Seema Chakravarti
MRCOG, MRCPI
Consultant Obstetrician BHR
Trust

 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

 Type 1
 Type 2
 Gestational Diabetics
 SOME WOMEN WITH
GDM WILL HAVE PRE
EXISTING DIABETES!!

 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

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

Pregnancy putcome by booking
HbA1c
100%
80%
60%
40%
20%
0%
<7.8 >7.8>14
14
Hb A1c
SB
Cong abnormality
Normal

 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

 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

 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

 Retinopathy digital pictures and mydriasis
 If retinopathy need preconception advice and possible treatment

Percentage of women developing sight threatening DR in pregnancy
30
20
10
0
60
50
40
No retinopathy
Minimal retinopathy
Mod to severe retinopathy

1.
2.
3.
Warn risk of PET/IUGR/SB
Refer for hospital PPC if creatinine more than 120micromole/litre and 24 hr urine protein >2gm
Consider asprin/clexane especially if proteinuria as increased thromboembolic risk

 Diet and lifestyle
 Optimise weight( BMI>35 independent risk factor for maternal mortality and morbidity)
 Adequate contraception
 Folic Acid 5mg until 12 weeks gestation.

Diabetes UK and CEMACH guidance on pre preg care Leaflet

 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

 Metformin safe NICE

 Thank you