Download Diabetes in Pregnancy

Diabetes in Pregnancy
Jill Little
Diabetes Specialist Nurse
Western General Hospital
The size of the problem
2-5% of pregnancies involve women with diabetes
Edinburgh ‘05-’08: 52% GDM, 37% T2DM, 13% T1DM
Prevalence
Total singleton
pregnancies
Number of
pregnancies in
England
600,200
Type 1 diabetes
0.3%
1,800
Type 2 diabetes
0.2%
1,200
Gestational diabetes
3.5%
20,400
Total diabetes in
pregnancy
23,400
Risks of diabetes (fetus)
Pre-existing diabetes
Gestational
miscarriage
neonatal hypoglycaemia
congenital malformation
perinatal death
stillbirth
neonatal death
fetal macrosomia
birth trauma (to mother and baby)
induction of labour or caesarean section
transient neonatal morbidity
obesity and/or diabetes developing later in the baby’s life
Pregnancy outcomes in Scotland
(Type 1 Diabetes)
273 pregnancies during 1998
40 (14.7%) ended in miscarriage
20 (7.3%) ended in termination
13 (5%) babies had congenital anomalies
4 (2%) babies were stillborn
6 (3%) babies died in the peri-natal period
Penney et al BJOG 2003: 110, 315-318
Risks of diabetes (maternal)
Miscarriage
Pre-eclampsia
Preterm labour
Intrapartum complications
Progression of microvascular complications
Severe hypoglycaemia
Ketoacidosis
Death – approx one mother per year
CMACE (CEMACH)
Centre for Maternal and Child Enquiries
“improving the health of mothers, babies and children”
CMACE (CEMACH)
Identified factors associated with poor pregnancy
outcomes in patients with diabetes:
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Social deprivation
No folic acid intake
Suboptimal self-management
Suboptimal preconception care
Suboptimal glycaemic control before/during pregnancy
Suboptimal diabetes/maternity care
Suboptimal fetal surveillance
Pre-existing complications
CMACE (CEMACH)
Conclusions:
– Majority of women did not achieve a good
preparation for pregnancy
– Only 37% of women had HbA1c recorded in 6
months prior to pregnancy
– Only 27% of HbA1c values were <7%
53mmolls
Publication of National Guidelines
CEMACH 2007
NICE 2008
SIGN 2010
Preconception care in patients with
pre-existing diabetes
Pre-pregnancy planning for all patients with diabetes
– Structured education
– Dietetic, weight, exercise advice
– Folic acid 5mg daily (until 12 weeks)
– Renal and retinal assessment
Optimise glycaemic control
– Monthly HbA1c
– HbA1c as low as possible and <7% 53mmolls as minimum
(SIGN), <6.1% 43mmolls (NICE)
– Blood glucose meter, ketone testing in T1DM
Review medications
– stop statins, ACEi/ARB, oral hypoglycaemics
– Continue metformin, glibenclamide, commence insulin if required
Metformin is safe in pregnancy
MiG trial
Rowan et al, NEJM 2008
GDM women randomised to
MF or insulin
46% of MF group needed
supplemental insulin
No difference between
groups in composite
outcome (neonatal
hypoglycaemia; prematurity;
reduced APGAR;
phototherapy; resp distress;
birth trauma)
Less neonatal
hypoglycaemia with MF;
more preterm births (7% vs
4%)
Retinopathy
43% of women with retinopathy show progression during
pregnancy
Sight-threatening retinopathy rare (2%)
Risk factors are poor glycaemic control and uncontrolled
hypertension
Pre-pregnancy screening, and during each trimester in preexisting diabetes; early referral to opthalmology
“Help me prepare for a pregnancy!”
38 year old woman; para 0+0
T2DM 4 years, obesity – dietetic, weight, exercise advice
Background retinopathy – retinal screening at baseline
Microalbuminuria – renal assessment
Drugs: Metformin, Lisinopril, Simvastatin – stop ACEi, statin, start folic acid
BP 138/84 mmHg – consider safe alternative antihypertensive agents
HbA1c 9.1% 76mmolls - consider insulin
Gestational Diabetes
Gestational diabetes
Defined as “carbohydrate intolerance of variable severity
with onset or first recognition during pregnancy”
– Includes women with undiagnosed type 1, type 2 or monogenic
(MODY) DM
– Primarily refers to women with abnormal glucose tolerance
which normalises post partum
– Usually develops after 28 weeks gestation
Complications (all reduced by intensive management)
– Crowther NEJM 2005
– Macrosomia/shoulder dystocia (3%)
– Neonatal hypoglycaemia (from neonatal hyperinsulinaemia)
61% neonates admitted to SCBU
– Neonatal death (1%)
– Late intra-uterine death (1%)
Screening for GDM
Controversial – tidal wave of GDM is here !!
Current SCRH screening programme:
– Urinalysis at every ante-natal visit
– Random venous plasma glucose if glycosuria detected
– Random venous plasma glucose at book-in and at 28 weeks
SIGN 116: Assess for risk factors for GDM at first antenatal visit
– BMI > 30kg/m2
– previous baby >4.5kg
– previous GDM
– Asian, Black Caribbean or Middle Eastern
– family history of DM (first degree relative) if one risk factor then
screen
Screening for GDM – SIGN 116
Screening in early pregnancy
– All women with risk factors (incl previous GDM)
should have HbA1c or fasting glucose measured:
– women in early pregnancy with levels of…
HbA1c ≥6.5% (48 mmol/mol)
fasting glucose ≥7.0 mmol/l
two hour glucose ≥11.1 mmol/l
– …should be treated as having pre-existing diabetes
Screening for GDM – SIGN 116
Screening in later pregnancy
– All women with risk factors or intermediate results in
early pregnancy should have a 75g OGTT at 24-28
weeks
– A fasting plasma glucose at 24-28 weeks is
recommended in low risk women
Diagnosis of GDM
75g OGTT:
– Fasting glucose ≥5.1mM
– 2 hour ≥ 8.5mM
– SIGN 116 also has a 1 hour diagnostic value
of ≥ 10mM
Management of GDM
HBGM
Dietetic input
Metformin/Insulin
– Fasting ≥5.5mM
– Pre-prandial ≥6mM
Weekly CTG and liquor volumes from 36 weeks
Induced at term
Insulin stopped once delivered
– OGTT at 12 weeks, 6-12 monthly screening for T2DM
Antenatal Care
Typical Antenatal Experience
Minimum 30 visits to hospital
Fortnightly visits until 30 weeks
– Ultrasound scans (fetal anomaly, cardiac, fetal
growth, liquor volumes)
– Retinal scans (1st antenatal visit, 28 weeks)
– Anaesthetic appointment
Weekly visits until 36 weeks
Twice weekly until 39-40 weeks
Minimal GP and community midwife contact
Antenatal Care
At each clinic visit
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Obstetrician
Diabetologist
Midwife
Diabetes Specialist Nurse
May also be seen by
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Dietician
Opthalmologist
Nephrologist
Paediatrician
Radiologist/Sonographer
Anaesthetist
Glycaemic control
SIGN
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Pre-prandial 4-6mM
1 hour post-prandial <8mM
2 hour post-prandial <7mM
Before bed <6mM
NICE
– Pre-prandial 3.5-5.9mM
– 1 hour post prandial <7.8mM
Lothian
– FBG <5.5mM, Pre-prandial <6
Hypoglycaemia during pregnancy
Insulin requirements change during pregnancy due to
gestational hormones
Hypoglycaemia
– Common (14-45% of patients experience a severe
hypo)
– Occurs most often during 1st trimester
– Risk factors include previous severe hypos, diabetes
duration, impaired hypoglycaemia awareness, erratic
control
Important that pre-pregnancy counseling includes
hypoglycaemia re-education
Intrapartum and Neonatal Care
Labour induced before 40 weeks
– Because of increased risk of IUD and other
maternal/fetal complications
– Increased risk of instrumental delivery and C Section
(60%)
Aim to continue normal insulin
Aim for BMs 4-7mM
CSII – continue when feasible
CGMS – pilot study of feasibility during labour
Immediate Postnatal Care
Neonatal care
– Hypoglycaemia
– Macrosomia
– Jaundice
– Respiratory distress syndrome
Maternal care
– Reduce insulin to pre-pregnancy doses
– Stop insulin in patients with GDM
– Avoid hypoglycaemia
Breast feeding
Postnatal Care
Pre-pregnancy planning for next
pregnancy!
Encourage breastfeeding
Adjust treatment regimen when necessary
GDM: 50% 5 year risk of T2DM
– Diet, weight, exercise advice
– 12 week OGTT
– Annual screening for T2DM
Summary
Diabetes confers significant risks on
pregnancy outcomes for mum and baby
– Risk reduction involves a multidisciplinary
approach and intensive input from the patient
A tidal wave of GDM and T2DM is coming
Pre-pregnancy planning is crucial
– Contraception, contraception, contraception!