Diabetes in pregnancy - from preconception to the postnatal period. NG3. December 2020

Question 1

What blood glucose range should women with T1DM be advised to aim for pre-pregnancy?

Answer 1

Fasting - 5-7 on waking
Pre-meal 4-7 at other times of the day

Question 2

Which HbA1c level should women be told to aim for pre pregnancy?

Answer 2

Below 48 or 6.5%

Question 3

Above which HbA1c level should women be advised not to get pregnant?

Answer 3

86 or 10%

Question 4

Which long acting insulin should be the first choice in pregnancy?

Answer 4

Isophane insulin aka NPH insulin

Consider continuing long acting insulin analogues - insulin detemir or insulin glargine - for women with established good control. Note this is off label

Question 5

When should you consider referring women to a nephrologist before stopping contraception?

Answer 5

Creatinine is 120 or more
Urinary albumin creatinine ratio is >30 or
eGFR is less than 45

Question 6

What are the risk factors for GDM that should prompt offering OGTT.

Answer 6

BMI >30
Previous macrosomic baby weight 4.5kg or more
Previous GDM
FHx of diabetes
Ethnicity with high prevalence diabetes

also glycosuria 2+ on 1 occasion, or 1+ on 2 or more occasions

Question 7

diagnose GDM if:

Answer 7

Fasting 5.6 or above
2 hour 7.8 or above

Question 8

If GDM is diagnosed

Answer 8

offer review in joint diabetes ANC within 1 week.

Question 9

When does the DVLA need to be informed

Answer 9

If insulin treatment last (or will last) more than 3 months
If insulin treatment for GDM continues for over 3 months after birth
If they get disabling hypoglycaemia
Bus coach or lorry drivers

Question 10

Below which level of fasting glucose can women be offered at trial of diet and exercise?

Answer 10

below 7mmol/litre at diagnosis.

Question 11

Offer metformin if targets are not being met with diet and exercise changes within how many weeks?

Answer 11

1-2 weeks

Question 12

If women have a fasting blood glucose level above 7mmol at diagnosis offer:

Answer 12

Immediate treatment with insulin with or without metformin and
Diet and exercise

Question 13

If fasting glucose is 6-6.9 but there is macrosomia or polyhydramnios consider

Answer 13

Immediate treatment with insulin with or without metformin and
Diet and exercise

Question 14

What are the target levels

Answer 14

Fasting - 5.3
1hr post meal 7.8 or
2hr post meal 6.4

Maintain above 4

Question 15

If a woman has pre existing diabetes when should retinal assessments be offered?

Answer 15

After the first ANC visit unless they have had an assessment in the last 3 months

If they have retinopathy offer additional assessments
between 16-20 weeks
at 28 weeks.

Question 16

refer a pregnant woman with pre existing diabetes to a nephrologist if:

Answer 16

Cr 120 or more
albumin creatinine ration greater than 30
Total protein excretion exceeds 0.5g a day

Question 17

What is the nephrotic range of proteinuria?

Answer 17

Proteinuria above 5g a day or
albumin creatinine ratio greater than 220mg/mmol

Question 18

What is the recommended US schedule for diabetes in pregnancy

Answer 18

fetal growth and LV every 4 weeks from 28-36 weeks.

Question 19

TOB for women with T1 or T2 diabetes with no other complications

Answer 19

advise IOL or ELCS (if indication) between 37 and 38+6

Question 20

TOB for women with T1 or T2 diabetes with metabolic or fetal complications.

Answer 20

Consider birth before 37 weeks

Question 21

TOB with GDM

Answer 21

Advise women to give birth NO LATER than 40+6

Question 22

What are the maintenance levels during labour and birth

Answer 22

between 4 and 7

Question 23

What postnatal tests are recommended?

Answer 23

Fasting blood glocose test between 6 and 13 weeks or
fasting blood glucose at 13 weeks or HbA1c

Question 24

What are the fasting blood glucose levels results and interpretation postnatally

Answer 24

<6 not diabetes
6-6.9 high risk of developing diabetes
=>7 - T2DM

confirmatory test required

Question 25

What are the postnatal HbA1c level significance/ interpretations.

Answer 25

<39 - not diabetes
39-47 - high risk
=>48 they have T2DM