19. Pregnancy and diabetes Flashcards
Is maternal hyperglycaemia good
Maternal Hyperglycemia during pregnancy is bad / very bad for the Fetus
Why does diagnosing maternal hyperglycaemia matter?
It affords an opportunity to Prevent:
- Morbidity In the offspring “from the uterus to the grave”
- An exacerbation of the obesity & Type 2 diabetes epidemic
- Future Type 2 diabetes in the mother
ANC booking groups
At ANC booking there are 2 groups
Women with Normal Glucose tolerance
Women with Abnormal Glucose tolerance
- Known Diabetes or IGT
- Unknown Diabetes or IGT
Types of hyperglycaemic scenarios during pregnancy
Pre-gestational Hyperglycaemia
Type 1 Diabetes
Type 2 Diabetes
Known
Unknown
Monogenic Diabetes
Impaired Glucose Tolerance (IGT)
“Gestational Diabetes” (GDM)
Any newly found Abnormal GTT after the
1st trimester of pregnancy ( i.e. Diabetes or IGT )Practical definitions of gestational diabetes
WHO criteria ( and NICE)
Diabetes OR Impaired Glucose Tolerance
Fasting glucose =/ > 5.6 mmol/l
2 hour GTT glucose =/ > 7.8 mmol/l
International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria Outcome based (HAPO study)
75 g Glucose Tolerance test
Fasting 5.1 mmol/l 1 hour 10.0 mmol/l 2 hours 8.5 mmol/l
Diagnose if 1 or more abnormal
What is the problem with hyperglycaemia in pregnancy?
Any degree of Maternal Hyperglycaemia during pregnancy can cause serious problems for the fetus
Stages of pregnancy
1st Trimester Organogenesis Carefully design the essential components Avoid Mistakes ( Teratogenesis) Construct & programme the placenta 2nd Trimester Further complex development & linkage 3rd Trimester Accelerated growth
How does maternal metabolism change as pregnancy progresses?
Early pregnancy = Facilitated Anabolism Increased Insulin sensitivity Glucose concentration slightly lower Increased maternal energy stores Later Pregnancy = Facilitated Catabolism Increased Insulin resistance Increased transplacental passage of nutrients -> Rapid fetal growth
How does maternal hyperglycaemia mess with the system?
1st trimester Increased Fetal abnormalities Fuel Mediated Teratogenesis Abnormal placental programming Increased risk of Pre-eclampsia Excessive glucose transport 3rd Trimester Excessive fat deposition Adverse Fetal programming ( epigenetics )
Possible feotal malformations as a result of first trimester maternal hyperglycaemia
Hydrocephalus Meningomyelocoele Congenital heart disease Single ventricle and sacral dysgenesis Renal agenesis
Preventing foetal malformation in hyperglycaemia of pregnancy
Start preconception for known diabetes
Good Diabetes Control in 1st Trimester Prepregnancy counselling Lifestyle Modification Intensive glucose monitoring Optimize Insulin Regimen If not on Insulin commence Insulin Folic Acid 5mg / day
Primary care & prevention of fetal malformation due to maternal hyperglycaemia
Identify Unknown cases of Diabetes / IGT by checking women with risk factors Previous Gestational Diabetes Obesity Polycystic ovarian syndrome Family history of type 2 diabetes High risk racial group
Problems in third trimester
Macrosomia & associated problems
Pre-eclapsia
Fetal or Neonatal death
Macrosomia -> Difficult Birth Shoulder Dystocia Breathing Problems Jaundice Hypoglycaemia
Risk of increased perinatal mortality for women with diabetes vs no diabetes
Type 2 diabetes - x 9
type 1 diabetes - x2
Lifelong foetal sequele of hyperglycaemia in pregnancy?
Obesity Insulin resistance Type 2 diabetes Dyslipaemia Hypertension Vascular disease
Who’s screened for for undiagnosed diabetes?
high risk women: Previous GDM Obesity ( BMI > 30) Family history High risk racial group Older age Polycystic ovary syndrome THEN Universal or Targeted Screening at 26 weeks To Detect GDM
Treatment of any pregnancy hyperglycaemia
Good maternal glucose control - Intensive blood glucose monitoring - Fasting + 1 hour post prandial minimum Appropriate nutrition Reasonable exercise Utrasound monitoring of Fetal abdominal girth - Monthly from 28 weeks Maternal observation of Fetal movements
Targets for hyperglycaemia of pregnancy
Fasting glucose < 5.1 mmo/l
1 hour postprandial glucose < 7 mmol/l
Fetal Abdominal girth < 70th centile
Less in Asians
Drug treatment to achieve good maternal glucose control in pregnancy
Prepregnancy /1st trimester hyperglycaemia Basal bolus Insulin regimen “Gestational” diabetes Metformin Basal Insulin Basal bolus Insulin Glibenclamide (Uncommon in UK)
Diabetes/GDM - post partum
Maintain good Glycaemic control - To prevent excess glucose in milk - Reduce maternal weight gain Advice re next pregnancy Contraception advice Encourage long term glycemic control Encourage Breast Feeding
breastfeeding and obesity
Child Any reduces risk by 30-50% - 19 studies 3-19 years - 6 studies 4-18 years Prolonged exclusive reduces by 67%
Mother
Reduces postpartum weight gain
Women who lactated for either 6–12 months or 12 months or longer had half the risk for diabetes
“Specific GDM” Management Post Partum
Screen for diabetes at 12 weeks post partum
- HbA1c +/- Fasting glucose, or GTT
Review GAD ect. antibody status if done
Lifestyle advice
Advice re next pregnancy
- Optimize exercise & Nutrition
- Pre pregnancy GTT
Annual glucose screening
- 50% develop type 2 diabetes at 10 years
GDM & Primary Care – Post PartumContraceptives & Diabetes / IGT
Progestagen only pill
Combined OCP ( low dose) after 6 weeks
Mirena Intrauterine system
Sterilisation / Vasectomy
Problem of hyperglycaemia in pregnancy
Maternal Hyperglycaemia
-> Serious fetal problems
Early - Teratogenesis
Late
· Macrosomia / hypoglycaemia / lung problems
· Pre-eclampsia
· Late Fetal deathManagement of hyperglycaemia in pregnancy
- Folic acid 5mg in 1st Trimester
- Aspirin 75 - 150 mg/day from 12/40
- if less than 16/40
- Attendance at multidisciplinary one stop clinic
- Tight glucose control throughout pregnancy
- Fetal Ultrasound monitoring in last trimester
- Maternal monitoring of Fetal movements
- Appropriate delivery strategy (NO DOGMA!!)
Screening for hyperglycaemia in pregnancy
Screen to detect “Gestational diabetes” High risk women at 12-14 weeks At 28 weeks - Everyone ( Universal screening ) or Targeted (NICE) Postpartum Screen “GDM women” for Diabetes - At 12 week post Partum - Annually for Diabetes (50% by 15 years)
