Managing Preexisting Diabetes for Pregnancy

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Managing Preexisting Diabetes for Pregnancy
2008
John L. Kitzmiller, MD, MS1, Jennifer M. Block, BS RN, CDE2, Florence M. Brown, MD3, Patrick M. Catalano, MD4, Deborah L. Conway, MD5, Donald R. Coustan, MD6, Erica P. Gunderson, RD, PHD7, William H. Herman, MD, MPH8, Lisa D. Hoffman, MSW, LCSW9, Maribeth Inturrisi, RN MS CNS, CDE10, Lois B. Jovanovic, MD11, Siri I. Kjos, MD12, Robert H. Knopp, MD13, Martin N. Montoro, MD14, Edward S. Ogata, MD15, Pathmaja Paramsothy, MD, MS16, Diane M. Reader, RD, CDE17, Barak M. Rosenn, MD18, Alyce M. Thomas, RD19 and M. Sue Kirkman, MD20
Diabetes Care

Summary of evidence and consensus recommendations for care

1 Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, California
2 Division of Pediatric Endocrinology, Stanford University Medical Center, Stanford, California
3 Department of Internal Medicine, Joslin Diabetes Center, Boston, Massachusetts
4 Department of Obstetrics and Gynecology, Metrohealth Medical Center, Cleveland, Ohio
5 Department of Obstetrics and Gynecology, University of Texas Health Sciences Center, San Antonio, Texas
6 Department of Obstetrics and Gynecology, Women and Infants Hospital, Brown Medical School, Providence, Rhode Island
7 Epidemiology and Prevention Section, Division of Research, Kaiser Permanente Foundation, Oakland, California
8 Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
9 Diabetes and Pregnancy Program, Obstetrix Medical Group, San Jose, California
10 California Diabetes and Pregnancy Program, Northcoast Region UCSF, San Francisco, California
11 Sansum Diabetes Research Institute, Santa Barbara, California
12 Department of Obstetrics and Gynecology, Harbor/UCLA Medical Center, Torrance, California
13 Northwest Lipid Research Clinic, University of Washington School of Medicine, Seattle, Washington
14 Division of Medical Endocrinology, University of Southern California School of Medicine, Los Angeles, California
15 Division of Neonatology, Children's Memorial Hospital, Northwestern University School of Medicine, Chicago, Illinois
16 Division of Cardiology, University of Washington School of Medicine, Seattle, Washington
17 International Diabetes Center, Minneapolis, Minnesota
18 Division of Maternal-Fetal Medicine, St. Luke's Roosevelt Hospital Center, New York, New York
19 Department of Obstetrics and Gynecology, St. Joseph's Regional Medical Center, Paterson, New Jersey
20 American Diabetes Association, Alexandria, Virginia

Corresponding author: John L. Kitzmiller, MD, MS, Santa Clara Valley Medical Center, 750 South Bascom Ave., Suite 340, San Jose, CA 95128. E-mail: kitz@batnet.com

Abbreviations: ACR, albumin-to-creatinine ratio Ô ADA, American Diabetes Association Ô ARB, angiotensin II receptor blocker Ô CAN, cardiac autonomic neuropathy Ô CHD, coronary heart disease Ô CrCl, creatinine clearance Ô CSII, continuous subcutaneous insulin infusion Ô CVD, cardiovascular disease Ô DCCT, Diabetes Control and Complications Trial Ô DKA, diabetic ketoacidosis Ô DPN, distal polyneuropathy Ô ECG, electrocardiogram Ô GFR, glomeruler filtration rate Ô IOM, Institute of Medicine Ô MNT, medical nutrition therapy Ô NPDR, nonproliferative diabetic retinopathy Ô PAD, peripheral arterial disease Ô PDR, proliferative diabetic retinopathy Ô RCT, randomized controlled trial Ô SMBP, self-monitoring of blood glucose Ô UAE, urinary albumin excretion


INTRODUCTION

This document presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The intent is to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy. A thorough discussion of the evidence supporting the recommendations is presented in the book, Management of Preexisting Diabetes and Pregnancy, authored by the consensus panel and published by the American Diabetes Association (ADA) in 2008 (1). A consensus statement on obstetrical and postpartum management will appear separately.

The recommendations are diagnostic and therapeutic actions that are known or believed to favorably affect maternal and perinatal outcomes in pregnancies complicated by diabetes. The grading system adapted by the ADA was used to clarify and codify the evidence that forms the basis for the recommendations (2). Unfortunately there is a paucity of randomized controlled trials (RCTs) of the different aspects of management of diabetes and pregnancy. Therefore our recommendations are often based on trials conducted in nonpregnant diabetic women or nondiabetic pregnant women, as well as on peer-reviewed experience before and during pregnancy in women with preexisting diabetes (3Ò4). We also reviewed and adapted existing diabetes and pregnancy guidelines (5Ò10) and guidelines on diabetes complications and comorbidities (2,3,11Ò14).

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© 2008 by the American Diabetes Association