DM Flashcards
What advice should you give to a diabetic preconception?
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
When should a diabetic avoid pregnancy? What is the aim for HbA1c?
Avoid if over 85mmol/mol (10%)
Aim for < 43mmol/mol (6.1%)
What are maternal complications in DM in pregnancy?
hypoglycaemia unawareness (especially in first trimester)
Increased risk of pre-eclampsia
Increased his of infection
Increased rates of Lower uterine Caesarean section
What are fetal complications of DM in pregnancy
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
What malformations occur in DM in pregnancy?
CNS - neural tube defects
CVS malforamtions
Fetal sacral agenesis
What is involved in antenatal care of DM in pregnancy?
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
What advise should you give about antenatal care?
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
What should you provide to a pregnant diabetic?
GlucoGel and glucagon kit - ensure partner knows how to use
What should you consider if pregnant diabetic is acutely unwell?
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
What drugs cannot pass through placenta?
Insulin
Heparin
When should delivery take place?
Elective delivery at 38 weeks
by 40 weeks if gestational diabetes
What should be given if preterm labour?
Corticosteroids to promote fetal lung maturity
What should happen during labour?
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
How should you manage insulin after delivery
Stop insulin infusion at delivery in GDM and T2DM if not on insulin pre-pregnancy
Return all others to pre-pregnancy regimen
What advise should be given postnatally?
Encourage breastfeeding (insulin, metformin are compatible)
Encourage pre-pregnancy counselling before next pregnancy
If pre-proliferative retinopathy, ophthalmology review for 6 months
Discuss contraception
What is criteria for gestational diabetes?
OGTT >= 7.8mmol/L
What is criteria for screening for GDM? How is ti screened?
Previous baby > 4.5kg
BMI > 30
Ethnicity (south Asia, Caribbean, Middle Eastern)
Previous GDM
OGTT ASAP after booking and at 24-28 weeks
What should you consider for management of GDM?
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
What are diagnostic thresholds for GDM?
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
What is management of pre-existing DM in pregnancy?
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
What are targets for self monitoring of pregnant women
Fasting 5.3mmol/L
1 hr after meals 7.8mmol/L
2 hr after meals 6.4mmol/L
