Miss M Maitra Consultant O&G UHCW 29 April 2015
What is Diabetes Mellitus? Metabolic disorder Multiple aetiology Chronic hyperglycaemia Defects in insulin secretion, insulin action or both
Physiological changes in pregnancy Insulin resistance Altered glucose homeostasis Insulin Vs Glucagon/Cortisol/HPL/Progesterone/hCG Placental barrier fetal consequences
Consequences
Complications Maternal Miscarriage Polyhydramnios Shoulder dystocia Birth trauma PET/HTN Caesarean section DM in future
Fetal Miscarriage Premature delivery Stillbirth/ NND Birth trauma Neonatal consequences Future obesity & diabetes
Diabetes in pregnancy Pre-existing diabetes Gestational diabetes 87.5% Type 1 7.5% Type2 5% African, Black Caribbean, South Asian, Chinese, Middle Eastern
Group work! 1. AB is a 28 yr old teacher who is known to have Type 1 DM since childhood. She is planning to have a baby. What will you advise? 2. CD is a 32 yr old housewife who has a h/o PCOS and is on metformin for Type 2 DM. She has a BMI of 35 and has recently found out that she is pregnant. She is currently 16 weeks of gestation. What is your management plan? 3. EF is a 40 yr old G3P2 – with a h/o GDM in the last pregnancy. She is now 7 weeks pregnant. Outline your management plan.
Management
Pre-conception care Optimise control! Avoid unplanned pregnancy! Discuss risks Lifestyle advice Folic acid Retinal and renal assessments
Medical Management Near-normoglycaemia ↑ self monitoring Adjustment of Rx doses Target capillary BG = mmol/L fasting and < 7.8 mmol/L 1 hr PP
Management – Type 1 DM requirement/monitoring Hypoglycaemia awareness
Management – Type 2 DM
Antenatal Care Scans Baseline renal functions / retinal checks Folic acid/Vitamin D Antihypertensives/aspirin
Timing of delivery INSULIN? DIET? ORAL RX CONTROL? WEEKS
Intra-partum Management Hourly capillary blood glucose levels Variable rate insulin infusion* Target range: 4-7 mmols
What happens postnatally? Return to pre-pregnancy doses (Type 1 & 2) Breastfeeding implications Lifestyle modification
Neonatal care Check BMs within 2-4⁰ to NNU if: - Hypoglycaemia/RDS/Polycythaemia/Jaundice - Congenital cardiac abnormalities - Need for tube feeding/IV fluids - Preterm (< 34/40)
Gestational Diabetes (GDM) ‘Carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy’ – National Diabetes Data Group (1985)
NICE 2015 a fasting plasma glucose level of 5.6 mmol/litre or above or a 2-hour plasma glucose level of 7.8 mmol/litre or above. [new 2015]
Risk factors for GDM BMI above 30 kg/m2 Previous macrosomic baby ≥ 4.5 kg / 90 th centile Previous GDM 1 relative with diabetes Ethnic origin Maternal age > 35 yrs PCOS Long term steroids Previous unexplained SB / recurrent miscarriage Polyhydramnios / Macrosomia / persistent glycosuria
GDM - Advice
HBGM: Glycaemic targets Fasting blood glucose = 3.5 – 5.3 mmol/L 1hr PP blood glucose <7.8 mmol/L INDIVIDUALISED targets
Antenatal Care Multidisciplinary care
Timing of Delivery 40 to 40+12
Postnatal care Stop Rx Check FBS after 6 weeks and then annually Life style modifications
Further reading