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Diabetes in pregnancyDiabetes in pregnancy
James PennyConsultant Obstetrician & Gynaecologist
Surrey & Sussex NHS Trust
DiseasesDiseases
• 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
Recent focusRecent focus
• St Vincent declaration
• NICE document on prenatal care
• NICE document on diabetes
• Cemach report on diabetes in pregnancy
Risks of diabetes Risks of diabetes Pedersen hypothesisPedersen hypothesis
Unexplained stillbirthCongenital malformationCaesarean sectionMiscarriageLong term effect of infant/child health
This talkThis talk
• Prepregnancy care for established diabetics
• Early pregnancy care
• Gestational diabetes
• Third trimester and delivery
The size of the problemThe size of the problem
Perinatal mortality (%)
0
5
10
15
20
25
30
35
1921-30 1931-40 1941-50 1951-60 1961-70 1971-76 1976-79 1980-84
Prepregnancy CarePrepregnancy Care
• Maternal health– Weight– Folate– Smoking– Long term health– contraception
Extremely tight control of blood sugar
Prepregnancy CarePrepregnancy Care
• Maternal health– Assess for
• Risk of miscarriage
Prepregnancy CarePrepregnancy Care
• Congenital anomalies– Comparison of % depending of timing of care
EEaarrllyy oorr pprreepprreeggnnaannccyyccaarree
LLaattee bbooookkiinngg
11..11 66..66
11..88 1100..55
44..99 99
11..22 1100..99
Prepregnancy CarePrepregnancy Care
• Congenital anomalies
If the HbA1c is >10% then ~ 30% of babies may have a congenital anomaly
Prepregnancy carePrepregnancy care
• Allows a detailed risk assessment
• Should be performed opportunistically
• Diabetic women should plan their pregnancy
Maternal risksMaternal risks
• Diabetic ketoacidosis is rare in pregnancy
• Hypoglycaemia accounts for most death in pregnant diabetics
Early pregnancyEarly pregnancyMultidiscplinary careMultidiscplinary care
Obstetrician
Physician
Midwife
Dietician
Diabetic nurse
Patient
ManagementManagement
• Diet to allow ideal weight gain
• Change oral hypoglycaemics to insulin
• Tight control of blood sugars– Fasting < 6– Postprandial < 8
• Q.D.S. insulin regime
• Post prandial levels are important
• Downside– Hypoglycaemia– Morning sickness
Gestational DiabetesGestational Diabetes
• Definition– Carbohydrate intolerance that arises during pregnancy
and disappears after delivery
• Is gestational diabetes an important condition
Trends in insulin resistance and Trends in insulin resistance and insulin production with ageinsulin production with age
1 100
Insulin resistance
Insulin production
Trends in insulin resistance and Trends in insulin resistance and insulin production with ageinsulin production with age
1 100
Pregnancy
Insulin ResistanceInsulin Resistance
Gestational DiabetesGestational DiabetesScreeningScreening
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
Gestational DiabetesGestational DiabetesDiagnosisDiagnosis
• 100g GTT (5.0, 9.2, 8.1, 6.9)
• 100g GTT (5.8, 10.6, 9.2, 8.1)
75g GTT75g mini GTTSerial capillary blood sugar
•50g GTT (AUC)
GDM – ScreeningGDM – Screening
• LOW RISK– Routine random sugar at 16 and 28 weeks
• HIGH RISK– 28 week simplified GTT
Gestational DiabetesGestational DiabetesManagementManagement
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/ proteinuriaInduction of labour -38-39wks on insulin. 40 wks if well controlled or
diet controlWellbeing screening at ADU C/S at 39 weeksPost natal care..
Third trimesterThird trimesterand fetal risksand fetal risks
• Fetal size
• Cardiac hypertrophy
• Stillbirth
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%
MacrosomiaMacrosomia
Fetal MonitoringFetal Monitoring
• Serial growth scans
• Biophysical profile
• Cardiotocography
• Doppler
DeliveryDelivery
• At 38 - 40 weeks gestation
• High incidence of caesarean
• Shoulder dystocia
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.
Early neonatal risksEarly neonatal risks
• Fetal hypoglycaemia
• Polycythaemia - jaudice
• Respiratory distress syn
• Birth trauma
PostnatalPostnatal
• Insulin requirements return to normal immediately
• GTT at 6-12 weeks post partum
• Long term F/U - mother and baby
Contraception?Contraception?
Barkerism
SummarySummary