Diabetes Mellitus in Pregnancy Flashcards
MDT for DM in pregnancy
CNS diabetes specialist midwife dietician obstetrician physician
Blood glucose monitoring in DM in pregnancy
7/day (before and 1hr after meals)
Pre-meal target glucose for DM in pregnancy
<5.3mmol/L
1 hour post prandial target in DM in pregnancy
<7.8mmol/L
Blood sugar at Higher risk of what during pregnancy? Why?
Hypoglycaemia
dangerous to mother and foetus
Insulin resistance increases throughout pregnancy
Metformin/insulin dose during second half of pregnancy
Increased bc of insulin resistance
Plan for pregnancy w/DM
Renal and retinal screening foetal surveillance (2-4wkly scans from 28-36 for macrosomia and polyhydramnios) plan for delivery
Extra anomaly scan for DM in pregnancy, why?
Foetal anomaly scan 19-20wk with and assessment of cardiac outflow tracts
If antenatal corticosteroids given to pregnant woman with DM?
Additional insulin to maintain normoglycaemia (usually admitted)
Aim for vaginal delivery in pregnancy w/DM
38-39wks
however complications rate means 50% get C-sec
T1DM or T2DM req. insulin need what else on labour ward?
Sliding scale or insulin and glucose in labour
Aim for maternal glucise in labour?
4-7mmol/L
Insulin requirement postpartum
should return to normal and insulin need be adjusted accordingly
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
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
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
- Joint DM/AN clinic within 1wk
- taught self monitoring BM
- Lifestyle advice
- Fasting <7 -> trial diet/ex.
- if not in targets after 2 weeks + metformin
- If still not met +insulin
- If at time of Dx BG>7 -> insulin
- 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
