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THE PERINATAL OUTREACH PROGRAMThe Perinatal Outreach Program is a collaborative effort betweenSSM Maternity Care at St. Mary’s Health Center, SSM Cardinal GlennonChildren’s Medical Center and Saint Louis University School of Medicine.It is designed to improve outcomes for mothers and babies througheducational programs and quality improvement activities for regionalperinatal care providers in eastern Missouri and Southern Illinois.The Perinatal Outreach Program is the designated AdministrativePerinatal Center for Southern Illinois.VOL. 27 NO. 1 | MARCH 2013PERINATAL TIMES EDITORIAL BOARDConnie Thompson, RNC, BSN, EditorSSM Cardinal Glennon Children’s Medical CenterAyoob Ali, MD, MPHGlenn Barber, RNC, BSNRobyn Gude, RN, MSNMary Hope, RN, BSNWilliam Keenan, MDPatricia OberkirschSSM St. Mary’s Health CenterErol Amon, MD, JDKathy Canchola, RN, BSNGilad A. Gross, MDKatie Kulaitis, RN, BSNThomas Myles, MDPam Randazzo, RNC, BSNSharon Rector, RNC, MSNJudy Wilson-GriffinFUNDINGFinancial support for the The Perinatal Times is provided bySSM Health Care - St. Louis and the Illinois Department of Public Health.IN THIS ISSUE:1346GLUCOSE CONTROL DURINGLABOR MADE EASY it’s not asformidable as it soundsFORMULARY FACTS: LEVEMIRDURING PREGNANCY a stepforward in managing diabetesINFANT OF A DIABETIC MOTHERa unique set of challenges forthe clinical practitionerMONITOR CORNER cervicalripening & labor induction dueto complex historyLETTERSThe Perinatal Times welcomes comments on any of its articles and willconsider such letters for publication. Suggestions for future topics ofinterest or announcements are encouraged.Please send correspondence to:The Perinatal TimesConnie Thompson, EditorSSM St. Mary’s Health Center6420 Clayton Road, Richmond Heights, MO 63317connie_thompson@ssmhc.com

GLUCOSE CONTROL DURING LABOR MADE EASYBY DOROTHEA MOSTELLO, MDControlling glucose in labor for women with diabetes is not asformidable as it sounds. Understanding three basic principlesthat underlie this practical approach to glucose management isthe key to success:1. Assure adequate hydration and nutrition2. Avoid high glucose values and large boluses of dextrose3. Frequently monitor and adjust fluids to achieve the goalof keeping the maternal glucose level between 70 and110 mg/dl.LABOR IS WORKLabor is work - work that is performedmost efficiently with adequatehydration and nutrition. Totalfluids in the range of 200-250 cc/hr result in faster labors. Thecells that do the work needfuel. Most women require6-10 grams per hour of glucoseto avoid starvation ketosis,when catabolism of fat andmuscle kicks in. No calculator isrequired: “D5” means 5 gramsof dextrose per 100 cc. It is easyto do the math from there. Avoidthe temptation to use only fluidswithout dextrose. The cells of womenwith diabetes need as much fuel as anyoneelse. Monitor for ketones in the urine to see ifthe laboring woman is getting enough nutrition for hertask. If she is, the ketones should be negative.MORE THAN DEXTROSEGiving dextrose is not enough. Glucose needs to get into thematernal cells to meet her needs. This job is accomplished byinsulin, either endogenous or prescribed, and insulin keepsthe circulating glucose levels appropriate. High circulatinglevels of glucose during labor easily cross the placenta and insome ways can undo months of even excellent control. Thehigh levels can ramp up the baby’s insulin production and leadto hypoglycemia in the nursery. In addition, a large supplyof glucose, either from high circulating levels or from a largebolus, can be detrimental to the fetus in times of distressby leading to build up of byproducts of anaerobic glucosemetabolism when oxygen is limited. Keep the maternalglucose in the target range.Monitor glucose about every 2 to 3 hours during latentphase or cervical ripening; increase to hourly in activelabor. An intravenous insulin infusion is the most commonway to control glucose levels in labor. The correct rate ofmaintenance insulin infusion is the rate that keeps the glucoselevel in the same range from hour to hour. The correctincremental increase will allow an elevated glucose levelto return to the target range within an hour. Fortunately,most women with diabetes in pregnancy can be maintainedin the target range with one unit per hour, withincremental increases of one unit per hourfor every 30 mg/dl above the targetrange. Some women with highinsulin resistance will need 2 unitsper hour for maintenance and atighter incremental increase.Very insulin-sensitive women(especially with type 1 diabetes)may only need 0.5 units/hr anda looser scale for increases. Ifthose rates and incrementalincreases don’t quite do it,adjust the scales empiricallyto achieve glucose levels in thetarget range. For St. Louis areaSSM hospitals, standard ordersets are in the electronic record,which make ordering and altering theseinfusions easier. These order sets haverecently been updated and will soon be released.THERE ARE ALWAYS CAVEATS1. An insulin infusion is not always required. Many dietcontrolledgestational diabetics can maintain glucosevalues in labor on their own, but this cannot beassumed, so monitoring these patients is just as critical.Repeated subcutaneous injections of rapid-acting insulinmay be an alternative to an intravenous infusion, butdoses are difficult to guesstimate and absorption may bevariable when sites of injection are exercised. Womenusing an insulin pump who present in active labor, maykeep their glucoses stable and in the acceptable rangethroughout the entire labor using their pump basalrates. Similarly, women taking insulin who present inactive labor may deliver before their insulin on board(Continued on page 2)THE PERINATAL TIMES | 1

GLUCOSE CONTROL DURING LABOR - MADE EASY(Continued from page 1)dissipates and not require any more insulin duringlabor. Some may actually require extra glucose iftheir insulin peaks while they are NPO during activelabor.2. With long inductions and cervical ripening, mealcoverage becomes an issue. Adjustments inan insulin infusion for the duration of the mealand the following hour can cover a meal, as willsubcutaneous injections. Most clear liquids havecalories, as well, that are quickly absorbed and causea spike in the glucose level if not covered. Thinkingahead and common sense are the best allies in theseatypical situations. ●REFERENCESReferences available on request.ABOUT THE AUTHORDr. Dorothea Mostello is a Saint Louis University Professor of Obstetrics andGynecology, Department of Obstetrics, Gynecology and Women’s Health; aMaternal-Fetal Medicine specialist in the Maternal-Fetal Medicine Division andDirector of the Diabetes-in-Pregnancy Program at SSM St. Mary’s Health Center,St. Louis, MO.FORMULARY FACTSBY AREZO NOORMOHAMMADI, PHARM.D.AND ALICIA B. FORINASH, PHARM.D., BCPS, BCACPNPH insulin, with or without rapid-acting insulin, had beenconsidered standard of care in pregnancy when patientsrequired insulin. Two basal insulins (glargine, Lantus® anddetemir, Levemir®) are widely used in non-pregnant patientsas an alternative for NPH. Studies have shown that detemirdoes not differ significantly from regular human insulin withregard to activation of insulin-like growth factor-I (IGF-I).1Stimulation of IGF-1 receptors increases the risk for excessivefetal growth. However, glargine has higher affinity to bind toIGF-I receptors than detemir thus decreasing the potential forglargine’s use in pregnancy. (1,2)Detemir is a peakless, long-acting insulin with a durationof 24 hours, administered once or twice daily. Because ofits peakless effects, fasting blood sugar (FBS) should be theprimary target for adjustments. Detemir should not be mixedwith other insulin and is stable at room temperature for 42days after opening. (3) In contrast, NPH has a peak that canvary but occurs approximately around 4-12 hours and isgenerally split into two doses per day. (4)Until recently, safety data was lacking for detemir duringpregnancy; however, a recent randomized, open-label,controlled, multicenter trial published in October 2012demonstrated similar effects of detemir and NPH duringpregnancy. (5) This trial evaluated the efficacy and safety ofinsulin detemir compared to NPH in 310 pregnant women withType 1 diabetes.Mathiesen and colleagues randomized patients to eitherdetemir or NPH plus insulin aspart with meals. Patients wereincluded if they had a singleton gestation between 8 and 12weeks or if they intended to become pregnant, were on insulinfor at least 12 months prior to enrollment, and had A1c

LEVEMIR IN PREGNANCYneonatal outcomes were not presented in this manuscript butshould be published later.The study was open-labeled, therefore it could have beeninfluenced by possible confounding factors. It is alsoimportant to note that the study was performed includingpatients with Type 1 diabetes, limiting its external validity inextrapolating to patients with gestational diabetes or type2. However, it is likely that similar results would be seen inpatients with gestational diabetes.Unfortunately, initial dosing strategies for detemir have notbeen published. However, in non-pregnant patients, detemircan be initiated at bedtime doses of 0.1-0.2 units/kg/day.When used in non-pregnant patients, the total daily insulindose is divided into 50% detemir and 50% rapid-acting insulin.The rapid-acting insulin is further divided to give 1/3 witheach meal.Detemir can now be considered an effective option formanagement of diabetes in pregnancy. Based on thesefindings, the FDA has changed detemir to pregnancy categoryB. (1) This is a major step forward in the management ofdiabetes in pregnancy. ●EFFICACY RESULTSREFERENCES1. Porcellati F, Rosetti P, Candeloro P, et al. Short-term effects of the long actinginsulin analog detemir and human insulin on plasma levels of insulin-likegrowth factor-I (IGF-I) and its binding proteins in humans. J ClinEndocrinMetab2009;94:3017-24.2. Varewijik AJ, Goudzwaard JA, Brugts MP, et al. Insulin glargine is more potentin activating the human IGF-I receptor than human insulin and insulin demetir.Growth Horm IFG Res 2010;20:429-41.3. Levemir [package insert]. Princeton, NJ: Novo Nordisk Inc; May 2012.4. Insulin pharmacokinetics. Facts and Comparison St. Louis, MO. Website http://online.factsandcomparisons.com/MonoDisp.aspx?monoID=fandc-hcp11093&quick=8274%7c24&search=8274%7c24&isstemmed=True&fromTop=true#InsulinPharmacokinetics. Accessed January 15, 2013.5. Mathiesen ER, Hod M, Ivanisevic M et al. Maternal efficacy and safety outcomesin a randomized, controlled trial comparing insulin detemir with NPH insulin in310 pregnant women with Type 1 diabetes. Diabetes Care 2012;35:2012-17.ABOUT THE AUTHORSAlicia B. Forinash, Pharm.D., BCPS, BCACP is an Associate Professor of PharmacyPractice at the Saint Louis College of Pharmacy and an OB-Gyn/Maternal-Fetal ClinicalPharmacy Specialist at SSM St. Mary’s Health Center, St. Louis, MO.Arezo Noormohammadi, Pharm.D. is a PGY2 Ambulatory Care Resident at the SaintLouis College of Pharmacy at SSM St. Mary’s Health Center.THE PERINATAL TIMES | 3

INFANT OF A DIABETIC MOTHERBY JEFFREY COOPER, MDIn our society, where diabetes and obesity problems areincreasing (no pun intended), we are seeing more and moreinfants born to diabetic mothers. This presents a unique setof challenges to the practitioner caring for these infants afterbirth. Improved maternal care during pregnancy may reducesome neonatal morbidities (hypoglycemia, polycythemia,hyperviscosity, intrauterine growth restriction), as well as fetalmacrosomia with consequent birth trauma. The following isa review of the care of the infant born to a diabetic mother(IDM).Macrosomia is the hallmark of diabetic pregnancy. Despitecontinued advances to normalize glucose concentrationsin mothers, fetal overgrowth occurs more than in normalpregnancies. As glucose passes across the placenta viafacilitated diffusion, maternal insulin does not cross. Thisrequires the infant to produce its own increased insulinsupply to utilize the glucose. This increase in insulin primarilystimulates adipose tissue. Brain and head growth tend to bespared, while shoulder size increases due to intrascapular fatdevelopment. IDMs have 50% more total body fat comparedwith infants of mothers with normal metabolism making themat increased risk for shoulder dystocia. They also have anincreased abdominal girth due to hepatomegaly from insulindrivingglycogen storage.Hypoglycemia occurs shortly after delivery, as the infant hasbeen receiving a steady state of glucose from the placenta.Once the cord is clamped, the infant transitions to using itsown glucose stored as glycogen or relying on glucose from oralintake. The insulin levels do not drop off immediately and theinfant requires sufficient glucose to prevent hypoglycemia.The goal of management should be to deliver enough glucoseto achieve normoglycemia while avoiding stimulation of thepancreas to produce more insulin.Hypocalcemia has also been observed, and infants may beasymptomatic, jittery or rarely, develop seizures. Recentdata may point to maternal diabetes causing urinary loss ofmagnesium, which blunts parathyroid hormone secretioncausing neonatal hypocalcemia.Respiratory distress syndrome (RDS) is another potentialproblem of IDMs. Fetal hyperinsulinemia impedes productionand release of surfactant into the lungs. Previous inaccurateestimates of gestational age due to macrosomia resulted inpreterm delivery with associated RDS.IDMs are at increased risk for polycythemia and possiblehyperviscosity syndrome in the neonatal period. Erythroidprecursors tend to be sensitive to insulin which causes anincreased number of RBCs in the circulation. Hyperviscosityresulting from polycythemia may cause renal vein thrombosis,stroke, and other organ damage.Due to high red cell mass, hyperbilirubinemia is commonin IDMs. In addition, macrosomic infants tend to bebruised at delivery, and resorption of that blood can lead tohyperbilirubinemia.These infants are also at risk for cardiomyopathy, includingthickened interventricular septum and left or right ventricularwall. Rarely, they present with aortic outflow obstructionsufficient enough to cause left ventricular failure. Mostabnormalities resolve within the first year.Finally, IDMs are at an increased risk for congenitalmalformations, such as cardiac anomalies, spinal agenesiscaudalregression syndrome, neural tube defects, andgastrointestinal and urinary tract anomalies. Neonatal smallleft colon is a transient finding in IDMs. They present withintestinal obstruction with a Hirschsprung-like radiograph;however, they have normal bowel innervation. Eventually,they develop normal function.There should be a clear and organized plan for delivery.Standard NRP protocol should be initiated at every delivery.Practitioners should be prepared for a possible shoulderdystocia, with resultant birth injury, and/or asphyxia during avaginal delivery. Care should be taken to properly document1 and 5 minute APGAR scores and look at cord blood gases ifasphyxia is a concern. Injury to the brachial plexus could causeproblems from damage to the nerves of the arm to unilateraldiaphragmatic paralysis if the phrenic nerve is affected.Respiratory distress syndrome (RDS) is a common complicationso the practitioner should be ready to appropriately ventilatethe patient with CPAP, PPV, or intubation as needed.Signs and symptoms of hypoglycemia are nonspecificand infants may not be symptomatic. Symptoms includejitteriness, agitation, poor feeding, lethargy, seizures, apnea,grunting and sweating. A plasma glucose should be checked ininfants of diabetic mothers, even in the absence of symptoms.As the plasma glucose concentration drops rapidly afterdelivery, a glucose level should be obtained within 30 minutesafter birth. Guidelines for the close glucose monitoring andVOL. 27 NO. 1 | MARCH 2013

management of theseinfants is as follows.(Remember that differentinstitutions may usedifferent guidelines forhypoglycemia.)If the level is > 45 mg/dL,oral feedings includingbreastfeeding shouldbe initiated within 3-4hours after delivery andmay be beneficial tomaintain plasma glucoseconcentrations. Infantswho have borderlineglucose measurementswho are fed initially canprogress to requiringIV dextrose fluids.Glucose should berechecked preprandialfor a minimum of threefeedings.Screening and Management of Postnatal Glucose Homeostasisin Late Preterm and Term SGA, IDM/LGA Infants[(LPT) Infants 34 - 36 6/7 weeks and SGA (screen 0 - 24 hours); IDM and LGA >34 weeks (screen 0 - 12 hours)]Birth to 4 hours of ageINITIAL FEED WITHIN 1 hourScreen glucose 30 minutes after 1st feedInitial screen

MONITOR CORNERA CASE STUDY BY SHARON RECTOR, RNC-OB, C-EFM, MSNPRESENTATIONMs. L is a 20 year old, G3P1011 who presented to labor anddelivery at 39 weeks and 3 days gestation with a spontaneouslyruptured bow of water, leaking green tinged amniotic fluid.Contractions on admission were mild and irregular occurringabout every 4-8 minutes. The fetal heart rate (FHR) baselinewas 140 bpm, with moderate variability, accelerationspresent and no decelerations (Category I). Her cervical examon admission was 2 cm, 50% effaced, -3 station, moderateconsistency and midposition with a cephalic presentation. Shewas admitted for expectant management of labor.BACKGROUNDMs. L was previously diagnosed with Bipolar II Disorder forwhich she had inconsistently taken her prescribed medications.She had a history of marijuana use with a positive urine drugscreen for marijuana during the pregnancy. She was alsodiagnosed with GBS bacteriuria in the first trimester.Her labor progressed spontaneously, and she received anepidural for pain management. She was given penicillin G 5million units IV followed by 2.5 million units IV every 4 hours.Approximately 1 hour after the epidural was placed strip #1was observed. Her cervical exam was 4 cm, 50% effaced, -2station, soft and midposition. Her blood pressure was 116/62to 120/70 and her heart rate was 62-68 bpm. Strip #2 occurredapproximately 15 minutes later. How would you interpretthese tracings? What interventions are indicated?INTERPRETATION AND DISCUSSIONIn strip #1 the baseline FHR is 145 bpm, the variability ismoderate, there are no accelerations and there are latedecelerations (Category II). A late deceleration is defined asa gradual (onset to nadir ≥ 30 seconds) decrease of the FHRfrom the baseline associated with a uterine contraction. Inmost cases the onset, nadir and recovery of the decelerationoccur after the beginning, peak and ending of the contraction,respectively. A late deceleration reflects disruption ofmaternal-fetal oxygen transfer from the environment tothe fetus resulting in transient fetal hypoxemia (Tucker,Miller & Miller, 2009). Interventions that will maximize fetaloxygenation are indicated and might include maternal positionchange, intravenous fluid administration, reduction of uterineactivity and oxygen administration. If the disruption of oxygentransfer is recurrent or sustained, it may progress to the stageof metabolic acidemia. The FHR during the decelerations isirregular, ranging from 80-90 bpm to 150-155 bpm, similarto the appearance of marked variability. Variability is aTRACING 1VOL. 27 NO. 1 | MARCH 2013

characteristic of the FHR baseline, and as such it shouldnot be used to describe decelerations. According to Tucker,Miller & Miller (2009) the appearance of variability duringa deceleration has not been studied, and they discourageassigning undue significance to its occurrence. The moderatebaseline variability in this strip is highly predictive of theabsence of fetal metabolic acidemia.In strip #2 the baseline FHR is 155 bpm, the variability isminimal, there is one acceleration near the end of the stripand there are recurrent late decelerations (Category II). Somemight question the presence of late decelerations. Theyare subtle, the onset to nadir is about 25 seconds and thetiming appears to be delayed. This doesn’t completely fit thedefinition of a late deceleration, but these characteristicsdon’t completely fit any of the definitions of the four typesof decelerations. What do you do when a decelerationpattern doesn’t quite fit any of the definitions perfectly?Use your clinical judgment to most accurately label thedeceleration pattern, continue appropriate interventions andobserve closely. It is imperative that this type of tracing bereviewed and discussed by all members of the care team.Communication among care providers is paramount especiallywhen there may be variation in the assessment, interpretationand plan of care.OUTCOMEInterventions in this situation included lateral positioning, IVfluid bolus and the administration of oxygen. Within about30 minutes the FHR returned to a baseline of 140 bpm,with moderate variability, occasional accelerations and noadditional late decelerations. The contractions became moreirregular with minimal change in her cervical exam.Oxytocin was administered and approximately 5 hours afterinitiation Ms. L was completely dilated. Shortly thereafter ababy boy was delivered vaginally with Apgar scores of 8 and9 at 1 and 5 minutes respectively. He weighed 4200 grams.Mom and baby had a normal postpartum course and weredischarged on day 2. ●REFERENCETucker, S.M., Miller, L.A., & Miller D.A. (2009). Fetal monitoring: A multidisciplinaryapproach (6th ed.). St. Louis, MO: Mosby Elsevier.ABOUT THE AUTHORSharon Rector is an Education Consultant specializing in perinatal nursing at SSMHealth Care in St. Louis.TRACING 2THE PERINATAL TIMES | 7

NUTRITIONAL MANAGEMENT OF DIABETES & PREGNANCYBY RITA A. CHRIVIA, RD, CSP, LDWith the rising rates of obesity in the United States and theresulting rise in diabetes, chances are you are seeing moremothers and infants affected by diabetes in pregnancy.Reported rates of diabetes in pregnancy range from 2-10%of all pregnancies with 88% of those due to gestationaldiabetes, another 8% due to Type 2 and 4% due to Type1. (1) Poorly controlled diabetes beforeconception and during the first trimestercan cause major birth defects in5-10% of pregnancies andcan result in spontaneousabortions in 15-20% ofpregnancies. Poorlycontrolled diabetesin the second andthird trimestersof pregnancycan result inexcessively largebabies, posinga risk to bothmother and childduring laborand delivery.Gestationaldiabetes is a riskfactor for Type2 diabetes in themother; 5-10% ofwomen diagnosedwith gestational diabetesare found to have diabetesimmediately after the pregnancy.An estimated 15-50% will developdiabetes in the decades following theaffected pregnancy. (2)The good news is that intensive treatment of diabetes inpregnancy is associated with outcomes similar to thosein control populations. (3) For all types of diabetes inpregnancy, this involves medical nutrition therapy. Takinginto account the total calories per day, the number of mealsper day and the composition of those meals is important forreaching the goals of euglycemia, appropriate weight gain,and a healthy outcome for mother and child.Although the carbohydrate content of the diet is the firstpriority, total nutrient content and total calorie intake cannotbe ignored. A well balanced diet containing importantsources of vitamins and minerals, and promoting appropriateweight gain, is the goal for any pregnancy.Total calories per day should be based on the prepregnancyweight as a percent of ideal bodyweight. Women who are 80-120%of their ideal body weight arerecommended to have intakesof 30 calories per kg or 14calories per pound. Forobese women (120-150% of ideal bodyweight or with aBMI greater than27 kg/m2), 25calories per kgor 11 caloriesper pound is therecommendedintake. Womenwho are greaterthan 150% oftheir ideal weightare recommendedto have intakes of12-15 calories per kgand limit weight gain tono more than 8kg (17-18pounds). (3) While weightloss during pregnancy is notrecommended, a modest energyand carbohydrate restriction may beappropriate. (4) Avoidance of ketosis is importantto allow adequate provision of glucose to the fetal brain.The diet should be culturally appropriate, containing 1-1.2 gprotein per kg and at least 175 g carbohydrates per day. Totalcarbohydrates should be less than 45% of energy in womenwith gestational diabetes to prevent hyperglycemia. (5) Thecarbohydrates should be from complex sources with simplesugars and high glycemic index foods limited. Fiber intakeof 25-30 g per day is recommended as is a low saturated fatintake of less than 10% total calories. (6)VOL. 27 NO. 1 | MARCH 2013

Normal hormonal changes in pregnancy lead todecreased insulin sensitivity and increased insulinresistance. This can result in transient hyperglycemiaafter meals. Hypoglycemia between meals and atnight can occur due to the continuous fetal draw ofglucose. Women with preexisting diabetes should beencouraged to maintain consistency in the timing oftheir meals and to include at least a bedtime snack toprevent hypoglycemia. The recommended distribution ofcarbohydrates to prevent hyperglycemia or hypoglycemiais 10-20% at breakfast, 20-30% at lunch, 30-40% atdinner with up to 30% for snacks. Insulin resistance ishighest in the morning due to increased cortisol levels.Adding protein to the morning meals and snacks mayhelp combat hunger. Smaller, more frequent mealsmay also help combat hunger, reduce the mealtimecarbohydrate load, reduce nausea and heartburn, andmaintain a more stable postprandial blood glucose level.Unless contraindicated, the pregnant woman should beencouraged to participate in physical activity 30 minutesper day for a minimum of 3 times per week to improveglycemic control and general health. (5,6)Involving a registered dietitian who is familiar with thecomponents of medical nutrition therapy of diabetesduring pregnancy will allow for an individualized mealplan that reflects treatment goals and takes the woman’slifestyle into account. Barriers to compliance can also beaddressed and the meal plan modified as needed for thebest outcome for mother and infant.Breastfeeding is recommended for women withpreexisting diabetes and some data suggests it maydecrease the risk of Type 1 diabetes in the infant. Thewoman with Type 1 diabetes who breastfeeds mayexperience hypoglycemia and should be encouraged tohave a meal or snack available before or during feeds.Women diagnosed with gestational diabetes whobreastfeed appear to have a lesser chance of developingType 2 diabetes. Their children also have a decreasedrisk of childhood obesity and impaired glucose tolerance.(6) Postnatal follow up should include adapting the mealplan for breastfeeding and for achieving a more optimalweight if needed to minimize the risk of developinggestational diabetes in future pregnancies. ●REFERENCES1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet:national estimates and general information on diabetes and prediabetes inthe United States,2011.Atlanta,GA:U.S. Department of Health and HumanServices, Centers for Disease control and Prevention,2011.2. Division of Reproductive Health. National Center for Chronic DiseasePrevention and Health Promotion. Pregnancy Complications,2012.http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PregComplications.htm3. Meltzer S. Management of Diabetes in Pregnancy: Challenges and trends.Canadian Journal of Diabetes. 2005:29(3):246-256.4. American Diabetes Association. Bantle JP, Wylie-Rosett J, Albright AL,et al. Nutrition recommendations and interventions for diabetes: aposition statement of the American Diabetes Association. Diabetes Care.2008:Jan;Suppl1:S61-78.5. American Dietetic Association(ADA). Gestational diabetes mellitus (GDM).Evidence based nutrition practice guideline. Chicago,IL;American DieteticAssociation (ADA);2008.6. Barbour LA, Friedman JE. Management of Diabetes in Pregnancy,2010.http://diabetesmanager.pbworks.com/w/page/17680258/Management%20of%20Diabetes%20in%20PregnancyABOUT THE AUTHORRita Chrivia is a Clinical Dietician at SSM Cardinal Glennon Children’s Medical Center inSt. Louis, MO.THE PERINATAL TIMES | 9

The Perinatal TimesSSM Cardinal GlennonChildren’s Medical Center1465 S. Grand Blvd.St. Louis, MO 63104ADDRESS SERVICE REQUESTEDCONTINUING EDUCATION OPPORTUNITIESMany continuing education opportunities,including traditional lectures, hands-on practiceas well as online presentations, are availablefor perinatal professionals in eastern Missouriand southern Illinois. These are offered throughSSM St. Mary’s Health Center, SSM CardinalGlennon Children’s Medical Center, Saint LouisUniversity School of Medicine and the PerinatalOutreach Program. Most programs offer nursingcontact hours and/or CMEs.For course calendars or more specificinformation on programs, please go to www.cardinalglennon.com and click on the “ForProfessionals” tab or call the Perinatal OutreachProgram at 314-577-5317.