Diabetes and pregnancy

Great Expectations!

Sister Lesley Mowat

Dr Shirley Copland

Pregnancy -the ideal outcome

• As normal a pregnancy as possible

• Healthy mother and baby

• Aiming to reduce the rates of miscarriage, congenital anomaly and perinatal mortality to the same levels as the background population

Topics

• Prepregnancy planning

• Care during pregnancy

• Gestational diabetes

Pre-pregnancy planning

• All patients with type 1, type 2 or secondary diabetes who are in the child bearing years should be made aware of the importance of planning for any pregnancy

• Discuss during routine review along with contraception issues

Pre-pregnancy planning

• Key message is that excellent glycaemic control prior to conception and during pregnancy results in the optimal outcome for mother and baby

• Self management of diabetes and issues of hypoglycaemia need to be discussed e.g. insulin adjustment, glucose targets, driving, teach use of hypostop/glucogon to partner

Pre-pregnancy planning

• Diabetes complications need to be recognised and managed optimally

• Review medications NB Ace inhibitors are teratogenic

• Rubella status to be checked

• Commence folic acid 5mg

• Review other health issues, menstrual status and gynaecological factors

Pre-pregnancy planning

• SIGN guidelines strongly recommend that pre-pregnancy care is provided by a mutli-disciplinary specialist team

• Advise early attendance at specialist clinic for pre-pregnancy advice i.e. Combined Diabetes/Obstetric Clinic, AMH (weekly Tues pm)

Why need to plan?

• Pregnancy in Type 1 diabetes is a high risk state for both the mother and the foetus

• Increased risks of diabetes complications

• Increased risk of obstetric complications

• Increased foetal and neonatal hazards

Why need to plan?

• Patients with type 2 diabetes are also at increased risk of obstetric complications and their babies are equally at risk of malformation and neonatal problems

• Type 2 diabetes increasing in young women

• Tight glycaemic control prior to and during pregnancy is essential and insulin therapy likely to be required

Maternal risks with Type 1 diabetes

• Severe hypoglycaemia with loss of hypoglycaemic awareness (30%)

• Ketoacidosis can develop more rapidly

• Worsening of pre-existing retinopathy - laser treatment can be required

• Worsening of pre-existing renal dysfunction and hypertension

Obstetric risks in diabetes

• Increased rates of miscarriage

• Higher incidence of pre-eclampsia

• Obstructed labour and polyhydramnios now less common

• High caesarean section rates (71%)

Foetal and neonatal risks

• Congenital malformation rates remain greater than the background population e.g. cardiac defects, sacral agenesis

• Late intrauterine deaths and increased foetal distress - aim to deliver between 38-40 weeks

• Macrosomia(most >50th centile, many 95th)

• Neonatal hypoglycaemia is common

G E S T A T IO N ( W E E K S )

4 24 03 83 63 43 23 0

W t .( K g )

6

5

4

3

2

1

9 0

5 0

Aims prior to conception

• Blood glucose levels between 4 - 7 mmols

• HbA1c target of 7.0% or less

• Avoiding disabling hypoglycaemia

• ?How

Patient commitment

• Home glucose monitoring 4 -6 times daily (or more!)

• Multiple injection insulin regime i.e. basal bolus regime with self adjustment

• Address lifestyle issues and review diet

• Clinic visits 6-8 weekly and telephone support

Pregnant at last!

• Patients should attend combined obstetric /diabetes ante-natal clinc as soon as pregnancy is confirmed

• May need admission for stabilisation of control early or at any time during the pregnancy - open door policy in Ashgrove Ward, AMH

• Routine 2- 4 weekly review schedule followed but seen as often as required

Pregnancy

• Patients strive for near normal glycaemia throughout the pregnancy i.e. blood sugar 4-7 mmols

• Self titration of the insulin dose is essential

• Insulin doses at least double by the end of pregnancy

• Encouraged to check for ketones if bs greater the 10 mmols and seek immediate advice if present (risk of foetal death)

Delivery

• Ideally vaginal delivery between 38 and 40 weeks gestation

• Neonatal intensive care facilities required

• During labour iv insulin/10 % dextrose regime used to maintain euglycamia

• High ceasarean section rate

• Post delivery insulin doses return to pre- pregnancy level in type 1 patients. Type 2 often diet alone initially if breast feeding

Gestational Diabetes

• Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy

• Usually seen in the third trimester and glycaemic control returns to normal immediately after pregnancy

• May be the first presentation of type 1 or type 2 diabetes

Gestational Diabetes

• Screening - by a random venous glucose if glycosuria ++ is detected and routinely at 28 weeks gestation

• If greater than 5.5 mmols/l two hours or more after food or greater than 7.0 mmols/l within two hours of eating then requires further investigation by a 75g OGTT

Gestational diabetes

• Diagnosis confirmed if fasting bs is greater than 5.5 mmols/l or two hour OGTT level greater than 9 mmols/l

• Associated with macrosomia and treatment by diet and/or insulin may cause a modest reduction in birth weight

• Initial management is dietary - if blood glucose remains elevated and if evidence of macrosomia then insulin treatment started

Gestational diabetes

• Marker for increased risk of future diabetes

• OGTT arranged 6 months post partum, majority are normal at that stage

• Up to 50% may go on to develop later diabetes mainly type 2

• Should be advised on lifestyle and weight reduction to reduce risk

• Protocol for follow up in primary care