Taken in isolation, a diagnosis of diabetes without vascular complications is compatible with all hormonal and non-hormonal contraception options: copper intrauterine device, levonorgestrel-releasing IUD, progestin implant, depo medroxyprogesterone acetate, progestin only pills, and combined estrogen-progestin methods Evidence of vascular disease is a contraindication to combined hormonal contraception and depo medroxyprogesterone acetate Concurrent conditions and habits such as poorly controlled hypertension, hypertriglyceridemia, or smoking increase the risk of venous thromboembolic events Systematic reviews failed to find sufficient evidence to assess whether progestogen-only and combined contraceptives differ from non-hormonal contraceptives in diabetes control, lipid metabolism, and complications in women with pre-existing diabetes , Long-acting reversible contraception LARC methods lasting years include copper and hormonal intrauterine devices as well as progestin implants.
There is no increase in pelvic inflammatory disease with the use of intrauterine devices in women with well controlled T1DM or T2DM after the post-insertion period. Immediate postpartum implants and IUDs are becoming increasingly available to patients who desire LARCs, and are effective in spacing pregnancies in high risk populations For women who have completed childbearing and desire permanent sterilization, laparoscopic methods are safe and effective Obesity alone or accompanied by Type 1 diabetes T1DM , Type 2 diabetes T2DM or gestational diabetes GDM carries significant risks to both the mother and the infant, and obesity is the leading health concern in pregnant women — Independent of preexisting diabetes or GDM, obesity increases the maternal risks of hypertensive disorders, non-alcoholic fatty liver disease NAFLD , proteinuria, gall bladder disease, aspiration pneumonia, thromboembolism, sleep apnea, cardiomyopathy, and pulmonary edema , In addition, it increases the risk of induction of labor, failed induction of labor, cesarean delivery, multiple anesthesia complications, postoperative infections including endometritis, wound dehiscence, postpartum hemorrhage, venous thromboembolism, postpartum depression, and lactation failure.
Maternal obesity independently increases the risk of first trimester loss, stillbirth, recurrent pregnancy losses, and congenital malformations including central nervous system CNS , cardiac, and gastrointestinal defects and cleft palate, shoulder dystocia, meconium aspiration, and impaired fetal growth including macrosomia.
Most significantly, obesity increases the risk of perinatal mortality Because so many women with T2DM are also obese, all of these complications increase the risk of poor pregnancy outcomes in this population.
This results in higher weight retention postpartum and higher pre-pregnancy weight for subsequent pregnancies. Obesity is an independent risk factor for congenital anomalies including spina bifida, neural tube defects, cardiac defects, cleft lip and palate, and limb reduction anomalies Several reports have demonstrated an association of maternal BMI with neural tube defects and possibly other congenital anomalies There is conflicting evidence on the role of folic acid in these obesity-associated congenital anomalies — Obese women with normal glucose tolerance on a controlled diet have higher glycemic patterns throughout the day and night by CGM compared to normal weight women both early and late in pregnancy , , The glucose area under the curve AUC was higher in the obese women both early and late in pregnancy on a controlled diet as were all glycemic values throughout the day and night.
Following bariatric surgery, pregnancy should not be considered for months post-operatively and after the rapid weight loss phase has been completed. Close attention to nutritional deficiencies must be maintained, especially with fat soluble vitamins D and K as well as folate, iron, thiamine, and B In a study of a cohort of infants born to obese women who had bariatric surgery, the offspring had improved fasting insulin levels and reduced measures of insulin resistance compared to siblings born prior to bariatric surgery Women with pre-existing diabetes and GDM should receive individualized medical nutrition therapy MNT as needed to achieve treatment goals.
Pregravid BMI should be assessed and gestational weight gain GWG recommendations should be consistent with the current Institute of Medicine IOM weight gain guidelines See Table 3 due to adverse maternal, fetal and neonatal outcomes This is an increasing public health concern given risks of excessive weight gain greater than IOM recommendations including cesarean deliveries, post-partum weight retention for the mother, large for gestational age infants, macrosomia, and childhood overweight or obesity for the offspring There is also increasing evidence that overweight or obese women with GDM may have improved pregnancy outcomes with less need for insulin if they gain weight less than the IOM recommendations without appreciably increasing the risk of SGA — The diet should be culturally appropriate and women should consume at least grams of carbohydrate, primarily as complex carbohydrate and limit simple carbohydrates, especially those with high glycemic indices Protein intake should be at least 1.
Diets high in saturated fat have been shown to worsen insulin resistance, provide excess TGs and FFAs for fetal fat accretion, increase inflammation, and have been implicated in adverse fetal programming effects on the offspring see risk to offspring above. For normal weight women with T1DM with appropriate gestational weight gain, carbohydrate and calorie restriction may not be necessary as long as it is appropriately covered by insulin.
Emphasizing consistent timing of meals with at least a bedtime snack to minimize hypoglycemia in proper relation to insulin doses is important. Many patients who dose prandial insulin based on an insulin to carbohydrate ratio are skilled at carbohydrate counting. The U. Department of Health and Human Services issued physical activity guidelines for Americans and recommend healthy pregnant and postpartum women receive at least minutes per week of moderate-intensity aerobic activity i.
Observational studies of women who exercise during pregnancy have shown benefits such as decreased GDM, cesarean and operative vaginal delivery and postpartum recovery time, although evidence from RCTs is limited , Some data suggest that women who continued endurance exercise until term gained less weight and delivered slightly earlier than women who stopped at 28 weeks but they had a lower incidence of cesarean deliveries, shorter active labors, and fewer fetuses with intolerance of labor Babies weighing less were born to women who continued endurance exercise during pregnancy compared with a group of women who reduced their exercise after the 20th week 3.
Contraindications for a controlled exercise program include women at risk for preterm labor or delivery or any obstetric or medical conditions predisposing to growth restriction. Given the strong associations between maternal diabetes and obesity and the risk of childhood obesity and glucose intolerance, the metabolic milieu of the intrauterine environment is a critical risk factor for the genesis of adult diabetes and cardiovascular disease , — The evidence of this fetal programming and its contribution to the developmental origins of human disease DoHAD is one of the most compelling reasons why optimizing maternal glycemic control, identifying other nutrients contributing to excess fetal fat accretion, emphasizing weight loss efforts before pregnancy, ingesting a healthy low-fat diet, and avoiding excessive weight gain are so critical and carry long term health implications to both the mother and her offspring.
The emerging field of epigenetics has clearly shown in animal models and non-human primates that the intrauterine environment, as a result of maternal metabolism and nutrient exposure, can modify fetal gene expression , In this study, higher maternal glucose levels postgram glucose tolerance test in the second trimester were associated with greater total body fat percentage as measured by DXA in the children at 5 years of age.
There are data, especially in animal and non-human primate models, to support that a maternal high fat diet and obesity can influence mesenchymal stems cells to differentiate along adipocyte rather than osteocyte pathways, invoke changes in the serotonergic system resulting in increased anxiety in non-human primate offspring, affect neural pathways involved with appetite regulation, promote lipotoxicity, regulate gluconeogenic enzymes in the fetal liver generating histology consistent with NAFLD, alter mitochondrial function in skeletal muscle, and program beta cell mass in the pancreas , — These epigenetic changes are being substantiated in human studies with evidence of differential adipokine methylation and gene expression in adult offspring of women with diabetes in pregnancy and through alterations in fetal placental DNA methylation of the lipoprotein lipase gene which are associated with the anthropometric profile in children at 5 years of age These findings further support the concept of fetal metabolic programming through epigenetic changes As a result, the intrauterine metabolic environment may have a transgenerational influence on obesity and diabetes risk in the offspring, influencing appetite regulation, beta cell mass, liver dysfunction, adipocyte metabolism, and mitochondrial function.
Offspring of mothers with type 2 diabetes and gestational diabetes have higher risk of childhood obesity, young adult or adolescent insulin resistance and diabetes, nonalcoholic fatty liver disease, hypertension, and cardiovascular disease — The risk of youth onset diabetes is higher in offspring of mothers born with pregestational type 2 diabetes than with gestational diabetes fold compared to 4-fold risk These epigenetic changes are not isolated to maternal BMI alone but it has also been demonstrated that paternal factors impact offspring risk of obesity and diabetes , The obstetric outlook for pregnancy in women with pre-existing diabetes has improved over the last century and has the potential to continue to improve as rapid advances in diabetes management, fetal surveillance, and neonatal care emerge.
However, the greatest challenge health care providers face is the growing number of women developing GDM and T2DM as the obesity epidemic increases affecting women prior to pregnancy. In addition, the prevalence of T1DM is increasing globally. Furthermore, obesity-related complications exert a further deleterious effect on pregnancy outcomes. The development of T2DM in women with a history of GDM as well as obesity and glucose intolerance in the offspring of women with preexisting DM or GDM set the stage for a perpetuating cycle that must be aggressively addressed with effective primary prevention strategies that begin in-utero.
Turn recording back on. National Center for Biotechnology Information , U. Contents www. Search term. Pregestational Diabetes Mellitus Erin M. Author Information Erin M. Email: ude. Stephen F. Elizabeth O. Table 1. Basal Insulin Basal insulin is given times daily or via a continuous insulin infusion pump.
Bolus Insulin Bolus insulin dosing is provided with short acting insulin with doses calculated based on pre-meal glucose and carbohydrate intake using a correction factor and insulin to carbohydrate ratio Importance of Glycemic Control Failure to achieve optimal control in early pregnancy may have teratogenic effects in the first 3- 10 weeks of gestation or lead to early fetal loss. Table 2. Evaluation of Pregnant Women with Preexisting Diabetes.
Glucose Monitoring Timing and Frequency Pregnant women with diabetes must frequently self-monitor their glucose in order to achieve tight glycemic control. Retinopathy Diabetic retinopathy may progress during pregnancy and throughout the first year postpartum. Cardiovascular Disease Although infrequent, cardiovascular disease CVD can occur in women of reproductive age with diabetes. Neuropathy There are limited data on diabetic neuropathy during pregnancy.
LABOR AND DELIVERY Delivery management and the timing of delivery is made according to maternal well-being, the degree of glycemic control, the presence of diabetic complications, growth of the fetus, evidence of uteroplacental insufficiency, and the results of fetal surveillance Immediate Risks to Newborn The immediate neonatal period is characterized by the transition from in-utero to independent physiology, with unique risks in neonates born to individuals with diabetes.
Breastfeeding Both the benefits of breastfeeding- and conversely, the risks of failing to do so- are profound and well documented for both mother and child TABLE 3. BMI Total weight gain lbs.
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Table 1. Action Profile of Commonly Used Insulins. Please Confirm.
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