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Gestational diabetes requires swift action

 


Treatment begins with dietary counseling, exercise, and lifestyle changes.2 Women must try to limit weight gain by avoiding ketosis while limiting carbohydrate intake. Since normoglycemia is a major therapeutic goal, women should first monitor their blood glucose levels four times daily (one fasting blood glucose level and three postprandial measurements).1,2 Continuous blood glucose monitoring is reserved for women experiencing severely fluctuating or unstable blood glucose or hypoglycemic episodes.2,3

ADA recommends target levels of glucose as follows:1:

  • Fasting blood glucose (FBG) <95 mg / dL
  • Blood glucose level less than 140 mg / dL 1 hour after meal
  • 2 hours postprandial glucose less than 120 mg / dL

ADA and the American College of Obstetricians and Gynecologists (ACOG) indicate that if hyperglycemia persists (for example, if one-third of the blood glucose level exceeds the target fasting or postprandial level within a week), insulin is next. It shows that it is a step of. Achieving these goals is very important. Research results show that women with FBG levels of 100 to 105 mg / dL are at a five-fold higher risk of fetal macrosomia than women with FBG levels of 75 mg / dL.Four

The target for glycated hemoglobin A1c (HbA1c) tends to be lower in pregnant women than in non-pregnant women.Five HbA1c levels above 5.9% may predict adverse effects of pregnancy5. If hypoglycemia is a problem, it makes sense to raise the HbA1c target to 7%.3

Medical therapy

About 20% of women with GD need insulin or oral hypoglycemic agents. ACOG and ADA prefer insulin because it does not cross the placenta. 1FDA does not approve oral hypoglycemic agents for GD. ACOG recommends metformin in three cases. It is a woman who cannot afford insulin, refuses it, or has compliance problems.2

Fast-acting insulin analogues (insulin aspart and insulin lispro) are often preferred because they are safe, have minimal placental transfer, and have no evidence of teratogenicity. It is more convenient than regular insulin, which requires you to wait 30-60 minutes before a meal because it can be given just before a meal.1 They also reduce the risk of delayed postprandial hypoglycemia compared to normal human insulin.6 Insulin Isophan Suspension (NPH) is the most frequently used intermediate / long-acting insulin, but clinicians also prescribe insulin detemir and insulin glargine.7 Insulin aspart, detemil, and glargine are not associated with pregnancy-related complications. Insulin lispro may reduce neonatal jaundice and severe maternal hypoglycemia, but slightly increases the incidence of fetal macrosomia.8

Insulin administration depends on the patient’s hyperglycemic episode and gestational age.1,2 Women with GD usually need a combination of basal (medium / long-acting) and bolus insulin (rapid / short-acting) to reach their blood glucose goals. Long-acting insulin is preferred because of its low risk of hypoglycemia. Most clinicians start insulin at 0.5 to 1 unit / kg per day with 50% basal and 50% bolus.

Oral hypoglycemic drug

Obstetricians tend to use two oral hypoglycemic agents, glybrid and metformin (Table 2).2,9-17) — There is no clear benefit from either during pregnancy. Both pass through the placenta.

Hypoglycemia

Pregnant women with GD develop hypoglycemia when their blood sugar levels fall below 70 mg / dL. Symptoms include confusion, dizziness, numbness in the lips and tongue, tremors, sweating, and tachycardia. Ingesting 15 to 20 g of glucose from a carbohydrate source should increase glucose levels within 20 minutes.1,2 Women should remeasure their blood glucose levels after 15 minutes and consider eating snacks containing 15 to 20 g of complex carbohydrates if their next meal is more than 30 minutes apart to prevent recurrence of hypoglycemia. There is.

Conclusion

Early diagnosis of GD and proper management of it can reduce the risk of neonatal complications and maternal pre-eclampsia.

Jeanette Y. Wick, MBA, RPh, FASCP, He is an assistant director of the Pharmacy Ability Development Office at the University of Connecticut at Stose.

References

  1. American Diabetes Association. 14. Management of diabetes during pregnancy: Medical Standards for Diabetes — 2020.. Diabetes care.. 2020; 43 (suppl 1): S183-S192.
    Doi: 10.2337 / dc20-SO014
  2. ACOG Practice Report No. 190 Gestational diabetes. Obstet Gynecol 2018; 131 (2): e49-e64. doi: 10.1097 / AOG.0000000000002501
  3. National Center for Cooperation for Women and Children’s Health (UK). Diabetes during pregnancy: Management of prejudice to postpartum diabetes and its complications. February 2015. Accessed on April 9, 2021. https: //www.ncbi.nlm.nih.gov/books/NBK293625/[RP1]
  4. HAPO Research Joint Research Group. Study of hyperglycemia and adverse pregnancy outcomes (HAPO). Int J Gynaecol Obstet.. 2002; 78 (1): 69-77.
    Doi: 10.1016 / s0020-7292 (02) 00092-9
  5. Hughes RCE, Moore MP, Gullam JE, Mohamed K, Rowan J. HbA1c ≥5.9% (41 mmol / mol) in early pregnancy is optimal for detecting diabetes and identifies women at high risk of adverse effects of pregnancy. Diabetes care.. 2014; 37 (11): 2953-2959 Doi: 10.2337 / dc14-1312
  6. Nicholson WK, Wilson LM, Witkop CT, etc. Treatment management, childbirth, and postnatal risk assessment and screening in gestational diabetes. Evid Rep Technol Assess (Full Rep).. 2008; (162): 1-96.
  7. Vellanki P, Umpierrez G. Detemir is not inferior to NPH insulin in women with gestational type 2 diabetes and gestational diabetes. Evid Based Med. 2016; 21 (3): 104-105. Doi: 10.1136 / ebmed-2015-110309
  8. Lv S, Wang J, Xu Y. Safety of insulin analogues during pregnancy: meta-analysis. Arch Gynecol Obstet.. 2015; 292 (4): 749-756 Doi: 10.1007 / s00404-015-3692-3
  9. Brown J, Martis R, Hughes B, Rowan J, Crowther CA Oral anti-diabetic pharmacological therapy for the treatment of women with gestational diabetes. Cochrane Database Syst Rev.. 2017; 1 (1): CD011967. doi: 10.1002 / 14651858.CD011967.pub2
  10. Denno KM, Sadler TW. The effect of the oral hypoglycemic drug biguanide class on mouse embryo formation. Teratogenicity.. 1994; 49 (4): 260-266. Doi: 10.1002 / tera.1420490405
  11. Pregnancy outcomes after first trimester exposure to Gilbert C, Valois M, Koren G. metformin: meta-analysis. Fertility infertility.. 2006; 86 (3): 658-663. doi: 10.1016 / j.fertnstert.2006.02.098
  12. Pregnancy outcomes of women with metformin for diabetes or other indications in women seeking Panchaud A, Rousson V, Vial T, and other teratogenic information services. Br J Clin Pharmacol.. 2018; 84 (3): 568-578 Doi: 10.1111 / bcp.13481
  13. Rowan JA, Rush EC, Plank LD, etc. Metformin in gestational diabetes: follow-up of offspring (MiG TOFU): body composition and metabolic results at ages 7-9 years. BMJ Open Diabetes Less Care.. 2018; 6 (1): e000456. Doi: 10.1136 / bmjdrc-2017-000456
  14. Spaulonci CP, Bernardes LS, Trindade TC, Zugaib M, Francisco RPV. Randomized trials of metformin and insulin in the management of gestational diabetes. Am J Obstet Gynecol.. 2013; 209 (1): 34.e1-7. Doi: 10.1016 / j.ajog.2013.03.022
  15. Comparison of the efficacy of metformin and insulin for gestational diabetes in Landi SN, Radke S, Boggess K and others in New Zealand. Pharmaco Epidemi All Drug Suff.. 2019; 28 (12): 1609-1619. doi: 10.1002 / pds.4907
  16. Song R, Chen L, Chen Y, etc. Comparison of glybrid and insulin in the management of gestational diabetes: meta-analysis. PLoS One.. 2017; 12 (8): e0182488. doi: 10.1371 / journal.pone.0182488
  17. Harper LM, Mele L, Landon MB, et al .; Eunice Kennedy Schreiber National Institute of Pediatric Health Development (NICHD) Maternal and Fetal Medicine Unit (MFMU) Network. Carpenter-Coustan was compared to the National Diabetes Data Group criteria for diagnosing gestational diabetes. Obstet Gynecol.. 2016; 127 (5): 893-898. doi: 10.1097 / AOG.0000000000001383

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