Diabetes in pregnancyDiabetes in pregnancy

James PennyConsultant Obstetrician & Gynaecologist

Surrey & Sussex NHS Trust

DiseasesDiseases

• Gestational Diabetes• Pre-existing Diabetes• Definition: Disorder of carbohydrate metabolism. It is an organ specific

autoimmume disease with a genetic component• Prevalence: 650,000 pregnancies-UK and Wales of which 2-5% are diabetic

pregnancies. The prevalence is increasing in both types. Type 2 is increasing in certain minority ethnic groups. Pregnancy complicated by diabetes ---Gestational diabetes accounts for

87.5% ,7.5% type 1 and 5% type 2 .• Types: Type 1-0.27% of births Type 2-0.10% of births

Recent focusRecent focus

• St Vincent declaration

• NICE document on prenatal care

• NICE document on diabetes

• Cemach report on diabetes in pregnancy

Risks of diabetes Risks of diabetes Pedersen hypothesisPedersen hypothesis

Unexplained stillbirthCongenital malformationCaesarean sectionMiscarriageLong term effect of infant/child health

This talkThis talk

• Prepregnancy care for established diabetics

• Early pregnancy care

• Gestational diabetes

• Third trimester and delivery

The size of the problemThe size of the problem

Perinatal mortality (%)

0

5

10

15

20

25

30

35

1921-30 1931-40 1941-50 1951-60 1961-70 1971-76 1976-79 1980-84

Prepregnancy CarePrepregnancy Care

• Maternal health– Weight– Folate– Smoking– Long term health– contraception

Extremely tight control of blood sugar

Prepregnancy CarePrepregnancy Care

• Maternal health– Assess for

• Risk of miscarriage

Prepregnancy CarePrepregnancy Care

• Congenital anomalies– Comparison of % depending of timing of care

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11..11 66..66

11..88 1100..55

44..99 99

11..22 1100..99

Prepregnancy CarePrepregnancy Care

• Congenital anomalies

If the HbA1c is >10% then ~ 30% of babies may have a congenital anomaly

Prepregnancy carePrepregnancy care

• Allows a detailed risk assessment

• Should be performed opportunistically

• Diabetic women should plan their pregnancy

Maternal risksMaternal risks

• Diabetic ketoacidosis is rare in pregnancy

• Hypoglycaemia accounts for most death in pregnant diabetics

Early pregnancyEarly pregnancyMultidiscplinary careMultidiscplinary care

Obstetrician

Physician

Midwife

Dietician

Diabetic nurse

Patient

ManagementManagement

• Diet to allow ideal weight gain

• Change oral hypoglycaemics to insulin

• Tight control of blood sugars– Fasting < 6– Postprandial < 8

• Q.D.S. insulin regime

• Post prandial levels are important

• Downside– Hypoglycaemia– Morning sickness

Gestational DiabetesGestational Diabetes

• Definition– Carbohydrate intolerance that arises during pregnancy

and disappears after delivery

• Is gestational diabetes an important condition

Trends in insulin resistance and Trends in insulin resistance and insulin production with ageinsulin production with age

1 100

Insulin resistance

Insulin production

Trends in insulin resistance and Trends in insulin resistance and insulin production with ageinsulin production with age

1 100

Pregnancy

Insulin ResistanceInsulin Resistance

Gestational DiabetesGestational DiabetesScreeningScreening

Random glucose - booking + 28 weeks

Timed random glucose - booking + 28 weeks

Urinary dipstick

Risk factor screening

50g mini GTT - booking or 28 weeks

50g mini GTT for women over 25

HbA1c

Gestational DiabetesGestational DiabetesDiagnosisDiagnosis

• 100g GTT (5.0, 9.2, 8.1, 6.9)

• 100g GTT (5.8, 10.6, 9.2, 8.1)

75g GTT75g mini GTTSerial capillary blood sugar

•50g GTT (AUC)

GDM – ScreeningGDM – Screening

• LOW RISK– Routine random sugar at 16 and 28 weeks

• HIGH RISK– 28 week simplified GTT

Gestational DiabetesGestational DiabetesManagementManagement

Obstetric management.

• Early referral to offer advice and support and review medication. Medical review for retinal and renal assessment

• Scans- 7-9 wks viability,NT scans –refer Tertiary unit, 20-22wks anomaly and cardiac scan, serial growth scan at 28,32.36 weeks. Dopplers liquor and fetal well being look for IUGR.

Regular antenatal visits monitoring insulin req and scans. BP/ proteinuriaInduction of labour -38-39wks on insulin. 40 wks if well controlled or

diet controlWellbeing screening at ADU C/S at 39 weeksPost natal care..

Third trimesterThird trimesterand fetal risksand fetal risks

• Fetal size

• Cardiac hypertrophy

• Stillbirth

Fetal Complications

• Macrosomia-63% vs 10%• Caesearean sections-56% vs 20%• Premature delivery-425 vs 12%• Preecclampsia-18%• Nronatal jaundice-18%• RDS-17%• Congenital anomlies-5% • Perinatal mortality-5%

MacrosomiaMacrosomia

Fetal MonitoringFetal Monitoring

• Serial growth scans

• Biophysical profile

• Cardiotocography

• Doppler

DeliveryDelivery

• At 38 - 40 weeks gestation

• High incidence of caesarean

• Shoulder dystocia

Postnatal Care

• Breasting not to continue previous drugs which were contraindicated.

• advice on contraception and planning future pregnancy.• Risk of hypos in the breast fed food before or during

and establish control pre pregnancy insulin doses.• GM stop insulin. Advise on diet exercise contraception,

watch for hyperglycaemia.• Subsequent screening.• FBs -6 weeks postnatal and annually• ophthalmology follow up inthose with proliferative dis.

Early neonatal risksEarly neonatal risks

• Fetal hypoglycaemia

• Polycythaemia - jaudice

• Respiratory distress syn

• Birth trauma

PostnatalPostnatal

• Insulin requirements return to normal immediately

• GTT at 6-12 weeks post partum

• Long term F/U - mother and baby

Contraception?Contraception?

Barkerism

SummarySummary