Diabetes and pregnancy

1. Diabetes and pregnancy Great Expectations! Sister Lesley Mowat Dr Shirley Copland

2. 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

3. Topics • Prepregnancy planning • Care during pregnancy • Gestational diabetes

4. 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

5. 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

6. 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

7. Pre-pregnancy planning • SIGN guidelines strongly recommend that pre-pregnancy care is provided by a mutli-disciplinary specialist team • Advise early attendance at specialist clinic for pre-pregnancy advice i.e. Combined Diabetes/Obstetric Clinic, AMH (weekly Tues pm)

8. 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

9. 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

10. 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

11. 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%)

12. 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

14. Aims prior to conception • Blood glucose levels between 4 - 7 mmols • HbA1c target of 7.0% or less • Avoiding disabling hypoglycaemia • ?How

15. 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

16. 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

17. Pregnancy • Patients strive for near normal glycaemia throughout the pregnancy i.e. blood sugar 4-7 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)

18. 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 pre- pregnancy level in type 1 patients. Type 2 often diet alone initially if breast feeding

19. 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

20. 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

21. 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

22. 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