Providing expert care for patients with pre-existing diabetes and gestational diabetes mellitus (GDM), endocrinologists and maternal-fetal medicine specialists in the Diabetes in Pregnancy Program at Brigham and Women’s Hospital (BWH) are utilizing innovative strategies to manage diabetes in pregnancy.
“Many of our patients have highly complex needs with vascular and other complications from diabetes and may be on the verge of needing dialysis when they come to us,” said Chloe A. Zera, MD, MPH, a maternal-fetal medicine specialist in the Program. “In order to see these patients safely through pregnancy and improve their health and their families’ health for the long term, we deliver seamless outpatient and inpatient care and delivery and postpartum follow up.”
Patients are evaluated and treated in a multidisciplinary clinic using a team-based model with endocrinologists, maternal-fetal medicine specialists, nurse practitioners, social workers, and nutritionists collaborating in the care of each patient in a single visit. The team employs an evidence-based approach to control diabetes while managing changes during pregnancy. Progressive approaches to medication management include expertise in insulin pump and continuous glucose monitoring, use of U-500 insulin, and oral agents when appropriate. To optimize a woman’s health prior to pregnancy, Emma Morton-Eggleston, MD, MPH, an endocrinologist in the Program, and Dr. Zera frequently counsel patients with Type 1 and Type 2 diabetes prior to conception.
“As more women develop Type 2 diabetes during their childbearing years and women with Type 1 diabetes plan pregnancies, we are facing an increasing number of challenging cases of pre-existing diabetes during pregnancy and growing concerns about both adverse outcomes in the short term and childhood metabolic outcomes,” said Dr. Morton-Eggleston. “The normal physiologic changes of pregnancy can make it very difficult to control glycemia and manage complications throughout pregnancy, even for patients who have previously had good control. It is critical to provide care with an integrated approach that provides advanced clinical expertise with a supportive approach that maximizes maternal and fetal outcomes while allowing women and their families to feel engaged in their care.”
Ellen W. Seely, MD, Director of Clinical Research in the Division of Endocrinology, Diabetes and Hypertension at BWH, and her team, including Dr. Zera, developed Balance after Baby, a web-based lifestyle intervention funded by the Centers for Disease Control and Prevention to promote weight loss after pregnancy by educating women on eating healthfully and increasing their physical activity. In a study published in 2014 Obstet Gynecol. 2014 Sep;124(3):563-70.), the team found that women who followed the online program reached their pre-pregnancy weight at one year after delivery, compared with weight gain in the control group of women with gestational diabetes who received standard care after delivery.
“We know that up to 60 percent of women who have gestational diabetes go on to develop Type 2 diabetes and that this risk is particularly high during the decade after birth,” said Dr. Seely. “We were able to demonstrate the feasibility and efficacy of a lifestyle modification program in decreasing postpartum weight retention in the first postpartum year for women with recent GDM.”
The team is engaged in a wide range of ongoing research related to diabetes in pregnancy. A current study using the Balance after Baby program is following women for two years after pregnancy to see if the weight loss is sustained and whether glucose levels are controlled during this time. As a founding member of the Boston area Diabetes in Pregnancy Study Group, the team is planning to launch a cohort study of psychosocial predictors of diabetes-related pregnancy outcomes in 2016.
“We are looking at the larger picture with the goal to promote health throughout the woman’s lifespan, not just during pregnancy,” said Dr. Zera.
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