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Diabetes in pregnancy

Diabetes in pregnancy. James Penny Consultant Obstetrician & Gynaecologist Surrey & Sussex NHS Trust. Diseases. Gestational Diabetes Pre-existing Diabetes Definition: Disorder of carbohydrate metabolism. It is an organ specific autoimmume disease with a genetic component

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Diabetes in pregnancy

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  1. Diabetes in pregnancy James Penny Consultant Obstetrician & Gynaecologist Surrey & Sussex NHS Trust

  2. Diseases • Gestational Diabetes • Pre-existing Diabetes • Definition: Disorder of carbohydrate metabolism. It is an organ specific autoimmume disease with a genetic component • Prevalence: 650,000 pregnancies-UK and Wales of which 2-5% are diabetic pregnancies. The prevalence is increasing in both types. Type 2 is increasing in certain minority ethnic groups. Pregnancy complicated by diabetes ---Gestational diabetes accounts for 87.5% ,7.5% type 1 and 5% type 2 . • Types: Type 1-0.27% of births Type 2-0.10% of births

  3. Recent focus • St Vincent declaration • NICE document on prenatal care • NICE document on diabetes • Cemach report on diabetes in pregnancy

  4. Risks of diabetes Pedersen hypothesis Unexplained stillbirth Congenital malformation Caesarean section Miscarriage Long term effect of infant/child health

  5. This talk • Prepregnancy care for established diabetics • Early pregnancy care • Gestational diabetes • Third trimester and delivery

  6. The size of the problem

  7. Prepregnancy Care • Maternal health • Weight • Folate • Smoking • Long term health • contraception

  8. Extremely tight control of blood sugar

  9. Prepregnancy Care • Maternal health • Assess for • Risk of miscarriage

  10. Prepregnancy Care • Congenital anomalies • Comparison of % depending of timing of care

  11. Prepregnancy Care • Congenital anomalies • If the HbA1c is >10% then ~ 30% of babies may have a congenital anomaly

  12. Prepregnancy care • Allows a detailed risk assessment • Should be performed opportunistically • Diabetic women should plan their pregnancy

  13. Maternal risks • Diabetic ketoacidosis is rare in pregnancy • Hypoglycaemia accounts for most death in pregnant diabetics

  14. Early pregnancyMultidiscplinary care Dietician Diabetic nurse Patient Obstetrician Physician Midwife

  15. Management • Diet to allow ideal weight gain • Change oral hypoglycaemics to insulin • Tight control of blood sugars • Fasting < 6 • Postprandial < 8 • Q.D.S. insulin regime • Post prandial levels are important

  16. Downside • Hypoglycaemia • Morning sickness

  17. Gestational Diabetes • Definition • Carbohydrate intolerance that arises during pregnancy and disappears after delivery • Is gestational diabetes an important condition

  18. Trends in insulin resistance and insulin production with age Insulin production Insulin resistance

  19. Trends in insulin resistance and insulin production with age Pregnancy

  20. Insulin Resistance

  21. Gestational DiabetesScreening • Random glucose - booking + 28 weeks • Timed random glucose - booking + 28 weeks • Urinary dipstick • Risk factor screening • 50g mini GTT - booking or 28 weeks • 50g mini GTT for women over 25 • HbA1c

  22. Gestational DiabetesDiagnosis • 50g GTT (AUC) • 100g GTT (5.0, 9.2, 8.1, 6.9) • 100g GTT (5.8, 10.6, 9.2, 8.1) 75g GTT 75g mini GTT Serial capillary blood sugar

  23. GDM – Screening • LOW RISK • Routine random sugar at 16 and 28 weeks • HIGH RISK • 28 week simplified GTT

  24. Gestational DiabetesManagement

  25. Obstetric management. • Early referral to offer advice and support and review medication. Medical review for retinal and renal assessment • Scans- 7-9 wks viability,NT scans –refer Tertiary unit, 20-22wks anomaly and cardiac scan, serial growth scan at 28,32.36 weeks. Dopplers liquor and fetal well being look for IUGR. Regular antenatal visits monitoring insulin req and scans. BP/ proteinuria Induction of labour -38-39wks on insulin. 40 wks if well controlled or diet control Wellbeing screening at ADU C/S at 39 weeks Post natal care..

  26. Third trimesterand fetal risks • Fetal size • Cardiac hypertrophy • Stillbirth

  27. Fetal Complications • Macrosomia-63% vs 10% • Caesearean sections-56% vs 20% • Premature delivery-425 vs 12% • Preecclampsia-18% • Nronatal jaundice-18% • RDS-17% • Congenital anomlies-5% • Perinatal mortality-5%

  28. Macrosomia

  29. Fetal Monitoring • Serial growth scans • Biophysical profile • Cardiotocography • Doppler

  30. Delivery • At 38 - 40 weeks gestation • High incidence of caesarean • Shoulder dystocia

  31. Postnatal Care • Breasting not to continue previous drugs which were contraindicated. • advice on contraception and planning future pregnancy. • Risk of hypos in the breast fed food before or during and establish control pre pregnancy insulin doses. • GM stop insulin. Advise on diet exercise contraception, watch for hyperglycaemia. • Subsequent screening. • FBs -6 weeks postnatal and annually • ophthalmology follow up inthose with proliferative dis.

  32. Early neonatal risks • Fetal hypoglycaemia • Polycythaemia - jaudice • Respiratory distress syn • Birth trauma

  33. Postnatal • Insulin requirements return to normal immediately • GTT at 6-12 weeks post partum • Long term F/U - mother and baby

  34. Contraception?

  35. Barkerism

  36. Summary

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