidney, vasculature, heart and nervous system and any other medical conditions

15. Medical Exam and Labs… • Metabolic Control: • A1c: Goal < 6.5 • Fasting Lipid Profile: • HDL: >50 mg/dL • Triglycerides (TG) <150 mg/dL • Total LDL Cholesterol <100 mg/dL • recommendation with DM & CAD < 70 mg/dL • Serum TSH screening and or free thyroxin level • Celiac disease screening in type 1

16. Medical Exam and Labs… 2. Blood pressure Controlled. Goal: < 130/80 • Cardiovascular exam / Electrocardiogram (EKG/ECG) Consider testing or referral for peripheral atherosclerotic vascular disease if a woman is at high risk or demonstrates signs and symptoms. EKG: women > 34; DM1 >10 years, DM2; or with signs and symptoms of angina, or exercise intolerance. • Dilated retinal exam: Ophthalmologist knowledgeable in diabetic eye conditions.

17. Medical Exam and Labs… 5. Renal status to test for potential nephropathy: Random urine: Normal random microalbumin/creatinine<30mg/day If abnormal: • 24 hour urine collection is for total protein, and or/creatinine • Total protein <150 mg/mg per 24 hours • Serum creatinine 0.7-0 .9

18. Medical Exam and Labs….. • Neurological: • Assessment of autonomic dysfunction • Hypoglycemia unawareness, orthostatic hypotension, excessive nausea and vomiting • Gastrointestinal autonomic neuropathy or gastroparesis

19. Medical Exam and Labs… • Dental Examination: Refer if woman does not have regular dental health care. • Foot exam: By PCP or podiatrist. • Immunological Status: Update all pertinent immunizations. (GFC, in print)

20. Summary of Laboratory Evaluation Recommended PCC testing: • A1c • Complete Blood Count • Serum TSH/T4 • Random Urine • Serum Creatinine • 24 hour urine protein • Microalbumin • Lipid profile

21. Planned Pregnancy…Management Includes • Contraception is utilized until glycemic control is achieved • Smoking cessation • Nutritional Supplementation • Folate 400µg/day • 4 mg/day with Hx neural tube defect or cleft palate defect • Multiple Vitamin • Medications compatible with pregnancy • Intensive insulin regimen • Medical nutrition therapy • Activity evaluation

22. Intensive Glycemic Control • Current regimen • Set realistic goals • Insulin adjustments • Evaluate self-management skills • Hypo/hyperglycemia • Safeguards • Signs and Symptoms • Glucagon • Ketones

23. Preconception: Plasma Glucose Values

24. Medical Nutrition Therapy…Healthy Eating • Determine energy needs • Achieve desirable body weight • Maintain balance in diet plan • Evaluate adherence • Educate about diet issues and pregnancy • Reinforce importance of dietary supplements

25. Activity Evaluation…Being Active • Endorphins to enhance mental well-being • Improves insulin sensitivity • Improves strength and endurance • Improves BMI • Improves cardiovascular status • Enhances a healthy lifestyle • Safeguards against hyperglycemic episodes • Any contraindications? Limitations?

26. Management Continues with Optimal Control… • Blood pressure normalization • Cardiovascular/Neurologic Stability • Stabilized retinopathy • A1c < 6.5 % • Evaluate Insulin Therapy

27. During Gestation • Early Referral to Sweet Success Program • Management will continue for optimal control • Psychosocial wellbeing • Glycemic control • Cardiovascular • Retinal • Renal • Metabolic • Fetal wellbeing

28. Preconception Care for Women with GDM History • Pregnancy History • Converted? • Contraception? • Weight reduction achieved? • Exercise? • Current Diet? • Folate? MVI/PNV? • Immunizations/General Health? • Utilize the “teachable moment”

29. Preconception Care…for GDM Patients If Postpartum Screen was NEGATIVE: • Test fasting every year thereafter • Test every 3rd year using 2 hour OGTT • Test at next PCC or at first prenatal visit • Attain normal BMI, life style of healthy coping, healthy eating; being active is recommended If Postpartum Screen was POSITIVE: • She should present for preconception care

30. Other Conditions Requiring Preconception Care: Polycystic Ovary Syndrome • A clinical diagnosis of chronic hyperandrogenism and anovulation • The leading cause of infertility • The most common endocrinopathy affecting 6-10% of women of reproductive age. • Not all have cysts • Many are normal weight

31. Clinical Features Associated with PCOS • Menstrual dysfunction-as early as age 12 • 15-30% have regular menses • Infertility and /or miscarriage • Facial and upper back acne • Obesity in ~ 60% • Excessive hair growth • Androgenetic alopecia • Acanthosis Nigricans in ~ 30% • Ovarian cortex containing multiple atretic follicles in ~ 80%

32. Metabolic Aberrations in PCOS Most significant is Insulin Resistance (IR) with compensatory Hyperinsulinemia

33. Endocrinopathy with PCOS • Chronically elevated Luteinizing hormone to FSH (LH:FSH = 3:1) • ↑ Levels free testosterone (usually ovarian source but can also be adrenal) • ↓ Sex hormone-binding globulin • Normal prolactin except for ~15% who have slight elevations

34. Insulin Sensitizers to Treat Insulin Resistance and Secondary Infertility • Multinational study: Metformin vs. placebo for obese women with PCOS • 34% ovulation vs. 4 % in placebo group • 90% Metformin plus clomid vs. 8% in placebo group • 8 fold increase in conception when taking Metformin (Nestler et al. 2002)

35. PCOS and Type 2 DM • 35 % of women with PCOS have clinical IGT and do not know it. • 10 % of women with PCOS are diagnosed with Type 2 DM by age 40(Ehrman et al. Diabetes Care, Jan 1999)

36. PCOS and GDM • Hypothesized that all have insulin resistance with compensatory hyperinsulinemia • ~ 40% PCOS develop GDM • 40 -52% GDM’s have PCOS ovarian morphology

37. Resources • www.cdph.ca.gov/programs/cdapp For Sweet Success information • www.marchofdimes.org For California Preconception Initiative Professional Resources for PCC • www.everywoman.org For California Preconception link (provider/consumer link) • www.cdc.gov/NCBDDD/preconceptional/default.htm For Centers for Disease Control & Prevention link

38. OK… Now… Get Pregnant… ……………………………………..FAST…..

39. Thank You!

40. Contact Information Gretchen Page , MPH, CNM Manager, Inland CountiesRegional Perinatal Programs, LLUMC/Children’s Hospital (909) 558-3996 gpage@llu.edu