DM

Question 1

What advice should you give to a diabetic preconception?

Answer 1

Avoid unplanned pregnancy
Adjust insulin to optimise control preconception
Aim for HbA1c < 43mmol/mol or 6.1%
Avoid pregnancy if HbA1c > 85mmol/mol (10%)
5mg of folic acid daily preconception
Dietician review
Stop oral hypoglycaemic (except metformin), statins, ACE inhibitor and ARBs
Treat retinopathy
Nephropathy may worsen - if severe avoid pregnancy
Glycosuria unrelated to DM is common

Question 2

When should a diabetic avoid pregnancy? What is the aim for HbA1c?

Answer 2

Avoid if over 85mmol/mol (10%)

Aim for < 43mmol/mol (6.1%)

Question 3

What are maternal complications in DM in pregnancy?

Answer 3

hypoglycaemia unawareness (especially in first trimester)
Increased risk of pre-eclampsia
Increased his of infection
Increased rates of Lower uterine Caesarean section

Question 4

What are fetal complications of DM in pregnancy

Answer 4

Miscarriage
Malformation rates increased - reduced with good glycaemic control
Macrosomia due to high blood glucose and compensatory fetal hyperinsulinaemia promoting growth
- thus risk fo shoulder dystocia
Growth restriction
Polyhydramnios
Preterm labour
Stillbirth

Question 5

What malformations occur in DM in pregnancy?

Answer 5

CNS - neural tube defects
CVS malforamtions
Fetal sacral agenesis

Question 6

What is involved in antenatal care of DM in pregnancy?

Answer 6

Early US to confirm pregnancy
Detailed anomaly scan at 18-20 weeks
Fetal echo at 18-20 weeks
Monitor fetal growth by scans every 4 weeks from 28 weeks

Question 7

What advise should you give about antenatal care?

Answer 7

Aim for home monitored glucose daily fasting, pre-meal, 1 hr after every meal (postprandial) and before bed

Insulin needs increase by 50-100% as pregnancy progresses
Aim for fasting glucose level 3.5-5.9mmol/L or 1h post-prandial level of <7.8mmol/L

Question 8

What should you provide to a pregnant diabetic?

Answer 8

GlucoGel and glucagon kit - ensure partner knows how to use

Question 9

What should you consider if pregnant diabetic is acutely unwell?

Answer 9

Exclude ketoacidosis
Assess renal function - refer to nephrologist if creatinine > 120umol/L or protein excretion > 2g/24h
Use thromboprophylaxis if >5g/24h protein excretion
Consider conversion to insulin pump if ongoing problematic hypoglycaemia

Question 10

What drugs cannot pass through placenta?

Answer 10

Insulin

Heparin

Question 11

When should delivery take place?

Answer 11

Elective delivery at 38 weeks

by 40 weeks if gestational diabetes

Question 12

What should be given if preterm labour?

Answer 12

Corticosteroids to promote fetal lung maturity

Question 13

What should happen during labour?

Answer 13

Continuous fetal monitoring
Avoid hyperglycaemia
Use sliding scale if on insulin
Aim for glucose level of 4-7mmol/L
Halve insulin infection rate on delivery of placenta in T1DM
Insulin needs to fall as labour progresses and immediately post partum

Question 14

How should you manage insulin after delivery

Answer 14

Stop insulin infusion at delivery in GDM and T2DM if not on insulin pre-pregnancy
Return all others to pre-pregnancy regimen

Question 15

What advise should be given postnatally?

Answer 15

Encourage breastfeeding (insulin, metformin are compatible)
Encourage pre-pregnancy counselling before next pregnancy
If pre-proliferative retinopathy, ophthalmology review for 6 months
Discuss contraception

Question 16

What is criteria for gestational diabetes?

Answer 16

OGTT >= 7.8mmol/L

Question 17

What is criteria for screening for GDM? How is ti screened?

Answer 17

Previous baby > 4.5kg
BMI > 30
Ethnicity (south Asia, Caribbean, Middle Eastern)
Previous GDM

OGTT ASAP after booking and at 24-28 weeks

Question 18

What should you consider for management of GDM?

Answer 18

Seen in join diabetes and antenatal clinic within a week
Taught about self monitoring blood glucose
Advice about diet (low glycemic index foods) and exercise

Fasting glucose < 7mmol/L - Diet/exercise
If targets not met within 1-2 weeks start metformin
If targets are still not met, add insulin

If fasting glucose >= 7mmol/L at diagnosis, start insulin

If fasting glucose 6-6.9mmol/L and evidence of complications - macrosomia, polyhydramnios - start insulin

Glibenclamide offered if metformin is not tolerated

50% develop T2DM - give lifelong dietary advice

Check fasting glucose 6w postpartum and screen annually

Question 19

What are diagnostic thresholds for GDM?

Answer 19

fasting glucose is >= 5.6 mmol/l

2-hour glucose is >= 7.8 mmol/l

Question 20

What is management of pre-existing DM in pregnancy?

Answer 20

Weight loss for women with BMI > 27
Stop oral hypoglycaemic apart from metformin and commence insulin
Folic acid 5mg/day from pre-concetion to 12 weeks gestation
Aspirin 75mg/day from 12 weeks until birth to reduce risk of pre-eclampsia
Detailed anomaly scan at 20 weeks including four chamber view of fetal heart

Question 21

What are targets for self monitoring of pregnant women

Answer 21

Fasting 5.3mmol/L
1 hr after meals 7.8mmol/L
2 hr after meals 6.4mmol/L