Download Diabetes and Pregnancy

Diabetes and Pregnancy
Successful outcome of pregnancy can usually be anticipated in women with pre existing diabetes.
However, diabetic pregnancy is statistically a high risk pregnancy with regard to fetal morbidity and
mortality. To achieve a good fetal outcome major efforts and attention to detail are required on the part of
the patient and her carers. Meticulous blood glucose control before and during pregnancy is the cornerstone
of management.
In addition to metabolic supervision, mothers require close clinical surveillance since there are increased
risks with regard to progression of diabetic retinopathy and nephropathy, pregnancy induced hypertension
and intrapartum complications.
The congenital abnormality rate in diabetic pregnancy is at least double that of the background population,
and there is convincing evidence that this relates to glycaemic control at or shortly after conception during
the period of organogenesis. This stage is often complete before the mother realises that she is pregnant.
For these reasons diabetic pregnancy should always be planned and reliable contraception is therefore
important.
It should then be split into the following linksL
Prior to conception
Confirmed pregnancy
Hypoglycaemia
Ketosis
Delivery
Prior to conception
Refer to a hospital or combined obstetric diabetic clinic for pre pregnancy assessment, where the following
steps are taken:

Achieve optimal glycaemic control aiming for an HbA1c result within or as near to the non-diabetic
range as is possible without inducing disabling hypoglycaemia

Provide blood glucose meter and test blood glucose four to six times daily

Blood glucose targets are fasting and pre meal 4.0-5.5 mmol/l, two hour post prandial <7.0 mmol/l

Review insulin regimen. For intensive blood glucose control most women are best treated with a
multiple injection regimen using a pen device

Patients with Type 2 diabetes should be considered for insulin therapy with treatment targets as above

Discuss lifestyle issues which may affect glycaemic control, e.g. difficulty with shift work and
reinforce antismoking advice

Review all medications and other potential teratogens

Arrange dietetic review

Commence folic acid 5mg daily. (High dose recommended in view of high risk of neural tube defects)

Ensure complication screening is complete and take action as appropriate – See 10.2 - Content of
Annual checks

Check rubella status

Assess general health, fitness for pregnancy, and screen for factors which could disturb glycaemic
control, e.g. urinary infection and thyroid status

Review menstrual and gynaecological factors which could impair fertility
Confirmed pregnancy
All diabetic women in whom pregnancy has been confirmed should be referred immediately to a hospital
combined obstetric / diabetic clinic for multidisciplinary supervision. Clinics are held weekly in Aberdeen
and Elgin, where women will be seen at one to four weekly intervals depending on metabolic control and
obstetric progress. Admission is not routine but may be recommended for stabilisation of blood glucose
control, management of diabetic complications or associated obstetric problems. There is a low threshold
for admission in these high-risk pregnancies.
Hypoglycaemia
Strict blood glucose control increases the risk of hypoglycaemia and warning signs are often lost in early
pregnancy. All women should be provided with Hypostop and a glucagon emergency kit, and their partner
should be instructed in their use. Ideally women should not sleep in a house alone in early pregnancy
because of the risk of hypoglycaemia. Women who lose awareness of hypoglycaemia in pregnancy should
be advised to stop driving until warning symptoms return to normal.
Ketosis
The fetus tolerates hypoglycaemia well, but is very sensitive to ketosis. Established ketoacidosis in
pregnancy results in a very high incidence of fetal loss at all gestations, and is usually potentially avoidable.
Pregnant women should all have facilities for urine testing for ketones. Elevation of blood glucose (>
10mmol/l) together with persistent non fasting ketonuria is an indication for increased insulin doses and
urgent further assessment usually involving hospital admission for intravenous insulin and dextrose.
Women must be advised to contact either their DSN, hospital team or GP in such circumstances without
delay. The most common cause of ketosis in pregnancy is urinary tract infection, which should be treated
on a presumptive basis.
Delivery
Women should be delivered where there are facilities for intensive neo-natal care. Ideally should be vaginal
and at term (but not beyond). An individual decision will be made for each patient, and in practice the
caesarean section rate remains about double that of the non-diabetic population.
All women on insulin receive an infusion of dextrose and insulin during labour to maintain
normoglycaemia.
Post partum insulin requirements usually fall to between 30% and 50% of that immediately prior to
delivery. Breast-feeding is encouraged.