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Standards
of Medical Care for Diabetic Mommies
The American
Diabetes Assocation publishes standards of medical care for diabetics
or clinical
practice recommendations. According to their research and studies,
they make recommendations to healthcare professionals as far as
diagnosis and treatment.
Below I
will provide links to various articles that have important information
for diabetic moms. I'll try to provide a brief summary and include
quotes. The quotes make it easier to know which article has information
you might be looking for. The quotes chosen are also based on the
types of questions I receive the most. This information comes from
the Diabetes Care Journal, January 2004, Volume 27, Supplement 1.
Remember,
the leader of your healthcare team is YOU. Sometimes you need
to act as a watchdog and remind your heathcare professionals when
you need some extra attention. These articles can be referenced
by you when talking to your doctor.
So now
you'll have a better idea why doctors do the things they do while
you are trying to conceive (preconception state), are a pregnant
diabetic, or just a plain ole' diabetic. Also, this information
will help you speak up and request care you might need, especially
during pregnancy.
INDEX:
Standards
of Medical Care in Diabetes
Preconception Care of Women with Diabetes
Gestational Diabetes Mellitus(helpful info regardless
of type)
Hospital Admission Guidelines for Diabetes
Standards
of Medical Care in Diabetes
Diabetes Care 2004, Volume
27, Supplement 15-35
© 2004 by the American Diabetes Association, Inc.
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SUMMARY:
This article
provides standards of care that include diagnostic and therapeutic
actions and recommendations for treatment. It includes information
about gestational diabetes and pre-pregnancy planning.
QUOTES: Go
to full text of Article
"People
with
diabetes should receive medical care from a physician-coordinated
team. Such teams may include, but are not limited to, physicians,
nurses, dietitians, pharmacists, and mental health professionals
with expertise and a special interest in diabetes."
"Instruct
the patient in self-monitoring blood glucose and routinely
evaluate the patient’s technique and ability to use data
to adjust therapy."
"By
performing an A1C test, health providers can measure a patient’s
average glycemia over the preceding 2–3 months (26) and,
thus, assess treatment efficacy. A1C testing should be performed
routinely in all patients with diabetes, first to document
the degree of glycemic control at initial assessment and then
as part of continuing care."
"Glycemic
control is best judged by the combination of the results of
the patient’s SMBG testing (as performed) and the current
A1C result. The A1C should be used not only to assess the
patient’s control over the preceding 2–3 months
but also as a check on the accuracy of the meter (or the patient’s
self-reported results) and the adequacy of the Self-monitoring
bloog glucose testing schedule. "
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"Medical
nutrition therapy is an integral component of diabetes management
and diabetes self-management education...Address individual
nutritional needs, taking into consideration personal and
cultural preferences and lifestyle while respecting the individual’s
wishes and willingness to change....For pregnant and lactating
women, provide adequate energy and nutrients needed for optimal
outcomes."
"A
regular physical activity program, adapted to the presence
of complications, is recommended for all patients with diabetes
who are capable of participating."
"Although
there are no well-controlled studies of diet and exercise
in the treatment of hypertension in persons with diabetes,
reducing sodium intake and body weight (when indicated), avoiding
excessive alcohol consumption, and increasing activity levels
have been shown to be effective in reducing blood pressure
in nondiabetic individuals (40). These nonpharmacological
strategies may also positively affect glycemia and lipid control."
"Blood
pressure should be measured at every routine diabetes visit.
Patients found to have systolic blood pressure 130 or diastolic
blood pressure 80 mmHg should have blood pressure confirmed
on a separate day."
"Patients
with diabetes should be treated to a systolic blood pressure
<130 mmHg. Patients with diabetes should be treated to
a diastolic blood pressure <80 mmHg."
"Advise
all patients not to smoke...Include smoking cessation counseling
and other forms of treatment as a routine component of diabetes
care."
"When
planning pregnancy, women with preexisting diabetes should
have a comprehensive eye examination and should be counseled
on the risk of development and/or progression of diabetic
retinopathy. Women with diabetes who become pregnant should
have a comprehensive eye examination in the first trimester
and close follow-up throughout pregnancy and for 1 year postpartum.
This guideline does not apply to women who develop GDM because
such individuals are not at increased risk for diabetic retinopathy."
"Major
congenital malformations remain the leading cause of mortality
and serious morbidity in infants of mothers with type 1 and
type 2 diabetes. Observational studies indicate that the risk
of malformations increases continuously with increasing maternal
glycemia during the first 6–8 weeks of gestation, as
indexed by first trimester A1C concentrations...malformation
rates above the 1–2% background rate seen in nondiabetic
pregnancies appear to be limited to pregnancies in which first
trimester A1C concentrations are >1% above the normal range."
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"...overwhelming
evidence supports the concept that malformations can be reduced
or prevented by careful management of diabetes before pregnancy.
"
"Planned
pregnancies greatly facilitate preconceptional diabetes care."
"To
minimize the occurrence of these devastating malformations,
standard care for all women with diabetes who have child-bearing
potential should include 1) education about the risk of malformations
associated with unplanned pregnancies and poor metabolic control
and 2) use of effective contraception at all times, unless
the patient is in good metabolic control and actively trying
to conceive."
"Women
contemplating pregnancy need to be seen frequently by a multidisciplinary
team experienced in the management of diabetes before and
during pregnancy. Teams may vary but should include a diabetologist,
an internist or a family physician, an obstetrician, a diabetes
educator, a dietitian, a social worker, and other specialists
as necessary. The goals of preconception care are to 1) integrate
the patient into the management of her diabetes, 2) achieve
the lowest A1C test results possible without excessive hypoglycemia,
3) assure effective contraception until stable and acceptable
glycemia is achieved, and 4) identify, evaluate, and treat
long-term diabetic complications such as retinopathy, nephropathy,
neuropathy, hypertension, and CAD."
"A1C
levels should be normal or as close to normal as possible
in an individual patient before conception is attempted."
"ACE
inhibitors should be discontinued before pregnancy."
"All
women with diabetes and child-bearing potential should be
educated about the need for good glucose control before pregnancy.
They should participate in family planning."
"Women
with diabetes who are contemplating pregnancy should be evaluated
and, if indicated, treated for diabetic retinopathy, nephropathy,
neuropathy, and CVD."
"Among
the drugs commonly used in the treatment of patients with
diabetes, statins are pregnancy category X and should be discontinued
prior to conception if possible. ACE inhibitors and ARBs are
category C in the first trimester (maternal benefit may outweigh
fetal risk in certain situations), but category D in later
pregnancy, and should generally be discontinued prior to pregnancy.
Among the oral antidiabetic agents, metformin and acarbose
are classified as category B and all others as category C;
potential risks and benefits of oral antidiabetic agents in
the preconception period must be carefully weighed, recognizing
that sufficient data are not available to establish the safety
of these agents in pregnancy. They should generally be discontinued
in pregnancy."
Preconception
Care of Women with Diabetes
Diabetes Care 2004, Volume 27, Supplement 76-78
© 2004 by the American Diabetes Association, Inc.
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SUMMARY:
Discusses preconception
treatment and care.
QUOTES: Go
to full text of Article
"To
prevent excess spontaneous abortions and congenital malformations
in infants of diabetic mothers, diabetes care and education
must begin before conception. This is best accomplished by
a multidisciplinary team that includes a diabetologist, internist,
or family practice physician skilled in diabetes management;
an obstetrician familiar with the management of high-risk
pregnancies; diabetes educators, including a nurse, dietitian,
and social worker; and other specialists, as deemed necessary.
Ultimately, the woman with diabetes must become the most active
member of the team, calling upon the other members for specific
guidance and expertise to help her achieve her goal of a healthy
pregnancy and newborn."
"The
desired outcome of the preconception phase of care is to lower
A1C test values to a level associated with optimal development
during organogenesis. Epidemiological studies indicate that
A1C test values up to 1% above normal are associated with
rates of congenital malformations and spontaneous abortions
that are not greater than rates in nondiabetic pregnancies.
However, rates of each complication continue to decrease with
even lower A1C test levels. Thus, the general goal for glycemic
management in the preconception period and during the first
trimester should be to obtain the lowest A1C test level possible
without undue risk of hypoglycemia in the mother. In particular,
levels that are <1% above the normal range are desirable."
"Laboratory
evaluation...assessment of metabolic control and detection
of diabetic complications that may affect or be affected by
pregnancy: A1C...Serum creatinine..urinary excretion of total
protein and/or albumin...measurement of serum thyroid stimulating
hormone and/or free thyroxine level in women with type 1 diabetes
"After
the initial visit, patients should be seen at 1- to 2-month
intervals depending on their mastery of the management program
and the presence or absence of coexisting medical conditions.
Frequent phone contact for adjustment of insulin doses and
other aspects of the treatment regimen is advised as well.
Once the patient has achieved stable glycemic control..[and
the] risk as well as the status of maternal diabetic complications
and any coexisting medical conditions are acceptable, then
contraception can be discontinued"
"If
conception does not occur within 1 year, the patient’s
fertility should be assessed."
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"...attempts
to achieve normal glycemic control in patients with type 1
diabetes increase the risk of severe hypoglycemia. The occurrence
of severe, frequent, or unexplained episodes of hypoglycemia
may be due to a number of factors, such as defective counterregulation,
hypoglycemia unawareness, insulin dose errors, and excess
alcohol intake."
"There
is no solid evidence that such hypoglycemia is an independent
risk to the developing human embryo. There is, however, clear
risk to the mother Thus, it is imperative that this risk be
explained to the woman with diabetes contemplating pregnancy
and that means of prevention or ultimate treatment be provided
to her and her family."
"Diabetic
retinopathy may accelerate during pregnancy. The risk can
be reduced by gradual attainment of good metabolic control
before conception and by preconceptual laser photocoagulation
in women with standard indications for that therapy. Thus,
a baseline dilated comprehensive eye examination is necessary
before conception..."
"Hypertension
is a frequent concomitant or complicating disorder of diabetes.
Patients with type 1 diabetes frequently develop hypertension
in association with diabetic nephropathy, as manifested by
the presence of gross proteinuria. Patients with type 2 diabetes
more commonly have hypertension as a concomitant disease.
In addition, pregnancy-induced hypertension is a potential
problem for the woman with diabetes, particularly when proteinuria
in excess of 190 mg/day is present before conception or in
early pregnancy. Aggressive monitoring and control of hypertension
in the preconception period is advised, if—for no other
reason—to reduce the risk of worsening diabetic nephropathy
or the development of retinopathy or clinical atherosclerosis.
ACE inhibitors, ß-blockers, and diuretics should be
avoided in women contemplating pregnancy."
"Baseline
assessment of renal function by serum creatinine and some
measure of urinary protein excretion (urine albumin-to-creatinine
ratio or 24-h albumin excretion) should be undertaken before
conception..."
"The
presence of autonomic neuropathy, particularly manifested
by gastroparesis, urinary retention, hypoglycemic unawareness,
or orthostatic hypotension, may complicate the management
of diabetes in pregnancy. These complications should be identified,
appropriately evaluated, and treated before conception. Peripheral
neuropathy, especially compartment syndromes such as carpal
tunnel syndrome, may be exacerbated by pregnancy."
"Untreated
cardiovascular diasease (CAD) is associated with a high mortality
rate during pregnancy. Evidence of CAD should be sought according
to the American Diabetes Association consensus statement on
the diagnosis of coronary heart disease (2). Successful pregnancies
have been undertaken after coronary revascularization in women
with diabetes. Exercise tolerance should be normal to maximize
the probability that the patient will tolerate the increased
cardiovascular demands of gestation. "
"At
the earliest possible time after conception, pregnancy should
be confirmed by laboratory assessment (urinary or serum B-hCG).
The woman should be reevaluated by the health care team to
reinforce goals and methods of management, which should remain
essentially stable throughout the first trimester."
Gestational
Diabetes Mellitus
Diabetes Care 2004, Volume 27, Supplement 88-90
© 2004 by the American Diabetes Association, Inc.
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SUMMARY:
Definition, detection,
diagnosis, and therapy suggestions for gestational diabetes.
QUOTES:
Go
to full text of Article
"Gestational
diabetes mellitus (GDM) is defined as any degree of glucose
intolerance with onset or first recognition during pregnancy
(1). The definition applies whether insulin or only diet modification
is used for treatment and whether or not the condition persists
after pregnancy. It does not exclude the possibility that
unrecognized glucose intolerance may have antedated or begun
concomitantly with the pregnancy."
"Women
with GDM are at increased risk for the development of diabetes,
usually type 2, after pregnancy. Obesity and other factors
that promote insulin resistance appear to enhance the risk
of type 2 diabetes after GDM, while markers of islet cell-directed
autoimmunity are associated with an increase in the risk of
type 1 diabetes. Offspring of women with GDM are at increased
risk of obesity, glucose intolerance, and diabetes in late
adolescence and young adulthood. "
"All
women with GDM should receive nutritional counseling, by a
registered dietitian when possible, consistent with the recommendations
by the American Diabetes Association."
"Noncaloric
sweeteners may be used in moderation."
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"Selection
of pregnancies for insulin therapy can be based on measures
of maternal glycemia with or without assessment of fetal growth
characteristics. When maternal glucose levels are used, insulin
therapy is recommended when MNT fails to maintain self-monitored
glucose at the following levels:
Fasting
whole blood glucose: 95 mg/dl (5.3 mmol/l)
Fasting plasma glucose: 105 mg/dl (5.8 mmol/l)
-OR-
1-h postprandial
whole blood glucose: 140 mg/dl (7.8 mmol/l)
1-h postprandial plasma glucose: 155 mg/dl (8.6 mmol/l)
-OR-
2-h postprandial whole blood glucose: 120 mg/dl (6.7 mmol/l)
2-h postprandial plasma glucose 130 mg/dl (7.2 mmol/l)"
"GDM
is not of itself an indication for cesarean delivery or for
delivery before 38 completed weeks of gestation. Prolongation
of gestation past 38 weeks increases the risk of fetal macrosomia
without reducing cesarean rates, so that delivery during the
38th week is recommended unless obstetric considerations dictate
otherwise."
"Breast-feeding,
as always, should be encouraged in women with GDM."
"Reclassification
of maternal glycemic status should be performed at least 6
weeks after delivery and according to the guidelines of the
"Report of the Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus"
"Education
should also include the need for family planning to ensure
optimal glycemic regulation from the start of any subsequent
pregnancy. Low-dose estrogen-progestogen oral contraceptives
may be used in women with prior histories of GDM, as long
as no medical contraindications exist."
"Offspring
of women with GDM should be followed closely for the development
of obesity and/or abnormalities of glucose tolerance."
Hospital
Admission Guidelines for Diabetes
Diabetes
Care 2004, Volume 27, Supplement 103
© 2004 by the American Diabetes Association, Inc.
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SUMMARY:
This article discusses
what situation might warrant hospitalization.
QUOTES:
Go
to full text of Article
"These guidelines are to be used for determining when a
patient requires hospitalization for reasons related to diabetes.
Inpatient care may be appropriate in the following situations:
Life-threatening acute metabolic complications of diabetes. Newly
diagnosed diabetes in children and adolescents. Substantial and
chronic poor metabolic control that necessitates close monitoring
of the patient to determine the etiology of the control problem,
with subsequent modification of therapy. Severe chronic complications
of diabetes that require intensive treatment or other severe conditions
unrelated to diabetes that significantly affect its control or
are complicated by diabetes. Uncontrolled or newly discovered
insulin-requiring diabetes during pregnancy. Institution of insulin-pump
therapy or other intensive insulin regimens."
"Poor metabolic control of established diabetes as defined
herein justifies admission if it is necessary to determine the
reason for the control problems and to initiate corrective action.
For admission under these guidelines, documentation should include
at least one of the following: Hyperglycemia associated with volume
depletion. Persistent refractory hyperglycemia associated with
metabolic deterioration. Recurring fasting hyperglycemia >300
mg/dl (>16.7 mmol/l) that is refractory to outpatient therapy
or an A1C level 100% above the upper limit of normal. Recurring
episodes of severe hypoglycemia (i.e., <50 mg/dl [<2.8 mmol/l])
despite intervention. Metabolic instability manifested by frequent
swings between hypoglycemia (<50 mg/dl [<2.8 mmol/l]) and
fasting hyperglycemia (>300 mg/dl [>16.7 mmol/l]). Recurring
diabetic ketoacidosis without precipitating infection or trauma.
Repeated absence from school or work due to severe psychosocial
problems causing poor metabolic control that cannot be managed
on an outpatient basis."
"Chronic cardiovascular, neurological, renal, and other
diabetic complications may progress to the stage where hospital
admission is appropriate. In these situations, the needs
governing admission for the complication per se (e.g., management
of end-stage renal disease) are the primary guidelines for determining
whether inpatient care is required. However, in applying
such guidelines, the fact that diabetes is present must be considered;
this may result in patients requiring admission who otherwise
might be managed on an outpatient basis. The same is true
for other medical conditions (e.g., infections) and treatments
(e.g., surgery, chemotherapy) in which 1) diabetes is a confounding
factor, 2) rapid initiation of rigorous control of diabetes can
improve outcome (e.g., pregnancy), 3) the primary medical
problem or the therapeutic intervention (e.g., large doses of
glucocorticoid) can cause a major deterioration in diabetes control,
or 4) there is acute onset of retinal, renal, neurological, or
cardiovascular complications of diabetes."
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Diabetes
and pregnancy, fertility issues, gestational diabetes, parenting, 
