Diabetes Mellitus in Pregnancy Flashcards by Toby Curtis-Mackenzie

MDT for DM in pregnancy

CNS
diabetes specialist midwife
dietician
obstetrician
physician

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Blood glucose monitoring in DM in pregnancy

7/day (before and 1hr after meals)

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Pre-meal target glucose for DM in pregnancy

<5.3mmol/L

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1 hour post prandial target in DM in pregnancy

<7.8mmol/L

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Blood sugar at Higher risk of what during pregnancy? Why?

Hypoglycaemia
dangerous to mother and foetus
Insulin resistance increases throughout pregnancy

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Metformin/insulin dose during second half of pregnancy

Increased bc of insulin resistance

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Plan for pregnancy w/DM

Renal and retinal screening 
foetal surveillance (2-4wkly scans from 28-36 for macrosomia and polyhydramnios)
plan for delivery

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Extra anomaly scan for DM in pregnancy, why?

Foetal anomaly scan 19-20wk with and assessment of cardiac outflow tracts

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If antenatal corticosteroids given to pregnant woman with DM?

Additional insulin to maintain normoglycaemia (usually admitted)

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Aim for vaginal delivery in pregnancy w/DM

38-39wks

however complications rate means 50% get C-sec

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T1DM or T2DM req. insulin need what else on labour ward?

Sliding scale or insulin and glucose in labour

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Aim for maternal glucise in labour?

4-7mmol/L

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Insulin requirement postpartum

should return to normal and insulin need be adjusted accordingly

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Effects of Pregnancy on DM

N+V
Tight control more important
Increase in insulin req. during 2nd half
Increased risk of hypo
Risk deterioration of pre-existing retino/nephropathy

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Effects of DM on pregnancy

Increased risk of miscarriage
Risk of congenital malformation
risk macrosomia
risk of pre-eclampsia
risk of still birth
risk of infection
increased operative delivery rate

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Summary of DM in pregnancy

Wt loss for BMI >27
Stop oral hypoglycaemic apart from metformin
Commence insulin
Folic acid 5mg preconception until 12wk
Aspirin 75mg/d from 12wk
Detailed anomaly scan 20w (4 chamber and outflow tracts)
Serial scans every 4 weeks 28-36
Tight control reduces complication rate 
Treat retinopathy

PACES counselling of DM in pregnancy

Risk: maternal (retino/nephropahty, traumatic birth, htn, macrosomia, neonatal hypo, risk surgical delivery
high dose folic acid and aspirin
growth scans 28-36wks

GDM Ix

Glycosuria on dipstick at routine care indicates need for further testing:
- If RF present do 2hr 75g
OGTT at 24-48 wks

RF for GDM

Obesity
prev macrosomic baby (>4.5kg)
Hx GDM
FHx DM
Ethnic minority

If GDM in previous pregnancy

Early self monitoring
2 hour 75g OGTT as soon as poss after booking (16weeks)
If normal repeat at 24-28wk

Diagnostic for GDM

Fasting glucose >5.6
2 hour OGTT >7.8mmol/L
If diagnosed review at joint DM and antenatal clinic within 1wk

Mx of GDM

Good control reduces macrosomia, trauma, induction, surgery, perinatal death
1st line (fasting <7) = lifestyle
2nd line (if target not met after 1-2 weeks) = metformin
3rd line = add insulin`

Lifestyle changes in GDM

Low GI foods
Dietician ref.
regular exercise

Fasting glucose >7mmol/L what do

Offer insulin straight away

If fasting gluose 6-6.9 w/Cx what should you do?

Cx e.g. macrosomia Offer insulin straight away consider glibenclamide

Antenatal Monitoring blood glucose for (G)DM

T1DM: test fasting, premeal, 1hr postmeal and bedtime daily T2DM or GDM on multiple daily insulin: fasting, premeal, 1hr postmeal and bedtime daily T2DM or GDM on cons./metformin: fasting an 1hr post meal daily`

Targets for blood glucose in pregnant women w/DM

Fasting: <5.3 1 hour post meal: <7.8 2 hour post: <6.4 If using glibenclamide keep BM >4

HbA1c in pregnancy

Measure at booking for preexisting DM to determine risk Consider measuring during T2+3 for pre-existing DM Risk increases if >48 Measure at time of Dx in GDM and undiagnosed T2 NOT routinely offered during T2-3

Managing diabetes during pregnancy

Advise risks of hypo Offer continuous sc. insulin if multiple daily insulin insuff. NOT routinely continuous glucose monitoring (only if struggling to achieve control) Retinal assessment if preexisting DM Offer USS FG and AFV every 4wks from 28-36wks Appointments 2wkly

Intrapartum care in (G)DM

T1/2DM elective birth but induction or C-sec 37-39weeks <37wk birth if complications GDM birth no later than 40+6 Capillary glucose every hour during labour and birth (maintain 4-7mmol)

Postnatal care in (G)DM

Increased risk of hypo (snack before feed) GDM: discontinue glucose lowering treatment immediately Test glucose for persistent hypergly.

If glucose returns to normal after birth in (G)DM

Lifestyle advice Fasting glucose 6-13wk pp to exclude DM Offer HbA1c if not tested by 13wk

If glucose does NOT return to normal after birth in (G)DM

<6 - low probability of DM, annual test, mod. risk developing DM 6-6.9: high risk DM >7 likely DM offer test to confirm

Risk of developing DM in women w/GDM

3-7x higher chance of developing T2DM | greatest risk first 5y

Summary of GDM

1. Joint DM/AN clinic within 1wk 2. taught self monitoring BM 3. Lifestyle advice 4. Fasting <7 -> trial diet/ex. 5. if not in targets after 2 weeks + metformin 6. If still not met +insulin 7. If at time of Dx BG>7 -> insulin 8. If glucose 6-6.9+evidence of Cx -> insulin If metformin not tolerated glibenclamide

PACES counselling of GDM

RF:age, (F)Hx, obesity, multiple preg. asian Dx: cant produce enough insulin to meet demands of baby Epi: 2-3% pregnancies Risks: - Mat: htn, traumatic birth, stillbirth - Foet: macrosomia, neonatal hypo Treatment options: lifestyle metformin, insulin glibenclamide Explain glucometer Will need to be seen at joint DM/AN clinic in a week and every 2 weeks after 4 weekly USS 28-36 weeks Medication r/v after birth