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Diabetes in pregnancy

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Type 2 is increasing in certain minority ethnic groups. Pregnancy complicated by diabetes ---Gestational diabetes accounts for 87.5% ,7.5% type 1 and 5% type 2 ... – PowerPoint PPT presentation

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Title: Diabetes in pregnancy


1
Diabetes in pregnancy
  • James Penny
  • Consultant Obstetrician Gynaecologist
  • Surrey Sussex NHS Trust

2
Diseases
  • Gestational Diabetes
  • Pre-existing Diabetes
  • Definition Disorder of carbohydrate metabolism.
    It is an organ specific autoimmume disease with
    a genetic component
  • Prevalence 650,000 pregnancies-UK and Wales of
    which 2-5 are diabetic pregnancies.
  • The prevalence is increasing in both types.
  • Type 2 is increasing in certain minority
    ethnic groups.
  • Pregnancy complicated by diabetes
    ---Gestational diabetes accounts for 87.5 ,7.5
    type 1 and 5 type 2 .
  • Types Type 1-0.27 of births
  • Type 2-0.10 of births

3
Recent focus
  • St Vincent declaration
  • NICE document on prenatal care
  • NICE document on diabetes
  • Cemach report on diabetes in pregnancy

4
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6
Risks of diabetes Pedersen hypothesis
Unexplained stillbirth Congenital
malformation Caesarean section Miscarriage Long
term effect of infant/child health
7
This talk
  • Prepregnancy care for established diabetics
  • Early pregnancy care
  • Gestational diabetes
  • Third trimester and delivery

8
The size of the problem
9
Prepregnancy Care
  • Maternal health
  • Weight
  • Folate
  • Smoking
  • Long term health
  • contraception

10
Extremely tight control of blood sugar
11
Prepregnancy Care
  • Maternal health
  • Assess for
  • Risk of miscarriage

12
Prepregnancy Care
  • Congenital anomalies
  • Comparison of depending of timing of care

13
Prepregnancy Care
  • Congenital anomalies
  • If the HbA1c is gt10 then 30 of babies may
    have a congenital anomaly

14
Prepregnancy care
  • Allows a detailed risk assessment
  • Should be performed opportunistically
  • Diabetic women should plan their pregnancy

15
Maternal risks
  • Diabetic ketoacidosis is rare in pregnancy
  • Hypoglycaemia accounts for most death in pregnant
    diabetics

16
Early pregnancyMultidiscplinary care
Dietician Diabetic nurse Patient
Obstetrician Physician Midwife
17
Management
  • Diet to allow ideal weight gain
  • Change oral hypoglycaemics to insulin
  • Tight control of blood sugars
  • Fasting lt 6
  • Postprandial lt 8
  • Q.D.S. insulin regime
  • Post prandial levels are important

18
  • Downside
  • Hypoglycaemia
  • Morning sickness

19
Gestational Diabetes
  • Definition
  • Carbohydrate intolerance that arises during
    pregnancy and disappears after delivery
  • Is gestational diabetes an important condition

20
Trends in insulin resistance and insulin
production with age
Insulin production
Insulin resistance
21
Trends in insulin resistance and insulin
production with age
Pregnancy
22
Insulin Resistance
23
Gestational DiabetesScreening
Random glucose - booking 28 weeks Timed random
glucose - booking 28 weeks Urinary
dipstick Risk factor screening 50g mini GTT -
booking or 28 weeks 50g mini GTT for women over
25 HbA1c
24
Gestational DiabetesDiagnosis
  • 50g GTT (AUC)
  • 100g GTT (5.0, 9.2, 8.1, 6.9)
  • 100g GTT (5.8, 10.6, 9.2, 8.1)

75g GTT 75g mini GTT Serial capillary blood sugar
25
GDM Screening
  • LOW RISK
  • Routine random sugar at 16 and 28 weeks
  • HIGH RISK
  • 28 week simplified GTT

26
Gestational DiabetesManagement
27
Obstetric management.
  • Early referral to offer advice and support and
    review medication. Medical review for retinal and
    renal assessment
  • Scans- 7-9 wks viability,NT scans refer Tertiary
    unit, 20-22wks anomaly and cardiac scan, serial
    growth scan at 28,32.36 weeks. Dopplers liquor
    and fetal well being look for IUGR.
  • Regular antenatal visits monitoring insulin req
    and scans. BP/ proteinuria
  • Induction of labour -38-39wks on insulin. 40 wks
    if well controlled or diet control
  • Wellbeing screening at ADU
  • C/S at 39 weeks
  • Post natal care..

28
Third trimesterand fetal risks
  • Fetal size
  • Cardiac hypertrophy
  • Stillbirth

29
Fetal Complications
  • Macrosomia-63 vs 10
  • Caesearean sections-56 vs 20
  • Premature delivery-425 vs 12
  • Preecclampsia-18
  • Nronatal jaundice-18
  • RDS-17
  • Congenital anomlies-5
  • Perinatal mortality-5

30
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31
Macrosomia
32
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33
Fetal Monitoring
  • Serial growth scans
  • Biophysical profile
  • Cardiotocography
  • Doppler

34
Delivery
  • At 38 - 40 weeks gestation
  • High incidence of caesarean
  • Shoulder dystocia

35
Postnatal Care
  • Breasting not to continue previous drugs which
    were contraindicated.
  • advice on contraception and planning future
    pregnancy.
  • Risk of hypos in the breast fed food before or
    during and establish control pre pregnancy
    insulin doses.
  • GM stop insulin. Advise on diet exercise
    contraception, watch for hyperglycaemia.
  • Subsequent screening.
  • FBs -6 weeks postnatal and annually
  • ophthalmology follow up inthose with
    proliferative dis.

36
Early neonatal risks
  • Fetal hypoglycaemia
  • Polycythaemia - jaudice
  • Respiratory distress syn
  • Birth trauma

37
Postnatal
  • Insulin requirements return to normal immediately
  • GTT at 6-12 weeks post partum
  • Long term F/U - mother and baby

38
Contraception?
39
Barkerism
40
Summary
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