Diabetes In Pregnancy Flashcards
What should you advise women with diabetes planning to become pregnant?
- Ensure the importance of avoiding an unplanned pregnancy.
- Advise women that their choice of contraception should be based on their preferences and any RFs
- Advise women about the risks associated with pregnancy increases with the duration of the woman’s diabetes.
- Advise the woman to use contraception until good blood glucose level.
- Blood glucose targets, glucose monitoring, medicines for treating diabetes and its complications will need to be reviewed before and during pregnancy.
- There will be frequent contact with healthcare professionals.
Why is it important to control blood glucose level before pregnancy?
Reduces the risk of miscarriage, congenital malformations, stillbirth and neonatal death.
How does diabetes affect pregnancy?
Maternal hyperglycaemia leads to fetal hyperglycaemia.
This results in increase production of insulin from fetal pancreas
Insulin = growth factor
This can result in MACROSOMIA
This in turn can lead to Polyhydramnios (fetal polyuria) which may lead to preterm labour or cord prolapse .
Macrosomia is also associated with higher incidence of induction, dysfunctional labour and Shoulder Dystocia and PPH
Fetal Hyperinsulinemia also leads to chronic fetal hypoxia stimulating haemopoesis and resultant polycythaemia and jaundice. This can lead to splenomegaly.
Respiratory distress syndrome- surfactant deficiency is common in babies born to diabetic mothers.
Following delivery the high circulating levels of insulin can result in neonatal hypoglycaemia
Effects of pregnancy on diabetes
Increasing doses of insulin during pregnancy
Worsening nephropathy or retinopathy
Increase hypoglycaemic attacks
Ketoacidosis- rare but may be associated with hyperemesis, infections, tocolytics or steroid therapy.
Ischaemic heart disease- pregnancy increases cardiac workload
Effect of diabetes on pregnancy
Maternal: Increased miscarriage Increased risk PET Worsening renal disease – hypoalbuminaemia, anaemia Infections Increased induction rate and LSCS rate
Fetal:
Increased congenital malformations (skeletal, cardiac, Neural tube defects NTD) pathopneumonic for diabetes in sacral agenesis
Unexplained stillbirth
Which complications of pregnancy are obese women at higher risk of?
Miscarriages Congenital malformations PET GDM Macrosomia VTE PPH Wound infections Anaesthetic difficulties
What is the advise for obese women before getting pregnant?
Reduce their weight and adopt a healthier diet.
Aim for a BMI less than 30
Higher doses of folic acid 5 mg as well as vitamin D 10 mg.
Preconception management of diabetes
Women should be offered general advise regarding weight loss, smoking and alcohol.
They should also be advised to take folic acid supplementation
In diabetic women this should be increased to 5mg Folic acid once daily and advised ideally at least 3/12 prior to pregnancy. The higher dose here is due to the increased risk of NTD.
Women should be advised regarding their current diabetic medication and the importance of continuing that medication. They should be switched onto either metformin or insulin, both of which are safe for use in pregnancy.
Women should aim for Blood glucose targets:
HbA1c <48
Evidence shows that women who have higher levels at conception are more likely to have complications.
In particular those with HbA1c >86 have a significant increase in the risk of congenital malformations and miscarriage- they should be advised not to get pregnant
Fasting Glucose 5-7
Premeal at other times of the day 4-7
Women should also be advised to have screening for retinopathy and nephropathy is they have not done so within the preceding 6 months.
If Urine Protein/Creatinine ratio > 30mg/mmol, eGFR <45 referral to nephrologist.
Antenatal care of pre-existing diabetes in pregnancy
All women should be advised to take Aspirin 75mg once daily to reduce their risk of Pre-eclampsia. This should be started before 12 weeks and continued throughout pregnancy
They should be advised to take blood glucose levels
Fasting, premeal and 1 hour postmeal and at bedtime
Those just on oral agents or diet control take fasting and postmeal and bedtime but need not take BM prior to other meals during the day
During pregnancy BM targets should be
Fasting <5.3mmol/litre
1 hour post meal < 7.8
Maintain above 4 mmol/litre
Type I diabetics should test for ketones
All women with pre-existing diabetes should be advised to seek help if they become unwell or hyperglycaemia due to the risk of diabetic ketoacidosis
Regular contact with a member of the MDT at least every 2/52
Retinal assessment at 1st appointment (unless done within 3/12) and at 28/40. In presence of retinopathy initially offer at 16-20/40 also
Renal assessment at 1st appointment and refer to nephrologist as per preconception advise
Don’t use HbA1c to assess a woman’s BM control in the 2nd or 3rd trimester.
How do you diagnose GDM?
They should be offered a 2 hour Oral Glucose Tolerance Test (OGTT) at 24-28/40
Diagnosis is made with following
Fasting glucose >5.6 mmol/litre
2 hour Plasma Glucose >7.8mmol/litre
women with Previous GDM should be offered earlier OGTT at 12-16/40 and then again at 24- 28/40
Risk factors for GDM
BMI >30 Previous GDM Previous baby >4.5kg Family history (1st degree relative) Ethnic origin with high relevance
How should you schedule USS appointments for diabetic women?
Routine dating at 11-13/40
Routine anomaly at ~20/40
Serial growth scans to assess fetal size and monitor for macrosomia and polyhydramnios every 4/52 from 28/40
Women with other co morbidities should be considered for anaesthetic assessment by the 3rd trimester
When should diabetic women deliver?
Offer all women with uncomplicated Type I and Type II between 37-38+6/40 elective delivery (either by LSCS or IOL )
Offer prior to 37/40 if women have maternal or fetal complications
Offer delivery before 40+6 in women with GDM
Diabetic Pregnancies with evidence of macrosomia and an EFW of > 4.5kg should be offered elective LSCS as an alternative to Vaginal delivery due to concerns regarding shoulder dystocia.
What should be commenced in T1DM women who can’t maintain BM within target in labour?
Intrapartum targets for BM are 4-7
Women with Type I Diabetes or who cannot maintain BM within target in labour should be commenced on insulin dextrose sliding scale during labour
How soon should a diabetic women breastfeed the infant to avoid hypoglycaemia complications?
Breastfeeding should be encouraged and ideally 1st feed should occur within 30 minutes and fetal blood sugars checked every 2-4 hours aiming to maintain above 2mmol/litre
