Camden Diabetes Education Day

June 2014

In England and Wales:

• 650,000 deliveries each year

• 2-5% pregnancies involve women with diabetes

• 87.5% gestational diabetes• 7.5% type 1 diabetes• 5% type 2 diabetes

• Key clinical issues

– Adequately prepare women with pre-existing diabetes for pregnancy

– Take appropriate steps during the pregnancy to minimise adverse outcomes

• LM – 30 year old type 1 diabetes 1994, gastroparesis– Known ACR 82, HbA1c 14%– On ACE, statin – Levemir, Novorapid

• Hospital admission with vomiting, found to be pregnant, discharged out of hours, ANC appt made for 2 weeks

• Risks discussed, started on folic acid 5mg• Termination discussed

• Made significant changes to insulin

• BGL rapidly improved

• PCR 512

• Miscarried at 20 weeks

Risks: pre-existing diabetes

• Miscarriage• Congenital anomalies

Maternal Risks:

• Hypoglycaemia

• Loss of hypo awareness

• (increased risk of seizures, trauma)

• Acceleration of complications (retinopathy and nephropathy)

Late complications (pre-existing diabetes / GDM)

• Fetal macrosomia or IUGR

• Shoulder dystocia

• Preterm labour

• Stillbirth

• Neonatal hypoglycaemia

• Pre-eclampsia

Factors associated with poor pregnancy outcome

• Maternal social deprivation

• Not using contraception

• Suboptimal diabetes control pre & during pregnancy

• Not taking Folic Acid 5mg

• No preconception care

Pregnancy in type 1 & type 2 diabetes

Experiences of professional support during pregnancy and childbirth – a qualitative study of women with t1.

• Explored the experience of professional support during pregnancy in women with t1 diabetes.

• Results:– Mothers concern about jeopardizing the baby’s

health– Women felt that HCP concern was towards the

baby and not them– Felt that they were used as messengers between

hc providers Berg et al 2009

Pre-conception

• Planned pregnancy (discuss with all women of child-bearing age)

• Review contraception

• Refer to pre-conception clinic

• Aim HbA1c <7%, use contraception until good glycaemic control, offer monthly measurement HbA1c

• Medication– Folic Acid 5mg (start preconception until 12 weeks)– Continue Metformin– Stop all other oral anti-diabetes drugs/substitute insulin– Stop ACE-I/ARBs– Stop Statins

• Type 1 – intensive support with control, pump therapy

• Retinal screening /Urine ACR and eGFR

Screening for Gestational Diabetes

• Screening 28 weeks– 50g glucose challenge test – Random BGL

• Diagnosis– 75g oral glucose tolerance test

Antenatal Care

• Regular appointments 1-3 weekly

• BGM 4 x/day– Fasting (target < 5.5)– 1 hour post prandial (target <7.5)

• Regular growth scans 4weekly (from 28wks)

• Delivery – based on scan, glycaemic control

Postnatal Care

• GDM– Postnatal GTT at 6 weeks

• Annual HbA1c

• High risk – address lifestyle measures

What support can you get?

• For women with type 2 diabetes:

– Vanessa Sawmynaden– Preconception counselling – Improve glycaemic control prior to pregnancy– Transfer onto insulin when necessary

Royal Free

• Miranda Rosenthal (Diabetologist)

UCLH

• Jakki Berry - preconception clinic

• Antenatal clinic UCLH (Monday mornings)

• Jo Modder / Nikki Lack (Consultant Obstetricians)

• Jakki Berry / Lydia Chinyerere (DSNs)• Sarita Naik (Diabetologist)

To summarise…..