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Transcript
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.