Diabetes in pregnancy

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Diabetes in pregnancy

• James Penny
• Consultant Obstetrician Gynaecologist
• Surrey Sussex NHS Trust

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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

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Recent focus

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

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Risks of diabetes Pedersen hypothesis
Unexplained stillbirth Congenital
malformation Caesarean section Miscarriage Long
term effect of infant/child health
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This talk

• Prepregnancy care for established diabetics
• Early pregnancy care
• Gestational diabetes
• Third trimester and delivery

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The size of the problem
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Prepregnancy Care

• Maternal health
• Weight
• Folate
• Smoking
• Long term health
• contraception

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Extremely tight control of blood sugar
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Prepregnancy Care

• Maternal health
• Assess for
• Risk of miscarriage

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Prepregnancy Care

• Congenital anomalies
• Comparison of depending of timing of care

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Prepregnancy Care

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

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Prepregnancy care

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

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Maternal risks

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

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Early pregnancyMultidiscplinary care
Dietician Diabetic nurse Patient
Obstetrician Physician Midwife
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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

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• Downside
• Hypoglycaemia
• Morning sickness

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Gestational Diabetes

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

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Trends in insulin resistance and insulin
production with age
Insulin production
Insulin resistance
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Trends in insulin resistance and insulin
production with age
Pregnancy
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Insulin Resistance
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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
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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
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GDM Screening

• LOW RISK
• Routine random sugar at 16 and 28 weeks
• HIGH RISK
• 28 week simplified GTT

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Gestational DiabetesManagement
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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..

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Third trimesterand fetal risks

• Fetal size
• Cardiac hypertrophy
• Stillbirth

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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

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Macrosomia
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Fetal Monitoring

• Serial growth scans
• Biophysical profile
• Cardiotocography
• Doppler

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Delivery

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

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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.

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Early neonatal risks

• Fetal hypoglycaemia
• Polycythaemia - jaudice
• Respiratory distress syn
• Birth trauma

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Postnatal

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

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Contraception?
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Barkerism
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Summary