Diabetes in Pregnancy

Question 1

What are the types of Diabetes that can affect pregnancy?

Answer 1

Pre-gestational:
- Type 1
- Type 2
- MODY
Gestational Diabetes.

Question 2

How is Gestational Diabetes defined?

Answer 2

WHO definition:
- Carbohydrate intolerance resulting in Hyperglycaemia of variable severity with onset or first recognition during pregnancy.

Question 3

What are the Complications related to Pre-existing diabetes in pregnancy?

Answer 3

All are related to poor control.
- Congenital anomalies (Related to high HbA1c at Booking)
- Miscarriage.
- Intra Uterine Death.
- Worsening Diabetic complications. e.g. retinopathy, Nephropathy.

Question 4

What are the complications related to both pre-existing and gestational diabetes in pregnancy?

Answer 4

• Pre-eclampsia.
• Polyhydramnios.
• Macrosomia.
• Shoulder dystocia - 10% risk compared to General Pop with 1%)
• Neonatal hypoglycaemia.

Question 5

What HbA1c should pregnancy be avoided in?

Answer 5

> 86mmol/mol (10%)

Question 6

What medication should be taken in T1DM and T2DM patients before conception?

Answer 6

High Dose Folic Acid 5mg. (3 months before conception to 12 wks of pregnancy)

Question 7

What medication should be stopped before conception in patients with Diabetes?

Answer 7

Any Embryopathic Medications e.g. Cholesterol lowering agents, ACEi’s.

Embryopathic Meds are ones which could potentially harm the embryo

Question 8

What is the General Antenatal Management in T1DM and T2DM?

Answer 8

Risk assessment for retinopathy, nephropathy.
Check medications.
Blood Glucose monitoring (real time CGM - Dexcom, FSL).
Education (Hypomanagement).
BG Targets.

INSULIN
INJECTIONS
PUMP
CLOSED LOOP
METFORMIN FOR T2DM.

Question 9

When should Scans be done in T1DM and T2DM pregnancy?

Answer 9

First USS scan at 6-7 wks.

Growth Scan 4 weekly from 28wks.

Eyes and Kidneys checked every 2 weeks.

Home BP Monitoring done 2 weekly.

Delivery 37-38wks.

Question 10

What are the risk factors for gestational Diabetes?

Answer 10

• Previous GDM.
• Obesity BMI >30.
• FH (1st Degree relative)
• Previous Big baby.
• Ethnic Variation (south asia, middle eastern, black caribbean).
• Polyhydramnios.
• Glycosuria.

Question 11

How is GDM caused?

Answer 11

Insulin sensitivity is reduced during pregnancy by placental hormones.

Question 12

What are the consequences of GDM?

Answer 12

Macrosomia and LFGA.
Overgrowth of Insulin sensitive tissues.
Hypoxaemic state in utero.
Short term metabolic complications.

Foetal metabolic reprogramming:
Leading to increased long term risk of Obesity, Insulin resistance and diabetes.

Question 13

When Should women with risk factors for GDM Have an OGTT?

Answer 13

Anyone with risk factors should be screened with an OGTT at 24-28wks.

Women with previous GDM also have an OGTT soon after the booking clinic.

Question 14

What risk factors for GDM warrant testing for GDM?

Answer 14

Previous GDM, Previous Macrosomic Baby (>4.5kg), BMI > 30, Ethnic origin (Black Caribbean, Middle eastern and South Asian), Family History of Diabetes (1st degree relative).

Question 15

When should an OGTT be performed?

Answer 15

In the morning after a fast.

The patient drinks 75g glucose at the start of the test.
The blood sugar is measured before the drink (fasting) and the 2 hrs after.

Question 16

What are the normal results for OGTT in GDM?

Answer 16

Fasting: <5.6 mmol/l.
At 2 hrs: <7.8 mmol/l

remember - 5,6,7,8

Question 17

How is GDM managed?

Answer 17

Women need 4 weekly USS scans to monitor foetal growth from 28wks.

Medical Management depends on the Fasting Glucose result.

A Fasting Glucose < 7mmol/l is managed with diet and exercise.

Above 7mmol/l is managed with Insulin +/- Metformin.

However, Above 6mmol/l and indication of Macrosomia (or other complication) - start Insulin +/- Metformin.

Question 18

What medical management is an option for women who decline Insulin or cannot tolerated metformin?

Answer 18

Glibenclamide (sulfonylurea)

Question 19

When should planned delivery for Patients with pre-existing diabetes be?

Answer 19

Between 37 and 38 + 6 wks.

Question 20

When should planned delivery for patients with GDM be?

Answer 20

Between 37 and 40 + 6 wks.

Question 21

What is the importance of Retinopathy screening during pregnancy with existing diabetes?

Answer 21

Should be performed shortly after booking and at 28 wks gestation.
Diabetes has a risk of rapid progression or retinopathy.

Question 22

When can women with GDM stop their medications after birth?

Answer 22

Immediately.

Question 23

When can women with pre-existing diabetes alter their medication after birth?

Answer 23

Should lower their insulin doses and be wary of Hypoglycaemia as insulin sensitivity will increase after birth and with breastfeeding.

Question 24

What are babies with mother who have DM at risk of?

Answer 24

• Neonatal Hypoglycaemia
• Polycythaemia (Raised Haemoglobin)
• Jaundice (Raised Bilirubin)
• Congenital Heart disease.
• Cardiomyopathy.

Question 25

What is the management of a baby with neonatal hypoglycaemia?

Answer 25

Aim to maintain Blood glucose above 2 mmol/l.

Treat with IV Dextrose of Nasogastric Feeding.