Maribeth Inturrisi

Managing preexisting diabetes for pregnancy: Summary of evidence and consensus recommendations for care

This document presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The intent is to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy. A thorough discussion of the evidence supporting the recommendations is presented in the book, Management of Preexisting Diabetes and Pregnancy , authored by the consensus panel and published by the American Diabetes Association (ADA) in 2008 (1). A consensus statement on obstetrical and postpartum management will appear separately. The recommendations are diagnostic and therapeutic actions that are known or believed to favorably affect maternal and perinatal outcomes in pregnancies complicated by diabetes. The grading system adapted by the ADA was used to clarify and codify the evidence that forms the basis for the recommendations (2). Unfortunately there is a paucity of randomized controlled trials (RCTs) of the different aspects of management of diabetes and pregnancy. Therefore our recommendations are often based on trials conducted in nonpregnant diabetic women or nondiabetic pregnant women, as well as on peer-reviewed experience before and during pregnancy in women with preexisting diabetes (3–4). We also reviewed and adapted existing diabetes and pregnancy guidelines (5–10) and guidelines on diabetes complications and comorbidities (2,3,11–14). ### A. Organization of preconception and pregnancy care #### Recommendations

Gestational weight gain and gestational diabetes mellitus: perinatal outcomes.

OBJECTIVE: To examine the association between gestational weight gain and perinatal outcome in women with gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study of women with nonanomalous singleton pregnancies with GDM enrolled in the Sweet Success California Diabetes and Pregnancy Program between 2001 and 2004. Gestational weight gain, calculated from prepregnancy weight and weight at last prenatal Sweet Success visit, was subgrouped into below, within, and above the Institute of Medicine (IOM) weight-gain guidelines. Perinatal outcomes were examined using &khgr;2 test and multivariable regression analysis with 15–35-lb weight gain as the reference group. RESULTS: There were 31,074 women meeting study criteria. Compared with women with gestational weight gain within the IOM guidelines, women who gained above the guidelines had higher odds of having large for gestational age neonates (adjusted odds ratio [aOR] 1.72, 95% confidence interval [CI] 1.53–1.93, number needed to harm 10), preterm delivery (aOR 1.30, 95% CI 1.14–1.48, number needed to harm 32), and primary cesarean delivery (aOR 1.52, 95% CI 1.26–1.83, number needed to harm 10). Women who gained below the guidelines had higher odds of having small for gestational age neonates (aOR 1.39, 95% CI 1.01–1.90) and maintaining diet-controlled GDM (aOR 1.47, 95% CI 1.34–1.63) and lower odds of having large for gestational age neonates (aOR 0.60, 95% CI 0.52–0.67). CONCLUSION: Women diagnosed with GDM who had gestational weight gain above the IOM guidelines have higher risk of undesirable outcomes, including preterm delivery, having macrosomic neonates, and cesarean delivery. Women who gained below guidelines are more likely to remain on diet control but have small for gestational age neonates. LEVEL OF EVIDENCE: II

Treatment of gestational diabetes mellitus: glyburide compared to subcutaneous insulin therapy and associated perinatal outcomes

Objective. To examine perinatal outcomes in women with gestational diabetes mellitus treated with glyburide compared to insulin injections. Study design. This is a retrospective cohort study of women diagnosed with gestational diabetes mellitus (GDM) who required pharmaceutical therapy and were enrolled in the Sweet Success California Diabetes and Pregnancy Program between 2001 and 2004, a California state-wide program. Women managed with glyburide were compared to women treated with insulin injections. Perinatal outcomes were compared using chi-square test and multivariable logistic regression models; statistical significance was indicated by p < 0.05 and 95% confidence intervals (CI). Results. Among the 10,682 women with GDM who required medical therapy and met study criteria, 2073 (19.4%) received glyburide and 8609 (80.6%) received subcutaneous insulin injections. Compared to insulin therapy and controlling for confounders, oral hypoglycemic treatment was associated with increased risk of birthweight >4000 g (aOR = 1.29; 95% CI [1.03–1.64]), and admission to the intensive care nursery (aOR = 1.46 [1.07–2.00]). Conclusion. Neonates born to women with gestational diabetes managed on glyburide, and were more likely to be macrosomic and to be admitted to the intensive care unit compared to those treated with insulin injections. These findings should be examined in a large, prospective trial.

Effect of gestational weight gain on perinatal outcomes in women with type 2 diabetes mellitus using the 2009 Institute of Medicine guidelines

OBJECTIVE We sought to examine associations between gestational weight gain according to the 2009 Institute of Medicine (IOM) guidelines and perinatal outcomes in overweight/obese women with type 2 diabetes mellitus (T2DM). STUDY DESIGN This is a retrospective cohort study of 2310 women with T2DM enrolled in the California Diabetes and Pregnancy Program. Gestational weight gain was categorized by 2009 IOM guidelines. Perinatal outcomes were assessed using the χ(2) test and multivariable logistic regression analysis. RESULTS With excessive gestational weight gain, the odds of having large-for-gestational age (adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.33-3.00) or macrosomic (aOR, 2.59; 95% CI, 1.56-4.30) neonates and cesarean delivery (aOR, 1.47; 95% CI, 1.03-2.10) was higher. Women with excessive gestational weight gain per week had increased odds of preterm delivery (aOR, 1.57; 95% CI, 1.11-2.20). CONCLUSION In overweight or obese women with T2DM, gestational weight gain greater than the revised IOM guidelines was associated with higher odds of perinatal morbidity, suggesting these guidelines are applicable to a diabetic population.

Perinatal outcomes in patients with gestational diabetes mellitus by race/ethnicity.

Objective. To determine if racial/ethnic differences exist in perinatal outcomes in women with gestational diabetes mellitus (GDM). Methods. This is a retrospective cohort study of singleton pregnancies with GDM cared for by the Sweet Success: California Diabetes and Pregnancy Program (CDAPP) between 2001 and 2004 at inpatient obstetric and neonatal services in California. There were a total of 26,411 women with gestational diabetes who were subgrouped by four races/ethnicities: Caucasian, African-American, Latina, and Asian. The chi-squared test was used to compare the dichotomous outcomes and p < 0.05 was used to indicate statistical significance. Multivariable logistic regression analyses were performed to control for potential confounders. Perinatal outcomes, including severity of GDM, cesarean delivery (CD), birthweight, preterm birth, intrauterine fetal demise (IUFD) and neonatal intensive care unit (NICU) admission were compared. Results. Compared to Caucasians, African-Americans had higher odds of primary CD [aOR = 1.29, 95% CI (1.05–1.59)] while lower odds were seen in Latinas [aOR = 0.84, 95% CI (0.75–0.94)] and Asians [aOR = 0.86, 95% CI (0.77–0.96)]. Asians had lower odds [aOR = 0.58 (95% CI 0.48–0.70)] of birthweight >4000 g. African-Americans had highest odds of IUFD [aOR = 5.93 95% CI (1.73–20.29)]. There were no differences in NICU admission. Conclusion. Perinatal outcomes in women diagnosed with GDM differ by racial/ethnic group. Such variation can be used to individually counsel women with GDM.

Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus

To investigate whether gestational weight loss (GWL) after the diagnosis of gestational diabetes mellitus (GDM) in overweight and obese women is associated with improved perinatal outcomes. Obesity and GDM are risk factors for adverse perinatal outcomes, but few studies have investigated weight loss during pregnancy in women with these comorbidities.

Diagnosis and Treatment of Hyperglycemia in Pregnancy

Hyperglycemia in pregnancy is an opportunity for women at risk for complications during pregnancy and beyond to change their life course to improve outcomes for themselves and their offspring. Providers of diabetes care during pregnancy complicated by hyperglycemia in pregnancy have the unique opportunity to make a significant difference.