Jill Little Diabetes Specialist Nurse Western General Hospital Diabetes in Pregnancy Jill Little Diabetes Specialist Nurse Western General Hospital

Number of pregnancies in England The size of the problem 2-5% of pregnancies involve women with diabetes Edinburgh ‘05-’08: 52% GDM, 37% T2DM, 13% T1DM Prevalence Number of pregnancies in England Total singleton pregnancies 600,200 Type 1 diabetes 0.3% 1,800 Type 2 diabetes 0.2% 1,200 Gestational diabetes 3.5% 20,400 Total diabetes in pregnancy 23,400

Risks of diabetes (fetus) Pre-existing diabetes Gestational miscarriage neonatal hypoglycaemia congenital malformation perinatal death stillbirth neonatal death fetal macrosomia birth trauma (to mother and baby) induction of labour or caesarean section transient neonatal morbidity obesity and/or diabetes developing later in the baby’s life

Pregnancy outcomes in Scotland (Type 1 Diabetes) 273 pregnancies during 1998 40 (14.7%) ended in miscarriage 20 (7.3%) ended in termination 13 (5%) babies had congenital anomalies 4 (2%) babies were stillborn 6 (3%) babies died in the peri-natal period Penney et al BJOG 2003: 110, 315-318

Risks of diabetes (maternal) Miscarriage Pre-eclampsia Preterm labour Intrapartum complications Progression of microvascular complications Severe hypoglycaemia Ketoacidosis Death – approx one mother per year

CMACE (CEMACH) Centre for Maternal and Child Enquiries “improving the health of mothers, babies and children”

CMACE (CEMACH) Identified factors associated with poor pregnancy outcomes in patients with diabetes: Social deprivation No folic acid intake Suboptimal self-management Suboptimal preconception care Suboptimal glycaemic control before/during pregnancy Suboptimal diabetes/maternity care Suboptimal fetal surveillance Pre-existing complications

CMACE (CEMACH) Conclusions: Majority of women did not achieve a good preparation for pregnancy Only 37% of women had HbA1c recorded in 6 months prior to pregnancy Only 27% of HbA1c values were <7% 53mmolls

Publication of National Guidelines CEMACH 2007 NICE 2008 SIGN 2010

Preconception care in patients with pre-existing diabetes Pre-pregnancy planning for all patients with diabetes Structured education Dietetic, weight, exercise advice Folic acid 5mg daily (until 12 weeks) Renal and retinal assessment Optimise glycaemic control Monthly HbA1c HbA1c as low as possible and <7% 53mmolls as minimum (SIGN), <6.1% 43mmolls (NICE) Blood glucose meter, ketone testing in T1DM Review medications stop statins, ACEi/ARB, oral hypoglycaemics Continue metformin, glibenclamide, commence insulin if required

Metformin is safe in pregnancy GDM women randomised to MF or insulin 46% of MF group needed supplemental insulin No difference between groups in composite outcome (neonatal hypoglycaemia; prematurity; reduced APGAR; phototherapy; resp distress; birth trauma) Less neonatal hypoglycaemia with MF; more preterm births (7% vs 4%) MiG trial Rowan et al, NEJM 2008

Retinopathy 43% of women with retinopathy show progression during pregnancy Sight-threatening retinopathy rare (2%) Risk factors are poor glycaemic control and uncontrolled hypertension Pre-pregnancy screening, and during each trimester in pre-existing diabetes; early referral to opthalmology

“Help me prepare for a pregnancy!” 38 year old woman; para 0+0 T2DM 4 years, obesity – dietetic, weight, exercise advice Background retinopathy – retinal screening at baseline Microalbuminuria – renal assessment Drugs: Metformin, Lisinopril, Simvastatin – stop ACEi, statin, start folic acid BP 138/84 mmHg – consider safe alternative antihypertensive agents HbA1c 9.1% 76mmolls - consider insulin

Gestational Diabetes

Gestational diabetes Defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy” Includes women with undiagnosed type 1, type 2 or monogenic (MODY) DM Primarily refers to women with abnormal glucose tolerance which normalises post partum Usually develops after 28 weeks gestation Complications (all reduced by intensive management) Crowther NEJM 2005 Macrosomia/shoulder dystocia (3%) Neonatal hypoglycaemia (from neonatal hyperinsulinaemia) 61% neonates admitted to SCBU Neonatal death (1%) Late intra-uterine death (1%)

Screening for GDM Controversial – tidal wave of GDM is here !! Current SCRH screening programme: Urinalysis at every ante-natal visit Random venous plasma glucose if glycosuria detected Random venous plasma glucose at book-in and at 28 weeks SIGN 116: Assess for risk factors for GDM at first antenatal visit BMI > 30kg/m2 previous baby >4.5kg previous GDM Asian, Black Caribbean or Middle Eastern family history of DM (first degree relative) if one risk factor then screen

Screening for GDM – SIGN 116 Screening in early pregnancy All women with risk factors (incl previous GDM) should have HbA1c or fasting glucose measured: women in early pregnancy with levels of… HbA1c ≥6.5% (48 mmol/mol) fasting glucose ≥7.0 mmol/l two hour glucose ≥11.1 mmol/l …should be treated as having pre-existing diabetes

Screening for GDM – SIGN 116 Screening in later pregnancy All women with risk factors or intermediate results in early pregnancy should have a 75g OGTT at 24-28 weeks A fasting plasma glucose at 24-28 weeks is recommended in low risk women

Diagnosis of GDM 75g OGTT: Fasting glucose ≥5.1mM 2 hour ≥ 8.5mM SIGN 116 also has a 1 hour diagnostic value of ≥ 10mM

Management of GDM HBGM Dietetic input Metformin/Insulin Fasting ≥5.5mM Pre-prandial ≥6mM Weekly CTG and liquor volumes from 36 weeks Induced at term Insulin stopped once delivered OGTT at 12 weeks, 6-12 monthly screening for T2DM

Antenatal Care

Typical Antenatal Experience Minimum 30 visits to hospital Fortnightly visits until 30 weeks Ultrasound scans (fetal anomaly, cardiac, fetal growth, liquor volumes) Retinal scans (1st antenatal visit, 28 weeks) Anaesthetic appointment Weekly visits until 36 weeks Twice weekly until 39-40 weeks Minimal GP and community midwife contact

Antenatal Care At each clinic visit May also be seen by Obstetrician Diabetologist Midwife Diabetes Specialist Nurse May also be seen by Dietician Opthalmologist Nephrologist Paediatrician Radiologist/Sonographer Anaesthetist

Glycaemic control SIGN NICE Lothian Pre-prandial 4-6mM 1 hour post-prandial <8mM 2 hour post-prandial <7mM Before bed <6mM NICE Pre-prandial 3.5-5.9mM 1 hour post prandial <7.8mM Lothian FBG <5.5mM, Pre-prandial <6

Hypoglycaemia during pregnancy Insulin requirements change during pregnancy due to gestational hormones Hypoglycaemia Common (14-45% of patients experience a severe hypo) Occurs most often during 1st trimester Risk factors include previous severe hypos, diabetes duration, impaired hypoglycaemia awareness, erratic control Important that pre-pregnancy counseling includes hypoglycaemia re-education

Intrapartum and Neonatal Care Labour induced before 40 weeks Because of increased risk of IUD and other maternal/fetal complications Increased risk of instrumental delivery and C Section (60%) Aim to continue normal insulin Aim for BMs 4-7mM CSII – continue when feasible CGMS – pilot study of feasibility during labour

Immediate Postnatal Care Neonatal care Hypoglycaemia Macrosomia Jaundice Respiratory distress syndrome Maternal care Reduce insulin to pre-pregnancy doses Stop insulin in patients with GDM Avoid hypoglycaemia Breast feeding

Postnatal Care Pre-pregnancy planning for next pregnancy! Encourage breastfeeding Adjust treatment regimen when necessary GDM: 50% 5 year risk of T2DM Diet, weight, exercise advice 12 week OGTT Annual screening for T2DM

Summary Diabetes confers significant risks on pregnancy outcomes for mum and baby Risk reduction involves a multidisciplinary approach and intensive input from the patient A tidal wave of GDM and T2DM is coming Pre-pregnancy planning is crucial Contraception, contraception, contraception!