Diabetes in pregnancy

Sham AcharyaClinical Director GNC Diabetes

Staff Endocrinologist JHH

Objectives

Diabetes (type 1 and type 2) and pregnancy

What you need to know from preconception to post natal journey

Maternal risks

Foetal risks

Treatment targets and how we prefer to do it

Gestational Diabetes

Maternal and foetal issues

How to diagnose and manage?

Case History

• Mel is a 29yrs old PhD student in Chemistry. She has had type 1 Diabetes for 18 years. HbA1c has been around 8.5%. She is busy and has not seen any specialist for some time. She is an infrequent visitor.

• She is recently married and she comes to see you to ask about pregnancy in Diabetes.

Her questions….

• Can I become pregnant with Diabetes?• Is there an increased risk of miscarriage?• What are the risks for my baby?• If I have a hypo would my baby suffer?• What medications are safe?• What happens to me and my diabetes during

pregnancy?• I am not on any contraception – can I conceive

now?

Maternal complications (Type 1 and Type 2 DM)

Pregnancy effects on Diabetes Increased risk of DKA, hypoglycaemia, altered

awareness Increased risk of retinopathy, nephropathy, HT Diabetes effects on pregnancy Miscarriage, PIH Polyhydromnios Pre-term labour, C-section Use of steroids

Foetal complications

• Increased risk of congenital malformations -Neural tube defects, cardiovascular, renal anomalies Sacral agenesis• Macrosomia• Birth injuries -Shoulder dystocia, fractures, brachial plexus injuries,

birth asphyxia• Neonatal hypoglycaemia, seizures, jaundice• Still birth

Teratogenic effect of hyperglycaemia in early pregnancy

• Depletion of myoinositol, increased free radicals• Alteration of arachidonic acid metabolism• Enhanced generation of NO an inducer of apoptotic cell

death• Most anomalies occur within 5-8 weeks of LMP• Crucial to seek advice before pregnancy!

Congenital anomaly

• Overall 6-8% prevalence (3 times higher)• If HbA1c is normal at conception, rate back to

background risk• Higher the HbA1c, higher the risk (40%)• Poor glycaemia often result in miscarriage up to 50%

St Vincent Declaration 1989

“ Outcome of diabetic pregnancy should be equal to that of non diabetic pregnancy

within 5 years”

WHO, IDF, EASD and European governments joined together in this declaration

13 Years after St Vincent Declaration….CEMACH (Mary C M Macintosh BMJ 16 June 2006)

• 2359 pregnancy with DM in 231 hospital (2002-03) across England, Wales, NI

• 27% pregnancy were type 2 DM• Peri natal mortality 31.8/1000LB (T1=T2)• PNM 4times higher• 141 major congenital anomaly (6%)• Median HbA1cs - 7.9% - major congenital anomaly - 8% - still birth - 7.4% - normal healthy baby

CEMACH Factors associated with poor pregnancy outcome

• Maternal social deprivation• Lack of contraceptive use in the 12 months before

pregnancy• No folic acid intake at any time in the 12 months before

pregnancy• Suboptimal approach of the woman to managing her

diabetes• Suboptimal preconception care• Suboptimal glycaemic control at any stage before and

during pregnancy• Suboptimal maternity and diabetes care during

pregnancy• Suboptimal foetal surveillance of big babies

HbA1c in Early Diabetic Pregnancy and Pregnancy Outcomes

A Danish population-based cohort of 573 pregnancies in women with type1 diabetes

HbA1c (%) Percentage of Adverse Outcomes (95% CI)

≤7 1.2 (7.6-17)7.1-8 17 (11-25)7.9-8.9 19 (12-27)9-10.2 35 (24-47)≥>10.2 79 (60-91)

Each 1% rise of HbA1c corresponds to 5.5% increased risk of an adverse outcome

Nelsen G.I, Moller M, Sorensen H.T Diabetes Care 29:2612-2616 2006

Pre-conception advice and management

Initial visit Review medical history

Type and duration of DMPrevious DKA, Hypoglycaemia, hypo unawarenessRetinopathy, neuropathy, nephropathyHypertensionVascular problems (IHD)Other medical problems (thyroid)Menstrual history, previous pregnancy, contraceptive useBlood glucose patterns, frequency of testingSelf management skillsSupport system including family and work environment

Pre-conception targets

HbA1c 6% or less but <7% mostly acceptable Aim fasting glucose 4 -5.5mmol, post prandial <7mmol Monthly HbA1c if planning pregnancy Optimise insulin therapy

-Basal-bolus or insulin pumps Stop SU, Glitazone, Gliptin, Exenatide Metformin is safe but discuss the limited evidence Folic acid 5mg till 12 weeks of gestation Discontinue ACEI, statins Methyldopa if hypertensive

Once pregnancy confirmed

• See them urgently and regularly• 2- 3 weekly review (preferably joint clinics with

obstetricians, endocrinologist)• First trimester – hypos are troublesome• Insulin doses escalate second and third trimesters –

almost double!

During pregnancy

• Aim fasting 4-5.5, post prandial 6-7mmol/l• Aim HbA1c <6%• Any glucose over 10mmol – check ketones – risk of DKA• Low threshhold for admission if any concerns• Retinal assessment, urine ACR each trimester• Regular foetal monitoring, additional USD• Aim to deliver around 39 weeks

Education

Education

• Structured educational program

-IEP, EMPOWERMENT• Dietitian (review calorie intake, carb counting)• Educator review (hypos, sick day management, ketone testing,

glucagon kit for family member)• Handout DVD, info leaflet about pregnancy• Review family and social support• Smoking and alcohol

During delivery

• IV insulin, Dextrose and potassium• Regular monitoring• Obstetrics and neonatal specialist support• Increased chance of operative delivery• NICU • Have post natal plan pre-delivery - if in doubt halve the insulin dose -breast feeding may need additional 25% insulin dose

reduction• If type 2 – may be able to discontinue insulin

Post-natal visit

• Recurrent hypos vs. poor control• Increased risk of puerperal sepsis and DKA• Contraception• May be at risk of another unplanned pregnancy!• Type 2 – may recommence OHA

Counselling

• Congenital anomalies; increased risk with poor control• Increased risk of abortion (15%)• Worsening acute and chronic complications of DM• Increased risk of obstetric complications• Risks to the foetus

• But…most would have a normal baby!

• Do not discourage pregnancy unless major contra- indications but always encourage a planned pregnancy

Gestational Diabetes

• By definition, the recognition of diabetes for the first time during pregnancy which disappears following delivery

• Different continents have different diagnostic methods and threshold because there is no single value of glucose that determines the absolute risks to baby or mother

• Opportunistic screening - Previous GDM -Previous macrosomia -Family history & ethnicity -Increasing maternal age and parity -Obesity• Universal screening

Complications of Gestational Diabetes

Foetal risks• Macrosomia• Birth injuries• Still birth• Neonatal hypoglycaemia

Maternal risks• Polyhydromnios, pre term labour• Increased risk of operative delivery

• Increased future risk of type 2 diabetes

Diagnosis of GDM

• If previous history of IFG or IGT – Assume GDM and monitor and treat early

• High risk 12-16 weeks OGTT, repeat at 24-28 weeks if negative• OGTT 24-28 weeks in all patients (if universal screening adapted)• Diagnostic criteria

Fasting: ≥ 5.5 1hr ≥ 10 2hr ≥ 8.0mmol/l • Proposed changes with HAPO

Fasting: ≥ 5.0 1hr ≥ 10 2hr ≥ 8.5mmol/l• Newcastle 8% prevalence at present without universal screening• Will increase the workload by additional 30% and if universal

screening 130% increase in work load!• We would expect around 500 pregnancies in a year!

Management

• Glycaemiac targets same as type 1 or type 2• Metformin may be an option• Insulin• 2 weekly review till delivery• 6 weeks OGTT and follow up • 50% risk of type 2 DM• Breast feeding cuts the risk enormously!

Thank you