Diabetes

Question 1

Outline your preconceptual counselling for a woman with T1DM:

Answer 1

Effect of pregnancy on T1DM:

• Needs more insulin
• Progression of nephropathy, retinopathy
• More hypos
• Progression of autonomic neuropathy and gastric paresis
• DKAs exacerbated by hyperemesis, infection or steroid therapy.

Effect of T1DM on pregnancy:

• Miscarriage
• PET
• Infections
• Congenital abnormalities: heart, NTDs, skeletal, sacral agenesis.
• LGA, shoulder dystocia
• Risk of IUGR, stillbirth
• Risk of CS
• Neonatal hypoglycaemia, jaundice and RDS.
• Long-term: baby gets obesity, diabetes

Aims:

• Optimise BSL control/HbA1c <48 before pregnancy.
• Update diabetic screening: retinopathy, nephropathy.
• Stop: ACEi/ARBs, statins.
• Effective contraception; esp if HbA1c >86
• Sick day advice: ketone testing strips/meter if hypos or unwell.
• Baseline Ix: HbA1c, FBC, serum Cr and eGFR, urine ACR, lipids, TSH/TPO antibodies, B12 level

Routine:

• MDT care
• Folic acid 5 mg daily
• Booking bloods
• Diet, exercise, GWG advice
• Vaccinations

Question 2

Outline your management plan for a T1DM woman who is pregnant:

Answer 2

MDT care: high risk obstetrics, obstetric physician/diabetologist, MW, nurse, dietician etc.

BSL aims: fasting <5.3; 2 hr PP <6.7

Antenatal:

• Folic acid 5 mg od, iodine 150 mcg od
• Diet, exercise, GWG
• Low dose aspirin and calcium
• Early dating scan
• Retinal assessment in every trimester.
• Sick day advice: ketone testing; low hypo awareness; continue insulin; seek help early.
• MSS/NIPT
• Anatomy scan
• Serial growth scans
• Midtrimester screening/vaccinations
• PET surveillance: BP, urine

Intrapartum:

• Anaesthetic review if obese or has neuropathy.
• IOL 38-40 weeks.
• Delivery in hospital.
• PPH risk: IVL, FBC, G&H, active 3rd stage management.
• SB risk: CEFM
• When NBM: glucose-insulin infusion and regular BSL monitoring Q1H.

Postpartum:

• Baby BSL monitoring; feed ASAP
• Paeds review if suspected complications.
• Contraception: LARC.
• Breastfeeding
• Return to pre-pregnancy medication
• Arrange follow-up with usual diabetes care provider.

Question 3

Outline your management for a woman with a new diagnosis of GDM at 28 weeks gestation:

Answer 3

Explanation of GDM:
During pregnancy your body doesn’t regulate glucose as well which predisposes women to developing GDM which is where your blood glucose level is abnormally high.

Effect of GDM on pregnancy:

• LGA, IUGR, shoulder dystocia
• Stillbirth
• Neonatal hypoglycaemia, jaundice
• PET
• CS

Effect of GDM long term:

• T2DM
• Child: obesity, T2DM

Antenatal management plan:

• HbA1C ?pre-existing T2DM.
• Blood sugar testing teach QID. Aim: fasting <=5; 2 hr PP <=6.7
• Hypo education
• Dietician/diet control
• Metformin and/or insulin
• Exercise, limit GWG
• Serial growth scans
• PET surveillance
• Regular follow-up with MDT GDM clinic

Intrapartum management plan:

• IOL 38-40 weeks
• Delivery in hospital
• IVL, FBC, G&H, active 3rd stage management
• CEFM in labour
• BSL monitoring in labour

Postpartum management plan:

• Stop GDM meds.
• Check BSLs
• Breastfeeding and ASAP
• BSL monitoring for baby +/- paeds review
• Contraception
• T2DM screening: OGTT or fasting glucose or HbA1c 3 months PP.

Question 4

What are the diagnostic cut offs for diagnosing GDM with an OGTT?

Answer 4

Fasting ≥5.1
2 hr ≥8.5