SEX EDUCATION AND PREGNANCY IN TYPE 1 DIABETES SANDY HOOPS, PA-C, CDE MARY VOELMLE, FNP, CDE OBJECTIVES • GROUP DISCUSSION OF CONTRACEPTIVE OPTIONS FOR THE PATIENT WITH TYPE 1 DIABETES • GROUP DISCUSSION OF MANAGEMENT OF PREGNANCY IN THE PATIENT WITH TYPE 1 DIABETES CASE 1 15 YEAR OLD with DM x 8 yrs • Current A1C 11.8% • MDI – GLARGINE and LISPRO • Question for the day: “What should my friend use for birth control?” Case 2 21 yr old female with DM x 8 yrs • • • • • • A:C Ratio 60 (<30 Normal) Tx Lisinopril 10mg QD Background retinopathy Smoking less than ½ ppd LMP May 28, 2008 – 6 weeks gestation MDI – GLARGINE and LISPRO HbA1c: 9.2% WHAT ADVISE DO YOU GIVE? Case 1 ISSUES TO DISCUSS WITH YOUR ADOLESCENT PATIENT (SEXUALLY ACTIVE OR THINKING ABOUT IT) • TIME = TRUST • CONFIDENTIALITY • OPTIONS -Preconceptual Counseling • CORRECT RESOURCES • TROUBLE SHOOTING Hormonal contraceptive • • • • • • • Depo Provera - subQ Femcon FE Implanon Mirena IUS Plan B Seasonique Yaz 24/4 Non Hormonal Contraception • • • • • • • IUD Diaphragm Cervical Cap Condom Vaginal Sponge Spermicides Abstinence What to Recommend? • • • • • • Preconceptual Counseling Hormonal vs. Non-Hormonal Patient specific Hormonal – Lo dose estrogen Non-Hormonal – IUD, barrier method ALWAYS CONDOMS!! Case 2 IMPROVE CONTROL NOW! • • • • • • Increase glucose testing to 10 x daily Consider CGM Quit smoking Add PNV Referral to perinatology Consider CSII Results! Planning Pregnancy • HbA1c level < 6% provide significantly better glucose levels than those > 6% * • Detection rate of hyper- and hypoglycemia higher in patients testing 10 or more times daily * • Established pre-pregnancy DM control key *Kerssen et al., Diabetologia, 2006, 49: 25-28. Risk to Mom with Type I • Hypoglycemia • Urgent reduction in glucose variability – strict control initiated within 24-48 hrs of pos HCG • Accelerated retinopathy • PIH • Preeclampsia • Diabetic ketoacidosis Risk Factor for Progression to PDR 1- Baseline retinopathy 2- Elevated HbA1c at conception 3- Rapid normalization of blood glucose 4- Duration of DM greater than 6 years 5- Proteinuria Phelps et al. Arch Ophthalmol 1986; 104:1806-10. Effect of Pregnancy on Microvascular Complications • Pregnancy in Type I DM induces transient increase in the risk of retinopathy; increased ophthalmologic surveillance is needed during pregnancy and 1st yr postpartum. • Long-term risk of progression of early retinopathy and albumin excretion do not appear to be increased in pregnancy DCCT, Diabetes Care, 23 (8), August 2000 Risk to Infant of Diabetic Mothers • Congenital malformations – occur during organogenesis – 7 weeks gestation • Spontaneous abortion due to maternal hyperglycemia, vascular disease, uteroplacental insufficiency • Congenital malformations 13% in women with diabetes vs 2% nondiabetic mothers Jovanovic. Endocrinlogy Metab Clinic N America 35 92006) 97-97. Pregnancy Goals • Hemoglobin A1C Goals: 5.0%-6.0% Glucose Goals: Pre-meal/Fasting 60-99 mg/dl 1-hour or peak postprandial <129 mg/dl Bedtime 100-130 mg/dl Overall average: 110 mg/dl • • • • • • Seen in clinic bi-monthly/ monthly for diabetes management. OB monthly to follow baby – perinatology referral if needed. Retinal eye exam in each trimester. 24 hr urine for protein excretion and creatinine 1st/3rd trimester. TSH and Free T4 at first visit. Treat TSH >2.5 Most deliver by induction at 37-39 weeks gestation if lungs are mature. Insulin Adjustments During Pregnancy • Intensification to insulin regime initially • 9-12 weeks expect more frequent hypoglycemia • 24-28 weeks initial insulin resistance • Insulin dose 2-3 x starting dose by delivery • Watch for undetermined hypoglycemia 36+ weeks to increase fetal monitoring A1c levels during pregnancy 7.20 7.05 7.00 p = 0.41 6.80 6.80 Comparison RTCGM group A1c % 6.60 6.46 6.41 6.40 6.26 6.19 6.20 p = 0.09 p < 0.03 6.11 6.00 5.95 p = 0.20 p = 0.13 5.95 p = 0.15 5.89 5.82 5.80 5.73 5.60 Baseline 3M 4M 5M Gestational Month 6M 7M Voelmle---Garg: 57, 2008 *p < 0.001 within Diabetes, groups from BL % RTCGM glucose readings at baseline and 3 months with A1c Reduction Baseline 3 Months after Sensor Start 8% 8% 46% 47% 46% BTR WTR 45% ATR Voelmle---Garg: Diabetes, 57, 2008 Conclusions Pregnancy is a motivator in itself to encourage optimal glucose control, yet tools such as RTCGM allow more patient awareness of continuous glucose level changes. This addition to SMBG may allow the patient to make more informed decisions about insulin therapy. A significantly lower A1c at 7 months of gestation leads us to believe that A1c reduction was significant at delivery and therefore indicative of superior glucose control. Severe hypoglycemia is a risk of obtaining and maintaining near normal A1c’s. Women who are pregnant need to have additional tools available at their disposal to help them detect glucoses values below target range (<60 mg/dl) and avoid dangerous outcomes. We conclude the use of RTCGM in pregnancy with diabetes may improve metabolic control throughout gestation. Pregnancy is clearly a motivating factor for women to reduce their A1c values, yet as pregnancy progresses RTCGM has the ability to maintain that reduction in A1c better than SMBG alone. Severe hypoglycemia can be avoided if patients are given tools to help detect glucoses in a low range. This pilot study supports the need for larger, randomized, controlled trial to evaluate the significance and clinical implications of RTCGM in the management of pregnant women with type 1 diabetes. Voelmle---Garg: Diabetes, 57, 2008 THANK YOU! QUESTIONS/COMMENTS? References Masimasi, N., Sivanandy, M., Thacker, H. “Update on Hormonal Contraception”, Cleveland Clinic Journal of Medicine, Vol. 74, No. 3, March 2007 ACOG Education Pamphlet AP159, accessed on 5/26/2008 www.acog.org/publications/patient_education Non-Hormonal Contraceptive Methods: A Quick Reference Guide for Clinicians, Association of Reproductive Health Professionals, www.arhp.org Visser J., Snel M., Van Vliet H , Hormonal versus non-hormonal contraceptives in women with diabetes mellitus type 1 and 2 (Review), Copyright 2008 The Cochrane Collaboration, Published by John Wiley & Sons, Ltd., 2008, issue 2. Tolaymat, L, Kaunitz A., Long-acting contraceptives in adolescents, Current Opinion in Obstetrics & Gynecology. 19(5):453-460, October 2007. Colorado Organization on Adolescent Pregnancy, Parenting and Prevention, The State of Adolescent Sexual Health in Colorado 2008 Accessed on 7/9/2008, www.coappp.org Teal S., Ginosar D., Contraception for Women with Chronic Medical Conditions, Obstetric Gynecology Clinic North America, 34(2007)113-126. Care of Children and Adolescents with Type 1 Diabetes, A statement of the American Diabetes Association, Diabetes Care 28:186-212, 2005. Preconception Care of Women with Diabetes, American Diabetes Association, Diabetes Care26:S91-S93, 2003. Managing Preexisting Diabetes for Pregnancy, Consensus Statement American Diabetes Association, Diabetes Care, Vol. 31, No. 5, May 2008. Charron-Prochownik D., Ferons-Hannan M., Sereika S., Becker D., Randomized Efficacy Trial of Early Preconception Counseling for Diabetic Teens (READY – Girls), Diabetes Care, Vol. 31, No 7, July 2008.