Diabetes and (pre-)pregnancy in primary care

Kate Hunt, Diabetes Consultant, KCHRita Forde, DSN, KCL

Lambeth CCG Diabetes Learning Event 4th October 2018

Learning objectives

• Why (pre-)pregnancy and diabetes is relevant in primary care

• Key messages about pregnancy and diabetes

• Opportunities and approaches for discussing pregnancy with women with diabetes

• When and how to refer

• Sources of information

Pregnancy in women with diabetes• Increased risk of adverse pregnancy outcomes:

– ↑Congenital malformation, ↑ Miscarriage, – ↑ Pre-eclampsia, – ↑ Fetal macrosomia, ↑ Birth trauma (to mother & baby), – ↑ Induction of labour or caesarean section,– ↑ Stillbirth, – ↑ Neonatal morbidity (SCBU/NICU admission,

hypoglycaemia, hyperbilirubinaemia, respiratory distress, neonatal death)

• Increased risk of maternal hypoglycaemia (1st trimester), DKA and deterioration of maternal diabetes complications

• Increased risk of obesity and/or T2DM in offspring

Pregnancy in women with diabetesEstablishing good blood glucose control (and other measures) BEFORE conception and continuing throughout pregnancy will reduce the risk of adverse pregnancy outcomes (miscarriage, congenital malformation, stillbirth and neonatal death)

NICE: pre-pregnancy in women with diabetes • Information about outcomes and risks for mother and baby• Diet and body weight if BMI >27 kg/m2• Folic acid 5mg (to reduce risk of neural tube defect)

• Self monitoring of blood glucose• HbA1c <48mmol/mol (6.5%) if achievable without problematic hypoglycaemia• Blood glucose lowering agents

– Metformin and insulin only – all others should be stopped and replaced with insulin

• Statins should be discontinued before pregnancy or as soon as pregnancy confirmed

• Alternative antihypertensives suitable for use during pregnancy should be substituted– Labetolol, Nifedipine, Methyldopa

• Screening (retinal and renal)• Contraception

NICE Guideline 3 2015

Enrolled in audit

1689 (51%)

1608 (49%)

National Pregnancy in Diabetes Audit - 2016

NDIP 2017

Enrolled in audit Live births after 24 weeks

1689 (51%) 1517

1608 (49%) 1521

Folic acid 5mg prior to pregnancy

7

National Pregnancy in Diabetes Audit 2017

Folic Acid 5mgsAt least one of the following:

statins/ACE I / ARB /adverse DM medication

Type 1 DM 41.8% 1.8%

Type 2 DM 22.8% 13.0%

NDIP 2017

Adverse DM medication - sulphonylurea or glitinide, gliptin, GLP-1 analogue and pioglitazone, irrespective of whether the woman was also taking metformin and/or insulin.

First contact with antenatal diabetes team <8/40

9

First HbA1c in pregnancy

10

Case 1 & Case 25 minsCase 1: tables 1-3Case 2: tables 4-6

Case 138 year old womanWants to get pregnant and has heard that diabetes might be a problem

PMH: T2DM diagnosed (Δ age 34)BMI 32 kg/m2Hypertension (Δ age 34)

Obstetric: G0Meds: Metformin 1000mg bd, Gliclazide 160mg bd, Sitagliptin 100mg od

Atorvastatin 40mg odBendrofluazide 2.5 mg od, Ramipril 10mg od

Recent investigations: HbA1c 58 mmol/mol (7.5%), BP 132/78 mmHg, TC 3.4 mmol/l, LDL 1.8 mmol/l, Retinal screening normal, uACR <2.5 mg/mmol

Questions: What are the issues?What would you discuss with her?What would you do?

Case 1What are the issues• HbA1c higher than ideal• Sitagliptin, gliclazide, atorvastatin, bendrofluazide, ramipril should be avoided in pregnancyWhat would you discuss with her?• Congratulate her for making an appointment to discuss this• Explain that her risks of adverse outcome are higher BUT risks can be reduced.• Explain HbA1c is higher than ideal & she is on several medications not safe in pregnancy• Explore if any other diet/exercise measures she might be able to introduce• Ask about smoking and alcohol• Advise her to avoid pregnancy until these issues are sorted out (need to explore this)• Advise her to let practice know immediately if she gets pregnant before thisWhat would you do?• Refer to Diabetes Pre-pregnancy clinic (eRS)• Diabetes UK Information Prescription / websites• Start folic acid 5mg od• In PCC or in primary care:

– Stop bendrofluazide and ramipril, change to labetolol– Consider stopping atorvastatin (stop when trying for pregnancy, or if not avoiding)– Consider stopping sitagliptin (stop when trying for pregnancy, or if not avoiding)– Continue metformin – Continue gliclazide until switched to insulin– Teach SMBG

Referral-thinking about pregnancy (in next 12 months)=eRS

Providing information

Diabetes UK Information Prescriptionhttps://www.diabetes.org.uk/professionals/resources/resources-to-improve-your-clinical-practice/information-prescriptions-qa

Providing information

Diabetes UK websitehttps://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/pregnancy

Providing information

NHS websitehttps://www.nhs.uk/conditions/pregnancy-and-baby/diabetes-pregnant/

Case 238 year old woman, Pregnant. LMP 8 weeks agoPMH: T2DM diagnosed (Δ age 34)

BMI 32 kg/m2Hypertension (Δ age 34)

Meds: Stopped all medication with positive pregnancy test 10 days ago Metformin 1000mg bd, Gliclazide 160mg bd, Empagliflozin 25mg od

Atorvastatin 40mg odAmlodipine 10mg od

Recent investigations: HbA1c 58 mmol/mol (7.5%), TC 3.4 mmol/l, LDL 1.8 mmol/l, uACR <2.5 mg/mmolRetinal screening normal Today: BP 132/78 mmHg, capillary blood glucose 12.5 mmol/l

Questions: What are the issues?What would you discuss with her?What would you do?

Case 2What are the issues• HbA1c higher than ideal• She has stopped all her medications and BG 12.5 mmol/l (pregnancy targets pre meals

<5.3mmol/l, 1 hour post meal < 7.8 mmol/l) but BP ok• Empagliflozin, sitagliptin, gliclazide, atorvastatin, amlodipine, should be avoided in pregnancy

What would you discuss with her?• Explain HbA1c is higher than ideal & she was on several medications not safe in pregnancy• Explain she will need to be seen urgently by the diabetes pregnancy team and will be taught

how to test BG and started on insulin

What would you do?• Refer to Diabetes Pregnancy team immediately (phone call). (Should be seen within 24-48

hours, taught SMBG and started on full basal bolus insulin)• Start folic acid 5mg od• Restart metformin. Stay off empagliflozin, gliclazide • Stay off amlodipine (as BP ok). (if concern start nifedipine)• Stay off atorvastatin

Referral-pregnant• We aim to see within 24-48 hours• Please DON’T use eRS (as turnaround too slow)• Please include patient’s mobile number, HbA1c, medication in referral

King’s College Hospital Denmark Hill• Email referral: kch-tr.diabetessupplies@nhs.netAND• Phone call (email only sufficient if HbA1c <48 mmol/mol on diet/metformin/insulin only & no other

concerns)

– Switchboard 02032999000, bleep Diabetes SpR – OR Consultant Connect

Guy’s & St Thomas Hospital Consultant connect• Email referral: gst-tr.DiabetesAndEndocrine@nhs.netAND• Phone call (email only sufficient if HbA1c <48 mmol/mol on diet/metformin/insulin only & no other

concerns)

– Diabetes department St. Thomas’ 0207188 1981 – OR Consultant Connect

Medications in (pre) pregnancyBlood glucose lowering agents

Metformin and insulin only all others should be stopped and replaced with insulin

Statins should be discontinued before pregnancy or as soon as pregnancy confirmed

Alternative antihypertensives suitable for use during pregnancy should be substituted

Labetolol (to replace other b-blockers, diuretics, ACEi, ARB-local guidance)Nifedipine (to replace other Ca channel blockers--local guidance)Methyldopa (3rd line)(NB: if microalbuminuria/proteinuria consider continuing ACEi/ARB until confirmed pregnancy)

Case 3 & Case 45 minsCase 4: tables 1-3Case 3: tables 4-6

Case 322 year old woman, Follow up appointment. Seen 2 weeks ago after doing fingerstick test using grandmother’s BG meter and found CBG 12.2mmol/l. Assymptomatic.

PMH: nil

Family history: mother has diabetes on tablets and grandmother diabetes on insulin

Meds: nil

Other: BMI 34 kg.m2, black African

Recent investigations: CBG in clinic 10.5 mmol/l, urine ketones negativeHbA1c 53 mmol/mol (7.1%), repeated 55 mmol/mol (7.2%)

Questions: What is the diagnosis?Is diabetes and pregnancy information relevant here?What would you discuss with her, when and how?

Case 3What is the diagnosis?• Type 2 diabetes

Is diabetes and pregnancy information relevant here?• Yes

What would you discuss with her, when and how?• Straight away!• ‘What are your thoughts on having a baby in the next

couple of years?’ • ‘Do you think you might (want to) have a baby in the

next couple of years?’• (Probably avoid ‘Are you planning pregnancy?)

Talking about pregnancy with women with diabetes

What are your thoughts on having a baby in the next couple of years?

Yes/Maybe/Unsure No

Refer Diabetes PPCAdvise avoid pregnancy until diabetes

care optimised

Signpost reliable contraceptionAdvise to discuss with PN/GP BEFORE

trying to get pregnant/discontinuing contraception

Do you know why we discuss pregnancy in diabetes?

How are you preventing pregnancy?How are you planning / preventing pregnancy?

Do you know why we discuss pregnancy in diabetes?

Discuss:Increased risk of adverse pregnancy outcomes in women with diabetesCorrect medications, good BG control, folic acid 5mg, lifestyle measures

PRIOR to pregnancy reduces riskInform PN/GP IMMEDIATELY if pregnant

Signpost information

Case 436 year old woman, attending for diabetes annual review

PMH: T2DM diagnosed (Δ age 32) (attended DESMOND)BMI 36 kg/m2Hypertension (Δ age 32)

Obstetric history: G3P2+1 miscarriage (1st trimester), 2 children aged 12 and 10

Meds: Metformin 1000mg bd, Gliclazide 160mg bd, Liraglutide 1.2 mg od Atorvastatin 40mg odRamipril 10mg od, amlodipine 10mg odMirena coil

Recent investigations: HbA1c 48 mmol/mol (6.5%), TC 3.4 mmol/l, LDL 1.8 mmol/l, uACR <2.5 mg/mmolRetinal screening normal BP 125/74 mmHg

Questions: Is diabetes and pregnancy information relevant here?What are the issues/possible assumptions?What would you discuss with her and how?

Is diabetes and pregnancy information relevant here?• Yes!

What are the issues/possible assumptions?• Just because she has 2 older children and has a Mirena coil, does

not mean she does not want further pregnancies• Her pregnancies were before she developed diabetes so she may

not realise there are any issues• DESMOND does not cover diabetes and pregnancy• If thinking about pregnancy gliclazide, liraglutide, atorvastatin,

ramipril not suitable If not thinking about pregnancy, could consider SGLT2i

What would you discuss with her (and how)?• ‘You have the Mirena coil at the moment. What are your thoughts

on having a baby in the next couple of years/do you think you might want to have another baby in the future?’

Case 4

Pregnancy as part of annual review

What are your thoughts on having a baby in the next couple of years?

Yes/Maybe/Unsure No

Refer Diabetes PPCAdvise avoid pregnancy until diabetes

care optimised

Signpost reliable contraceptionAdvise to discuss with PN/GP BEFORE

trying to get pregnant/discontinuing contraception

Do you know why we discuss pregnancy in diabetes?

How are you preventing pregnancy?How are you planning / preventing pregnancy?

Do you know why we discuss pregnancy in diabetes?

Discuss:Increased risk of adverse pregnancy outcomes in women with diabetesCorrect medications, good BG control, folic acid 5mg, lifestyle measures

PRIOR to pregnancy reduces riskInform PN/GP IMMEDIATELY if pregnant

Signpost information

Woman <50 years old attending for diabetes annual review

What happened to this lady?

Case 4-missed opportunitiesOver the following year:• Mirena coil removed December 2017 (no

discussion about diabetes and pregnancy)• Self-started folic acid 400 mcg od

• Pregnant March 2018. Missed miscarriage at 8/40 with ERPC. (no discussion about diabetes and pregnancy)

• Pregnant Oct 2018. Self referred for maternity care at 8/40

Healthcare professionals perspectives about pre-pregnancy care for women with type 2

diabetes

I hadn’t thought about it until you asked me -

we don’t talk about pregnancy when women are newly

diagnosed, there isn’t anything in there

[DESMOND] about it at all, which is

interesting ‘cause we do stuff for men.

(DSN PC1)

I don't give them support until they come to me and say, ‘Actually, we’re thinking of trying for a family,’ which is interesting – it’s more

reactive, really.(GP 03)

• Asking them about their contraception or planning doesn't enter my thought process, and that’s just mainly down to timing issues ‘cause you know if you go there it takes time, and you just don't have time to deal with everything (GP5).

• Well I think obviously the time is pressure for us. I mean we have our fingers in an awful lot of pies in general practice. And we have to cover a lot of areas (PN2).

• Pre-conceptual and planning tends to go lower on your prioritisation list because you're dealing with the here and now, so to start a conversation like that… it’s time(GP1).

• Well if we got paid for it I would remember to do it (PN 4)

Healthcare professionals perspectives about pre-pregnancy care for women with type 2 diabetes

Pre-pregnancy care for women with type 2 diabetes – Rita Forde, PhD thesis KCL

• I’m not going to do the specialised pre-conception care, it would be a specialist nurse that would do that - so it really is about me identifying them [women with T2DM] and flagging them up (GP2).

• I don't deal with it [pre-pregnancy care]. So I would pass it on to someone who would be the appropriate person to do it, because we’re so specialised in certain areas (DSN SC1).

• I’m specialised in other fields of diabetes, whereas my other colleagues are more specialised in pre-pregnancy care, so I would ask their advice and help, but I think it’s important for us to have an understanding of it, but I could happily give people general information about it and help them (DSN SC2).

• You can't expect every GP to know everything there is to know about everything (CE1).

• I don't think across the board between secondary and primary care, there's a lot of interface (PN2).

Healthcare professionals perspectives about pre-pregnancy care for women with type 2 diabetes

Pre-pregnancy care for women with type 2 diabetes – Rita Forde, PhD thesis KCL

Pregnancy as part of annual review

What are your thoughts on having a baby in the next couple of years?

Yes/Maybe/Unsure No

Refer Diabetes PPCAdvise avoid pregnancy until diabetes

care optimised

Signpost reliable contraceptionAdvise to discuss with PN/GP BEFORE

trying to get pregnant/discontinuing contraception

Do you know why we discuss pregnancy in diabetes?

How are you preventing pregnancy?How are you planning / preventing pregnancy?

Do you know why we discuss pregnancy in diabetes?

Discuss:Increased risk of adverse pregnancy outcomes in women with diabetesCorrect medications, good BG control, folic acid 5mg, lifestyle measures

PRIOR to pregnancy reduces riskInform PN/GP IMMEDIATELY if pregnant

Signpost information

Woman <50 years old attending for diabetes annual review

EMIS

Raising awareness

-Mailshot to women aged 18-50 on DECS mailing list Oct 2018-A4 posters available to display in primary care (please!)-Any other ideas?

Learning objectives• Why (pre-)pregnancy and diabetes is relevant

in primary care• Key messages about pregnancy and diabetes• Opportunities and approaches for discussing

pregnancy with women with diabetes• When and how to refer• Sources of information