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High Risk Pregnancy - 2009
High Risk Pregnancies
•Disordered Eating•Obesity•Hypertensive Disorders •Gestational Diabetes
Disordered Eating & Pregnancy: Prevalence
• Few data on prevalence of disordered eating in pregnancy• Difficult to adequately capture this information from women.
Women may have needs for secrecy and denial so information about history of eating disorders is often not given to health care providers during pregnancy
• Some published numbers for disordered eating in the population ((Mitchell et al. J midwifery & women’s health, 2006)– Prevalence of binge eating disorder ~ 1.2%-4.5%– Prevalence of anorexia nervosa in young females is 0.03%– About 25% of individuals with anorexia nervosa develop a chronic
course.
Diagnostic Criteria: Anorexia Nervosa (American Psychiatric Association)
• Refusal to maintain body weigh at or above normal weight for age and height
• Intense fear of gaining weight or becoming fat, even through underweight
• Disturbance in the way in which one’s body weigh or shape is experienced,
• Undue influence of body weigh or self-evaluation or denial of the seriousness of current low body weight
• In postmenarcheal females, amenorrhea (absence of at least three consecutive menstrual cycles)
Diagnostic Criteria: Bulimia Nervosa (American Psychiatric Association)
• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:– In a discrete period of time, eating an amount of food definitely
larger than most people would eat– A sense of lack of control over eating during the episode
• Recurrent inappropriate compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications.
• Binge eating and inappropriate compensatory behaviors occur at least twice a week for 3 months
• Self-evaluation is unduly influenced by body shape and weight
• The disturbance does not occur exclusively during anorexia nervosa.
Diagnostic Criteria: Not otherwise specified (American Psychiatric
Association)• For females, all the criteria for AN are met, except
that the individual has regular menstrual cycles.• All criteria for AN is met, except the weight is WNL,
despite significant weight loss• Regular use of inappropriate compensatory behaviors
in an individual of normal weight after eating small amounts of food
• Repeated chewing and spitting out food, but not swallowing
• Binge-eating disorder: recurrent episodes of binge eating in the absence of regular use of compensatory behaviors characteristic of BN
Disordered Eating & Pregnancy
Results of published studies are inconsistent Developmental tasks of pregnancy are often
about the same issues that arise in some women with eating disorders
Body changes Alterations in roles Concerns about a woman’s own mothering
and needs for psychological separation.
Pregnancy and Eating Disorders: A review and clinical Implications (Franko and Walton, Int.J. Eating Disorders,
1993) British report on 6 of 327 women who had
attended eating disorder clinic and got pregnant
Median BMI was 16.8 (range 14.9-18.1) Median length of time with AN was 15 years
(range 11-17) Average weight gain was 8 kg (range 5-14) -
recommendations for low BMI are 13-18 Poor third trimester fetal growth was found in all
5 babies who were monitored Babies had some catch up in infancy
Pregnancy Outcome and Disordered Eating (Abraham et al J Psychosom Obstet Gynecol, 1994)
• 24 women reported previous problems with disordered eating.
• These women had higher rates of antenatal complications such as IUGR, PIH, edema, GDM, vaginal bleeding (p<0.05)
• These women also were more likely to have infants with birthweights < 25th % ile (p<0.02)
Bulimia Symptoms and other risk behaviors during pregnancy in women with Bulimia
Nervosa (Crow et al, Int J Eat Disord, 2004)
• 129 participants in a long-term follow up study of women who had been treated for BN at the University of Minnesota
• 322 pregnancies
Crow et al., 2004
2 Studies from Sweden….
Pregnancy and neonatal outcomes in women with eating disorders (Kouba et al.
Obstet Gynecol, 2005)• Recruited women from 13 Swedish prenatal clinics & screened
and diagnosed eating disorders.• 68 controls & 49 nulliparous, nonsmoking women diagnosed
with:• 24 AN• 20 BN• 5 NOS
• Mean duration of eating disorders was 9 years (range 3-15)• 16 (33%) of women with hx of eating disorders had received
TX• 11 (22%) of women with eating disorders had a relapse during
pregnancy that led to contact with a psychologist or psychiatrist.
Kouba, 2005
Kouba, 2005
Birth outcomes and pregnancy complications in women with a history of AN
(Ekeus et al, BJOG, 2006)
• Birth register study– 1000 primiparous women who were discharged from
hospital with dx of AN from 1973-1996 who gave birth 1983-2002
– All non AN births (827,582)
• Birthweights lower (p=0.005) in AN group:– Mean AN, 3387– General population mean, 3431– Longer hospital say for AN (> 6 months) not associated with
different outcomes
• No difference in SGA and any other negative birth outcomes for mother or baby
Birth outcomes and pregnancy complications in women with a history of
AN (Ekeus et al, BJOG, 2006)
• Authors’ explanation of findings:– “Our findings may be a result of gradual
improvement in the care process, both AN and maternity care.”
– “A country with a satisfactory maternity surveillance, outcome of pregnancy and delivery may be just as good for women with a hx of AN as for the general population.”
• OR…..the fertility problems associated with AN mean that pregnancy will only occur in less severe cases…
Recency of ED(Micali et al. J Psychosom. Research, 2007)
• N=12,252– 57 reported recent episode of ED (6 AN, 51
BN)– 395 reported past history of ED
• Note: “recent” not defined in paper.
• Asked about behaviors at 18 weeks and 36 weeks via mailed questionnaire
Recent ED Past ED Non-obese controls
Laxative use in pg
8.2 0.8 0.2
Pregnancy SIV 26.5 3.9 0.7
High exercise in pregnancy
32.7 31.2 21.2
Strong desire to loose weight
63.5 31.4 22.2
Loss of control over eating
72.5 42.8 36.1
Postpartum eating and Body Image for all Women
• It is of note that in a general population of postpartum women, eating disorder behaviors increase markedly in the first 3 months post-partum and remain high for the next 9 months.
• Some women actually first experience clinical eating disorders during this time. (Stein et al Eating Habits and Attitudes in the Post Partum Period. Psychosomatic Med., 1996)
Eating Habits and Attitudes in the Post
Partum Period (Stein et al. Psychosomatic Med., 1996)
• N=97, prospective cohort study of primip. women followed during pregnancy and at 3 and 6 mos pp.
• Eating Disorder Examination (EDE): restraint, eating concern, shape concern, weight concern and global scores about state over last 28 days
• Repeated measures ANOVA indicated that changes in eating disorder pathology pp were largely due to changes in body weight.
An observational study of mothers with eating disorders and their infants ( Stein et al., J Child Psychol Psychiat, 1994)
• 2 groups of primips:• Index group, women who had met EDE criteria
for disordered eating during pp period, n=34• Control group, balanced for SES, age, and
child’s gender, n=24• At one year:
• EDE• Child’s growth• Structured observation of child and mother at
task and mealtime
Mealtime Behaviors ( Stein et al., J Child Psychol Psychiat, 1994)
Index Control
Negative Expressedemotion toward child
3.27 0.90**
Intrusiveness 8.91 1.20**
% of maternalcontrollingstatements
27.3% 26.11%
** p<0.01
Discussion ( Stein et al., J Child Psychol Psychiat, 1994)
• Index mothers were more intrusive than control mothers
• About 1/3 of the index infants and one of the control infants had growth faltering
• Regression analysis models to predict infant weights were best fit when included:
– maternal height,– infant birthweight– conflict during meals – mothers concern about own body shape
• Also, eating disordered women make poor role models. Your influence could lead your daughters to their own eating disorders and your sons to believe that the most important thing about women is their weight.
Clinical Implications
• Careful screening and monitoring• Possible use of self administered,
computer assisted screening tool• Psychotherapy may be indicated• Interventions are not evidence based at
this time, but based on case studies & individual counselor’s experiences
Clinical Interventions: Nutrition
• “Frequent weigh-ins, lectures about weight gain, and even well-meaning comments by clinical staff can be triggers for increasing the frequency of eating disordered behaviors.” (Mitchell et al. J midwifery & women’s health, 2006)
• If appropriate:– Discuss and provide materials about nutrients and food in
pregnancy– Design individual food plan– Determine optimal range of weight gain– Discuss hydration shifts in pregnancy and need for fluid
Clinical Interventions: Exercise
• Assess exercise level
• Suggest joining exercise groups and new mothers groups to normalize experience of weight concerns
Clinical Interventions: Psychosocial
• Making the fetus as real as possible to the patient very early– Focus on fundal measurements?
• Empathetically addressing fears of weight gain and feelings of being out of control
• Assurance about normal weight gain and patterns of pp weight loss
• Education of significant others
Clinical Intervention: Infant Feeding
• Offer assistance with parenting concerns
• Offer information about infant feeding:– infant’s ability to self regulate– attention to infant cues & signals– use of food as reward or control
mechanism
Bulik Hypothesis (Int J Eat Disord, 2005)
• Preterm birth is associated with threefold increase in risk of AN
• Neurodevelopmental insults in premature infants could contribute to delayed oral-motor growth and onset of early eating problems.
• Women with low prepreg BMI & inadequate nutrition during gestation have increased risk for preterm delivery – cycle of risk is established.
Maternal Obesity
• Rates of obesity are increasing world-wide
• Obesity before pregnancy is associated with risk of several adverse outcomes
• Nutrition and Pregnancy Outcome. Henriksen, Nutrition Reviews, 2006
• Management of Obesity in Pregnancy. Catalono. Obstetrics and Gynacology, 2007
• Position of the American Dietetic Association and American Society for Nutrition: Obesity, Reproduction, and Pregnancy Outcomes. J Am Diet Assoc. 2009;109:918-927
Pregnancy Concerns Associated with Maternal Obesity
Fertility
• Obesity associated with increased time to conception
• 25% of ovulatory infertility attributed to obesity
• Less success with assisted reproductive technologies
• Potential mechanisms– Adipose tissue impact on hormone availability– Insulin resistance associated with lowered fertility
Diagnosis of Pregnancy
• Menses tend to be irregular and pelvic exams and ultrasound exams may be difficult
• AFP values are lower in obese women due to increased plasma volume
• Blood pressure monitoring may be difficult
Antepartum Outcomes
• Higher rates of NTD even with folic acid supplementation (RR = 3.0 in one study)
• Increased risk for both chronic and pregnancy induced hypertension
• Increased risk for severe preeclampsia (BMI < 32.3, risk was 3.5 times that of controls)
• Increased risk of GDM, IDD and NIDD
• Increased twining• Increased UTI
Fetal Outcomes
• Morbidly obese women have increased risk of preterm delivery– 25% of preterm births are indicated because of
maternal medical/ob problems
• Neonatal death - stillbirth– Increase in overweight women twice that of
normal weight women– Increase in morbidly obese women is 240%
greater
Labor and Birth Outcomes
• Increased incidence of cesarean births in nulliparous women
• BMI < 30: 21%• BMI 30-35: 34%• BMI 35-40: 48%
• VBAC success rates:– Normal weight women = 71%– Overweight women = 66%– Obese women = 55%
Concerns with surgical births
– Operative times are longer– Increased incidence of blood loss during
surgery– Differences in responses to anesthesia
(greater spread/higher levels)– Increased risk of post-op complications
• Wound infections• Deep venous thrombophlebitis• endometritis
Postpartum Outcomes
• Increased risk for endometrial infection
• Increased prevalence of urinary incontinence
• Decreased rates of lactation success– Initiation– Duration– Amount of milk produced
Infant Outcomes
• Large infants - effect is independent of maternal diabetes- rates of macrosomia (>4000 g):– Normal weight women: 8 %– Obese women: 13% – Morbidly obese women: 15%
• Increased infant mortality - RR for infants born to obese women was 4.0 compared to women with BMI < 20
Long Term Risks to Infant
• Children born to obese mothers twice as likely to be above 95th percentile BMI at age 2
• Metabolic syndrome in at age 11:– Hazard ratio = 2.19 (1.25-3.82) if LGA– Hazard ratio = 1.81 (1.03-3.19) if maternal
obesity
Swedish population-based study (Cedergren, 2004)
• n=805,275• Morbid obesity (BMI>40) compared to
“normal” weight– 5 fold risk of preeclampsia– 3 fold risk of still birth after 28 weeks– 4 fold risk of LGA
• BMI >35, <40, associations remain, but not as strong
Cost
• Costs were 3.2 times higher for women with BMI > 35
• Longer hospitalizations
ADA Position Statement, 2009“Given the detrimental influence of maternal overweight and obesity on reproductive and pregnancy outcomes for the mother and child, it is the position of the ADA and the American Society for Nutrition that all overweight and obese women of reproductive age should receive counseling prior to pregnancy, during pregnancy, and in the interconceptional period on the roles of diet and physical activity in reproductive health, in order to ameliorate these adverse outcomes.”
Emerging Issues: Bariatric Surgery
• Outcomes
• Challenges of studies:– Appropriate control groups?– Outcomes to measure?– Selection bias– Changes in procedures over time
• Clinical recommendations
Outcomes After Malabsorptive Procedures such as Roux-en-Y(Bernert et al. Diabetes Metab. 2007; Catalono. Obstet Gynecol, 2007)
• Associated Complications:
• Small bowel ischemia
• Nutrient deficiencies (iron, folate, B12)
• Fetal abnormalities
• SGA & preterm birth
• Cesarean delivery
Pregnancy Outcomes after Gastric-Bypass Surgery
• Dao, et al. Am J Surg, 2006• N= 21 pregnant within first year post-
surgery; 13 pregnant after first year (Texas)
• Author's conclusions: “Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes or pregnancy complications.”
Pregnancy following gastric-bypass (Dao, 2006)
< 1 year (21) > 1 year (13)
Mean BMI: At surgery
At pregnancy49
35
46
28
Mean weight gain 4 # 34#
Mean birthweight 2868 g
(2 sets twins)
2727 g
(3 sets twins)
“Major” pregnancy complications
5 1
“Minor” pregnancy complications
5 3
Birth Outcomes in Obese Women After Laparoscopic Adjustable Gastric Banding
• Dixon et al. Obstet Gynecology. 2005• N=79 (Australia)• Mean maternal weight gain= 9.6 +/- 9.0
kg• Mean birthweight = 3,397• Incidence of PIH, GDM, stillbirth, preterm
delivery low and high birth weights more similar to population than obese women.
Dixon Conclusions:
• “Pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women. The adjustability of the LABG assists in achieving these outcomes.”
Pregnancy after Bariatric Surgery: A comprehensive review. Sheiner. Arch
Gynecology Obstet. 2008. • Post surgery women at increased risk
for poor perinatal outcomes.
• “Clinicians should be aware that data collected on this subject are often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies.”
Clinical Management of Pregnancy Following Bariatric Sugary (ACOG Committee and Catalano, Obstet Gynecology, 2007)
1. Advise women about risk of unexpected pregnancy following LAGB & need for contraception
2. Delay pregnancy for 12-18 months – avoid rapid weight loss phase and catabolic state
3. Close monitoring during pregnancy by both ob and surgeon to allow for adjustments of gastric bands
4. Supplement with folate, calcium, B12
Hypertensive Disorders During Pregnancy
• Incidence
• Definitions
• Etiology/pathophysiology
• Nutritional Implications
WORKING GROUPREPORT ON HIGHBLOOD PRESSUREIN PREGNANCY
N A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E
July 2000
Incidence• Second leading cause of maternal
mortality in US• 15% of maternal deaths (disseminated
intravascular coagulation, cerebral hemorrhgae, hepatic failure, acute renal failure)
• Hypertensive disorders occur in 6 to 8% of pregnancies
• Contribute to neonatal morbitity and mortality
High risk
First pregnancy and under age 17 or over 35 Family history of hypertension Poor nutritional status Smoking Overweight Other health problems such as renal disease,
diabetes Multiple gestation Some Fetal anomalies
Chronic Hypertension
• Known hypertension before pregnancy or rise in blood pressure to > 140/90 mm Hg before 20 weeks
• Hypertension that is diagnosed for the first time during pregnancy and that does not resolve postpartum is also classified as chronic hypertension.
Gestational Hypertension
Hypertension in pregnancy is present when diastolic BP is 90 or greater, systolic BP is 140 or greater
• the use of BP increases of 30 mm Hg systolic and 15 mm Hg diastolic has not been recommended - women in this group not likely to have increased adverse outcomes
• ¼ of women with gestational htn advance to preeclampsia
Preeclampsia
Preeclampsia is defined as the presence of hypertension accompanied by proteinuria– In the absence of proteinuria the disease is
highly suspect when increased blood pressure with headache, blurred vision, and abdominal pain, or with abnormal laboratory tests, specifically, low platelet counts and abnormal liver enzymes.
Proteinuria
• Proteinuria is defined as the urinary excretion of 0.3 g protein or greater in a 24-hour specimen.– This will usually correlate with 30 mg/dL (“1+
dipstick”) or greater in a random urine determination with no evidence of urinary tract infection.
• because of the discrepancy between random protein determinations and 24-hour urine protein in preeclampsia it is recommended that the diagnosis be based on a 24-hour urine if at all possible
Findings that increase the possibility of Eclampsia and indicate need for FU:
Severe Preeclampsia
Edema
Eclampsia
• Occurrence in a woman with preeclampsia, of seizures that can not be attributed to other causes
• Rare: 4% of women with preeclampsia advance to eclampsia
Etiology
• Not fully understood
• Primary pathophysiology is placental function
• Secondary pathophysiology involves endothelial cell dysfunction due to factors released because of insufficient placental blood supply
Characterized by:
• Vasospasm
• Activation of the coagulation system
• Perturbations in systems related to volume and blood pressure control
Pathogenic Mechanisms
Delivery is only known cure - research has focused on placenta– failure of the spiral arteries (terminal
branches of uterine artery) to remodel– alterations in immune response at the
maternal interface– increase in inflammatory cytokines in
placenta and maternal circulation, “natural killer” cells, and neutrophil activation
Pathophysiology
Decreased blood flow Decreased renal blood flow, decreased GFR, Na
retention Tissue hypoxia Damage to organs – multi-organ disease affecting
the liver, kidneys, and brain
Pathophysiology
Decreased blood volume Decreased placental blood flow may
occur 3-4 weeks before increased BP Hypoxia Decreased nutrient delivery
Outcomes
Increased LBW and IUGR for infant There is mounting evidence that children born
to mothers whose blood pressure was elevated during pregnancy are at greater risk for elevated blood pressure during childhood and adolescence
Also long term maternal health may be affected by consequences of maternal damage to renal and CV systems.
Focus of Possible Interventions
Smooth muscle contraction Prostaglandin synthesis
Calcium
Epi studies suggest inverse relation between dietary calcium and PIH
Intraerythrocyte calcium levels and intracellular calcium ion conc. increased in women with pre-eclampsia
HO: Ca supplementation reduced serum parathyroid hormone – reduced intracellular Ca conc. in vascular smooth muscle cells and reduces response to pressure stimuli
Several RCT have found reduced risk of PIH with Ca supplementation to prevent (not treat) PIH.
Calcium, cont.
Recent meta-analysis found Ca intake of 1.5-2 g associated with sig. reductions in systolic and diastolic BP without adverse effects.
Question remains: does lowering BP have effect on pathophysiology of PIH?
Omega-3 Fatty Acids In Maternal Erythrocytes and Risk of Preeclampsia (Williams et al, Epidemiology, 1995)
• Theory:– Ratio of omega 6 and omega 3 fa may
modify processes related to PIH such as platelet and leukocyte reactivity, vasodilation, and inflammatory processes.
• Study design: – small case control, n=22 cases, 40 controls– adjusted for parity and pre-pregnancy BMI
Omega-3 Fatty Acids In Maternal Erythrocytes
and Risk of Preeclampsia (Williams et al, Epidemiology, 1995)
• Results:– Women with the lowest tertile of n-3 in
erythrocytes had odds ratio of 7.6 (95% CI=1.4-40.6) for developing preeclampsia.
Cochrane: Marine oil, and other prostaglandin precursor, supplementation for pregnancy
uncomplicated by preeclampsia or intrauterine growth
restriction (2006)
• 6 trials
• No “clear difference” in the RR of preeclampsia between groups
• 2 trials, lower risk of giving birth before 34 weeks – RR 0.69 (95% CI 0.49-0.99)
Antioxidants and Preeclampsia: Possible Mechanisms
• Placental underperfusion may mediate a state of oxidative stress.
• Oxidative stress, coupled with an exaggerated inflammatory response, may result in the release of maternal factors that result in inappropriate endothelial cell activation and endothelial cell damage
• Supplementing women with antioxidants may increase their resistance to oxidative stress, and hence could limit the systemic and uteroplacental endothelial damage seen in pre-eclampsia
Cochrane, 2008
Cochrane: Antioxidants for preventing pre-eclampsia (2008)
• Ten trials, 6533 women– 5 were rated high quality
• Most trials used combined vitamin C and E
Cochrane: Antioxidants for preventing pre-eclampsia (2008)Outcome # trials RR 95% CI
preeclampsia 9 0.73 0.51-1.06
Severe preeclampsia
2 1.25 0.89-1.76
Preterm birth 5 1.10 0.99-1.22
SGA 5 0.83 0.62-1.11
Any baby death 4 1.12 0.81-1.53
Maternal abdominal pain
1 1.61 1.11-2.34
Cochrane: Antioxidants for preventing pre-eclampsia (2008)
• “Evidence from this review does not support routine antioxidant supplementation during pregnancy to reduce the risk of pre-eclampsia and other serious complications in pregnancy.”
Other Nutrition Related Factors
Na: Pregnant women with proteinuric hypertension have lower plasma volume Na. restriction is associated with accelerated volume depletion – not recommended
Energy and Protein intake: increases not found to be useful
Weight reduction or limited gain in pregnancy: not found to be useful
Position StatementGestational Diabetes Mellitus
American Diabetes Association2004
Definition
• Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The definition applies whether insulin or only diet modification is used for treatment and whether or not the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy.
Prevalence
• 7% of all pregnancies are complicated by GDM in US
• more than 200,000 cases annually in US
• prevalence may range from 1 to 14% of all pregnancies, depending on the population studied and the diagnostic tests employed.
Diagnosis
• Assess risk at first visit• If high risk (marked obesity, personal
history of GDM, glycosuria, or a strong family history of diabetes) GTT ASAP
• Women of average risk should have testing undertaken at 24–28 weeks of gestation
• Low-risk status requires no glucose testing
Low Risk Criteria
• Age <25 years
• Weight normal before pregnancy
• Member of an ethnic group with a low prevalence of GDM
• No known diabetes in first-degree relatives
• No history of abnormal glucose tolerance
• No history of poor obstetric outcome
Non GTT dx
• A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200 mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge
One-step Approach
• Perform a diagnostic oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening
• May be cost-effective in high-risk patients or populations (e.g., some Native-American groups).
Two-step approach
• Initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load
• Diagnostic OGTT on that subset of women exceeding the glucose threshold value on the GCT
Table 1— Diagnosis of GDM with a 100-g oral glucose load
Two or more of the venous plasma concentrations must be met or exceeded for a positive diagnosis. The test should be done in the morning after an overnight fast of between 8 and 14 h and after at least 3 days of unrestricted diet ( 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated and should not smoke throughout the test.
mg/dl mmol/l
Fasting 95 5.3
1-h 180 10.0
2-h 155 8.6
3-h 140 7.8
Infant Concerns in GDM
• Higher risk of:• neural tube defects• birth trauma• hypocalcemia• hypomagnsemia• hyperbilirubinemia• prematurity syndromes• subsequent childhood and adolescent obesity
and risk of diabetes
Infant Concerns, cont.
– Macrosomia in infant due to high glucose levels from mother and fetal insulin response leading to increased fat deposition, associated with complications at delivery.
– Hypoglycemia of infant following delivery due to high fetal insulin levels at delivery and sudden withdrawal of maternal glucose transfer
Maternal Concerns
• Higher risk of: – hypertension– preeclampsia– urinary tract infections– cesarean section– future diabetes
Nutritional Therapy in GDM
• Goals:– prevent perinatal morbidity and mortality by
normalizing the level of glycemia– prevent ketosis– provide adequate energy and nutrients for
maternal and fetal health • dependent on maternal body composition
Monitoring
• Daily self-monitoring of blood glucose (SMBG)
• Urine glucose monitoring is not useful in GDM. Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction.
Monitoring
• Blood pressure and urine protein monitoring to detect hypertensive disorders.
• Increased surveillance for pregnancies at risk for fetal demise is appropriate
• Assessment for asymmetric fetal growth by ultrasonography to assess need for insulin
Nutrition Management
• All women with GDM should receive nutritional counseling, by a registered dietitian when possible
• For obese women (BMI >30 kg/m2), a 30–33% calorie restriction (to 25 kcal/kg actual weight per day) has been shown to reduce hyperglycemia and plasma triglycerides with no increase in ketonuria
• Restriction of carbohydrates to 35–40% of calories has been shown to decrease maternal glucose levels and improve maternal and fetal outcomes
Insulin
• Insulin therapy is recommended when MNT fails to maintain self-monitored glucose at the following levels: – Fasting whole blood glucose 95 mg/dl (5.3 mmol/l) – Fasting plasma glucose 105 mg/dl (5.8 mmol/l) – 1-h postprandial whole blood glucose 140 mg/dl (7.8 mmol/l) – 1-h postprandial plasma glucose 155 mg/dl (8.6 mmol/l) – 2-h postprandial whole blood glucose 120 mg/dl (6.7 mmol/l) – 2-h postprandial plasma glucose 130 mg/dl (7.2 mmol/l)
• Oral glucose-lowering agents have generally not been recommended during pregnancy
Exercise
• Programs of moderate physical exercise have been shown to lower maternal glucose concentrations in women with GDM
Exercise for Diabetic Pregnant Women: Cochrane, 2009
• 4 trials, 114 women with GDM• Trials conducted in third trimester for
about 6 weeks; exercising three times a week for 20-45 minutes
• “There is insufficient evidence to recommend, or advise against diabetic pregnancy women to enroll in exercise programs…..further trials needed.”
Long Term• Reclassification of maternal glycemic status
should be performed at least 6 weeks after delivery
• If glucose levels are normal post-partum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals
• education regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal body weight through MNT and physical activity.
Long Term
• Avoid medications that worsen insulin resistance (e.g., glucocorticoids, nicotinic acid)
• Seek medical attention if develop symptoms suggestive of hyperglycemia.
• Use family planning to assure optimal glycemic regulation from the start of any subsequent pregnancy
• Diabetes Care. Supplement July 2007– Pathophysiology– Therapy– Impact on infants– Maternal follow-up
5th International Workshop-Conference on Gestational Diabetes Mellitus
(Diabetes Care. Supplement July 2007)
• treatment started before 30 weeks reduces likelihood of serious neonatal morbidity– Individualize MNT– Daily self monitoring of blood glucose
(SMBG)– Insulin when needed (20% needed)
Conference, cont.
• Metabolic management based on fetal growth measures is promising technique
• Oral antihyperglycemic agents:– Glyburide (glibenclamide): studies indicate may
be useful adjunct to MNT/PA; may be less successful with obese patients
– Metformin: crosses placenta, insufficient evidence that prevents GDM
– Acarbose: safety not fully evaluated
Offspring
• Newborns of women with GDM have increased adiposity and reduced fat free mass even if not macrosomic
• Breastfeeding may be protective against childhood overweight in children born to GDM
Maternal Follow-up
• Majority will eventually develop diabetes- – 35-60 percent within 10 years– risk continues at least 1-2 decades after GDM
pregnancy• Increased risk of congenital anomalies in
subsequent pregnancies• “There is substantial research evidence that
lifestyle change and use of metformin or thazolidinediones can prevent or delay the progression of IGT to type 2 diabetes after GDM.”
Treatments for Gestational Diabetes: Cochran, 2009
• 8 RCTS, 1418 women• Reduced risk of pre-eclampsia with intensive tx
(dietary advice & insulin) compared to usual care• Reduced perinatal morbidity (death, shoulder
dystocia, bone fracture, nerve palsy) with intensive TX compare to usual care
• Reduction in proportion of infants weighing more than 4000 g; no sig diff when mothers received oral drugs compared to insulin.
• “Specific treatment including dietary advice and insulin for mild GDM reduces the risk of maternal and perinatal morbidity.”