Diabetes in pregnancy NICE Flashcards
Risk of T1/T2DM on pregnancy?
Increased risk miscarriage, congenital malformation, stillbirth neonatal death
Reduced but not eliminated with good glycaemia control
Pre-pregnancy advice T1/T2DM
Lose weight if BMI >27
5mg folic acid until 12/40
Monthly HbA1ca aiming <48 6.5%
T1DM fasting BM 5-7 on waking and before meals 4-7
Stop other agents other than insulin and metformin
Stop ACEi/ARBs/statins
Retinal assessment
Renal assessment - measure alumbinuria
If HbA1C above which level should you advice against pregnancy until lowered?
> 86 10%
Which long acting insulin is 1st line in pregnancy?
Isophane insulin (NPH insulin) or can continue long acting analogues (detemir/glargine)
When to refer to nephrologist before stopping contraception
Serum creatinine >120 or
urinary albumin creatinine ration >30
eGFR < 45
Which women are at risk of GDM
BMI >30
Previous >4.5kg baby
Prv GDM
1st degree relative with GDM
Ethnicity with high prevelcne
Glycosuria 2+ 1 occasion, or 1+ on 2 occasions
If previous GDM when to offer testing
Either early self monitoring
or
75g 2 hr OGTT as soon as after booking and at 24/28 weeks gestation
If other risk factor when to perform OGTT
24-28 weeks
Dx women with OGTT if
Fast >5.6
2hr >7.8
After GDM Dx, how quickly should be seen in JANC?
1 week
What risks should be explained to GDM
Fetal macrosomia
Trauma during birth (her and baby)
IOL and CS
Neonatal hypoglycaemia
Perinatal death
Reduced with BM control
For which women can a trial of diet and exercise be offered
If fasting BM <7
If targets not met within 1-2 weeks offer metformin
If fasting BM >7 in GDM Dx
Offer immediate treatment with insulin +/- metformin
Diet and exercise changes
If BMI 6-6.9 and complications such as macrosomia/hydramnios
Immediate Insulin +/- metformin
Diet and exercise
If Type 1 or Type 2/GDM on multiple day insulin, when to test Bus
Fasting
Pre-meal
1 hours post meal
Bedtime blood glucose
T2DM or GDM managing with diet or single therapy or intermediate/long acting insulin
Fasting
1 hour post meal
What are the BM targets for fasting, 1 hour after meal, 2 hour after meal
fasting 5.3
1 hour 7.8
2 hour 6.4
If on insulin aim >40
When to measure HbA1c for pre-existing
At booking, consider in 2nd/3rd trimester
> 48 associated with risk to pregnancy
Why need to rate insulin infections sites
Avoid cutaneous amyloidosis
How to minimise risk of hypoglycaemia
Educated women on insulin treated DM from 1st trimester
Always have fasting acting form of glucose available
Provide glucagon to T1DM, explain to partner/family for to use
Consider continuo subcut insulin - if multiple daily injections of insulin, multip hypos
Who should be offered real time continuous glucose monitoring?
T1DM or T2DM/GDM if problematic hypos, unstable BMa
Offered intermittently scanned continue BM monitoring if unable to use rtCGM or patient preference
How to minimise risk of DKA
Type 1 DM - offer blood ketone testing strips
T2DM/GDM: advise if unwell or high BM seek medical attention
Test blood ketones early if DM and high BMs/unwell
If suspected DKA - level 2 critical unit
When to offer retinal assessment?
Pre-exisiting DM
1st appointment
If they have DM retinopathy - again 16-20 weeks
Another test 28 weeks
When to offer renal assessment, when to refer to nephrologist?
At 1st appointment if not done in last 3 months
refer if
Creatinine >120
urinary albumin: creatinine ration >30
Total protein excretion >0.5g/day
When to consider thromboprophylaxsis in pregnant women?
Proteinuria >5g/day
Which women require aspirin?
T1DM or T2DM
USS in pregnancy
7-9 week viability USS
Detailed 20 week including cardiac
Every 4 weeks from 28-36 weeks
How often should be seen in JANC
Every 1-2 weeks
What do discuss at 36 weeks
USS
Timing/mode delivery
Analgesia/anaesthesia
Changes to blood glucose lower therapy PP
Care of baby after birth
Breastfeeding, effect of breastfeeding on blood glucose control
Contraction and FU
If AN steroid needed for insulin treated DM
Offer additional insulin
When should T1/T2 DM with no other complications be delivery
Offer IOL (or CS if indicated) 37-38+6 weeks
T1DM/T2DM who have metabolic, maternal/fetal complications?
Consider birth before 37 weeks
Timing of delivery GDM
Delivery by no later than 40+6
Which DM women should be seen by anaesthetics in 3rd trimester?
High BMI
Autonomic neuropathy
IF GA for brith how often should BM be monitored
Every 30 mins from GA until baby born and woman conscious
How often should BM be monitored in labour, what is the target?
Hourly
4-7
When to consider IV dex + insulin infusion
Type 1 or
Not maintaining BM 4-7 in labour
When to test baby Bus
Between 2 and 4 hours
When to consider fetal ECHO
Clinical signs CHD/cardiomyopathy including heart murmur
Whan can babies of diabetic mothers be transferred to community?
24hrs hold and satisfied maintain BM and feeding well
How often should women with DM feed their babies?
As soon as possible after birth (within 30mins) and then every 203 hours to maintain pre-feed CBG >2
Only offer additional measures if <2 on 2 reading, abnormal clinical signs, baby not feeding effectively
Post delivery what change to DM medication
Pre-exisiting DM - reduce insulin immediately, be aware of risk of hypoglycaemia
GDM - stop blood glucose lowering therapy
PN advice
Contraceptive care
GDM - test glucose before discharge, early testing next pregnancy, lifestyle advice, 6-13 week fasting glucose, >13 weeks HbA1C.
If 6-13 weeks fasting BM
<6, HbA1c <39
6-6.9/ 39-47
>7/>47
<6/<39 low probability of DM at the moment, continue lifestyle, annual blood glucose level/HbA1x
6-6.9/39-47 high risk developing T2DM, advice, guidance
> 7/>48 - have T2DM
