Of births to mothers treated with DTG during conception , 4 0. In the analysis, 14 NTDs were noted in 11, births 0. The ramifications of this finding are considerable. DTG is known to be superior to other ARVs with respect to clinical efficacy and tolerability and with a greater barrier to developing resistance. A letter recently published in the Lancet has highlighted the sensitivity of the rate of NTDs to further surveillance data.
Benefits of breastfeeding. State Who started nurse service organization Find the latest data by state. Acta Paediatr ;— Diabetes Care ;—8. Infectious Disease Advisor : Is there data available on folate supplementation in the mothers in this study other than mothers in whose West michigan peri pregnancy the neural tube defects occurred? The latter was defined by International Obesity Task Force sex- and age- specific overweight criteria In the analysis, 14 NTDs were noted in 11, births 0. Longer-term follow up is not yet available. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Such an approach has the potential to improve maternal and child health, with significant savings West michigan peri pregnancy the health-care system.
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Background: Maternal prepregnancy adiposity may influence child adiposity beyond the transmitted genetic effects, which, if true, may accelerate the obesity epidemic, but the evidence for this mechanism is inconsistent.
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Denice S. This chapter discusses pregnancy in both pre-existing diabetes type 1 and type 2 diabetes diagnosed prior to pregnancy , overt diabetes diagnosed early in pregnancy and gestational diabetes GDM or glucose intolerance first recognized in pregnancy. Some management principles are common to all types of diabetes. Preconception care improves maternal and fetal outcomes in women with pre-existing diabetes.
This involves educating women about the importance of optimal glycemic control prior to pregnancy, discontinuing potentially harmful medications and achieving a health body weight.
Hyperglycemia is teratogenic and if glycemic control is poor in the first few weeks of conception, the risk of congenital anomalies is increased.
Preconception care should also include advice regarding folic acid supplementation. There are no intervention trials to support folic acid doses greater than 1 mg for women with diabetes. A higher dose of folic acid may be considered in women with obesity, although there is no clinical evidence that this higher dose reduces congenital anomalies.
Measurement of red blood cell RBC folate may also be useful to guide adjustment of folic acid dosage in women with obesity or women who have had bariatric surgery. It is not known if these medications cross the placenta or if they are secreted in breastmilk. Gestational timing of exposure needs to be considered in situations where potential benefit to the woman justifies the potential fetal risk.
Intravitreal anti-VEGF therapy in pregnancy should be avoided especially in the first trimester. Second and third trimester use should occur only if absolutely necessary after discussion of the potential risks and benefits.
Diabetic macular edema may often regress after pregnancy without specific therapy. Data are lacking to guide treatment recommendations for diabetic macular edema during pregnancy. A systematic review of risk factors for preeclampsia demonstrated a 3. Type 1 diabetes is more often associated with preeclampsia whereas type 2 diabetes is more often associated with chronic hypertension. In the general population, the risk of preeclampsia is highest in nulliparous women and lower in multiparous women.
Other risk factors for hypertension, such as poor glycemic control in early pregnancy, are potentially modifiable. Any type and degree of hypertension is associated with adverse outcomes. A large randomized controlled trial in pregnant women with nonproteinuric pre-existing or gestational hypertension that included women with GDM showed that targeting a diastolic blood pressure BP of 85 mmHg vs.
Finally, a number of antihypertensive medications are safe and effective in pregnancy, including calcium channel blockers, labetalol and methyldopa. Chronic kidney disease. Prior to conception, women should be screened for chronic kidney disease CKD. An estimated glomerular filtration rate eGFR should be used prior to pregnancy to determine risk of adverse outcomes. However, inadequate BP control in pregnancy may account for this observed difference in this study.
The decision to discontinue an ACE inhibitor or ARB prior to pregnancy should be discussed with the woman and may depend on the indication for use and availability of an effective alternative medication. Painful peripheral neuropathy management. As with all medications used in pregnancy, benefits need to be weighed against risk. Cardiovascular disease. Although rare, cardiovascular disease CVD can occur in women of reproductive age with diabetes.
Women with known CVD should be evaluated and counselled about the significant risks associated with pregnancy. An early working relationship should be established between the woman and the DHC team to optimize care, facilitate the planning of pregnancy, ensure adequate self-care practices and to discuss the need for social support during pregnancy. Elevated BG levels have adverse effects on the fetus throughout pregnancy.
As a result, meticulous glycemic control throughout pregnancy is required for optimal maternal and fetal outcomes. However, optimal targets for fasting, preprandial and postprandial BG levels in women with pre-existing diabetes have not been examined in randomized controlled trials; and a variety of BG targets are used in clinical practice. In women with type 1 diabetes and good glycemic control during pregnancy with an A1C of 4. In the absence of comparative studies of specific BG targets for women with pre-existing diabetes, use of the mean BG plus 2 standard deviation SD of pregnant women without diabetes appears to be appropriate.
However, since the hypoglycemia level is often individualized to each person with diabetes, with consideration of symptoms, therapy, medical condition and associated risk; the official lower limit of BG level during pregnancy is difficult to clearly establish. Overall, it is understood that pregnant women have lower BG values that can be judged as normal even if below the traditional level of 4. Health-care providers should ensure that pregnant women with diabetes: a have a glucagon kit; b are advised regarding effective interventions if a severe hypoglycemic event occurs; and c are encouraged to inform close relatives and co-workers of this increased risk, especially in the first and early second trimester.
SMBG 4 to 7 times per day is also recommended for pregnant women with type 2 diabetes i. Evidence for the use of CGM to improve glycemic control, and maternal and fetal outcomes is conflicting.
Finally, a study examining CGM use to prevent episodes of severe hypoglycemia early in pregnancy in women with a history of episodes in the year prior to pregnancy did not demonstrate benefit.
Women with pre-existing diabetes during pregnancy should have A1C levels measured during pregnancy to assist in management. The optimal frequency of A1C measurement is not known; however, testing more than the usual every 3 months may be appropriate see Monitoring Glycemic Control chapter, p. Institute of Medicine IOM guidelines for weight gain in pregnancy were first established in based on neonatal outcomes.
The researchers suggest that aiming for the lower weight gain range based on BMI category may be useful in the management of women with pre-existing diabetes. Furthermore, prepregnancy overweight and obesity are risk factors for adverse maternal and neonatal outcomes.
Therefore, diabetes education and management for this group of women in preconception and regularly throughout pregnancy should be inclusive of both optimal glycemic control, healthy preconception weight and weight gain through pregnancy.
Until additional data on specific weight gain recommendations for women with pre-existing diabetes becomes available, these women should be advised to gain weight as per the IOM guidelines based on their prepregnancy BMI category to lower the risk of LGA, macrosomia and caesarean deliveries. Intensive insulin therapy with basal-bolus therapy or continuous subcutaneous insulin infusion CSII or insulin pump therapy is recommended to achieve glycemic targets prior to pregnancy and during pregnancy.
Women using CSII should be educated about the possible increased risk of diabetic ketoacidosis DKA in the event of insulin pump failure.
Rapid-acting bolus analogues e. A randomized trial of women with type 1 diabetes randomized to insulin aspart vs. There are no data to date on faster-acting insulin aspart. Long-acting insulin analogues, glargine and detemir, appear safe with similar maternal and fetal outcomes compared to neutral protamine hagedorn NPH insulin. Finally, there are no benefit or harms data on the use of glargine insulin U, lispro insulin U, degludec insulin U and U, or glargine biosimilar in pregnancy.
CSII therapy during pregnancy. Overall, studies show no difference in maternal or fetal outcomes with CSII, but also no increase in harms, such as maternal hypoglycemia, DKA or weight gain.
Noninsulin antihyperglycemic agents and pregnant women with type 2 diabetes. Women with type 2 diabetes who conceive on metformin or glyburide can continue these agents until insulin is initiated.
Three smaller randomized trials have examined the use of metformin in pregnant women with type 2 diabetes. However, given the small sample sizes in the study and other methodological challenges, the findings from these studies offer limited generalizability. Currently, a large, double-blind randomized trial is underway to determine whether adding metformin to insulin will benefit mothers with type 2 diabetes and their infants Metformin in Women with Type 2 Diabetes in Pregnancy [MiTy] and Metformin in Women with Type 2 Diabetes in Pregnancy Kids [MiTy Kids] trials.
In conclusion, some studies indicate a possible benefit to adding metformin to insulin in women with type 2 diabetes; however, due to limitations in the research, there is insufficient evidence to recommend the addition of metformin to insulin in pregnant women with type 2 diabetes. Pregnant women with diabetes receiving steroids. In women suspected of preterm delivery, 2 doses of betamethasone is often given to aid in the maturation of the fetal lungs.
It has been hypothesized that a marked or rapid decrease in insulin requirements could be a harbinger of placental insufficiency. Therefore, not surprisingly, those with the greater decrease in insulin requirements compared to those without, were admitted more frequently to the NICU Although care was taken not to include the period within 5 days of antenatal steroid administration when calculating the percent fall in insulin dosing in this study, the substantially higher antenatal steroid use in the pregnancies with falling insulin requirements However, caution is required in the interpretation of these retrospective studies since decreasing insulin requirements may impact decisions regarding timing of delivery which may, in turn, impact pregnancy outcomes.
In contrast, results from other studies found no association with decreasing insulin requirements and birthweight, and neonatal weight distribution i. Caution is required when interpreting the findings as researchers used differing calculation methods to indicate fall in insulin requirements or perhaps due to heterogeneity in the population of women with type 2 diabetes included in the studies. The use of advanced sonographic and fetal doppler assessment in the surveillance of the fetus at risk, as in other high-risk pregnancies, may allow further stratification of risk in this population, but the optimal indicator of feto-placental compromise, particularly in women with diabetes, remains unclear.
In summary, the impact of decreasing insulin requirements is still not certain. The goal of fetal surveillance and planned delivery in women with pre-existing diabetes in pregnancy is the reduction of preventable stillbirth. Although there is no single strategy for antenatal surveillance for pre-existing diabetes pregnancies, the initiation of some form of fetal surveillance in all women with pregnancies complicated by pre-existing diabetes while applying more intensive protocols for fetal surveillance in pregnancies with additional risk factors is required.
As a general rule, intensified fetal surveillance should begin at a period in gestation when intervention i. For GDM, fetal surveillance and timing of delivery are more complex as there is less evidence for increased perinatal mortality in this group. This is likely due to the fact that the risk for perinatal mortality is probably limited to the subgroup of women with poor glycemic control, inclusion of women with pre-existing diabetes in GDM cohorts, obesity and other comorbidities and the rarity of these events.
Based on the large dataset, a relative risk was calculated of expectant management compared with induction of labour, while taking into consideration both the risk of stillbirth expectant management and infant death expectant management and induction of labour and showed a significant increased risk of stillbirth with expectant management at both 39 and 40 weeks of gestation when compared with induction of labour.
As the absolute risk difference was small, the number needed to deliver to prevent 1 excess perinatal death was estimated as 1, at 39 weeks' gestation and 1, at 40 weeks' gestation.
However, this study is limited by unadjusted confounders, including adequacy and method of glycemic control as well as obesity, thus limiting the generalizability of the study.
There are additional potential benefits of induction of labour in diabetic pregnancies, including reduction of excess fetal growth, shoulder dystocia and caesarean section rate. In this trial of insulin requiring GDM and pre-existing diabetes in pregnancies, expectant management after 38 weeks of gestation was associated with increased birthweight and macrosomia, but no change in caesarean section rate. Conversely, induction of labour at 38 but not 39 weeks was associated with an increase in NICU admission.
Importantly, these results remained significant after adjusting for important confounders, including parity, insulin treatment and BMI. Two recently published randomized controlled trials shed additional light on this clinical question.
The study found no difference in caesarean section rates between groups, but an increase in hyperbilirubinemia was noted in the IOL group. In summary, there is a paucity of quality evidence to guide clinical decisions regarding optimal fetal surveillance and timing of delivery in diabetic pregnancies.
Clinical identification of increased risk of stillbirth should be the target of prenatal care and lead to an individualized approach to defining the appropriate regimen of fetal surveillance and timing of delivery. In pre-existing diabetes, poorly controlled GDM or pre-existing diabetes in pregnancy associated with comorbidities, initiation of weekly assessment of fetal well-being at 34 to 36 weeks gestation is recommended.
Acceptable methods of assessment of fetal well-being near term can include the nonstress test, amniotic fluid index, biophysical profile or a combination of these.
When making decisions regarding timing of delivery before 40 weeks' gestation, the benefits with regards to prevention of stillbirth and a possible decrease in the caesarean rate need to be weighed against the likely increase in neonatal complications.
Planning insulin management during labour and delivery is an important part of care and must be adaptable given the unpredictable combination of work of labour, dietary restrictions and need for an operative delivery. Options for peripartum BG control include watchful waiting until BG rises above a specified threshold e. In a retrospective study of consecutive women with type 1 diabetes, women who chose to continue on CSII during labour had better glycemic control than women using CSII during pregnancy but who chose to convert to intravenous insulin infusion during labour.
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E-mail address: clinicaleffectiveness rcog. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. What care should be provided in the primary care setting to women of childbearing age with obesity who wish to become pregnant? Primary care services should ensure that all women of childbearing age have the opportunity to optimise their weight before pregnancy. Advice on weight and lifestyle should be given during preconception counselling or contraceptive consultations.
Weight and BMI should be measured to encourage women to optimise their weight before pregnancy. Women should be informed that weight loss between pregnancies reduces the risk of stillbirth, hypertensive complications and fetal macrosomia. Weight loss increases the chances of successful vaginal birth after caesarean VBAC section.
What nutritional supplements should be recommended to women with obesity who wish to become pregnant? Obese women are at high risk of vitamin D deficiency. However, although vitamin D supplementation may ensure that women are vitamin D replete, the evidence on whether routine vitamin D should be given to improve maternal and offspring outcomes remains uncertain.
Care of women with obesity in pregnancy can be integrated into all antenatal clinics, with clear local policies and guidelines for care available. This risk assessment should address the following issues:. The list should include details of safe working loads, product dimensions, as well as where specific equipment is located and how to access it. Clear communication of manual handling requirements should occur between the labour and theatre suites when women are in early labour.
This should be decided on an individual basis. All pregnant women should have their weight and height measured using appropriate equipment, and their BMI calculated at the antenatal booking visit. Measurements should be recorded in the handheld notes and electronic patient information system. For women with obesity in pregnancy, consideration should be given to reweighing women during the third trimester to allow appropriate plans to be made for equipment and personnel required during labour and birth.
There is a lack of consensus on optimal gestational weight gain. Until further evidence is available, a focus on a healthy diet may be more applicable than prescribed weight gain targets. Women should be given the opportunity to discuss this information. Dietetic advice by an appropriately trained professional should be provided early in the pregnancy where possible in line with NICE Public Health Guideline Difficulties with venous access and regional and general anaesthesia should be assessed.
In addition, an anaesthetic management plan for labour and birth should be discussed and documented. Multidisciplinary discussion and planning should occur where significant potential difficulties are identified. This should involve the use of a validated scale to support clinical judgement. What special considerations are recommended for screening, diagnosis and management of gestational diabetes in women with obesity? What special considerations are recommended for screening, diagnosis and management of hypertensive complications of pregnancy in women with obesity?
An appropriate size of cuff should be used for blood pressure measurements taken at the booking visit and all subsequent antenatal consultations. The cuff size used should be documented in the medical records. What special considerations are recommended for prevention, screening, diagnosis and management of venous thromboembolism in women with obesity? Risk assessment should be individually discussed, assessed and documented at the first antenatal visit, during pregnancy if admitted or develop intercurrent problems , intrapartum and postpartum.
What special considerations are recommended for screening, diagnosis and management of mental health problems in women with obesity? There is insufficient evidence to recommend a specific lifestyle intervention to prevent depression and anxiety in obese pregnant women. What special considerations does maternal obesity have for screening for chromosomal anomalies during pregnancy?
All women should be offered antenatal screening for chromosomal anomalies. Women should be counselled, however, that some forms of screening for chromosomal anomalies are slightly less effective with a raised BMI. Consider the use of transvaginal ultrasound in women in whom it is difficult to obtain nuchal translucency measurements transabdominally.
What special considerations does maternal obesity have for screening for structural anomalies during pregnancy? Screening and diagnostic tests for structural anomalies, despite their limitations in the obese population, should be offered. However, women should be counselled that all forms of screening for structural anomalies are more limited in obese pregnant women.
Where external palpation is technically difficult or impossible to assess fetal presentation, ultrasound can be considered as an alternative or complementary method. There is a lack of definitive data to recommend routine monitoring of post dates pregnancy.
However, obese pregnant women should be made aware that they are at increased risk of stillbirth. Women with maternal obesity should have an informed discussion with their obstetrician and anaesthetist if clinically indicated about a plan for labour and birth which should be documented in their antenatal notes.
Active management of the third stage should be recommended to reduce the risk of postpartum haemorrhage PPH. Elective induction of labour at term in obese women may reduce the chance of caesarean birth without increasing the risk of adverse outcomes; the option of induction should be discussed with each woman on an individual basis.
The decision for a woman with maternal obesity to give birth by planned caesarean section should involve a multidisciplinary approach, taking into consideration the individual woman's comorbidities, antenatal complications and wishes.
Where macrosomia is suspected, induction of labour may be considered. Parents should have a discussion about the options of induction of labour and expectant management.
Class I and II maternal obesity is not a reason in itself for advising birth within a CLU, but indicates that further consideration of birth setting may be required. The additional intrapartum risks of maternal obesity and the additional care that can be provided in a CLU should be discussed with the woman so that she can make an informed choice about planned place of birth.
This communication should be documented by the attending midwife in the notes. Women with class III obesity who are in established labour should receive continuous midwifery care, with consideration of additional measures to prevent pressure sores and monitor the fetal condition. What specific interventions may be required during labour and birth for women with maternal obesity? What specific surgical techniques are recommended for performing caesarean section on the obese woman including incision, closure?
Surgical approaches should therefore follow NICE CG but clinicians may decide alternative approaches are merited depending on individual circumstances.
Women with class 1 obesity or greater having a caesarean section are at increased risk of wound infection and should receive prophylactic antibiotics at the time of surgery. How can the initiation and maintenance of breastfeeding in women with maternal obesity be optimised? Obesity is associated with low breastfeeding initiation and maintenance rates.
What ongoing care, including postnatal contraception advice, should be provided to women with maternal obesity following pregnancy? Maternal obesity should be considered when making the decision regarding the most appropriate form of postnatal contraception.
Women with class I obesity or greater at booking should continue to be offered nutritional advice following childbirth from an appropriately trained professional, with a view to weight reduction in line with NICE Public Health Guideline What support can be given in the community to ensure minimal interpregnancy weight gain or to minimise risks of a future pregnancy?
Women should be supported to lose weight postpartum and offered referral to weight management services where these are available. What are the clinical risks of previous bariatric surgery to maternal and fetal health during pregnancy? Women with previous bariatric surgery should have nutritional surveillance and screening for deficiencies during pregnancy. Woman with previous bariatric surgery should be referred to a dietician for advice with regard to their specialised nutritional needs.
Obesity is becoming increasingly prevalent in the UK population and has become one of the most commonly occurring risk factors in obstetric practice, with Obese women with a BMI below a specified threshold may also benefit from recommendations in a higher BMI group, depending on individual circumstances. The prevalence of obesity in the general population in the UK has increased markedly since the early s.
Pregnant women who are obese are also at increased risk of caesarean birth. Maternal size can make the assessment of fetal size, presentation and external monitoring of fetal heart tracing more challenging during pregnancy. Initiation and maintenance of breastfeeding are also more difficult in the women with obesity. The search was inclusive of all relevant articles published until May The databases were searched using the relevant Medical Subject Headings MeSH terms, including all subheadings and synonyms, and this was combined with a keyword search.
The search was limited to studies on humans and papers in the English language. Where possible, recommendations are based on available evidence. Infants of obese mothers are at increased risk of congenital anomalies, 35 stillbirth, 12 , 36 prematurity, 8 macrosomia 9 , 15 and neonatal death. There is evidence that in women with obesity, weight loss between pregnancies reduces the risk of stillbirth, 39 - 42 hypertensive complications 40 and macrosomia.
Weight loss also increases the chances of successful VBAC 43 in a linear manner. In the general maternity population, a systematic review of five trials, including pregnancies with a history of a pregnancy affected by a neural tube defect [NTD] and with no history of NTDs , demonstrated that daily folic acid supplementation in doses ranging from 0. However, there is insufficient evidence to determine whether folic acid reduces the risk of other birth defects.
In addition, they had lower serum folate levels even after controlling for folate intake. The findings from the studies above suggest that obese women should receive higher doses of folate supplementation in order to minimise the increased risk of fetal NTDs.
Prepregnancy BMI is inversely associated with serum vitamin D concentrations among pregnant women. The main source of vitamin D is synthesis on exposure of the skin to sunlight. However, in the UK there is limited sunlight of the appropriate wavelength, particularly during winter. However, when calcium and vitamin D are combined, the risk of preterm birth is increased. This may not be feasible in areas of high prevalence due to capacity and resources.
It is therefore important that all health professionals providing maternity care are aware of the maternal and fetal risks, and the specific interventions required to minimise these. Evidence level 4. It is recommended that units should have a documented process to assess this on a regular basis. Five areas have been identified in the risk assessment of the bariatric patient journey: patient factors; equipment; communication; building space; and organisational and staff issues.
Moving and handling courses and updates should be mandatory and include the management of class III obesity. Appropriate care of women with maternal obesity can only be possible with consistent identification of those women who are at risk. The guidelines were later extended to include advice for overweight and obese pregnant women.