Welcome to Diabetes and Pregnancy information for midwives

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Welcome to Diabetes and Pregnancy - information
for midwives
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Problems of pregnancy diabetes main menu

• Foetal and neonatal problems
• Maternal problems
• Risks of foetal loss
• Prevention of problems
• Management of the diabetes during pregnancy
• Dealing with hypoglycaemia
• Antenatal management of the woman with diabetes
• Management of labour
• Post-partum care
• Gestational diabetes.
• Troubleshooting guide - FAQs

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Problems affecting the foetus in utero and during
labour

• Congenital malformations
• IUGR (in mothers with nephropathy or vascular
  disease)
• IUD
• Macrosomia therefore obstructed labour/shoulder
  dystocia

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Problems affecting the neonate

• Dysmaturity RDS
• Polycythaemia
• Neonatal hypoglycaemia
• Neonatal hypocalcaemia
• Neonatal jaundice
• Increased rate of foetal loss

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Maternal problems associated with diabetes

• Weight gain
• Hypoglycaemia and loss of hypoglycaemia awareness
• More likely to have a caesarean section
• Risk of worsening of retinopathy
• Pregnancy-induced hypertension
• Worsening of renal disease/proteinuria
• Myocardial infarction

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Congenital malformations

• High maternal glucose is toxic to the early
  embryo hypoglycaemia is not.
• Many types of CM may occur but numerically most
  important are renal, cardiac and central nervous
  system abnormalities
• Caudal regression syndrome

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Risks of congenital malformations and how to
avoid them

• Risk rises with worsening glycaemic control at
  conception and in early first trimester
• Risk of CM is 5 to 10 times that in a baby of a
  non-diabetic mother
• Try to plan the pregnancy in advance, aiming for
  HbA1c below 7.0 at conception

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Macrosomia-nature and causes

• Birth weight gt 4000gm or gt 90th centile
• High placental transfer of glucose leads to
  hyperplasia of foetal pancreas and foetal
  hyperinsulinaemia
• Insulin is the main growth hormone for the foetus
  hence macrosomia

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Effects of macrosomia

• Much of the excess weight is truncal fat, hence
  shoulder dystocia
• Macrosomia occurs in 25 of infants of type 1
  diabetic mothers
• Excessive insulin secretion persists after birth,
  ? hypoglycaemia
• Hyperglycaemia is the main causative factor in
  delayed lung maturation

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Risk of foetal loss (1)

• Northern Regional survey (Hawthorne 1997)
  perinatal mortality 48/1000 for babies of
  diabetic mothers, compared to 8.9/1000 for
  background population

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Risk of foetal loss (2)

• Merseyside Regional survey (Casson 1997)
• 24 of pregnancies overall failed to come to
  successful conclusion
• 17 spontaneous abortions, 2 stillbirths, 5
  medically terminated
• Stillbirth rate 25/1000 total births, compared to
  5/1000 for background population

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Problems for the mother (2)

• Rapid tightening of glycaemic control may lead to
  rapid worsening of retinopathy
• Women with microalbuminuria or proteinuria are
  more at risk of PIH or worsening
  proteinuria/worsening renal function as pregnancy
  progresses
• Caesarean section rate around 50

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Approach to preventing problems in diabetic
pregnancy

• All young diabetic women who are at risk of
  pregnancy should be counselled by physician,
  dietitian and diabetes specialist nurse
• Good, reliable contraception (including combined
  OC Pill)
• Plan pregnancy in advance so as to achieve
  optimal glycaemic control at conception
• Stop any hazardous drugs e.g. ACE inhibitors
• Folic acid

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Management of diabetes in pre-pregnancy planning

• Multiple injections of short- and long-acting
  insulin
• Frequent blood tests (ideally 4 or more per day).
  Aim for pre-meal glucose below 6 and post-meal
  below 8.
• Aim for HbA1c below 7
• Advise family and friends on management of
  hypoglycaemia

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What to do when pregnancy is confirmed

• See diabetes physician as soon as pregnancy test
  ve
• Continue multiple injections of short- and
  long-acting insulin
• Four blood tests each day, at various times
• Targets fasting BG less than 5
• pre-meals less than 5.5
• after meals less than 8
• HbA1c as close to 6 as possible

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Continuing management of the diabetes

• Seen every two weeks until 30 weeks, then weekly.
  
• Insulin doses likely to rise through second and
  third trimester, reaching 150 of baseline by 36
  38 weeks

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Other aspects of medical management

• Retinal screening as soon as pregnancy confirmed,
  then repeated in each trimester
• Control blood pressure with methyldopa,
  nifedipine or labetalol
• Stop smoking

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Antenatal management

• Early ultrasound (less than 13 weeks) for dating
• Regular scans for assessment of foetal size and a
  detailed anomaly scan at 18 22 weeks.
• Biophysical profile weekly from 36 weeks
• Aim for vaginal delivery at 39 weeks if possible

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Management of diabetes during labour

• Normal diet and insulin until onset of labour
• Continuous monitoring of FH
• During labour IV glucose 10 (100ml/hr), with
  KCl (10mmol per 500ml of glucose), IV insulin
  by sliding scale
• Capillary blood glucose hourly
• Adjust insulin so as to keep the blood glucose
  between 4 and 6 mmol/l
• Paediatrician present at delivery

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Post-partum care of mother

• Reduce insulin infusion rate by 50 as soon as
  delivery has occurred
• Maternal insulin requirement drops immediately to
  pre-pregnancy level or may even be 10 15 below
  that.
• Women with gestational diabetes do not need any
  insulin once the placenta is delivered
• Mother may need less insulin or more calories if
  breast feeding (500kcal per day) close liaison
  with dietitian.

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Post-partum care of neonate

• Many babies will go to SCBU because of
  hypoglycaemia or other problems but SCBU
  admission should not be automatic.

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Gestational diabetes

• Defined as diabetes developing in pregnancy
  (usually after 20 weeks) which remits after
  delivery
• Occurs in 2 - 4 of pregnancies

Risks for developing GDM Screening
for GDM GTT for diagnosis of GDM
Foetal hazards of GDM Management of GDM
Long-term consequences of GDM for
mother
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Risks for developing gestational diabetes

• Aged 35 or over
• Overweight
• Positive FH of type 2 diabetes
• Previous unexplained stillbirth, foetal
  malformation or large baby (gt4.5kg)
• Persistent fasting glycosuria
• More than 3 previous children

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Screening for GDM

• Wide variety of screening strategies!
• Ideally, 50gm oral glucose load at booking, with
  blood glucose measured 1 hr later. If BG gt 7.8,
  formal GTT.
• If any random BG in pregnancy is gt 7.0, formal
  GTT.

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GTT for gestational diabetes

• WHO criteria
• 75gm oral glucose load, blood
• samples at 0 and 120 mins.
• If fasting glucose ? 7.0 OR 2-hour glucose ?
  7.8, patient should be managed as diabetic

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Risks to the foetus associated with GDM

• Congenital malformations are not an issue
• Same risk as for pre-conception diabetes as
  regards
• macrosomia (strongly linked to maternal weight)
• dysmaturity
• neonatal hypoglycaemia (5 to 24 of infants of
  GDM mothers have blood glucose lt 2.2 soon after
  birth.

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Management of GDM (1)

• Teach the patient how to monitor her own blood
  sugars. Same blood sugar targets as for
  pre-conceptual diabetes except that the post-meal
  tests should be done 1hr after eating
• Refer to dietitian.

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Management of GDM (2)

• Commence pre-meal insulin or q.d.s. insulin if BG
  targets are not being met, especially if pre-meal
  glucose values are gt 6.0
• Labour management as for pre-conception diabetes.
  
• No insulin after delivery.
• GTT 6 weeks post-partum

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Later risk to mother of having had GDM

• By 20 years after a pregnancy complicated by GDM,
  about half of the women concerned will have
  established type 2 diabetes.

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Question - glycosuria

• Q. My patient has glycosuria. What action should
  I take?
• A. If the glycosuria is trace only, no action is
  required. If 1 or more, arrange a venous blood
  glucose measurement 1 to 2 hrs after a meal. If
  this is gt 7.0, arrange for a formal GTT. If
  screening glucose value is gt6.0, continue
  monitoring for glycosuria and repeat blood
  glucose if 1 or greater

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Question planning for a pregnancy in a woman
with diabetes

• Q. A patient with known diabetes wishes to start
  a pregnancy. What advice should I give her?
• A. Before she stops using contraception she
  should talk to her diabetes physician and
  diabetes specialist nurse about getting her
  diabetic control as good as she can (HbA1c less
  than 7). She should also stop smoking, stop ACE
  inhibitors and start taking folic acid.

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Question pregnancy test positive

• Q. A lady with diabetes informs me that she has
  not had a period for 8 weeks and has had a
  positive pregnancy test. What advice should I
  give her?
• A. She should contact her diabetes physician or
  diabetes specialist nurse immediately. She
  should stop smoking and taking any potentially
  hazardous drugs. She is likely to need multiple
  injections of insulin and will need to do lots of
  blood tests!

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Problems with diabetes during pregnancy (1)

• Q. A patient with type 1 diabetes is 7 weeks
  pregnant and is vomiting regularly. How should
  this be managed?
• A. She should be checking her blood tests very
  frequently (at least 4 times a day) and should
  talk to the diabetes specialist nurse about
  testing her blood or urine for ketones. She
  should also see the dietitian about ways of
  maintaining her calorie intake. She should be
  helped to make an individual decision about
  whether or not she wishes to take anti-emetics.

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Problems with diabetes during pregnancy (2)

• Q. A diabetic lady who is 26 weeks has noticed
  that her blood sugars are rising, averaging 10
  before meals and 13 after meals. What should she
  do?
• A. She should contact her diabetes physician or
  specialist nurse urgently. It is likely that she
  will need an increase of 20 - 30 in all of her
  insulin doses.

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Problems with diabetes during pregnancy (3)

• Q. A diabetic lady who is 34 weeks has noticed a
  reduction in foetal movements and is having a lot
  more hypos than she did a couple of weeks ago.
  What should she do?
• A. This is a very serious state of affairs which
  could indicate an intra-uterine death. She
  requires urgent ante-natal assessment and should
  be admitted.

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Antenatal problems - hypertension

• Q. A diabetic lady who is 36 weeks has a large
  baby (abdominal circumference gt 95th centile).
  Her BP is 155/100. What course of action is
  likely to be recommended?
• A. She should be admitted for rest and CTG
  monitoring. If monitoring is not favourable she
  should be induced.

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Diabetes management in labour

• Q. A diabetic lady is in labour and is on an IV
  insulin sliding scale. Her blood sugars are
  varying rapidly from high to low. What should be
  done?
• A. The steps in her sliding scale are probably
  too large and the scale needs to be made
  shallower, e.g. 0.5 unit instead of 1 unit. The
  scale should be reviewed by a doctor.

Sliding scale
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Management in labour
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Insulin sliding scale
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Dealing with hypoglycaemia symptoms

• Headache
• Nausea
• Sweating
• Palpitations
• Trembling
• Feeling faint

• Pallor
• Confusion
• Looking or feeling spaced out
• Odd behaviour
• Slurred speech

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The unconscious patient
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Dealing with hypoglycaemia management (1)

• 1.Make sure the patient is safe in a chair or on
  the bed.
• 2.Check capillary blood glucose with meter
  (Optium or Hemocue). Treat if the reading is lt
  4.0 mmol/l.
• 3.If the patient can swallow, give
• ? 3 glucose (Dextrosol) tablets or
• ? a glass of water with 2 tsp sugar or
• ? a mini-Mars bar or
• ? 100 ml of Lucozade.

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Dealing with hypoglycaemia management (2)

• 4. Follow the rapid-acting carbohydrate with a
  sandwich, a piece of fruit or a bowl of cereal.
• 5. Ask yourself Why has the hypo occurred?
  Consider asking medical staff to review insulin
  doses.

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Hypoglycaemia the patient who cant swallow or
is unconscious

• If the patient is unconscious or seriously
  incapacitated, call for help urgently. If
  necessary place the patient in the recovery
  position.
• Give glucagon, 1mg IM stat.
• Keep the patient under close observation until
  fully conscious.
• Consider IV glucose 10 infusion if hypoglycaemia
  is recurrent.
• Give oral feed as soon as possible sandwich,
  fruit or a bowl of cereal.

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List of FAQs

• Finding of glycosuria
• Planning for a pregnancy
• When the pregnancy test is positive
• Diabetes in pregnancy (1) - vomiting in early
  pregnancy
• Diabetes in pregnancy (2) - high blood sugars
• Diabetes in pregnancy (3) - reduced foetal
  movements and hypos
• Antenatal problems - hypertension
• Diabetes management in labour

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