Diabetes in pregnancy

Question 1

What is the pre-conception management of pre-existing diabetes in pregnancy?.

Answer 1

Stop all glucose lowering agents except Metformin + Insulin

Stop Statins

Stop ACEi + ARB, use alternate antihypertensives

High dose folic acid 5mg preconception till 12w

Question 2

What is the antenatal management of pre-existing diabetes in pregnancy?

Answer 2

Measure HbA1c at booking

Arrange joint diabetes + antenatal clinics every 1-2w

Ensure mother up to date with renal + retinal screening

CBG monitoring: fasting, pre-meal, 1h postprandial + bedtime

Specialist foetal cardiac scan at 19-20w

Serial growth scans every 4w from 28-36w

Repeat maternal retinal + renal screening at 28w (if abnormal at booking repeat at 16-20w)

Question 3

What is the antenatal pharmacological management of pre-existing diabetes in pregnancy?

Answer 3

High dose folic acid 5mg OD until 12w

Low dose aspirin 75mg OD from 12w

Rapid activating Insulin (Asport/ Lispro) may need increasing since insulin resistance increases through pregnancy

Question 4

What is the intrapartum management of pre-existing diabetes in pregnancy?

Answer 4

Organise elective birth 37-38+6w: IOL or CS

Consider delivery before if foetal/ maternal complications

Advise birth in hospital

Monitor CBG hourly during labour + birth

If on insulin, commence a sliding scale during labour, aim BG 4-7mmol/l

Question 5

What is the postnatal management of pre-existing diabetes in pregnancy?

Answer 5

Check neonatal blood glucose within 4h of birth

Women should feed baby within 30 mins of birth + then every 2-3h until pre-feed CBG maintains >,2 mol/l

Adjust insulin + metformin doses back to pre-pregnancy doses immediately

Question 6

What caution must be taken if preterm delivery is needed in a diabetic mother?

Answer 6

If antenatal corticosteroids are needed, ADDITIONAL INSULIN therapy must be given concurrently to maintain normoglycemia

Question 7

What investigations and results may be found in diabetic mothers during pregnancy?

Answer 7

Fundal height: polyhydramnios + macrosomia

Fasting plasma glucose level >5.6 mmol/L,
or
2h plasma glucose level >7.8 mmol/L

Question 8

What are the risks of pregnancy in a diabetic mother?

Answer 8

Maternal
Difficult delivery due to macrosomia
Retinal + renal issues
Increased risk of Pre-eclampsia

Foetal:
Miscarriage
Stillbirth
Prematurity
Congenital malformation
Macrosomia