1. City Wide Update Event

2. Programme Overview 7.00 pm 'Legs Matter’ - Brenda King
7.30 pm Pre-conception Care for Women with Diabetes –
Dr Soon H Song, Sallianne Kavanagh & Dr Jenny Stephenson 
8.30 pm OTC Consultation Skills: Low Back Pain Workshop
9pm Close
Kindly sponsored by GSK

3. Pre-pregnancy care in diabetes: Setting the scene
Soon H Song MD FRCP
Consultant Diabetologist
Diabetes Lead for Antenatal Service
Northern General Hospital
Sheffield

4. Pre-pregnancy care in diabetes
Good pre-pregnancy care leads to better antenatal outcomes
Pre-conception treatment aims:
folic acid 5mg daily (not low dose 400ug)
stop teratogenic medications (statin, fibrate, ACE-I, ARB)
HbA1c <48 mmol/mol
Demographics are changing:
Significant rise in women with type 2 diabetes of child bearing age
60% antenatal diabetes patients have type 2 diabetes
Driven by increasing obesity in the young and gestational diabetes
Majority of young type 2 diabetes patients under primary care

5. Pre-pregnancy care National Diabetes in Pregnancy Audit 2016
Sheffield data: 50% women not folic acid at booking
Up to 10% were on teratogenic medications
(ACE-I/ARB and statins)
70% have HbA1c > 48 mmol/mol
Type 2 diabetes patients less likely to receive folic acid
and more likely to receive teratogenic medications

6. Prescription of ACE-I/ARB and statins in diabetic women aged 15-45 yr
Type 1 diabetes Type 2 diabetes
n= n=784
ACE-I 2.3% %
ARB 2.5% %
Statin % %
Data from Sheffield CCG June 2018

7. Pre-pregnancy care: Opportunities for improvement:
Raise awareness of good pre-pregnancy care as part of routine diabetes care
for all diabetic women of child-bearing age (50% pregnancies are unplanned)
Prioritise personalised approach to women who had stillbirth, miscarriage,
congenital abnormality
Refer to antenatal diabetes team for pre-pregnancy counselling and care
especially type 2 diabetes – insulin start, changes to diabetes treatment
Innovative approach to improve uptake of pre-pregnancy care in community
- role of community pharmacists

8. Involving pharmacists in the community with pre-pregnancy care
GP practice-based and community pharmacists
Raise awareness on importance of planning for pregnancy
Give advice on basic pre-pregnancy care
Medication review - start folic acid 5mg and/or stop teratogenic medications
Expand clinical role of pharmacists in the community
Collaborative working with GPs and practice nurses to improve care
Selected for National Diabetes in Pregnancy Quality Improvement Collaborative

9. How can pharmacy teams support women with diabetes?
Sallianne Kavanagh
Lead pharmacist- Diabetes and Endocrinology
Sheffield Teaching Hospitals NHSFT

10. Context More women are going into pregnancy with increased body weight
Increased risk of GDM, undiagnosed DM2
Maternal glucose crosses the placenta
But insulin doesn’t
Foetal hyperglycaemia
Foetal rise in insulin secretion
Pregnancy is a state of insulin resistance
Especially towards the end
Diabetes in pregnancy
90% GDM
10% pre-existing diabetes
Note prevalence of both is increasing
Hyperglycaemia in 1st trimester
Risk of Major congenital abnormality
DM1 5.9%
DM2 4.4%
GDM 1.4%
Ref Farrel (2002) Diabetic medicine 19;4:

11. Maternal complications of hyperglycaemia
Pre- eclampsia
UTIs
Polyhydramnios, PROM
Anomalies, spontaneous abortion
Sudden IUD
Increased use of instruments to assist delivery
Birth trauma
Operative delivery (C-section)
Increased risk if GDM if subsequent pregnancies
Increased risk of developing Type2 diabetes

12. Complications for the child
Foetal complications
Later in life
4x risk of congenital anomalies (pre-existing DM women)
Macrosomia
Shoulder dystocia
Prematurity
Respiratory distress syndrome
Hypoglycaemia
Jaundice
Obesity DM
Reproductive problems
Metabolic syndrome
HAPO study 2008 ‘ strong continuous associations of perinatal outcomes’
Carry graver consequences
Preconception planning is important# good glucose control imp to prevent complications during organogenesis (1st trimester)

13. Clinical guidelines
The National Institute for Health and Clinical Excellence (NICE) guideline for diabetes in pregnancy- NG3 (August 2015)
Covers the care and treatment of pregnant women with diabetes in the NHS in England and Wales, and the care of their newborn babies
It is written for women who have diabetes or who develop gestational diabetes in pregnancy
Some of the recommendations include
preconception advice for adolescents
screening for women at risk of gestational diabetes
the induction of labour or caesarean section after the 38th week of pregnancy
Aim to empower women with diabetes to have a positive experience of pregnancy and childbirth by providing information, advice and support that will help to reduce the risks of adverse pregnancy outcomes for mother and baby

14. Clinical guidelines: Preconception
Planning to become pregnant
Establishing good blood glucose control before conception and continuing this throughout pregnancy will reduce the risk of
miscarriage
congenital malformation
stillbirth
neonatal death
It is important to explain that risks can be reduced but not eliminated
Level of risk is associated with how long she has had diabetes

15. Clinical guidelines: Preconception
Provide information about how diabetes affects pregnancy and how pregnancy affects diabetes
The role of diet, body weight and exercise
The risks of hypoglycaemia and impaired awareness of hypoglycaemia during pregnancy
How nausea and vomiting in pregnancy can affect blood glucose control
Hypoglycaemia due to poor intake
Hyperglycaemia due to stress response
The increased risk of having a baby who is large for gestational age
increases the likelihood of birth trauma, induction of labour and caesarean section
The need for assessment of diabetic retinopathy before and during pregnancy
The need for assessment of diabetic nephropathy before pregnancy
The importance of maternal blood glucose control during labour and birth and early feeding of the baby, in order to reduce the risk of neonatal hypoglycaemia
The possibility of temporary health problems in the baby during the neonatal period, which may require admission to the neonatal unit
The risk of the baby developing obesity and/or diabetes in later life

16. Clinical guidelines: Preconception & medication
Start Folic acid 5mg- note higher dose compared to the general population
Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%)
if this is achievable without causing problematic hypoglycaemia
Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy
Likely benefits from improved blood glucose control outweigh the potential for harm
All other oral blood glucose‑lowering agents should be discontinued before pregnancy  insulin
ACEi and ARBS should be discontinued before conception
Alternative antihypertensive agents suitable for use during pregnancy should be substituted
Statins should be discontinued before conception

17. Clinical guidelines: Target blood glucose levels
Fasting: 5.3 mmol/litre
1 hour after meals: 7.8 mmol/litre or
2 hours after meals: 6.4 mmol/litre
Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 4 mmol/litre avoid hypoglycamia

18. Role of the pharmacist Identify patients
Change in request for contraception
MECC conversations
NMS/MUR
Targeted medicines review for CCG medicines management pharmacist and GP pharmacist
Systems review- HbA1c good/low on at risk drugs
Repeat purchase of glucose tablets
Patient education- hypoglycaemia awareness
Polypharmacy review
Adherence reviews
Healthy living pharmacy campaign

19. Role of the pharmacist- NMS/MUR
Medication discussions for women with diabetes who may wish to become pregnant
Adherence
Essential to achieving the ideal pre-pregnancy HbA1c
Folic acid
Refer to GP practice service for Folic acid 5mg
Polypharmacy review
Refer to GP practice service for CI medication to be reviewed
Statins
ACE/ARB
Oral diabetes medications (except metformin)

20. Information prescriptions
Available from Diabetes UK website: Information to be provided for women.
Local version created
The risk
Medication
Blood glucose
Folic acid
Lifestyle
Co-design crib sheets for NMS/MUR

21. Interested and want to know more?
Women with diabetes: University eLearning package- free to access
Preconception care for diabetes: The Health foundation
diabetes
Planning a pregnancy when you have diabetes- DUK video
diabetes/Pregnancy
NHS choice- your pregnancy and baby guide

22. PLANNING PREGNANCY- WHAT HAPPENS IN PRACTICE?
Dr Jenny Stephenson, GP June 2018

23. COMMUNITY - THINK ‘AT RISK’!
Community Pharmacists and GPs/PNs need to be aware -
1. The diabetic woman consulting you may get pregnant, anytime
2. Mother & baby outcomes are so much better if she can be prepared BEFORE becoming pregnant
3. Certain common drugs can cause harm to the baby
4. Poor diabetic control around conception time can cause harm to mother and baby
ACTION: consider having a computer flag on notes of women with diabetes aged 15-50? Sheffield Diab Template has a relevant page

24. GP - WHAT HAPPENS IN PRACTICE?
GPs and PNs use the Sheffield Diabetes Template to record data and checks. It has a checklist regarding pre-pregnancy advice
During routine Diabetes checks, pregnancy risk will have been discussed, and if deemed at risk of pregnancy then she must be warned about optimising control of HBA1c/glucose
If not at risk, eg sterilisation, then consider flagging the notes accordingly, to prevent asking again
GPs do Medication Reviews every 6-12 months depending on recall. They need to be alert to dangers of statins, ACE inhibitors, and some oral hypoglycemic drugs other than metformin

25. COMMUNITY - RAPID RESPONSE!
Patients self refer via the Receptionists to the Specialist Team
Receptionists need to know the protocol
Community Pharmacists will come across this potential problem – to increase awareness for during MURs or general contact
May be difficult for a Pharmacist to broach the subject, but perhaps needs to think to ask, confidentially, if there is a pregnancy risk if a woman of this ‘age group’ is on any of the potentially teratogenic drugs

26. COMMUNITY– RAPID REFERRAL!
At the desk, the Receptionists need to direct the pregnant diabetic woman to the Specialist Team - urgent fax referral on
She also needs to make an urgent referral to the Community Midwife
Currently the slip of paper they are given by the Receptionist asks for their name and contact details only; the receptionist may not necessarily know or think to ask if she is diabetic, so training is required
COMMUNITY PHARMACIST – advise the woman to discuss her potential or actual pregnancy with her GP Practice as soon as possible

27. PHARMACISTS » GPs
When a community Pharmacist discovers a diabetic woman considering pregnancy, refer to GP or Specialist Nurse
When a community Pharmacist has concerns following a MUR, eg a woman considering pregnancy but on potentially teratogenic drugs, refer to or contact the GP depending on the wishes of the patient
Make a note that the issue has been discussed.
Offer relevant literature or website advice.
DISCUSSION

28. Low Back Pain
Back Pain Additional reading: <accessed 5/6/18> <accessed 5/6/18> Low back pain and sciatica in over 16s: assessment and management <accessed 5/6/18>

29. Close Thank you all for attending
Thank you to all of our guest speakers
Thank you to our Sponsor - GSK