W7 Diabetes in Pregnancy (Gestational Diabetes PD)

Question 1

Pre-Conception Planning for women with diabetes (NICE NG3)
Provide information advice and support:
What to advise or offer? (6)

Answer 1

• Good glucose control will reduce risk of complications (e.g. miscarriage, congenital
  malformation, stillbirth and neonatal death
• Importance of diet, weight and exercise
• N&V can affect blood glucose control
• Implications for larger babies on birth
• Offer retinopathy and nephropathy assessment
• Effects on neonate – risk of hypoglycaemia post birth, and later life complications

Question 2

Pre-Conception Planning for women with diabetes (NICE NG3)
Other things to advise/offer?

Answer 2

• Weight management for women with DM and BMI > 27Kg/m2
• Advise women with DM to take folic acid (5 mg/day) until 12 weeks of gestation to
  reduce the risk of having a baby with a neural tube defect.
• In type 1, aim for fasting blood glucose 5 – 7 mmol/L on waking and 4 – 7 mmol/L before
  meals at other times of day
• If possible, keep HbA1c level below 48mmol/mol (6.5%); avoid pregnancy if 10%
• When the likely benefits from improved blood G control outweigh the potential for harm, advise using metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy,.
• Stop all other oral blood G-lowering agents before pregnancy, and use insulin instead

Question 3

Pre-Conception Planning for women with diabetes:
drug management:
Other things to advise/offer?

Answer 3

• Rapid-acting insulin analogues (aspart and lispro) are safe for mum and foetus
• Use isophane insulin (intermediate-acting) as the first choice for long-acting insulin during
  pregnancy.
• Consider continuing treatment with long-acting insulin analogues (insulin detemir or insulin glargine) for women with diabetes who have established good blood G control before
  pregnancy.
• STOP ACEI, ARBs before conception or as soon as pregnancy confirmed and prescribe
  alternate antihypertensive (consider labetolol, nifedipine (some products are contra-indicated), methyldopa).
• STOP statins before conception or as soon as pregnancy confirmed.

Question 4

Aetiology of Gestational Diabetes:
What are the causes? (5)

Answer 4

Prediabetes
Family history
Obesity
Age > 25
Race

Question 5

What are the Symptoms/Presentation
of Gestational diabetes?

Answer 5

• Often no symptoms
• With hyperglycaemia:
  Tiredness
  Polyuria/polydipsia
  Dry mouth
  Genital thrush

Question 6

Risk factors for gestational diabetes?

Answer 6

• Older age
• BMI above 30 kg/m2
• Previous macrosomic baby weighing 4.5 kg or more
• Previous gestational diabetes
• Family history of diabetes (first-degree relative with diabetes)
• An ethnicity with a high prevalence of diabetes

If risk factor present, offer testing for gestational diabetes – oral glucose
tolerance test

Question 7

Diagnose gestational diabetes if the woman has either: (2)

Answer 7

• a fasting plasma G level of 5.6 mmol/litre or above or
• a 2-hour plasma G level of 7.8 mmol/litre or above.

Question 8

Interventions for GD

Answer 8

• Self-monitor their blood G.
• Regular exercise and healthy diet during pregnancy, and switch from high to low glycaemic index food.
• If blood G targets are not met with diet and exercise offer metformin
• If metformin is contraindicated or unacceptable to the woman, offer insulin.
• If blood G targets are not met with diet and exercise changes plus metformin, offer insulin
  as well.
• Measure HbA1c levels at diagnosis to identify pre-existing type 2 DM
• Advise on the risk of hypoglycaemia.
• Aspirin 75mg – 150mg daily from 12 weeks to birth

Question 9

Post-natal Care

Answer 9

• Women with insulin-treated pre-existing DM should reduce their insulin immediately after birth and monitor their blood G levels to find the appropriate dose.
• Explain to women with insulin-treated pre-existing DM that they are at increased risk of
  hypoglycaemia in the postnatal period (especially when breastfeeding), and advise them to have a meal or snack available before or during feeds.
• Women who have been diagnosed with gestational DM should STOP blood glucose-lowering therapy immediately after birth.
• Women with pre-existing DM2 who are breastfeeding can resume or continue metformin immediately after birth, but should avoid other oral blood glucose-lowering therapy while breastfeeding.
• Note that this is an off-label use of metformin.
• Women with diabetes who are breastfeeding should continue to avoid any medicines for their DM complications that were stopped for safety reasons when they started planning the pregnancy.