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Pre-conception Advice for Type 2 Diabetes

Pre-conception Advice for Type 2 Diabetes. Why Bother?. If conception HbA1c is >10% the congenital malformation rate is 10% If the conception HbA1c is <7% the congenital malformation rate is that of the population. Abnormalities. Cardiac malformation (4x) Neural tube defects (5x)

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Pre-conception Advice for Type 2 Diabetes

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  1. Pre-conception Advice for Type 2 Diabetes

  2. Why Bother? • If conception HbA1c is >10% the congenital malformation rate is 10% • If the conception HbA1c is <7% the congenital malformation rate is that of the population.

  3. Abnormalities • Cardiac malformation (4x) • Neural tube defects (5x) • Caudal regression (252x) • Duodenal/anal atresia (4x) • Renal anomalies (5X) • Situs invertus (84x)

  4. CEMACH factors around poor outcomes • Maternal social deprivation • No contraception in preceeding year • No folic acid in preceeding year • Poor pre-conceptive care • Poor glycaemic control before/during pregnancy • Pre-existing complications

  5. Pre-conception care • Aim for pre-conception HbA1c <7% (NICE state <6.1%) • Stop teratogenic medications (esp ACE1) • Lifestyle advice – smoking, alcohol, diet, exercise • Start folic acid 5mg • Complications may deteriorate • Schedule of events • Who to contact immediately when pregnant

  6. Glycaemic control pre-pregnancy • Continue Metformin • Stop ALL other oral anti-diabetic agents including injectables (Exenatide, Liraglutide) • Start insulin if necessary • Background – IsophanevsLantus/Levemir • Short acting analogues Novorapid & Humalog are safe • Blood glucose monitoring • Ketone testing strips

  7. Contraception • All methods are acceptable • Women for whom pregnancy would be dangerous need a method with low failure rate • OCP – may cause transient change in diabetes control • Combined OCP – hypertension may cause acceleration of nephropathy & retinopathy • Monitor closely or avoid if complications already present

  8. Metabolic changes • Increased glucose to foetus - pre meal hypoglycaemia - increased starvation & ketosis • Insulin resistance (to increase available nutrients to foetus) - post meal glucose peaks • Foetal hyperinsulinaemia & macrosomia

  9. Glycaemic targets • Organogenesis to week 12 • Risk of severe hypo’s up to 14 weeks as lowest period of insulin requirement (12 – 14 weeks) • Weeks 14 – 28 most crucial time for preventing macrosomia etc • Third trimester – increased requirements

  10. Glycaemic targets continued • Fasting level 3.5 – 5.9 mmols/l (NICE) • 2 hours post meal <7.0 mmols/l • HbA1c unreliable – high rate cell turnover

  11. Post delivery • Mostly delivered 38 to 39 weeks • Hypo’s common in third trimester • T2D – return to pre-pregnancy therapy unless breast feeding (Metformin safe) • If breast feeding – reduce insulin dose by approx. 30% • Contraceptive advice

  12. Gestational Diabetes • Any degree of glucose intolerance with an onset or first recognition in pregnancy – WHO definition 1998 • Fasting glucose >6mmol/l • 2 hour glucose>7.8mmol/l (75G OGTT) • Marker of maternal risk of type 2 diabetes • Long term implications for the baby

  13. Screening for GDM • Previous GDM • Persistent glycosuria • Previous large babies (>4kg) • Current large baby (>95thcentile) • Polyhydramnios • First degree relative with diabetes • PCOS • Previous unexplained stillbirth • BMI >35 • Ethnicity (Asian, Afrocaribbean)

  14. Screening for GDM • When? – when risk factor identified and again at 28 weeks • How? – 75G OGTT • Interpretation – positive if: EITHER fasting >6.9mmol/l or 2hour >7.8mmol/l

  15. Management • Pre-meal <5.5mmol/l • 2 hour < 7.0mmol/l until 35 weeks then <8.0mmol/l • Use diet, then Metformin, then insulin if necessary

  16. Ongoing management • 6 week repeat OGTT to exclude ongoing DM or IGT • NICE – fasting glucose at 6 weeks and then annually • 2 – 3% still have diabetes • 31% have pre-diabetes

  17. Remember:- • Type 2 diabetes has same risks as type1 • Pre-pregnancy counselling reduces risks (RR 0.4) • Tight glucose control improves outcomes – refer immediately • Keep on Metformin, all other anti diabetic meds stop. Insulin as necessary • GDM have high risk of future diabetes

  18. Thank you to Dr Julia Platts at Llandough Hospital for the use of her information from a previous lecture.

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