Diabetes Management During Pregnancy: Insights From 3 Specialists

At an Institute for Value-Based Medicine^® (IVBM) event held in Cleveland, Ohio, The American Journal of Managed Care^® (AJMC^®) spoke to 3 specialists in the field of diabetes and pregnancy:

• Stacey Ehrenberg, MD, maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Cleveland Clinic
• Kevin Borst, DO, director of the Endocrine Disorders in Pregnancy Center at Cleveland Clinic.
• Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, director of education and training in diabetes technology at Cleveland Clinic

These conversations covered a range of topics surrounding diabetes management during pregnancy, including the process of diagnosing diabetes during pregnancy, treatment strategies, postpartum considerations, and the importance of ongoing monitoring and lifestyle adjustments to mitigate long-term risks.

Stacey Ehrenberg, MD – Cleveland Clinic

AJMC: How does diabetes get diagnosed in pregnancy?

Ehrenberg: We diagnose diabetes in pregnancy a couple of different ways. We diagnose gestational diabetes by evaluating a patient at their first prenatal visit for any risk factors for diabetes. And if they have risk factors that really are risk factors outside of pregnancy for diabetes—things like carrying extra weight before pregnancy, polycystic ovarian syndrome, having a family history of diabetes—if any of those things are present, then we test the patient early, usually before 15 weeks of pregnancy, by doing a glucose tolerance test where they drink a certain amount of glucose and we test their blood sugar an hour later in the lab. If patients don't have any risk factors for diabetes, we do a similar test, and we do that at 24 to 28 weeks.

In the first trimester, we can also use the tests that are used outside of pregnancy. So, if a woman has risk factors for diabetes, then we can use a hemoglobin A_1C [test], we can do a 2-hour glucose test, we can do a random glucose test. Really any of the tests that we use outside of pregnancy, we can use inside of pregnancy to diagnose type 2 diabetes in the first trimester.

AJMC: How does treatment of diabetes in pregnancy differ from treatment for nonpregnant individuals?

Ehrenberg: Most of the first set of treatments is actually exactly the same. The first thing we always recommend for any woman with diabetes and pregnancy, whether it's gestational or pregestational, is diet and exercise. Adjusting your diet plan with a dietitian and trying to eat a more low-carbohydrate, high-protein, higher-fat diet is really the first recommendation, and increasing your exercise. I always tell my patients I'm not looking for you to start training for a marathon or start kickboxing classes. It really just needs to be something as simple as turning some music on and dancing around the family room [or] going for a walk for 20 to 30 minutes after dinner. It really can be something very simple. There are a lot of great YouTube videos now for exercise [during] pregnancy that can really be done at home in your family room with nothing more than a bit of floor space. I don't need people to do anything fancy, just to get their heart rate up and keep their bodies moving for 20 to 30 minutes straight is all we need.

Those are very similar to the recommendations outside of pregnancy. The biggest difference comes in when you need medications. And there are a lot of medications that are phenomenal for use outside of pregnancy that we just don't have any data on in pregnancy. So, we're very limited in pregnancy with the medications we can use, because we don't want something that can cross the placenta and potentially harm the baby, whether it's short-term complications for the baby or long-term complications that we may not know about during the pregnancy or immediately after birth. Insulin is really the first-line medication in pregnancy because the insulin molecule is too big to cross the placenta, so we know that there can't be any complications to the baby from the insulin itself, only the positive benefits of lowering the blood sugar, because mom's glucose can cross the placenta and go to the baby.

Kevin Borst, MD – Cleveland Clinic

Borst: In pregnancy, the patients are much more high risk than outside of pregnancy, and the targets for glycemic control are much more stringent. For example, targets for fasting blood sugar are less than 90 mg/dL; targets for 2-hour postmeal blood glucose are less than 120 mg/dL. These targets are significantly different than targets we would use outside of pregnancy and hemoglobin A_1C targets are also much more stringent in pregnancy. Ideally, we have these patients less than 6.5%, which again would be a lot more stringent than what we would have a patient who is not pregnant.

AJMC: Is it harder to get them to those targets?

Borst: It is for various reasons. One reason is the means that we have to treat diabetes and pregnancy are much more limited. Basically, we're able to use insulin, and metformin really is the only oral agent that you're able to use during pregnancy. So, in that regard, yes it is more difficult.

AJMC: What are the best practices for teaching patients how to utilize insulin pumps and automated insulin delivery, and after they start, what follow-ups are you doing to ensure things are going smoothly?

Borst: Generally, I will meet with a patient and determine if a patient is first interested in using these types of systems during their pregnancy, and if they are interested in it, we have them meet with diabetes educator who will formally review with them the ins and outs of how to use these systems. They certainly need to know how to do it before they start it, but we have diabetes educators that go through this with the patients and help them before they start.

During pregnancy, again, it's a little bit more intensive than when patients are not pregnant, and when patients are on these systems during pregnancy, I review their data weekly. All their data is stored in clouds and we're able to access it remotely, so patients don't need to come in every week. But we're able to review the data every week and send them messages through our portal with changes that need to be made in their pump settings or their insulin dosing, for example. And as pregnancy progresses, there are many changes that need to be made.

AJMC: How does diabetes treatment and monitoring change from when a patient is pregnant to postpartum?

Diana Isaacs, PharmD – Cleveland Clinic

Isaacs: For someone with gestational diabetes, the good news is, even if they required insulin, often, they're going to be able to stop insulin. However, they have a much higher risk of developing type 2 diabetes. We generally perform an oral glucose tolerance test 6 to 12 weeks after delivery. However, getting people to do that test is really tough, so many times people get lost to follow-up, and we need more resources to really address the postpartum period. The other thing that happens for those with type 1 diabetes, throughout the pregnancy, we are increasing those insulin doses. And often we'll send them home with a plan where we decrease those doses.

But with breastfeeding, as many people do, that throws a whole other thing into the equation, which often leads to hypoglycemia. So, it's really important to have these frequent follow-ups and check-ins after delivery to make sure we are decreasing the doses appropriately, because it's hard enough in the postpartum period—like the fatigue and lack of sleep—that we don't want to be throwing hypoglycemia into the mix. We don't need to have weekly visits forever like we did in pregnancy, but we should have a touch point shortly after, a few days after discharge from the hospital and a couple early on, and then it can be spaced out more.

Borst: [Diabetes management] after delivery is a different can of worms. I always tell my patients that's a time where diabetes management is probably the most difficult because they've just gone through an entire pregnancy where they've had to be very rigid about everything that they're doing, and then they deliver the baby and it's a time where people tend to exhale a little bit. Also, they're dealing with a newborn baby which, when you're trying to manage diabetes, it's difficult if diabetes is coming in sixth or seventh place, and that's just what happens after you deliver a newborn baby.

First of all, their insulin requirements change quite a bit, and generally I put them back on something similar to what they were on before the pregnancy. And then I try to, for lack of a better way to put it, keep them on the rails for the first several weeks until things start to calm down at home, and the baby starts sleeping, and then people start getting back into the routine a little bit more.

AJMC: Does gestational diabetes always go away? How do you transition a person from treatment during pregnancy to treatment postpartum?

Ehrenberg: This is a great question, and probably one of the first questions my patients ask me is, "Is this going to go away or am I going to have diabetes forever?" Well, the answer is "maybe." I mean, this certainly puts you at risk for lifelong diabetes.

So, after pregnancy, we do another glucose test, and 30% of women who have gestational diabetes will have prediabetes or type 2 diabetes immediately after delivery, and 50% of women will develop type 2 diabetes in the next 10 years. This is a huge risk factor for lifelong diabetes, and even if the test is normal right after delivery, we always want patients to let their primary care physician know that they've had gestational diabetes so that they can be watched more closely, tested more frequently, and catch it early so that they're not the patients who are going to have the long-term complications from uncontrolled diabetes.

We always tell our patients in pregnancy, these tips and tricks that we're teaching you now, as far as dietary adjustments and exercise, are really things that you can use even after pregnancy to help either postpone or completely avoid the diagnosis of type 2 diabetes.