Dr. Nicola Cowap

 Lack of awareness of the risks associated with hyperglycaemia during pregnancy. Risks are the same in Type 1 & 2 diabetes.  Congenital anomaly.  Retinopathy progression.

 ↑ mortality (R.R=10)  ↑ hypoglycaemia in 1 st – 2 nd trimester  ↑ DKA (1-3%)  ↑ hypertension & pre-eclampsia  ↑ polyhydramnios  ↑ instrumental delivery & Caesarean section (x3)  retinopathy progression( R.R=1.63)

 ↑ miscarriage (↑3% per + S.D >HbA1C >6%)  ↑ stillbirth (RR=4.7)  ↑ perinatal mortality (RR=3.8)  ↑ premature delivery  ↑ macrosomia  ↑ instrumental or operative delivery  ↑ risk of future DM and/or metabolic syndrome

 Background rate = 1%  Type 1 diabetes = 5.9%  Type 2 diabetes = 4.4%  HbA1C >10% at time of conception=10.9%  HbA1C <6.9% at time of conception=3.9%  Occurs in all organ systems, but cardiac defects are most common. Caudal agenesis is pathognomic.  Hyperglycaemia is teratogenic.

Use it!

 Diabetic pregnancy carries an increased risk, but with optimal glycaemic control and good obstetric and diabetic care, almost all maternal & foetal risks can be reduced.  Fertility – ↓ menstrual irregularity in type 1 (often assoc. with poor control) & PCOS in type 2.  Eyes must be checked before pregnancy.  Present as soon as pregnancy test is positive.

 Folic acid 5mg o.d  Stop ACEIs, ARBs substitute calcium channel blockers or labetalol  Stop statins – diet control, monitor lipids carefully  Continue metformin. Stop all other OHDs. Add insulin if optimal glycaemic control not achieved.  Frequent SMBG, 4-6 times daily.  Glycaemic targets = HbA1C<6.5% FBG<5mmol/l PPG<7mmol/l

 Type 1 Diabetes:- - 6% risk of inheriting type 1 (RR=70) - 15% risk of inheriting type 2 (RR=3), reduced if good control during pregnancy  Type 2 Diabetes:- - 30% if one parent (>r if mother)and 60% if both parents

 39 women aged 15 to 45yrs Type 1 = 15 Type 2 = 23  Average Age:- Type 1 = 35yrs Type 2 = 39yrs

Obstetric HistoryNumberOutcomePercentages Nulliparous162 miscarriages & 2 tops 42% of all diabetic women Pregnant while diabetic 63 type 1s & 3 type 2s 27% of all parous women Pregnant before diabetes dx 163 type 1s and 13 type 2s 73% of all parous women Gestational diabetes 2One had child before dx Miscarriages among parous women 32 prior to dx Stillbirths2Both post dx (one of these women also had a miscarriage)

Average A1c Women who were diabetic before conception 8.4% Women with no record of contraception 8.9% (n=23) One woman currently trying to get pregnant 6.1%

MethodNo. of women COC1 POP1 Depot3 Implanon2 IUCD1 Tubal ligation1 Hysterectomy2 Endometrial Abalation1 Vasectomy2 Total 14 (37%)

 One woman (17%) took folic acid 5mg before conception.  In 4 out of 6 diabetic pregnancies there was a record of pre-conception counselling, 3 of these were the type 1 pregnancies.

 Pregnancy intention should be routinely enquired about and recorded in all women of reproductive age at annual reviews.  Opportunistically check contraceptive use when relevant.  Conduct and record pre-conception counselling in all women who are planning a pregnancy.  Start folic acid and stop all teratogenic and OHDs apart from metformin discuss unlicensed use in pregnancy.  Optimise glycaemic control if pregnancy is planned. Refer to in-house diabetic team if type 2 and community specialist team if type 1.  Organise retinopathy screen if not undertaken in last 12 months and refer any patient with more than background retinopathy to the opthalmologists.

 Unplanned pregnancy in a diabetic is a disaster – don’t let it happen to a woman near you!  The risks are the same in type 1 & type 2 diabetes.  Good glycaemic control before and during pregnancy will facilitate optimal outcomes.