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

Question 9

What is gestational diabetes?

Answer 9

Diabetes arising in pregnancy

Question 10

List 6 risk factors for GDM

Answer 10

BMI >30
Previous macrosomic baby
Previous GDM
1st degree relative with DM
Ethnicity with high prevalence DM
PCOS

Question 11

What is the test of choice for GDM? When is this performed?

Answer 11

Oral glucose tolerance test (OGTT)
If hx GDM: ASAP after booking + at 24-28w
If GDM RFs: 24-28w

Question 12

What is the diagnostic threshold for GDM?

Answer 12

Fasting glucose >,5.6 mmol/L
OR
2-hour glucose >,7.8 mmol/L

Question 13

Describe initial management of all women with GDM

Answer 13

See in joint diabetes + antenatal clinic within a week
Teach about self-monitoring of blood glucose
Advise about diet (inc. foods with a low glycaemic index) + exercise

Question 14

Describe management of GDM if fasting plasma glucose is <7

Answer 14

Offer trial of diet + exercise
If targets not met within 2w: start metformin
If targets still not met: start short acting insulin

Question 15

Describe management of GDM if fasting plasma glucose is >7 at the time of diagnosis

Answer 15

Insulin

Question 16

When is glibenclamide offered in GDM?

Answer 16

If metformin not tolerated
OR
Failure to meet glucose targets with metformin but decline insulin

Question 17

What are the blood glucose targets in pre-existing and gestational diabetes?

Answer 17

Fasting: 5.3
1h after meals: 7.8
2h after meals: 6.4