Page 60 - Retail Pharmacy Magazine October 2020

58 CPD ACTIVITY FROM PAGE 57 should be part of antenatal management. Hyperglycaemia in pregnancy To prevent the adverse consequences of hyperglycaemia (ie, stimulation of fetoplacental growth due to increased production of insulin, leptin, and insulin growth factor), pregnant women are routinely screened for GDM from 24 weeks gestation. Where a GDM diagnosis is made, the Australasian Diabetes in Pregnancy Society (ADIPS) recommends strict control of glucose levels during pregnancy. Women with GDM should be counselled to maintain the following blood glucose levels: 18 • Pre-prandial (fasting) 4.0-5.0 mmol/lt. • One hour post-prandial (after food) <7.4 mmol/lt. • Two hours post-prandial <6.7 mmol/lt. The primary maternal management target for all women with GDM is to maintain normoglycaemia. However, less evidence exists to support specific treatment regimens in obese women with GDM, where diet alone has failed. Pharmacists should expect to see more pregnant women with GDM treated with metformin, due to an increasing national and international evidence base supporting it as a safe and effective alternative to or combination with insulin.18-21 It is critical that metformin’s off-label indication of GDM does not constitute a barrier to dispensing metformin for pregnant women. Pharmacists should reassure women that metformin use to maintain normal blood glucose levels has led to comparable outcomes to insulin and safe pregnancy outcomes for mother and baby. Pregnancy-induced hypertension and pre-eclampsia While women who are overweight preconception will require blood pressure management during their pregnancy, a cohort will develop hypertension during pregnancy and a further subset will experience pre-eclampsia (escalating fluid retention and proteinuria potentially requiring early delivery to relieve sequelae). The risk of pre-eclampsia is twice as high in pregnant women who are obese compared with those of healthy weight.22 Although no proven strategies to prevent pre-eclampsia have been identified, the World Health Organisation recommends:23 • Avoiding excessive GWG. • Tight control of diabetes. • Consideration of calcium supplements where there is low dietary calcium intake. • Low-dose aspirin for prophylaxis. Labour and delivery Maternal obesity is associated with obstetric complications. Obstructive sleep apnoea can complicate anaesthesia with caesarean delivery. Non-alcoholic fatty liver disease and associated elevated liver function tests may be confused with complications of pre-eclampsia, specifically HELLP syndrome (haemolysis, elevated liver enzyme, and low platelet counts).10 Foetal macrosomia associated with maternal GDM may also change delivery plans, eg, induction of labour or surgical delivery, with their associated risks, such as decreased ability to monitor the foetal heart-rate pattern, primary postpartum haemorrhage and wound infection.10 Pressures on new mothers to lose their post-pregnancy weight gain Postpartum, women have many challenges and adjustments to make in their lives, including acclimatising to motherhood, reduced sleep, changes in body weight and shape. The weight retained after pregnancy is defined as the difference between postpartum and prepregnancy weight.24 Linne and colleagues25 examined long- term weight changes after pregnancy in a 15-year follow-up study. They found that by six months postpartum, 56.3 per cent of women who did not become overweight at 15-year follow-up had returned to within 1.5kg of their pre-pregnancy weight, compared with the 27.7 per cent who became overweight. At one year, these statistics had risen to 60.4 per cent in the non-overweight and only 34.6 per cent in the overweight group. In a second study26, women who lost all pregnancy weight by six months postpartum, regardless of breastfeeding status, were only 2.4kg heavier 10 years after childbirth, while those who retained postpartum weight were 8.3kg heavier at 10-year follow- up. The authors proposed that failure to lose pregnancy weight by six months postpartum be considered an important predictor of long-term obesity. Studies estimate that, at about one year postpartum, women may retain 0.5 to 4.0kg on average.27 However, a subset of women are at greater risk of significant RETAIL PHARMACY • OCT 2020