Diabetes and Pregnancy: The Importance of Preconception Counseling
Women with both type 1 and type 2 diabetes mellitus require special attention before becoming pregnant. Pregestational (pre-existing) diabetes is associated with significant and potentially life-threatening complications for both the pregnant woman and her unborn child. These complications include spontaneous abortion, fetal demise, fetal anomalies, macrosomia, neonatal hypoglycemia, neonatal hyperbilirubinemia, and maternal preeclampsia.1 When pregestational diabetes is not optimally controlled, especially prior to conception, the risk for these complications is much higher.2 Gestational diabetes mellitus (GDM) occurs during the latter part of pregnancy in women with no prior history of type 2 diabetes mellitus (T2DM) and can lead to complications that may affect the safe delivery of a healthy baby. While this condition usually resolves after delivery, as many as >70% of these women will develop T2DM later in life.3 fact, GDM is one of the major risk factors for the development of T2DM.
The great news is that good medical care-- (prioritizing patient education and counseling about the importance of pre- pregnancy planning, self-care, strict glycemic control, and risk reduction before pregnancy-- makes it possible for women with either pregestational diabetes or GDM to have successful, safe pregnancies and healthy babies. This article reviews the importance of preconception counseling.
Pregestational Diabetes
Optimize glycemic control. Hyperglycemia is a known teratogen. Complications resulting from uncontrolled diabetes during pregnancy include intrauterine fetal demise and infant death (4.56-fold and 1.86-fold higher risk, respectively, for offspring of mothers with pregestational diabetes).1,4 The risk of fetal malformations increases in proportion to A1C elevations during the first 10 weeks of pregnancy, when many women do not realize that they are pregnant. The seriousness of this risk is underscored by a consensus panel’s recommendation that patients use effective contraception until blood glucose levels are stable.5 The risk of fetal and infant death has been associated with glycated hemoglobin (A1C) >6.6% during pregnancy.4
Macrosomia, which occurs in the third trimester, affects 27% to 62% of infants born to mothers with diabetes, compared with roughly 10% of children of nondiabetic women. This complication raises the risk of cesarean delivery, birth trauma, fetal death, and neonatal complications.5
Diabetes places the pregnant woman at risk for complications, too. Of particular concern is the development of preeclampsia, especially if the woman has underlying hypertension. Women
with type 1 diabetes have a 2- to 4-fold higher risk of preeclampsia when compared to women without diabetes.6,7 Elevated prepregnancy A1C values have been associated with a higher risk of preeclampsia.6 In addition, microvascular complications, in particular the development and progression of diabetic retinopathy and nephropathy, are also associated with pregnancy.1,5 Urinary albumin excretion rises during pregnancy.1 Preeclampsia raises the risk of diabetic nephropathy in women with type 1 diabetes.8
Despite these data, women with diabetes often do not receive preconception counseling (≤62% of those with type 1 and <36% of those with type 2).9 Preconception counseling about these risks and the importance of effective contraception should be included in well visits and routine diabetes visits for all females of childbearing age, starting at puberty and including women who have recently given birth.5 Preconception counseling also should address the importance of achieving A1C <6.5% or as close as possible without severe hypoglycemia in order to reduce the risk of congenital anomalies.1
Highlights and Insights from the Metabolic and Endocrine Disease Summit
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
Supported by an educational grant from:
Merck & Co., Inc.
Activity Information
EXPIRED
Original Release Date: May 31, 2017
Expiration Date: May 31, 2018
Estimated Time to Complete Activity: 2.0 hours
EXPIRED
Target Audience
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
Faculty
 | DONNA L. JORNSAY, MS, CPNP, CDE, CDTC |
 | CHRISTINE KESSLER, CNS, ANP, BC-ADM, CDTC, FAANP |
 | DAVIDA F. KRUGER, MSN, APRN-BC, BC-ADM |
 | ELLEN D. MANDEL, DMH, MPA, PA-C, RDN, CDE |
 | LUCIA M. NOVAK, MSN, ANP-BC, BC-ADM, CDTC |
 | JOYCE ROSS, MSN, ANP, CRNP, FPCNA, FNLA |
 | SCOTT URQUHART, PA-C, DFAAPA |
 | KIM ZUBER, PA-C |
Method of Participation
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a webpage that will allow you to receive your certificate of credit via email or you may print it out at that time.
The online post-test and evaluation can be accessed at https://tinyurl.com/meds16suppl
Inquiries may be directed to Global Academy for Medical Education [email protected] or (973) 290-8225.
Accreditation Statements
Physicians
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Global Academy for Medical Education, LLC The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians.
Designation Statement
The University of Cincinnati designates this Live Activity for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing Credit
Postgraduate Institute for Medicine (PIM) is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.3 contact hours is provided by Postgraduate Institute for Medicine. Pharmacotherapy contact hours are .4 for Advance Practice Registered Nurses and will be designated on your certificate.
Educational Needs
Primary care providers are often the first point of care for diabetes and kidney disease. The Metabolic & Endocrine Disease Summit 2016, a CME/CE conference, explored the latest advances in the management of these conditions. Obesity raises the risk of many other conditions. Providers would benefit from a discussion of how to address this frequently encountered problem in clinical practice. Lipoprotein (Lp) (a) is an inherited, independent risk factor for atherosclerotic cardiovascular disease. New therapies show some promise for addressing this form of dyslipidemia. Diabetes raises the risk of major depressive disorder, and depression increases the risk of diabetic complications. Psychosocial intervention can improve glycemic control and symptoms of diabetes-related distress. Nephropathy is a common complication of diabetes but glycemic control, careful choice of medications, and regular monitoring can promote renoprotection.
Diabetes presents issues throughout a patient’s life; three touchpoints are the transition of a young adult from pediatrics to adult care, the detection and management of diabetes during pregnancy, and diabetes in the older adult. Anticipation of the relevant issues and implementation of a transition program can contribute to retaining young adults in care. Preconception counseling and early detection of diabetes can reduce the risk of adverse outcomes. Clinicians must be knowledgeable about how to balance the many complex issues to consider when establishing glycemic targets and selecting a treatment plan for an older adult with diabetes. At this writing, four new insulin-only preparations have been approved by the US Food and Drug Administration (FDA) since February 2015. The ability to differentiate these options is important for clinicians.
Learning Objectives
After reading and studying this journal supplement, participants should be better able to:
- Differentiate the many insulin options available to treat people with diabetes, and their applications in clinical practice
- Display an understanding of the contributors to and consequences of obesity, and interventions to address unhealthy weight
- Evaluate the contribution of elevated Lp (a) to vascular risk and its influence on treatment
- Apply the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) glycemic goals and pharmacologic recommendations in the context of individual patient concerns and practical limitations.
- Incorporate consideration of renal function in monitoring, medication choice, and general management of diabetes
- Understand common errors in medication choice and dosing that are associated with kidney injury, and plan how to avoid them
- Demonstrate an understanding of the effect of depression—and its treatment—on diabetes
- List tools to assess and manage depression in patients with diabetes
- Identify risks of transition of young adults with diabetes from pediatric to adult services, and list elements of successful transition
- Demonstrate familiarity with assessment and treatment recommendations for older adults with diabetes
- Detect and manage pregestational and gestational diabetes mellitus to reduce risk of complications for the mother and child during and after pregnancy
Disclosure
In accordance with the ACCME Standards for Commercial Support of CME, the speakers for this course have been asked to disclose to participants the existence of any financial interest and/or relationship(s) (e.g., paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation or whose products or services may be mentioned during their presentation. The following disclosures were made:
Planning Committee Members
Susan P. Tyler No Relevant Relationships
Rick Ricer, MD No Relevant Relationships
Eileen McCaffrey No Relevant Relationships
Sylvia Reitman No Relevant Relationships
Shirley Jones No Relevant Relationships
The following PIM planners and managers, Judi Smelker-Mitchek, RN, BSN, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/ life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
Donna L. Jornsay, MS, CPNP, CDE, CDTC, has indicated that she is a Consultant for Becton, Dickinson and Company and Eli Lilly; a Shareholder of Medtronic Diabetes; and is on the Speaker’s Bureau for Insulet.
Christine Kessler, CNS, ANP, BC-ADM, CDTC, FAANP, is a Consultant for AstraZeneca, Medtronic, and Novo Nordisk; and is on the Speaker’s Bureau for Novo Nordisk.
Davida F. Kruger, MSN, APRN-BC, BC-ADM, has indicated that she is on the Advisory Board of Abbott, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk; and Intarcia; on the Speaker’s Bureau for Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk, Valeritas; has stock in Dexcom; and received grants/research support from Astra Zeneca, Dexcom, Eli Lilly, Helmsley Foundation, Lexicon, and Novo Nordisk, and receives research support of 40% salary from NIH.
Ellen D. Mandel, DMH, MPA, PA-C, RDN, CDE, has nothing to disclose.
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC, has indicated that she is on the Speaker’s Bureau for AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Joyce Ross, MSN, ANP, CLS, CRNP, FPCNA, FNLA, has indicated that she is a on the Advisory Board for Akcea Therapeutics, Kaneka America, Kastle Pharma; and on the Speaker’s Bureau for AbbVie, Amarin, Amgen, Kaneka America, KOWA, and Sanofi/Regeneron.
Scott Urquhart, PA-C, DFAAPA, has indicated that he is on the Advisory Board for AstraZeneca and Shire; a Consultant for Abbott and Acella Pharma; and on the Speaker’s Bureau for Abbott and AstraZeneca.
Kim Zuber, PA-C, has indicated that she is on the Speaker’s Bureau for Amgen and Janssen Pharmaceuticals.
All information provided by program participants is confidential and will not be shared with any other parties for any reason without permission.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email [email protected].
Copyright
The faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Eileen McCaffrey, medical writer, in the development of this supplement. It has been reviewed and approved by the faculty as well as the editors of Clinical Endocrinology News.
Neither the editors of Clinical Endocrinology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporter or of the Publisher.
Copyright © 2017 by Global Academy for Medical Education, LLC, Frontline Medical Communications Inc., and its Licensors. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. Global Academy for Medical Education, LLC, will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned This continuing medical education (CME) supplement was developed from faculty presentations at the Metabolic & Endocrine Disease Summit October 5 - 8, 2016.
References
1. American Diabetes Association. Management of diabetes in pregnancy. Diabetes Care. 2017;40 (Suppl 1):S114-S119.
2. Feldman AZ, Brown FM. Management of type 1 diabetes in pregnancy. Curr Diabetes Reports. 2016;16(8):76.
3. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: A systematic review. Diabetes Care. 2002;25(10):1862-1868.
4. Tennant PW, Glinianaia SV, Bilous RW, Rankin J, Bell R. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: A population-based study. Diabetologia. 2014;57(2):285-294.
5. Kitzmiller JL, Block JM, Brown FM, et al. Managing preexisting diabetes for pregnancy: Summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31(5):1060-1079.
6. Holmes VA, Young IS, Patterson CC, et al. Optimal glycemic control, pre- eclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial. Diabetes Care. 2011;34(8):1683- 1688.
7. Sullivan SD, Umans JG, Ratner R. Hypertension complicating diabetic pregnancies: Pathophysiology, management, and controversies. J Clin Hypertens (Greenwich). 2011;13(4):275-284.
8. Gordin D, Hiilesmaa V, Fagerudd J, et al. Pre-eclampsia but not pregnancy- induced hypertension is a risk factor for diabetic nephropathy in type 1 diabetic women. Diabetologia. 2007;50(3):516-522.
9. Slocum JM. Preconception counseling and type 2 diabetes. Diabetes Spectrum. 2007;20(2):117-123.
10. Camelo Castillo W, Boggess K, Sturmer T, Brookhart MA, Benjamin DK, Jr., Jonsson Funk M. Association of adverse pregnancy outcomes with glyburide vs insulin in women with gestational diabetes. JAMA Pediatr. 2015;169(5):452-458.
11. Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) Study: Associations with maternal body mass index. BJOG. 2010;117(5):575-584.
12. Catalano PM, Mele L, Landon MB, et al. Inadequate weight gain in overweight and obese pregnant women: What is the effect on fetal growth? Am J Obstet Gynecol. 2014;211(2):137.e131-e137.
13. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Preventing Chronic Disease. 2014;11:E104.
14. American Diabetes Association. Classification and diagnosis of diabetes. Diabetes Care. 2017;40(Suppl 1):S11-S24.
16. Pu J, Zhao B, Wang EJ, et al. Racial/ethnic differences in gestational diabetes prevalence and contribution of common risk factors. Paediatr Perinat Epidemiol. 2015;29(5):436-443.
17. Gunderson EP. Childbearing and obesity in women: Weight before, during, and after pregnancy. Obstet Gynecol Clin North Am. 2009;36(2):317-332, ix.
18. Xiang AH, Li BH, Black MH, et al. Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus. Diabetologia. 2011;54(12):3016-3021.
19. Mitanchez D, Yzydorczyk C, Simeoni U. What neonatal complications should the pediatrician be aware of in case of maternal gestational diabetes? World J of Diabetes. 2015;6(5):734-743.
20. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA:
US Department of Health and Human Services; 2014. https://www.cdc.gov/diabetes/ pubs/statsreport14/national-diabetes-report-web.pdf. Accessed April 19, 2017.