High%20Risk%20Pregnancy%20-%202007

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High Risk Pregnancy - 2007
2
High Risk Pregnancies

• Disordered Eating
• Obesity
• Hypertensive Disorders
• Gestational Diabetes

3
Disordered Eating Pregnancy Prevalence

• Few data on prevalence of disordered eating in
  pregnancy
• Difficult to adequately capture this information
  from women. Women may have needs for secrecy and
  denial so information about history of eating
  disorders is often not given to health care
  providers during pregnancy
• Some published numbers for disordered eating in
  the population ((Mitchell et al. J midwifery
  womens health, 2006)
• Prevalence of binge eating disorder 1.2-4.5
• Prevalence of anorexia nervosa in young females
  is 0.03
• About 25 of individuals with anorexia nervosa
  develop a chronic course.

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Diagnostic Criteria Anorexia Nervosa (American
Psychiatric Association)

• Refusal to maintain body weigh at or above normal
  weight for age and height
• Intense fear of gaining weight or becoming fat,
  even through underweight
• Disturbance in the way in which ones body weigh
  or shape is experienced,
• Undue influence of body weigh or self-evaluation
  or denial of the seriousness of current low body
  weight
• In postmenarcheal females, amenorrhea (absence of
  at least three consecutive menstrual cycles)

5
Diagnostic Criteria Bulimia Nervosa (American
Psychiatric Association)

• Recurrent episodes of binge eating. An episode of
  binge eating is characterized by both of the
  following
• In a discrete period of time, eating an amount of
  food definitely larger than most people would eat
• A sense of lack of control over eating during the
  episode
• Recurrent inappropriate compensatory behavior
  such as self-induced vomiting, misuse of
  laxatives, diuretics, enemas or other
  medications.
• Binge eating and inappropriate compensatory
  behaviors occur at least twice a week for 3
  months
• Self-evaluation is unduly influenced by body
  shape and weight
• The disturbance does not occur exclusively during
  anorexia nervosa.

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Diagnostic Criteria Not otherwise specified
(American Psychiatric Association)

• For females, all the criteria for AN are met,
  except that the individual has regular menstrual
  cycles.
• All criteria for AN is met, except the weight is
  WNL, despite significant weight loss
• Regular use of inappropriate compensatory
  behaviors in an individual of normal weight after
  eating small amounts of food
• Repeated chewing and spitting out food, but not
  swallowing
• Binge-eating disorder recurrent episodes of
  binge eating in the absence of regular use of
  compensatory behaviors characteristic of BN

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Disordered Eating Pregnancy

• Results of published studies are inconsistent
• Developmental tasks of pregnancy are often about
  the same issues that arise in some women with
  eating disorders
• Body changes
• Alterations in roles
• Concerns about a womans own mothering and needs
  for psychological separation.

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Pregnancy and Eating Disorders A review and
clinical Implications (Franko and Walton, Int.J.
Eating Disorders, 1993)

• British report on 6 of 327 women who had attended
  eating disorder clinic and got pregnant
• Median BMI was 16.8 (range 14.9-18.1)
• Median length of time with AN was 15 years (range
  11-17)
• Average weight gain was 8 kg (range 5-14)
  -recommendations for low BMI are 13-18
• Poor third trimester fetal growth was found in
  all 5 babies who were monitored
• Babies had some catch up in infancy

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Pregnancy Outcome and Disordered Eating (Abraham
et al J Psychosom Obstet Gynecol, 1994)

• 24 women reported previous problems with
  disordered eating.
• These women had higher rates of antenatal
  complications such as IUGR, PIH, edema, GDM,
  vaginal bleeding (plt0.05)
• These women also were more likely to have infants
  with birthweights lt 25th ile (plt0.02)

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Bulimia Symptoms and other risk behaviors during
pregnancy in women with Bulimia Nervosa (Crow et
al, Int J Eat Disord, 2004)

• 129 participants in a long-term follow up study
  of women who had been treated for BN at the
  University of Minnesota
• 322 pregnancies

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Crow et al., 2004
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2 Studies from Sweden.
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Pregnancy and neonatal outcomes in women with
eating disorders (Kouba et al. Obstet Gynecol,
2005)

• Recruited women from 13 Swedish prenatal clinics
  screened and diagnosed eating disorders.
• 68 controls 49 nulliparous, nonsmoking women
  diagnosed with
• 24 AN
• 20 BN
• 5 NOS
• Mean duration of eating disorders was 9 years
  (range 3-15)
• 16 (33) of women with hx of eating disorders had
  received TX
• 11 (22) of women with eating disorders had a
  relapse during pregnancy that led to contact with
  a psychologist or psychiatrist.

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Kouba, 2005
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Kouba, 2005
16
Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)

• Birth register study
• 1000 primiparous women who were discharged from
  hospital with dx of AN from 1973-1996 who gave
  birth 1983-2002
• All non AN births (827,582)
• Birthweights lower (p0.005) in AN group
• Mean AN, 3387
• General population mean, 3431
• Longer hospital say for AN (gt 6 months) not
  associated with different outcomes
• No difference in SGA and any other negative birth
  outcomes for mother or baby

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Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)

• Authors explanation of findings
• Our findings may be a result of gradual
  improvement in the care process, both AN and
  maternity care.
• A country with a satisfactory maternity
  surveillance, outcome of pregnancy and delivery
  may be just as good for women with a hx of AN as
  for the general population.
• OR..the fertility problems associated with AN
  mean that pregnancy will only occur in less
  severe cases

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Avon Longitudinal Study of Parents and Children

• N14,472
• Representative of women in the UK
• 8590 of women who were expected to deliver
  babies in Avon geographical area between April
  1991 and December 1992

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Associated Risks Percents(Micali et al. Br J
Psych., 2007)
AN (n171) BM (n191) AN BN (n82) Other Pysch. Disord (n1166) General Population (n10,636)
Smoking T1 28 26 40 40 21
Smoking T2 20 21 24 33 16
Alcohol T1 12 19 25 19 15
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Recency of ED(Micali et al. J Psychosom.
Research, 2007)

• N12,252
• 57 reported recent episode of ED (6 AN, 51 BN)
• 395 reported past history of ED
• Note recent not defined in paper.
• Asked about behaviors at 18 weeks and 36 weeks
  via mailed questionnaire

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Recent ED Past ED Non-obese controls
Laxative use in pg 8.2 0.8 0.2
Pregnancy SIV 26.5 3.9 0.7
High exercise in pregnancy 32.7 31.2 21.2
Strong desire to loose weight 63.5 31.4 22.2
Loss of control over eating 72.5 42.8 36.1
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Postpartum eating and Body Image for all Women

• It is of note that in a general population of
  postpartum women, eating disorder behaviors
  increase markedly in the first 3 months
  post-partum and remain high for the next 9
  months.
• Some women actually first experience clinical
  eating disorders during this time.

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Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)

• N97, prospective cohort study of primip. women
  followed during pregnancy and at 3 and 6 mos pp.
• Eating Disorder Examination (EDE) restraint,
  eating concern, shape concern, weight concern and
  global scores about state over last 28 days
• Repeated measures ANOVA indicated that changes in
  eating disorder pathology pp were largely due to
  changes in body weight.

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Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)
p lt0.05, plt 0.01, plt0.001
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An observational study of mothers with eating
disorders and their infants ( Stein et al., J
Child Psychol Psychiat, 1994)

• 2 groups of primips
• Index group, women who had met EDE criteria for
  disordered eating during pp period, n34
• Control group, balanced for SES, age, and childs
  gender, n24
• At one year
• EDE
• Childs growth
• Structured observation of child and mother at
  task and mealtime

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Mealtime Behaviors ( Stein et al., J Child
Psychol Psychiat, 1994)
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Play Behaviors ( Stein et al., J Child Psychol
Psychiat, 1994)
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Discussion ( Stein et al., J Child Psychol
Psychiat, 1994)

• Index mothers were more intrusive than control
  mothers
• About 1/3 of the index infants and one of the
  control infants had growth faltering
• Regression analysis models to predict infant
  weights were best fit when included
• maternal height,
• infant birthweight
• conflict during meals
• mothers concern about own body shape

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www.anred.com

• You could become depressed and frantic because of
  weight gain during pregnancy. You might feel so
  out of control of your life and body that you
  would try to hurt yourself or the unborn baby.
  You might worry and feel guilty about the damage
  you could be causing the baby.

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• Some women with eating disorders welcome
  pregnancy as a vacation from weight worries. They
  believe they are doing something important by
  having a baby and are able to set aside their
  fear of fat in service to the health of the
  child. Others fall into black depression and
  intolerable anxiety when their bellies begin to
  swell. Most fall somewhere between these two
  extremes.

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• You might underfeed your child to make her thin,
  or, you might overfeed her to show the world that
  you are a nurturing parent. Power struggles over
  food and eating often plague families where
  someone has an eating disorder. You could
  continue that pattern with your child.

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• Motherhood is stressful. If you are not strong in
  your recovery, you will be tempted to fall back
  on the starving and stuffing coping behaviors
  that are so familiar to you. Ideally, as you
  begin raising a family, you will already have
  learned, and will have had practice using, other
  more healthy and effective behaviors when you
  feel overwhelmed.

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• Also, eating disordered women make poor role
  models. Your influence could lead your daughters
  to their own eating disorders and your sons to
  believe that the most important thing about women
  is their weight.

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Clinical Implications

• Careful screening and monitoring
• Possible use of self administered, computer
  assisted screening tool
• Psychotherapy may be indicated
• Interventions are not evidence based at this
  time, but based on case studies individual
  counselors experiences

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Clinical Interventions Psychosocial

• Making the fetus as real as possible to the
  patient very early
• Focus on fundal measurements?
• Empathetically addressing fears of weight gain
  and feelings of being out of control
• Assurance about normal weight gain and patterns
  of pp weight loss
• Education of significant others

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Clinical Interventions Nutrition

• Frequent weigh-ins, lectures about weight gain,
  and even well-meaning comments my clinical staff
  can be triggers for increasing the frequency of
  eating disordered behaviors. (Mitchell et al. J
  midwifery womens health, 2006)
• If appropriate
• Discuss and provide materials about nutrients and
  food in pregnancy
• Design individual food plan
• Determine optimal range of weight gain
• Discuss hydration shifts in pregnancy and need
  for fluid

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Clinical Interventions Exercise

• Assess exercise level
• Suggest joining exercise groups and new mothers
  groups to normalize experience of weight concerns

38
Clinical Intervention Infant Feeding

• Offer assistance with parenting concerns
• Offer information about infant feeding
• infants ability to self regulate
• attention to infant cues signals
• use of food as reward or control mechanism

39
Bulik Hypothesis (Int J Eat Disord, 2005)

• Preterm birth is associated with threefold
  increase in risk of AN
• Neurodevelopmental insults in premature infants
  could contribute to delayed oral-motor growth and
  onset of early eating problems.
• Women with low prepreg BMI inadequate nutrition
  during gestation have increased risk for preterm
  delivery cycle of risk is established.

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Maternal Obesity

• Rates of obesity are increasing world-wide
• Obesity before pregnancy is associated with risk
  of several adverse outcomes

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Pregnancy Concerns Associated with Maternal
Obesity

• Nutrition and Pregnancy Outcome. Henriksen,
  Nutrition Reviews, 2006
• Management of Obesity in Pregnancy. Catalono.
  Obstetrics and Gynacology, 2007

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Diagnosis of Pregnancy Problems

• Menses tend to be irregular and pelvic exams and
  ultrasound exams may be difficult
• AFP values are lower in obese women due to
  increased plasma volume
• Blood pressure monitoring may be difficult

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Antepartum Outcomes

• Higher rates of NTD even with folic acid
  supplementation (RR 3.0 in one study)
• Increased risk for both chronic and pregnancy
  induced hypertension
• Increased risk for severe preeclampsia (BMI lt
  32.3, risk was 3.5 times that of controls)
• Increased risk of GDM, IDD and NIDD
• Increased twining
• Increased UTI

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Fetal Outcomes

• Morbidly obese women have increased risk of
  preterm delivery
• 25 of preterm births are indicated because of
  maternal medical/ob problems
• Neonatal death - stillbirth
• Increase in overweight women twice that of normal
  weight women
• Increase in morbidly obese women is 240 greater

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Labor and Birth Outcomes

• Increased incidence of cesarean births in
  nulliparous women
• BMI lt 30 21
• BMI 30-35 34
• BMI 35-40 48
• VBAC success rates
• Normal weight women 71
• Overweight women 66
• Obese women 55

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Concerns with surgical births

• Operative times are longer
• Increased incidence of blood loss during surgery
• Differences in responses to anesthesia (greater
  spread/higher levels)
• Increased risk of post-op complications
• Wound infections
• Deep venous thrombophlebitis
• endometritis

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Postpartum Outcomes

• Increased risk for endometrial infection
• Increased prevalence of urinary incontinence

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Infant Outcomes

• Large infants - effect is independent of maternal
  diabetes- rates of macrosomia (gt4000 g)
• Normal weight women 8
• Obese women 13
• Morbidly obese women 15
• Increased infant mortality - RR for infants born
  to obese women was 4.0 compared to women with BMI
  lt 20

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Long Term Risks to Infant

• Children born to obese mothers twice as likely to
  be above 95th percentile BMI at age 2
• Metabolic syndrome in at age 11
• Hazard ratio 2.19 (1.25-3.82) if LGA
• Hazard ratio 1.81 (1.03-3.19) if maternal
  obesity

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Swedish population-based study (Cedergren, 2004)

• n805,275
• Morbid obesity (BMIgt40) compared to normal
  weight
• 5 fold risk of preeclampsia
• 3 fold risk of still birth after 28 weeks
• 4 fold risk of LGA
• BMI gt35, lt40, associations remain, but not as
  strong

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Cost

• Costs were 3.2 times higher for women with BMI gt
  35
• Longer hospitalizations

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Emerging Issues Bariatric Surgery

• Outcomes
• Challenges of studies
• Appropriate control groups?
• Outcomes to measure?
• Selection bias
• Changes in procedures over time
• Clinical recommendations

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Outcomes After Malabsorptive Procedures such as
Roux-en-Y(Bernert et al. Diabetes Metab. 2007
Catalono. Obstet Gynecol, 2007)

• Associated Complications
• Small bowel ischemia
• Nutrient deficiencies (iron, folate, B12)
• Fetal abnormalities
• SGA preterm birth
• Cesarean delivery

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Pregnancy Outcomes after Gastric-Bypass Surgery

• Dao, et al. Am J Surg, 2006
• N 21 pregnant within first year post-surgery 13
  pregnant after first year (Texas)
• Author's conclusions Pregnancy outcomes within
  the first year after weight-loss surgery revealed
  no significant episodes of malnutrition, adverse
  fetal outcomes or pregnancy complications.

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Pregnancy following gastric-bypass (Dao, 2006)
lt 1 year (21) gt 1 year (13)
Mean BMI At surgery At pregnancy 49 35 46 28
Mean weight gain 4 34
Mean birthweight 2868 g (2 sets twins) 2727 g (3 sets twins)
Major pregnancy complications 5 1
Minor pregnancy complications 5 3
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Birth Outcomes in Obese Women After Laparoscopic
Adjustable Gastric Banding

• Dixon et al. Obstet Gynecology. 2005
• N79 (Australia)
• Mean maternal weight gain 9.6 /- 9.0 kg
• Mean birthweight 3,397
• Incidence of PIH, GDM, stillbirth, preterm
  delivery low and high birth weights more similar
  to population than obese women.

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Dixon Conclusions

• Pregnancy outcomes after LAGB are consistent
  with general community outcomes rather than
  outcomes from severely obese women. The
  adjustability of the LABG assists in achieving
  these outcomes.

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Pregnancy Outcome of Patients with Gestational
Diabetes Mellitus Following Bariatric Surgery

• Sheiner et al. Am J Obstet Gynecol. 2006
• N 28 (16 gastric banding)
• Compared to 7988 GDM pregnancies without surgery
• Israel between 1988 and 2002
• No differences in obstetric characteristics,
  perinatal outcomes, congenital malformations,
  Apgar, Hgb A1c, fasting glucose.

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Sheiner et al. conclusions

• Previous bariatric surgery in patients with GDM
  is not associated with adverse perinatal
  outcome.
• Note not associated with better outcomes
  either.

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Clinical Management of Pregnancy Following
Bariatric Sugary (ACOG Committee and Catalano,
Obstet Gynecology, 2007)

1. Advise women about risk of unexpected pregnancy
   following LAGB need for contraception
2. Delay pregnancy for 12-18 months avoid rapid
   weight loss phase and catabolic state
3. Close monitoring during pregnancy by both ob and
   surgeon to allow for adjustments of gastric bands
4. Supplement with folate, calcium, B12

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Hypertensive Disorders During Pregnancy

• Incidence
• Definitions
• Etiology/pathophysiology
• Nutritional Implications

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N A T I O N A L I N S T I T U T E S O F H E A
L T H N A T I O N A L H E A R T , L U N G , A N D
B L O O D I N S T I T U T E
WORKING GROUP REPORT ON HIGH BLOOD PRESSURE IN
PREGNANCY
July 2000
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Incidence

• Second leading cause of maternal mortality in US
• 15 of maternal deaths (disseminated
  intravascular coagulation, cerebral hemorrhgae,
  hepatic failure, acute renal failure)
• Hypertensive disorders occur in 6 to 8 of
  pregnancies
• Contribute to neonatal morbitity and mortality

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High risk

• First pregnancy and under age 17 or over 35
• Family history of hypertension
• Poor nutritional status
• Smoking
• Overweight
• Other health problems such as renal disease,
  diabetes
• Multiple gestation
• Some Fetal anomalies

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Chronic Hypertension

• Known hypertension before pregnancy or rise in
  blood pressure to gt 140/90 mm Hg before 20 weeks
• Hypertension that is diagnosed for the first time
  during pregnancy and that does not resolve
  postpartum is also classified as chronic
  hypertension.

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Gestational Hypertension

• Hypertension in pregnancy is present when
  diastolic BP is 90 or greater, systolic BP is 140
  or greater
• the use of BP increases of 30 mm Hg systolic and
  15 mm Hg diastolic has not been recommended -
  women in this group not likely to have increased
  adverse outcomes
• ¼ of women with gestational htn advance to
  preeclampsia

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Preeclampsia

• Preeclampsia is defined as the presence of
  hypertension accompanied by proteinuria
• In the absence of proteinuria the disease is
  highly suspect when increased blood pressure with
  headache, blurred vision, and abdominal pain, or
  with abnormal laboratory tests, specifically, low
  platelet counts and abnormal liver enzymes.

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Proteinuria

• Proteinuria is defined as the urinary excretion
  of 0.3 g protein or greater in a 24-hour
  specimen.
• This will usually correlate with 30 mg/dL (1
  dipstick) or greater in a random urine
  determination with no evidence of urinary tract
  infection.
• because of the discrepancy between random protein
  determinations and 24-hour urine protein in
  preeclampsia it is recommended that the diagnosis
  be based on a 24-hour urine if at all possible

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Findings that increase the possibility of
Eclampsia and indicate need for FU Severe
Preeclampsia
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(No Transcript)
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Edema
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Dx of Preeclampsia Superimposed on Chronic Htn.
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Eclampsia

• Occurrence in a woman with preeclampsia, of
  seizures that can not be attributed to other
  causes
• Rare 4 of women with preeclampsia advance to
  eclampsia

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Etiology

• Not fully understood
• Primary pathophysiology is placental function
• Secondary pathophysiology involves endothelial
  cell dysfunction due to factors released because
  of insufficient placental blood supply

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Characterized by

• Vasospasm
• Activation of the coagulation system
• Perturbations in systems related to volume and
  blood pressure control

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Pathogenic Mechanisms

• Delivery is only known cure - research has
  focused on placenta
• failure of the spiral arteries (terminal branches
  of uterine artery) to remodel
• alterations in immune response at the maternal
  interface
• increase in inflammatory cytokines in placenta
  and maternal circulation, natural killer cells,
  and neutrophil activation

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Pathophysiology

• Decreased blood flow
• Decreased renal blood flow, decreased GFR, Na
  retention
• Tissue hypoxia
• Damage to organs multi-organ disease affecting
  the liver, kidneys, and brain

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Pathophysiology

• Decreased blood volume
• Decreased placental blood flow may occur 3-4
  weeks before increased BP
• Hypoxia
• Decreased nutrient delivery

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Outcomes

• Increased LBW and IUGR for infant
• There is mounting evidence that children born to
  mothers whose blood pressure was elevated during
  pregnancy are at greater risk for elevated blood
  pressure during childhood and adolescence
• Also long term maternal health may be affected by
  consequences of maternal damage to renal and CV
  systems.

80
Focus of Possible Interventions

• Smooth muscle contraction
• Prostaglandin synthesis

81
Calcium

• Epi studies suggest inverse relation between
  dietary calcium and PIH
• Intraerythrocyte calcium levels and intracellular
  calcium ion conc. increased in women with
  pre-eclampsia
• HO Ca supplementation reduced serum parathyroid
  hormone reduced intracellular Ca conc. in
  vascular smooth muscle cells and reduces response
  to pressure stimuli
• Several RCT have found reduced risk of PIH with
  Ca supplementation to prevent (not treat) PIH.

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Calcium, cont.

• Recent meta-analysis found Ca intake of 1.5-2 g
  associated with sig. reductions in systolic and
  diastolic BP without adverse effects.
• Question remains does lowering BP have effect on
  pathophysiology of PIH?

83
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)

• 12 studies met criteria
• Randomized trials comparing at least one gram
  daily of calcium during pregnancy with placebo.
• RR of high blood pressure with Ca supplements
  0.70 (95 CI, 0.57-0.86)
• RR of preeclampsia with Ca supplements 0.48
  (95 CI, 0.33-0.69)

84
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)

• 5 trials of Ca supplements in high risk women
• RR 0.22 (95 CI, 0.12-0.42)
• 7 trials in women with low baseline Ca
• RR 0.22 (95 CI, 0.18-0.70)

85
Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems updated 2006

• Reviewers conclusions
• Calcium supplementation appears to almost halve
  the risk of pre-eclampsia, and to reduce the rare
  occurrence of the composite outcome 'death or
  serious morbidity'. There were no other clear
  benefits, or harms.

86
Cochrane Magnesium supplementation in
pregnancy updated 2001

• There is not enough high quality evidence to show
  that dietary magnesium supplementation during
  pregnancy is beneficial.

87
Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)

• Theory
• Ratio of omega 6 and omega 3 fa may modify
  processes related to PIH such as platelet and
  leukocyte reactivity, vasodilation, and
  inflammatory processes.
• Study design
• small case control, n22 cases, 40 controls
• adjusted for parity and pre-pregnancy BMI

88
Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)

• Results
• Women with the lowest tertile of n-3 in
  erythrocytes had odds ratio of 7.6 (95
  CI1.4-40.6) for developing preeclampsia.

89
Cochrane Marine oil, and other prostaglandin
precursor, supplementation for pregnancy
uncomplicated by preeclampsia or intrauterine
growth restriction (2006)

• 6 trials
• No clear difference in the RR of preeclampsia
  between groups
• 2 trials, lower risk of giving birth before 34
  weeks
• RR 0.69 (95 CI 0.49-0.99)

90
Antioxidants and Preeclampsia Definitions

• Antioxidants any substance that, when present in
  low concentrations compared to that of an
  oxidizable substrate, significantly delays or
  inhibits oxidation of that substrate
• Free radical scavengers include vitamin C
  (ascorbate), vitamin E (tocopherols), carotenoids
  
• Antioxidant enzymes include glutathione
  peroxidase, superoxide dismutase and catalase,
  which are dependent on the presence of co-factors
  such as selenium, zinc and iron

91
Antioxidants and Preeclampsia Possible Mechanisms

• Placental underperfusion may mediate a state of
  oxidative stress.
• Oxidative stress, coupled with an exaggerated
  inflammatory response, may result in the release
  of maternal factors that result in inappropriate
  endothelial cell activation and endothelial cell
  damage
• Supplementing women with antioxidants may
  increase their resistance to oxidative stress,
  and hence could limit the systemic and
  uteroplacental endothelial damage seen in
  pre-eclampsia

Cochrane, 2005
92
Cochrane Antioxidants for preventing
pre-eclampsia (2005)

• 7 trials involving 6082 women
• Only 3 of 7 were rate high quality
• All randomized and quasi-randomized trials
  comparing one or more antioxidants with either
  placebo or no antioxidants during pregnancy for
  the prevention of pre-eclampsia, and trials
  comparing one or more antioxidants with another,
  or with other interventions.

93
Cochrane Antioxidants for preventing
pre-eclampsia (2005)

• Supplementing with any antioxidants during
  pregnancy compared to control
• RR of preeclampsia 0.61 (95 CI, 0.50,0.70)
• RR SGA 0.64 (95 CI, 0.47,0.87)
• Increased risk of preterm birth RR 1.38 (95 CI,
  1.04,1.82)

94
Cochrane Antioxidants for preventing
pre-eclampsia (2005)

• These results should be interpreted with
  caution, as most of the data come from poor
  quality studies. Nevertheless, antioxidant
  supplementation seems to reduce the risk of
  pre-eclampsia. There also appears to be a
  reduction in the risk of having a
  small-for-gestational-age baby associated with
  antioxidants, although there is an increase in
  the risk of preterm birth. Several large trials
  are ongoing, and the results of these are needed
  before antioxidants can be recommended for
  clinical practice.

95
Other Nutrition Related Factors

• Na Pregnant women with proteinuric hypertension
  have lower plasma volume Na. restriction is
  associated with accelerated volume depletion
  not recommended
• Energy and Protein intake increases not found
  to be useful
• Weight reduction or limited gain in pregnancy
  not found to be useful

96
Position StatementGestational Diabetes Mellitus
American Diabetes Association2004
97
Definition

• Gestational diabetes mellitus (GDM) is defined as
  any degree of glucose intolerance with onset or
  first recognition during pregnancy. 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.

98
Prevalence

• 7 of all pregnancies are complicated by GDM in
  US
• more than 200,000 cases annually in US
• prevalence may range from 1 to 14 of all
  pregnancies, depending on the population studied
  and the diagnostic tests employed.

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Diagnosis

• Assess risk at first visit
• If high risk (marked obesity, personal history of
  GDM, glycosuria, or a strong family history of
  diabetes) GTT ASAP
• Women of average risk should have testing
  undertaken at 2428 weeks of gestation
• Low-risk status requires no glucose testing

100
Low Risk Criteria

• Age lt25 years
• Weight normal before pregnancy
• Member of an ethnic group with a low prevalence
  of GDM
• No known diabetes in first-degree relatives
• No history of abnormal glucose tolerance
• No history of poor obstetric outcome

101
Non GTT dx

• A fasting plasma glucose level gt126 mg/dl (7.0
  mmol/l) or a casual plasma glucose gt200 mg/dl
  (11.1 mmol/l) meets the threshold for the
  diagnosis of diabetes, if confirmed on a
  subsequent day, and precludes the need for any
  glucose challenge

102
One-step Approach

• Perform a diagnostic oral glucose tolerance test
  (OGTT) without prior plasma or serum glucose
  screening
• May be cost-effective in high-risk patients or
  populations (e.g., some Native-American groups).

103
Two-step approach

• Initial screening by measuring the plasma or
  serum glucose concentration 1 h after a 50-g oral
  glucose load
• Diagnostic OGTT on that subset of women exceeding
  the glucose threshold value on the GCT

104
Table 1 Diagnosis of GDM with a 100-g oral
glucose load
mg/dl mmol/l

Fasting 95 5.3
1-h 180 10.0
2-h 155 8.6
3-h 140 7.8
Two or more of the venous plasma concentrations
must be met or exceeded for a positive diagnosis.
The test should be done in the morning after an
overnight fast of between 8 and 14 h and after at
least 3 days of unrestricted diet ( 150 g
carbohydrate per day) and unlimited physical
activity. The subject should remain seated and
should not smoke throughout the test.
105
Infant Concerns in GDM

• Higher risk of
• neural tube defects
• birth trauma
• hypocalcemia
• hypomagnsemia
• hyperbilirubinemia
• prematurity syndromes
• subsequent childhood and adolescent obesity and
  risk of diabetes

106
Infant Concerns, cont.

• Macrosomia in infant due to high glucose levels
  from mother and fetal insulin response leading to
  increased fat deposition, associated with
  complications at delivery.
• Hypoglycemia of infant following delivery due to
  high fetal insulin levels at delivery and sudden
  withdrawal of maternal glucose transfer

107
Maternal Concerns

• Higher risk of
• hypertension
• preeclampsia
• urinary tract infections
• cesarean section
• future diabetes

108
Nutritional Therapy in GDM

• Goals
• prevent perinatal morbidity and mortality by
  normalizing the level of glycemia
• prevent ketosis
• provide adequate energy and nutrients for
  maternal and fetal health
• dependent on maternal body composition

109
Monitoring

• Daily self-monitoring of blood glucose (SMBG)
• Urine glucose monitoring is not useful in GDM.
  Urine ketone monitoring may be useful in
  detecting insufficient caloric or carbohydrate
  intake in women treated with calorie restriction.
  

110
Monitoring

• Blood pressure and urine protein monitoring to
  detect hypertensive disorders.
• Increased surveillance for pregnancies at risk
  for fetal demise is appropriate
• Assessment for asymmetric fetal growth by
  ultrasonography to assess need for insulin

111
Nutrition Management

• All women with GDM should receive nutritional
  counseling, by a registered dietitian when
  possible
• For obese women (BMI gt30 kg/m2), a 3033 calorie
  restriction (to 25 kcal/kg actual weight per
  day) has been shown to reduce hyperglycemia and
  plasma triglycerides with no increase in
  ketonuria
• Restriction of carbohydrates to 3540 of
  calories has been shown to decrease maternal
  glucose levels and improve maternal and fetal
  outcomes

112
Insulin

• 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)
• 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)
• 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)
• Oral glucose-lowering agents have generally not
  been recommended during pregnancy

113
Exercise

• Programs of moderate physical exercise have been
  shown to lower maternal glucose concentrations in
  women with GDM

114
Long Term

• Reclassification of maternal glycemic status
  should be performed at least 6 weeks after
  delivery
• If glucose levels are normal post-partum,
  reassessment of glycemia should be undertaken at
  a minimum of 3-year intervals
• education regarding lifestyle modifications that
  lessen insulin resistance, including maintenance
  of normal body weight through MNT and physical
  activity.

115
Long Term

• Avoid medications that worsen insulin resistance
  (e.g., glucocorticoids, nicotinic acid)
• Seek medical attention if develop symptoms
  suggestive of hyperglycemia.
• Use family planning to assure optimal glycemic
  regulation from the start of any subsequent
  pregnancy

116
Emerging Understandings 5th International
Workshop-Conference on Gestational Diabetes
Mellitus

• Diabetes Care. Supplement July 2007
• Pathophysiology
• Therapy
• Impact on infants
• Maternal follow-up

117
Emerging Issues Pathophysiology

• Basic In GDM insulin levels are insufficient to
  meet insulin demand
• Categories of dysfunction chronic exposed by
  the general insulin resistance of pregnancy
  rather than acute due to
• Autoimmune b-cell dysfunction (fast
  deterioration)
• Genetic abnormalities that lead to impaired
  insulin secretion (5, monogenic forms of
  diabetes such as maturity-onset diabetes of the
  young (MODY) and mitochondrial diabetes
• b-cell dysfunction associated with chronic
  insulin resistance

118
Therapeutic Interventions During Pregnancy

• Recent RCT found treatment started before 30
  weeks reduced likelihood of serious neonatal
  morbidity
• Individualize MNT
• Daily self monitoring of blood glucose (SMBG)
• Insulin when needed (20 needed)

119
Treatment, cont.

• Metabolic management based on fetal growth
  measures is promising technique
• Oral antihyperglycemic agents
• Glyburide (glibenclamide) studies indicate may
  be useful adjunct to MNT/PA may be less
  successful with obese patients
• Metformin crosses placental, insufficient
  evidence that prevents GDM
• Acarbose safety not fully evaluated

120
Offspring

• Newborns of women with GDM have increased
  adiposity and reduced fat free mass even if not
  macrosomic
• Breastfeeding may be protective against childhood
  overweight in children born to GDM

121
Maternal Follow-up

• Majority will eventually develop diabetes-
• 35-60 percent within 10 years
• risk continues at least 1-2 decades after GDM
  pregnancy
• Increased risk of congenital anomalies in
  subsequent pregnancies
• There is substantial research evidence that
  lifestyle change and use of metformin or
  thazolidinediones can prevent or delay the
  progression of IGT to type 2 diabetes after GDM.