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Guidelines and Recommendations for a Preconception Care Program ... - PowerPoint - PowerPoint

VIEWS: 10 PAGES: 35

									       Preconception Planning &
Care for Women With Diabetes Mellitus

          David Winmill, DNP, CDE, BC-ADM
        Intermountain Endocrine & Diabetes Clinic
Preconception Care: Objectives

1. Identify the risks and complications associated
   with hyperglycemia in early pregnancy.

2. Review and discuss the benefits of
  preconception planning and care.

3. Identify the components of preconception care
  for diabetes and discuss how these may be
  implemented as part of clinical practice.
Diabetes & Pregnancy: Statistics

• Diabetes affects 3.6% of the 4.1 million births
  registered in the US each year.
• Pre-gestational diabetes (type 1 and type 2)
  affects between 1-2 % of all births.
• In Utah, pre-gestational diabetes reported in
  334 (0.6%) of 55,063 births.
• Poor glycemic control carries significant risk for
  both mother and fetus.

               Jovanovic & Nakai, Endo & Metab Clin, 35(1) 2006
               Baksh, Birth Statistics. (2009)
Pregnancy Complications & Diabetes
Maternal                                  Fetal
•    Spontaneous abortion                 •   Congenital anomalies
•    Hyperglycemia                        •   Fetal Demise
•   Severe hypoglycemia                   •   Growth restriction
•   Diabetic ketoacidosis (DKA)           •   Polyhydramnios/Oligohydramnio
•   Aggravation of end-organ                  s
    disease (eye, heart & kidney)         •   Macrosomia
•   Preeclampsia                          •   Preterm Delivery
•   Urinary tract infection               •   Birth trauma
•   Chronic anemia
                                          Neonatal
•   Cesarean delivery
                                          •   Respiratory distress syndrome
•   Injury to genital tract and/or
                                          •   Hypoglycemia
    surrounding viscera
                                          •   Hyperbilirubinemia
•   Postpartum hemorrhage
                                          •   Serum electrolyte imbalance
•    Postpartum soft tissue infection
                                          •   Death
                             Sources: Bernasko, Obstet & Gynec Surv, 59(8) 2004
                                Leguizamón et al, Obstet & Gynec Clin 34(2) 2007
Pregnancy Complications & Diabetes
  Risk for congenital anomalies associated with
  hyperglycemia in first 7-8 weeks of pregnancy.
  System             Manifestations
  Neurologic         Anencephaly, microcephaly, holoprosencephaly, neural tube defects

                     Transposition of great vessels, aortic coarctation with or without VSD or patent
  Cardiovascular     ductus arteriosus, atrial septal defect, single ventricle, hypoplastic left ventricle,
                     pulmonic stenosis, pulmonary stenosis, pulmonary valve atresia, double outlet right
                     ventricle truncus arteriosus

  Gastrointestinal   Duodenal atresia, imperforate anus, anorectal atresia, small left colon syndrome,
                     situs inversus

  Genitourinary      Ureteral duplication, renal agenesis, hydronephrosis

  Skeletal           Caudal regression syndrome (sacral agenesis), hemivertebrae

  Other              Single umbilical artery



                                               Tyrala, Obstet & Gyn Clin 23(1) 1996
Pregnancy Complications & Diabetes

Mechanisms of Fetal Death and Anomaly
  •   Hyperglycemia
  •   Maternal vascular disease
  •   Uteroplacental insufficiency
  •   Possible immunologic factors
  •   DNA fragmentation due to changes in
      regulation of apoptosis regulatory gene.

               Jovanovic & Nakai, Endo & Metab Clin, 35(1) 2006
               Moley et al. Nat Med, 4(12) 1998
Fetal Complications: Anencephaly




                      www.humpath.com
Fetal Complications:
Spina bifida with myelomeningocele




                      www.humpath.com
Caudal Regression & Limb Agenesis




                      Source: www.humpath.com
Diabetes & Pregnancy: The Dilemma
  • Organogenesis occurs within first 7 weeks after
    conception.
  • Pregnancy is recognized after critical period and
    glycemic control established, but fetal malformation
    may already have occurred.
  • Despite the known risk, 50% of women do not plan
    their pregnancies, and thus do not participate in
    preconception planning.
  • Once pregnancy is recognized, optimal blood sugars
    must be established quickly.

            But, the dilemma continues. . .
Maternal Risk in Diabetes

 Retinopathy
 • Retinopathy may worsen during pregnancy; not as likely to
   present de novo.

 • Strict glycemic control associated with worsening retinopathy
   dependent on:
    – Level of existing retinal disease
    – Rapid reduction of hyperglycemia.

 • Milder forms of retinopathy typically regress after pregnancy,
   but more severe forms may persist or progress.

 • Gradual normalization of glucose levels recommended

                   Jovanovic and Nakai, Endo Metab Clin 35 (1) 2006
Maternal Risk in Diabetes
Nephropathy
• Microalbuminuria and nephropathy associated with increased
  risk preterm birth often due to preeclampsia.

• Nephropathy when not associated with hypertension does not
  impact fetal outcome unless kidney function is more than 50%
  impaired.

• Pregnancy not associated with permanent worsening of renal
  function in absence of uncontrolled HTN or if serum creatinine
  < 1.5mg/dL.



                 Jovanovic & Nakai, Endo Metab Clin 35 (1) 2006
Maternal Risk in Diabetes:

Cardiovascular Disease
• Type 1 diabetes (after 10 years) increases risk of MI from 1 in
  10,000 in general population to 1 in 350.*

• Odds ratio for pregnancy related MI for women with diabetes
  is 3.2 (1.5–6.9) p<0.01. **

• Unrecognized and untreated coronary artery disease
  associated with (38%) maternal or fetal death. No deaths
  reported with recognition and revascularization (CABG).*


                    *Leguizamon, et al. Obstet Gynecol Clin, 34(2) 2007
                    **James et al, Circulation, 113(12) 2006
Diabetes Preconception Planning & Care

Care and management provided prior to
 pregnancy to reduce risk of fetal and
 maternal complications, consisting of the
 following components:
  • Preconception Counseling
  • Glycemic Control
  • Management of Complications
  • General Pre-pregnancy Care
 History of Diabetes Preconception Care
• Discovery of Insulin in 1922 a landmark in care of
  patients with type 1 diabetes.
• Increased longevity of life but introduced problem of
  long-term complications
• Advances in insulin therapy in the 1970 and 1980s
  improved quality of life and reduced long-term
  complications; fetal abnormalities and complications
  remained high.
• Preconception Care programs began emerging in the
  late 1980s and 1990s
• Diabetes Complications & Control Trial (1993)
Multi-centric Survey Pregnancy Outcomes

Outcomes of 435 pregnancies with diabetes
mellitus type 1 (n=289) and type 2 (n=146)
compared to general population
–   Overall perinatal mortality- 4.4% vs. 0.7%
–   Major congenital malformations - 4.1% vs. 2.2%
–   Preterm delivery rate - 38.2 vs. 4.7%
–   Maternal Complications
     • Progression of retinopathy 39 (39.4%)
     • Progression of nephropathy 23 (67.6%)
     • Pre-eclampsia noted in 54 (18.7%) type 1 subjects and
       26 (17.8%) type 2 subjects.

                         Boulot et al, Diabetes Care 26(11) 2003
Multi-centric Survey of Pregnancy Outcomes

       Comparison by first trimester HgA1C
                         HgA1C HgA1C Odds             95% Confidence
                         > 8.0% < 8.0% Ratio             Interval
 Perinatal Mortality     9.2%      2.5%     3.9        1.5-9.7; p<0.05
 Congenital Anomaly      8.3%      2.5%     3.5        1.3-8.9 p<0.05
 Preterm Delivery        57.6%     24.8%    1.5       1.1-1.7, P<0.005
 1st Trimester HgA1C >   43.5%     4.0%     18.5      8.3-40.9; p<0.005
 8.0% non-PCC vs.
 PCC
 Key Point:
  80-90% of perinatal deaths and congenital abnormalities were in
 unplanned pregnancies and in subjects with A1C greater than 8.0%
                                 Boulot et al, Diabetes Care 26(11) 2003
Serious Adverse Pregnancy Outcomes

   Prospective study of 1,215 pregnancies in 933 subjects
     with type 1 diabetes mellitus (58% attended PCP).

 HgA1C >10.4           Study     Gen Pop      RR         95% C.I.
 Congenital Anomaly    10.9%       2.8%       7.3         1.8-7.8*
 Perinatal Mortality   5.5%       0.75%       3.9        2.5-19.8*
 Adverse Outcome       16.3%       3.5%       4.7         2.5-8.1*
 HbA1C < 6.9%
 Congenital Anomaly    3.9%        2.8%       1.4         0.8-2.4
 Perinatal Mortality   2.1%       0.75%       2.8         1.3-6.1*
 Adverse Outcome       5.6%         3.5       1.6         1.0-2.6
                                                             *p<0.05
                               Jensen et al, Diabetes Care 32(6) 2009
Why Women Don’t Plan Pregnancies

• Retrospective study of 85 women with diabetes recruited 6
  months postpartum from 52 Washington hospitals
      • 35 (41%) planned
      • 50 (59%) unplanned

• 94% of women with planned and 68% with unplanned
  pregnancies knew of need for diabetes control.

• All women with planned pregnancies were married, 48% of
  women with unplanned pregnancies were not married

• Women with unplanned pregnancies often told they
  shouldn’t get pregnant.
                        Holing et al, Diabetes Care, 21(6), 1998
Why Women Don’t Plan Pregnancies

• Women with planned pregnancies (71%) more likely
  to have positive relationship with provider vs. 28% for
  women with unplanned pregnancies

•   75% of women with planned pregnancies received
    encouraging advice about desire for pregnancy vs.
    38% of women with unplanned pregnancies.

• Women with unplanned pregnancies no more likely to
  plan subsequent pregnancies (regardless of
  outcome).
Diabetes Preconception Care

• Preconception Counseling

• Glycemic Control

• Identification and Management of
  Complications

• General Pre-pregnancy Care
Barriers to Preconception Counseling

• Questionnaire developed by a team: endocrinologist,
  nurse practitioner, registered nurse, dietitian and
  statistician.

• Questions to be Answered
    What professionals are providing PCC
    What barriers do they experience in providing PCC
    What resources do they need to better provide PCC


• Survey piloted among small group of diabetes
  educators & providers prior to obtaining IRB
  approval.
Barriers to Preconception Counseling
• 400 individuals contacted and invited to participate
  through a listserv maintained by the Utah
  Department of Health.

• 75 individuals (18.75%) responded by completion
  of the online survey, 69 involved in diabetes care,
  counseling or education.

• 41 Certified Diabetes Educators (CDEs) responded
  to the survey representing 59.4% of response but
  51.3% of CDEs in the state.
Outcomes: Respondent Demographics; N=69
   Age in Years         Respondents          Percentage
   25-34                8                    11.6%
   35-44                14                   20.3%
   45-54                25                   36.2%
   55-64                21                   30.4%
   65-74                1                    1.4%
   Professional or Clinical Role*
   CDE**                41                   59.4%
   Dietitian            14                   20.3%
   Registered Nurse     32                   46.4%
   Nurse Practitioner   6                    8.7%
   Physician            4                    5.8%
   Social Worker        1                    1.4%
   Other                6                    8.7%

                                    *Multiple responses allowed
                                    **Certified Diabetes Educator
Outcomes: Respondent Demographics (N=69)
   Level of Education

   Associates Degree          10   14.5%
   Bachelors Degree           32   46.4%
   Masters Degree             20   29.0%
   Doctorate                  3    4.3%
   Medical Doctor             3    4.3%
   Other                      1    1.9%
   Years in Practice (n=66)
   < 5 Years                  14   21.2%
   5-9 Years                  18   27.2%
   10-14 Years                17   25.7%
   15+                        17   25.7%
Respondents Providing PCC
 No. Respondents (n=69) providing preconception counseling for
 women of reproductive age (13-49) who have diabetes.
 Response               No. Respondents        Percentage
 Yes                    44                     63.8%
 No                     25                     36.2%
 For respondents providing preconception counseling (N=44),
 percentage of their patients that receive preconception counseling.
 Less than 25%          13                     29.5%
 25-49%                 6                      13.6%
 50-74%                 3                      6.8%
 75-99%                 5                      11.3%
 All                    16                     36.3%
 Does Not Apply         1                      2.3%
Barriers to Preconception Counseling

• Summary of Findings
  – 36.2% of respondents did not provide
    preconception planning
  – Certified Diabetes Educators (CDE’s) as likely to
    provide PCC as physicians.
  – More experienced CDEs more likely to provide
    PCC.
  – Barriers include:
     • Lack of prompt or reminder
     • Lack of patient education materials
     • Inadequate staff training
 Preconception Care

Preconception Counselling:
• Information provided consistently to all women of
  childbearing age (13-49) regarding risks for pregnancy
  if blood sugars uncontrolled at time of conception.

• Importance of planning pregnancy and establishing
  optimal blood sugar control (glycated hemoglobin
  <6.9%)

• Effective use of contraception until blood sugar control
  maintained for 3-6 months.
Preconception Care

Glycemic Control
• Effective insulin/glucose management (target HbA1C
  <6.9) maintained for 3-6 months prior to conception.

• Effective dietary management

• Evaluation of hypoglycemic response (unawareness).

• Consideration of insulin pump and/or continuous
  glucose sensor.
Preconception Care

Identification & Management of Complications
• Ophthalmologic consult and management.

• Evaluation of renal function (24 hour urine) and
  consult.

• Evaluation of neuropathy (gastroparesis, autonomic
  neuropathy).

• Cardiovascular screening.
Components of Preconception Care

 General Principles
 • Blood pressure & lipid management: Discontinuation
   of ACE inhibitors, statins, anti-coagulants.
 • Adequate nutrition: folic acid supplements
 • Reduce exposure to toxic substances
    – Avoid alcohol
    – Limit caffeine
    – Limit exposure to toxic substances
 • Dental care
Preconception Planning & Care

Summary
• With preconception planning & care, women with
  diabetes can reduce their risk of complications to
  that of women who do not have diabetes.

• 50% of women do not plan their pregnancies.

•    Preconception counseling should be provided
    regularly to all women of child-bearing age/potential.

• Certified diabetes educators recognize their role in
  providing preconception counseling.
Thank You!
REFERENCES
Bernasko, J. (2004). Contemporary management of type 1 diabetes mellitus in
    pregnancy. Obstetrical & Gynecological Survey, 59(8), 628-636.
Boulot, P., Chabbert-Buffet, N., d'Ercole, C., Floriot, M., Fontaine, P., Fournier,
    A., et al. (2003). French multicentric survey of outcome of pregnancy in
    women with pregestational diabetes. Diabetes Care, 26(11), 2990-2993.
DCCT (1993). The effect of intensive treatment of diabetes on the development
    and progression of long-term complications in insulin-dependent diabetes
    mellitus. The Diabetes Control and Complications Trial Research Group.
    New England Journal of Medicine, 329(14), 977-986.
Holing, E. V., Beyer, C. S., Brown, Z. A., & Connell, F. A. (1998). Why don't
    women with diabetes plan their pregnancies? Diabetes Care, 21(6), 889-
    895.
Jensen, D. M., Korsholm, L., Ovesen, P., Beck-Nielsen, H., Moelsted-
    Pedersen, L., Westergaard, J. G., et al. (2009). Peri-conceptional A1C and
    risk of serious adverse pregnancy outcome in 933 women with type 1
    diabetes. Diabetes Care, 32(6), 1046-1048.
References
James, A. H., Jamison, M. G., Biswas, M. S., Brancazio, L. R., Swamy, G. K., &
   Myers, E. R. (2006). Acute myocardial infarction in pregnancy: a United States
   population-based study. Circulation, 113(12), 1564-1571.
Jovanovic, L., & Nakai, Y. (2006). Successful pregnancy in women with type 1
   diabetes: from preconception through postpartum care. Endocrinology and
   Metabolic Clinics of North America, 35(1), 79-97, vi.
Leguizamón, G., Igarzabal, M. L., & Reece, E. A. (2007). Periconceptional care of
   women with diabetes mellitus. Obstetric & Gynecololic Clinics of North
   America, 34(2), 225-239, vi
Moley, K. H., Chi, M. M., Knudson, C. M., Korsmeyer, S. J., & Mueckler, M. M.
   (1998). Hyperglycemia induces apoptosis in pre-implantation embryos through
   cell death effector pathways. Nature Medicine, 4(12), 1421-1424.
Tyrala, E. E. (1996). The infant of the diabetic mother. Obstetrics & Gynecologic
   Clinics of North America, 23(1), 221-241.

								
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