Diabetes & Gestational Diabetes

Question 1

When is HbA1c measured for known diabetes?

Answer 1

Booking apt

Question 1

Preconception diabetes

Answer 1

Medication:
- Stop all glucose lowering agents, except metformin and insulin
- Stop ACEi or ARBs
- 5mg folic acid (pre-conception to 12 weeks)

Question 2

How often are known diabetics monitored?

Answer 2

Joint diabetes and antenatal clinic every 1-2 weeks

Question 3

Conservative antenatal management for known diabetes?

Answer 3

• Weight loss BMI >27
• Retinal and renal screening
• Advice about implications of diabetes in pregnancy

Question 4

How often is CBG monitored (known diabetes)?

Answer 4

Min 7x day
- Fasting
- Pre-meal
- 1 hour post-meal
- Bedtime

Question 5

What are the blood glucose targets (known diabetes and GDM)?

Answer 5

• Pre-prandial <5.3mmol/L
• 1hr post-prandial <7.8mmol/L
• 2hrs post-prandial <6.4mmol/L

If taking insulin, keep CBG >4mmol/L

Question 6

Antenatal monitoring known diabetes

Answer 6

• Specialist foetal cardiac scan 19-20 weeks
• Serial growth scans 28-36 weeks (every 4 weeks)
• Repeat maternal retinal and renal screening at 28 weeks (if abnormal at booking, repeat at 16-20 weeks then 28 weeks)

Question 7

Medical management known diabetes

Answer 7

• 5mg folic acid preconception to week 12
• Low-dose aspirin 75-150mg OD from 12 weeks
• May need to increase insulin after 20 weeks (increasing insulin resistance during pregnancy)

Question 8

Antenatal management known diabetes without complications?

Answer 8

IOL/CS between 37 to 38+6

Question 9

What should be given if antenatal corticosteroids are needed?

Answer 9

Additional insulin to maintain normoglycaemia

Question 10

How often is CBG monitored during labour?

Answer 10

Every hour

Question 11

How is insulin delivered during labour and birth?

Answer 11

For women on insulin, sliding scale (aim 4-7mmol/L)

Question 12

Postnatal management known diabetes

Answer 12

• Neonatal blood glucose within 4 hours
• Feed baby within 30 minutes then every 2-3 hours until pre-feed CBG is at least 2mmol/L
• Adjust insulin and metformin doses to pre-pregnancy immediately after birth

Question 13

When is GDM usually diagnosed?

Answer 13

Week 24-28

Question 14

What are the scans for GDM?

Answer 14

Serial growth scans from 28-36 weeks every 4 weeks

Question 15

Management for GDM with fasting glucose <7mmol/L

Answer 15

• Change to low glycaemic index foods
• Refer to dietician
• Regular exercise (walking 30 mins after meal)

Question 16

Management for GDM if targets are not met within 1-2 weeks and not on medication

Answer 16

Metformin, if metformin contraindicated offer insulin (contraindicated with renal impairment)

Question 17

Managment for GDM if diet, exercise and metformin not effective

Answer 17

Add insulin

Question 18

Management for GDM if women decline insulin

Answer 18

Glibenclamide (sulphonylurea)

Question 19

When is insulin offered straight away for GDM?

Answer 19

If fasting glucose >7mmol/L or 6-6.9mmol/L with complications insulin + metformin straight away

Question 20

What is the intrapartum management of GDM?

Answer 20

Elective birth no later than 40+6 weeks

If not given by 40+6 weeks IOL or CS

Question 21

What is the immediate postnatal management of GDM?

Answer 21

• Discontinue blood lowering tx immediately
• Assess blood glucose of baby 2-4 hours after birth and early feeding

Question 22

What is the ongoing postnatal monitoring for GDM?

Answer 22

Fasting blood glucose 6-13 weeks postnatal (or HbA1c if after 13 weeks) to exclude diabetes diagnosis

• <6mmol/L moderate T2DM risk, annual HbA1c and diet and exercise
• 6-6.9mmol/L high T2DM risk, annual HbA1c and diet and exercise
• > 7mmol/L likely to have, diagnostic test to confirm

Future pregnancies:
- OGTT at booking and 24-28 weeks

Question 23

Which insulin is used in GDM?

Answer 23

Short acting

Question 24

What are the diagnostic thresholds for GDM?

Answer 24

• Fasting >= 5.6mmol/L
• 2 hr >= 7.8mmol/L