Diabetes in Pregnancy

Question 1

What is gestational diabetes?

Answer 1

Diabetes which is 1st diagnosed in pregnancy.

May be that symptoms were present before conception however if diagnosed in pregnancy still classed as gestational.

Question 2

What are the maternal complications of pre gestational diabetes? (6)

Answer 2

Increased risk of:

• C-section delivery
• Polyhydraminos
• Pre-Eclampsia (12%)
• Chronic HTN (10%)
• Diabetic Ketoacidosis
• Preterm labour

Pneumonic
Chronic Diabetes Can Precipitate Pre Eclampsia & labour

Question 3

What are the fetal complications of pre-gestational diabetes? (5)

Answer 3

Hyperglycaemia is teratogenic therefore increases congenital abnormalities (2-3x more likely)

Spontaneous miscarriage and increased risk of still birth

Late intrauterine fetal death (high fetal mortality associated with DKA)

Fetal macrosomia associated with shoulder dystocia

Pre term labour and prolonged premature rupture of membranes.

Question 4

What is the recommended HbA1c level for a women with diabetes to try conceiving?

Answer 4

Less than 6.1 %

Question 5

What normally happens to mother’s blood glucose levels during pregnancy?

Answer 5

Fasting blood glucose levels become lower in pregnancy

Question 6

What are the recommendations for antepartum management of pre gestational diabetes?

Answer 6

Insulin (needs to be slightly increased as pregnancy goes on) + diet control.

Aim for fasting blood glucose of less than 95mg/dL

Ophthalmic screening each trimester.
Monitor renal function closely (24hr urinary protein and creatinine clearance) .

Low dose aspirin from 12 weeks (reduce incidence of pre-eclampsia)

Consider thyroid function testing.

Question 7

What are the risks of gestational diabetes to the mother?

Answer 7

Increased risk of:

• Pre-eclampisa
• Polyhydraminos
• C-section
• Pre term labour

But more likely to develop gestational diabetes again (50%).

Increased risk of developing diabetes (40-60%).

Question 8

What are the risks to the foetus of gestational diabetic mothers?

Answer 8

Increased risk of macrosomia associated with:
-Increased risk of shoulder dystocia

Pre-term labour

Increased still birth risk

Post part hypoglycaemia

Question 9

What is the screening programme for gestational diabetes?

Answer 9

At risk groups are offered screening with a GTT at 28 weeks.

If previously had gestational diabetes screened at 18 weeks.

Question 10

What are the risk factors for developing gestational diabetes?

Answer 10

Previous pregnancy:

• Previous gestational diabetes
• Previous macrocosmic baby

PMH:

• 1st degree relative with diabetes
• South asian/afro-carribean
• PCOS

Current:

• Obesity
• Persistent glycosuria
• Polyhdraminos

Question 11

What is classed as a positive GTT test in gestational diabetes?

Answer 11

Fasting plasma glucose level of 5.6 mmol/L or above

OR

2-hour plasma glucose level of 7.8 mmol/L or above.

Question 12

How is gestational diabetes treated?

Answer 12

Stepwise approach + monitoring

BM monitoring 7 times a day before and after each meal + once before bed.

1. Diet only (1-2 week trial)
2. Metformin
3. Insulin +/- metformin

If fasting blood glucose is greater than 7 on diagnosis start at step 3.

Question 13

What should a pregnant women aim for her BM readings to be?

Answer 13

Before meals should be below 5.2mmol/L

After meals should be below 7.8mmol/L

Question 14

What is the routine management of delivery with a gestational diabetic mother?

Answer 14

C-section if macrocosmic baby greater than 4kg

May also induce early (stop baby getting too big)

Usually done by 39 weeks