Diabetes in pregnancy Flashcards
What are physiological changes in pregnancy which cause diabetes?
Placental hormones cause increased insulin resistance
This sometimes exceeds insulin reserves and develop raised glucose or GDM (gestational diabetes)
Treatment required later in pregnancy
What is the effect of increased glucose levels in early pregnancy?
Increased risk of neural tube and cardiac abnormalities - teratogenic effect
Excessive fetal growth
Fetal hyper insulinamemia (maintains normal fetal glucose)
What are neonatal problems relating to excess growth and glucose control?
Hypoglycaemia
Hyperbilirubinaemia
Poor adaptation to birth
Metabolic changes
What is the pathophysiology of gestational diabetes?
Insulin resistance
Some endogenous insulin
What does higher maternal glucose lead to?
Excess glucose across the placents
How is gestational diabetes/T2 diabetes managed in pregnancy?
Diet and exercise
Metformin, sometimes insulin
Good control = better growth, easier birth
Birth 38-40 weeks (GDM)
Birth 37-40 weeks (T2)
What is the pathophysiology of T1 diabetes in pregnancy?
Autoimmune beta islet cell destruction
No endogenous insulin
Insulin resistance later in pregnancy
Diagnosis usually before pregnancy (some DKA risk)
How is T1 diabetes managed in pregnancy?
Always use insulin
Good control = less congenital defects
Birth 37-40 weeks
What is the difference between onset in pregnancy of T2 diabetes and gestational diabetes?
T2 diabetes - raised glucose before pregnancy
GDM - raised glucose later in pregnancy
What are maternal effects of diabetes?
Increase in:
- Miscarriage
- Pre-eclampsia
- Infection
- PTB - early induction of labour
- Caesarean section
- Induction labour
- Macrosomia
- Poor progress in labour
What are fetal and neonatal effects of diabetes?
Increase in:
- Congenital malformation e.g. neural tube
- Macrosomia
- Birth risks e.g. shoulder dystocia
- Risk of stillbirth/neonatal death
- Polycythaemia
- Jaundice
- Fetal hypoglycaemia
What are challenges to glycaemic control in pregnancy?
Hyperemesis
Early pregnancy insulin sensitivity
Later pregnancy insulin sensitivity
What are the effects of diabetes on the kidneys in pregnancy?
Deterioration in diabetic nephropathy re increased GFR
What are the effects of diabetes on the eyes in pregnancy?
Progression of diabetic retinopathy
What are the effects of diabetes on birth in pregnancy?
Glucose control during birth complicated - may need variable rate insulin infusion which requires intense monitoring
What is pre-pregnancy management of diabetes?
Optimise glycaemic control - aim HbA1c < 48mmol/mol if safe (hypoglycaemic risk
Advise against pregnancy if HbA1c >86mmol/mol
Pre-conception folic acid 5mg OD
Medications - Review (avoid ACE inhibitors, statins)
Eyes - Retinal screen (pre and during pregnancy)
Kidneys - Renal screen (BP, proteinuria, creatinine)
What is antenatal management of diabetes?
Tight glycaemic control (fasting <5.3, 1hour <7.8)
Aspirin 150mgs from 12 weeks
Dating scan and anomaly scan (NTD and cardiac)
Growth scans (28,32,36 weeks)
What is T2DM antenatal management?
continue metformin, STOP other DM treatments
often need insulin
What is diabetic management during birth?
Timely birth - 37-40 weeks
Good glycaemic control before and during birth
Intrapartum glucose control - variable rate insulin
Antepartum corticosteroids PRN if birth before 36 weeks - risk of hyperglycaemia
(may need VRIII or insulin increase)
What is post partum management of diabetes in the mother?
Insulin requirements reduce rapidly (placenta delivered)
Reduce treatment to pre-pregnancy levels
Further reduction especially if breast feeding
What is post partum management of diabetes in neonates?
Test for hypoglycaemia
Early regular feeding -breastfeeding recommended
Breast feeding safe with insulin / metformin
What are the GDM risk factors which are assessed?
- BMI >30kg/m2
- Previous macrosomic baby (>4.5kg)
- Previous GDM
- Family history diabetes in 1st degree
- Ethnic origin (asian, middle eastern, south european, afro-caribbean)
- PCOS
- Medications e.g. steroids, antiretrovirals, antipsychotics
- Glycosuria ++
What is the diagnostic test for GDM?
Glucose tolerance test: 2 hour 75g oral glucose test
GDM if fasting ≥ 5.6 mmol/l or 2-hour ≥ 7.8 mmol/l
What is antenatal GDM management?
Teach self monitoring of blood glucose: fasting and 1 hour post-prandial +/- bedtime
Diet and exercise
Metformin and/or insulin if CBGs not controlled
Glucose targets as per pre-existing diabetes
Assess fetal growth (growth scans from 28 weeks)
Delivery by 40+6 weeks
What is GDM management at birth?
Good glucose control (insulin infusion)
What is postpartum GDM managment?
STOP DM treatments - diabetes goes away as placenta is removed
Future tests for glycaemia
Diet and exercise
Annual fasting blood glucose or HbA1c
What is the management of the baby after birth?
Early feeding and hypoglycaemia monitoring
When does hyperglycaemia as a result of GDM resolve?
After delivery of the placenta
What are risks of GDM to the mother?
PET, trauma due to larger baby
What are risks of GDM to the fetus?
Macrosomia
Birth trauma
Shoulder dystocia
LSCS
Prematurity
What are risks of GDM to the neonate?
Hypoglycaemia
Polycythaemia
Increased perinatal mortality rate
