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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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Disclaimer:

This is not a health care site. The editor is not a health care professional, is not qualified, and does not give medical or mental health advice.

Please consult with qualified professionals in order to find the right regimen and treatment for you. Do not make changes without consulting your health care team. .

Because this site is for all diabetics at all stages of life, some information may not be appropriate for you - remember information may be different for type 1, type 2, type 1.5, and gestational diabetics.

Articles submitted by other authors represent their own views, not necessarily the editor's.

The editor and contributing writers cannot be held responsible in any shape or form for your physical or mental health or that of your child or children. They cannot be held responsible for how any of the information on this site or associated sites affects your life.

The community associated with this site is a sort of self-help support group. Advice or information shared is personal and possibly not optimal for you. It is up to you to use this information as you see fit in conjunction with your medical care team. The results are your own responsibility. Other members or the editor or contributors cannot be held responsible.

 
Elizabeth "Bjay" Woolley, Editor & Webmaster
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