Download Diabetes and pregnancy

Diabetes and pregnancy
Great Expectations!
Sister Lesley Mowat
Dr Shirley Copland
Pregnancy -the ideal outcome
• As normal a pregnancy as possible
• Healthy mother and baby
• Aiming to reduce the rates of miscarriage,
congenital anomaly and perinatal mortality
to the same levels as the background
population
Topics
• Prepregnancy planning
• Care during pregnancy
• Gestational diabetes
Pre-pregnancy planning
• All patients with type 1, type 2 or
secondary diabetes who are in the child
bearing years should be made aware of the
importance of planning for any pregnancy
• Discuss during routine review along with
contraception issues
Pre-pregnancy planning
• Key message is that excellent glycaemic
control prior to conception and during
pregnancy results in the optimal outcome
for mother and baby
• Self management of diabetes and issues of
hypoglycaemia need to be discussed e.g.
insulin adjustment, glucose targets, driving,
teach use of hypostop/glucogon to partner
Pre-pregnancy planning
• Diabetes complications need to be
recognised and managed optimally
• Review medications NB Ace inhibitors are
teratogenic
• Rubella status to be checked
• Commence folic acid 5mg
• Review other health issues, menstrual status
and gynaecological factors
Pre-pregnancy planning
• SIGN guidelines strongly recommend that
pre-pregnancy care is provided by a mutlidisciplinary specialist team
• Advise early attendance at specialist clinic
for pre-pregnancy advice i.e. Combined
Diabetes/Obstetric Clinic, AMH (weekly
Tues pm)
Why need to plan?
• Pregnancy in Type 1 diabetes is a high risk
state for both the mother and the foetus
• Increased risks of diabetes complications
• Increased risk of obstetric complications
• Increased foetal and neonatal hazards
Why need to plan?
• Patients with type 2 diabetes are also at
increased risk of obstetric complications
and their babies are equally at risk of
malformation and neonatal problems
• Type 2 diabetes increasing in young women
• Tight glycaemic control prior to and during
pregnancy is essential and insulin therapy
likely to be required
Maternal risks with Type 1 diabetes
• Severe hypoglycaemia with loss of
hypoglycaemic awareness (30%)
• Ketoacidosis can develop more rapidly
• Worsening of pre-existing retinopathy laser treatment can be required
• Worsening of pre-existing renal dysfunction
and hypertension
Obstetric risks in diabetes
• Increased rates of miscarriage
• Higher incidence of pre-eclampsia
• Obstructed labour and polyhydramnios now
less common
• High caesarean section rates (71%)
Foetal and neonatal risks
• Congenital malformation rates remain
greater than the background population e.g.
cardiac defects, sacral agenesis
• Late intrauterine deaths and increased foetal
distress - aim to deliver between 38-40
weeks
• Macrosomia(most >50th centile, many 95th)
• Neonatal hypoglycaemia is common
6
5
90
4
Wt.(Kg)
50
3
2
1
30
32
34
36
38
GESTATION (WEEKS)
40
42
Aims prior to conception
• Blood glucose levels between 4 - 7 mmols
• HbA1c target of 7.0% or less
• Avoiding disabling hypoglycaemia
• ?How
Patient commitment
• Home glucose monitoring 4 -6 times daily
(or more!)
• Multiple injection insulin regime i.e. basal
bolus regime with self adjustment
• Address lifestyle issues and review diet
• Clinic visits 6-8 weekly and telephone
support
Pregnant at last!
• Patients should attend combined obstetric
/diabetes ante-natal clinc as soon as
pregnancy is confirmed
• May need admission for stabilisation of
control early or at any time during the
pregnancy - open door policy in Ashgrove
Ward, AMH
• Routine 2- 4 weekly review schedule
followed but seen as often as required
Pregnancy
• Patients strive for near normal glycaemia
throughout the pregnancy i.e. blood sugar 47 mmols
• Self titration of the insulin dose is essential
• Insulin doses at least double by the end of
pregnancy
• Encouraged to check for ketones if bs
greater the 10 mmols and seek immediate
advice if present (risk of foetal death)
Delivery
• Ideally vaginal delivery between 38 and 40
weeks gestation
• Neonatal intensive care facilities required
• During labour iv insulin/10 % dextrose
regime used to maintain euglycamia
• High ceasarean section rate
• Post delivery insulin doses return to prepregnancy level in type 1 patients. Type 2
often diet alone initially if breast feeding
Gestational Diabetes
• Carbohydrate intolerance of variable
severity with onset or first recognition
during pregnancy
• Usually seen in the third trimester and
glycaemic control returns to normal
immediately after pregnancy
• May be the first presentation of type 1 or
type 2 diabetes
Gestational Diabetes
• Screening - by a random venous glucose if
glycosuria ++ is detected and routinely at 28
weeks gestation
• If greater than 5.5 mmols/l two hours or
more after food or greater than 7.0 mmols/l
within two hours of eating then requires
further investigation by a 75g OGTT
Gestational diabetes
• Diagnosis confirmed if fasting bs is greater
than 5.5 mmols/l or two hour OGTT level
greater than 9 mmols/l
• Associated with macrosomia and treatment
by diet and/or insulin may cause a modest
reduction in birth weight
• Initial management is dietary - if blood
glucose remains elevated and if evidence of
macrosomia then insulin treatment started
Gestational diabetes
• Marker for increased risk of future diabetes
• OGTT arranged 6 months post partum,
majority are normal at that stage
• Up to 50% may go on to develop later
diabetes mainly type 2
• Should be advised on lifestyle and weight
reduction to reduce risk
• Protocol for follow up in primary care