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. 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 1. Warn risk of PET/IUGR/SB 2. Refer for hospital PPC if creatinine more than 120micromole/litre and 24 hr urine protein >2gm 3. 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

16. 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

17. Breast feeding Metformin safe NICE

18. Thank you