Diabetes in pregnancy- an update

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Diabetes in pregnancy- an update

• Seema Chakravarti
• MRCOG, MRCPI
• Consultant Obstetrician BHR Trust

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CEMACH DIABETES REPORT

• 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

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Subtypes

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

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Factors associated with poor pregnancy outcome

• 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

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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 lt7
• Counsel regarding risks and management strategies

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Booking HbA1c and pregnancy outcome
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Solutions

• 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

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Targets

• Pre conception Hb A1c lt7.0 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

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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

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Assess diabetes

• Retinopathy digital pictures and mydriasis
• If retinopathy need pre-conception advice and
  possible treatment

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Percentage of women developing sight threatening
DR in pregnancy
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Nephropathy

• Warn risk of PET/IUGR/SB
• Refer for hospital PPC if creatinine more than
  120micromole/litre and 24 hr urine protein gt2gm
• Consider asprin/clexane especially if proteinuria
  as increased thromboembolic risk

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General advice

• Diet and lifestyle
• Optimise weight( BMIgt35 independent risk factor
  for maternal mortality and morbidity)
• Adequate contraception
• Folic Acid 5mg until 12 weeks gestation.

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Diabetes UK and CEMACH guidance on pre preg care
Leaflet
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(No Transcript)
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Other changes

• 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

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Breast feeding

• Metformin safe NICE

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• Thank you