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Welcome to Diabetes and Pregnancy information for midwives

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Same risk as for pre-conception diabetes as regards: ... Labour management as for pre-conception diabetes. No insulin after delivery. ... – PowerPoint PPT presentation

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Title: Welcome to Diabetes and Pregnancy information for midwives


1
Welcome to Diabetes and Pregnancy - information
for midwives
Next
2
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

Exit
3
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

Next
Main menu
4
Problems affecting the neonate
  • Dysmaturity RDS
  • Polycythaemia
  • Neonatal hypoglycaemia
  • Neonatal hypocalcaemia
  • Neonatal jaundice
  • Increased rate of foetal loss

Back
Main menu
5
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

Next
Main menu
6
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

Main menu
Next
7
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

Main menu
Back
8
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

Next
Main menu
9
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

Back
Main menu
10
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

Next
Main menu
11
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

Main menu
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12
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

Back
Main menu
13
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

Main menu
Next
14
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

Main menu
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15
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

Next
Main menu
16
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

Main menu
Back
Next
17
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

Back
Main menu
18
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

Main menu
Question?
19
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

Main menu
20
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.

Next
Main menu
21
Post-partum care of neonate
  • Many babies will go to SCBU because of
    hypoglycaemia or other problems but SCBU
    admission should not be automatic.

Main menu
Back
22
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
Main menu
23
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

Back to GDM
Main menu
24
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.

Question?
Main menu
Back to GDM
25
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

Main menu
Back to GDM
26
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.

Back to GDM
Main menu
27
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.

Main menu
Next
Back to GDM
28
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

Back to previous
Back to GDM
Main menu
29
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.

Back to GDM
Main menu
30
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

Back
Main menu
Next
FAQ menu
31
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.

Next
Main menu
Back
FAQ menu
32
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!

Main menu
Back
FAQ menu
33
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.

Main menu
FAQ menu
Next
34
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.

FAQ menu
Main menu
Next
35
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.

Main menu
FAQ menu
Back
36
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.

Main menu
FAQ menu
Back
37
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
Main menu
FAQ menu
Management in labour
38
Insulin sliding scale
Back
39
Dealing with hypoglycaemia symptoms
  • Headache
  • Nausea
  • Sweating
  • Palpitations
  • Trembling
  • Feeling faint
  • Pallor
  • Confusion
  • Looking or feeling spaced out
  • Odd behaviour
  • Slurred speech

Main menu
Next
The unconscious patient
40
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.

Main menu
Next
Back
41
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.

Main menu
Back
Next
42
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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Main menu
43
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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