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Diabetes in pregnancy- an update

Diabetes in pregnancy- an update. Seema Chakravarti MRCOG, MRCPI Consultant Obstetrician BHR Trust. CEMACH DIABETES REPORT. Perinatal mortality 5 fold increased 3 fold increase in neonatal deaths in first month of life 2 fold increase in cong abnormalities (NTD/Cardiac)

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Diabetes in pregnancy- an update

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  1. Diabetes in pregnancy- an update Seema Chakravarti MRCOG, MRCPI Consultant Obstetrician BHR Trust

  2. CEMACH DIABETES REPORT • Perinatal mortality 5 fold increased • 3 fold increase in neonatal deaths in first month of life • 2 fold increase in cong abnormalities (NTD/Cardiac) • Adverse outcomes same for type 1 and 2 DM • Prem delivery 5 fold, macrosomia • High csection rate 70% • Severe PET

  3. Subtypes • Type 1 • Type 2 • Gestational Diabetics • SOME WOMEN WITH GDM WILL HAVE PRE EXISTING DIABETES!!

  4. Factors associated with poor pregnancy outcome • Maternal social deprivation • Lack of contraceptive use in 12 months preceding pregnancy • No folic acid intake pre pregnancy 5mg • Suboptimal diabetes management • Suboptimal preconception care • Suboptimal glycemic control before and during pregnancy

  5. Key recommendations for specialist preconception services • Multidisciplinary- diabetic physician/obstetrician/midwife/diabetic nurse • Appropriate contraception • High dose folic acid supplementation • Assess and manage diabetic complications • Optimise glycemic control HbA1c <7 • Counsel regarding risks and management strategies

  6. Booking HbA1c and pregnancy outcome

  7. Solutions • Pre- conception counselling- good diabetic control at conception and pregnancy reduce incidence of miscarriage, malformation, SB and NND • Contraceptive advice, importance of avoiding unplanned preg should be an essential component of diabetic education for all diabetic women DOCUMENT • Only 1/3 women currently get PPC, 40% pregnancies unplanned

  8. Targets • Pre conception Hb A1c <7.0% if safe • Increase frequency of self monitoring • Pre meal 5.5 mmol/l • Post meal 7.7mmol/l • Retinal screening treat pre pregnancy if proliferative retinopathy • Assess nephropathy- PCR/renal biochem • Review medication

  9. Review medication • Stop ACE inhibitors discuss pros and cons • Beta blockers with caution as higher R/O IUGR • Methyl dopa, nifedepine,hydralazine • Stop statins • Metformin/glibenclamide can be used in pregnancy, early referral

  10. Assess diabetes • Retinopathy digital pictures and mydriasis • If retinopathy need pre-conception advice and possible treatment

  11. Percentage of women developing sight threatening DR in pregnancy

  12. Nephropathy • Warn risk of PET/IUGR/SB • Refer for hospital PPC if creatinine more than 120micromole/litre and 24 hr urine protein >2gm • Consider asprin/clexane especially if proteinuria as increased thromboembolic risk

  13. General advice • Diet and lifestyle • Optimise weight( BMI>35 independent risk factor for maternal mortality and morbidity) • Adequate contraception • Folic Acid 5mg until 12 weeks gestation.

  14. Diabetes UK and CEMACH guidance on pre preg care Leaflet

  15. Other changes • Can continue/start metformin/glibenclamide in pregnancy • HAPO Trial- safe, no increased risk of malformations, better control in Type 2 Dimples hypos with tighter control • Watch for lactic acidosis – euglycemic acidosis

  16. Breast feeding • Metformin safe NICE

  17. Thank you

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