Diabetes in pregnancy
James Penny
Consultant Obstetrician & Gynaecologist
Surrey & Sussex NHS Trust
Diseases
• Gestational Diabetes
• Pre-existing Diabetes
• Definition: Disorder of carbohydrate metabolism. It is an organ specific
autoimmume disease with a genetic component
• Prevalence: 650,000 pregnancies-UK and Wales of which 2-5% are diabetic
pregnancies.
The prevalence is increasing in both types.
Type 2 is increasing in certain minority ethnic groups.
Pregnancy complicated by diabetes ---Gestational diabetes accounts for 87.5%
,7.5% type 1 and 5% type 2 .
• Types: Type 1-0.27% of births
Type 2-0.10% of births
Recent focus
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St Vincent declaration
NICE document on prenatal care
NICE document on diabetes
Cemach report on diabetes in pregnancy
Risks of diabetes
Pedersen hypothesis
Unexplained stillbirth
Congenital malformation
Caesarean section
Miscarriage
Long term effect of infant/child health
This talk
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Prepregnancy care for established diabetics
Early pregnancy care
Gestational diabetes
Third trimester and delivery
The size of the problem
Perinatal mortality (%)
35
30
25
20
15
10
5
0
1921-30 1931-40 1941-50 1951-60 1961-70 1971-76 1976-79 1980-84
Prepregnancy Care
• Maternal health
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Weight
Folate
Smoking
Long term health
contraception
Extremely tight control of blood sugar
Prepregnancy Care
• Maternal health
– Assess for
• Risk of miscarriage
Prepregnancy Care
• Congenital anomalies
– Comparison of % depending of timing of care
Early or prepregnancy
care
1.1
Late booking
1.8
10.5
4.9
9
1.2
10.9
6.6
Prepregnancy Care
• Congenital anomalies
If the HbA1c is >10% then ~ 30% of babies may
have a congenital anomaly
Prepregnancy care
• Allows a detailed risk assessment
• Should be performed opportunistically
• Diabetic women should plan their pregnancy
Maternal risks
• Diabetic ketoacidosis is rare in pregnancy
• Hypoglycaemia accounts for most death in
pregnant diabetics
Early pregnancy
Multidiscplinary care
Obstetrician
Physician
Midwife
Dietician
Diabetic nurse
Patient
Management
• Diet to allow ideal weight gain
• Change oral hypoglycaemics to insulin
• Tight control of blood sugars
– Fasting < 6
– Postprandial < 8
• Q.D.S. insulin regime
• Post prandial levels are important
• Downside
– Hypoglycaemia
– Morning sickness
Gestational Diabetes
• Definition
– Carbohydrate intolerance that arises during pregnancy
and disappears after delivery
• Is gestational diabetes an important condition
Trends in insulin resistance and
insulin production with age
Insulin production
Insulin resistance
1
100
Trends in insulin resistance and
insulin production with age
Pregnancy
1
100
Insulin Resistance
Gestational Diabetes
Screening
Random glucose - booking + 28 weeks
Timed random glucose - booking + 28 weeks
Urinary dipstick
Risk factor screening
50g mini GTT - booking or 28 weeks
50g mini GTT for women over 25
HbA1c
Gestational Diabetes
Diagnosis
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100g GTT (5.0, 9.2, 8.1, 6.9)
100g GTT (5.8, 10.6, 9.2, 8.1)
•50g GTT (AUC)
75g GTT
75g mini GTT
Serial capillary blood sugar
GDM – Screening
• LOW RISK
– Routine random sugar at 16 and 28 weeks
• HIGH RISK
– 28 week simplified GTT
Gestational Diabetes
Management
Obstetric management.
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Early referral to offer advice and support and review medication.
Medical review for retinal and renal assessment
• Scans- 7-9 wks viability,NT scans –refer Tertiary unit, 20-22wks
anomaly and cardiac scan, serial growth scan at 28,32.36 weeks.
Dopplers liquor and fetal well being look for IUGR.
Regular antenatal visits monitoring insulin req and scans. BP/
proteinuria
Induction of labour -38-39wks on insulin. 40 wks if well controlled or
diet control
Wellbeing screening at ADU
C/S at 39 weeks
Post natal care..
Third trimester
and fetal risks
• Fetal size
• Cardiac hypertrophy
• Stillbirth
Fetal Complications
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Macrosomia-63%
vs
10%
Caesearean sections-56% vs 20%
Premature delivery-425 vs
12%
Preecclampsia-18%
Nronatal jaundice-18%
RDS-17%
Congenital anomlies-5%
Perinatal mortality-5%
Macrosomia
Fetal Monitoring
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Serial growth scans
Biophysical profile
Cardiotocography
Doppler
Delivery
• At 38 - 40 weeks gestation
• High incidence of caesarean
• Shoulder dystocia
Postnatal Care
• Breasting not to continue previous drugs which were
contraindicated.
• advice on contraception and planning future pregnancy.
• Risk of hypos in the breast fed food before or during
and establish control pre pregnancy insulin doses.
• GM stop insulin. Advise on diet exercise contraception,
watch for hyperglycaemia.
• Subsequent screening.
• FBs -6 weeks postnatal and annually
• ophthalmology follow up inthose with proliferative dis.
Early neonatal risks
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Fetal hypoglycaemia
Polycythaemia - jaudice
Respiratory distress syn
Birth trauma
Postnatal
• Insulin requirements return to normal
immediately
• GTT at 6-12 weeks post partum
• Long term F/U - mother and baby
Contraception?
Barkerism
Summary