Diabetes and Pregnancy

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Diabetes and Pregnancy

• Tony Robinson
• 12th September 2007

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Diabetes and Pregnancy

• Contraception
• Preconception type 1 type 2
• Antenatal care gestational diabetes
• Risk of future diabetes
• ACHOIS, CEMACH, HAPO

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Contraception in Diabetes

• Unplanned pregnancy is associated with increased
  miscarriage, neonatal morbidity and mortality
• Holing et al (1998). In unplanned pregnancies 70
  used contraception less than 50 0f the time
• 49 didnt know they could get pregnant

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Contraception in Diabetes

• A Reliable Method is more important than risk
• Most reliability associated with the OCP
• Most risk associated with the OCP

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DIABETES AND PREGNANCY

• Can a woman with diabetes bear children
  successfully?
• Will the children develop diabetes?
• Will the children be healthy?
• Is the pregnancy dangerous to the mother?

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CEMACH Diabetes Programme Primary Aims

• To determine national perinatal mortality and
  congenital anomaly rates for babies of women with
  diabetes
• To assess the degree to which standards of care
  are met for women with diabetes and their babies
  from preconception to the postnatal period
• To improve quality of maternity care and
  pregnancy outcome for women with pre-existing
  diabetes

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Pregnancy in Women with Type 1 and Type 2
Diabetes
3808 pregnancies 1 in 260 births
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Adverse pregnancy outcomes A comparison with the
population of England, Wales and N Ireland in 2003
Key finding
Maternal age-adjusted per 1000 total births
per 1000 live births
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Key Finding 1
Increased risks for babies of women with diabetes
Stillbirths 4.7x Death of baby in first
four weeks 2.6x Major congenital anomaly 2x
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Key finding 2 Type 2 diabetes different
needs, equivalent risks

• The babies of women with type 2 diabetes have
  comparable risks of PNMR compared to those of
  babies of women with type 1 diabetes

8.5
5.7
3.6
per 1000 total births per 1000 live births
Key finding
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Type 2 as a proportion of diabetic pregnancies
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Tests documented pre-pregnancy and by 13 weeks
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Social Deprivation
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Women with Type 2 diabetes-Glycaemic control

• Less likely to have a pre-pregnancy test of
  glycaemic control
• Less likely to have a test of glycaemic control
  by 13 weeks
• Either pre-pregnancy and early care is less
  critically managed
• OR these women are not accessing services

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Glycaemic control and outcome
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Key Messages

• Women with Type 2 diabetes have at least an
  equivalent risk of perinatal mortality and fetal
  congenital malformation compared to women with
  Type 1 diabetes
• All women with diabetes of reproductive age need
  education about the importance of pregnancy
  preparation
• Improvement in the provision of education for
  women with diabetes
• Structured education packages need to include
  pregnancy

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Key findings

• Perinatal outcomes remain poor
• Type 2 diabetes different needs, equivalent
  risk
• Prevalence of type 2 diabetes in pregnancy
• Poor preparation for pregnancy
• Glycaemic control poor pre-pregnancy level
• High preterm delivery rate and caesarean section
  rate
• Large babies and difficult deliveries
• High separation rates from mother at birth,
  failures to use reliable glucose test in baby and
  low breastfeeding rates

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DIABETES AND PREGNANCY

• Risk Associated with Pregnancy
• Miscarriage (rate related to HbA1C)
• Aim below 7 preferably lt6.5
• 2. Congenital Malformations increased
• Increased risk of Intra-uterine death
• Increased risk of Macrosomia
• Increased risk of hypoglycaemia
• Worsening Complications

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DIABETES AND PREGNANCY

• Worsening Complications
• Hypoglycaemic awareness
• Retinopathy can deteriorate
• Renal disease worsens
• Pre-eclampsia rate higher

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DIABETES AND PREGNANCY

• Congenital Malformations
• Complex cardiac problems (VSD,ASD, Transposition
  of the great vessels)
• Skeletal abnormalities Sacral agenesis
• Remember Heart beat seen at 6-7 weeks gestation

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DIABETES AND PREGNANCY

• TYPE 1 2
• Planned pregnancy
• Good glycaemic control before Conception
• Folic acid (5mg)
• Diet/tablets to insulin as part of plan

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DIABETES AND PREGNANCY

• ANTENATAL CLINIC
• Joint clinic (doctors and nurses)
• Early dating to confirm EDD
• Minimum 4 weekly appointments often more regular
• Nuchal scan ?
• 20 week scan

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DIABETES AND PREGNANCY

• ANTENATAL CLINIC (contd)
• Regular growth scans
• Planning Delivery
• Retinal screening
• Protein screening
• HbA1c and Fructosamine (4 weekly)

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DIABETES AND PREGNANCY

• INSULIN REQUIREMENTS
• 1st Trimester Stable if good control before.
  Nausea may effect
• 2nd Trimester early mild reduction often seen,
  but back to original levels at 20 weeks. Start to
  rise at 24 weeks
• 3rd Trimester Significant rise from 24-36 weeks,
  then small reduction occur until term
• Increase is 2 fold, but may be 5-7 fold
• Return to pre-pregnancy levels

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DIABETES AND PREGNANCY

• GESTATIONAL DIABETES
• Diabetes may come during pregnancy
• Diabetes may occur only during pregnancy being
  absent at other times
• Diabetes may cease with delivery, recurring some
  time afterwards
• Pregnancy is liable to be interrupted by death of
  the foetus.. The dead foetus is sometimes
  described as enormous.
• Duncan 1882

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DIABETES AND PREGNANCY

• MACROSOMIA
• Increased Abdominal circumference
• Intra-uterine death
• Problems with delivery Shoulder dystocia, Erbs
  Palsy and increased section rate
• Delivery often at 38 /40

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DIABETES AND PREGNANCY

• Hypoglycaemia
• Islet cell hyperplasia
• Delivery hypoglycaemia in neonate
• NG feeding
• Increased risk of Polycythaemia, jaundice and
  hypocalcaemia
• Increased risk of prematurity

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DIABETES AND PREGNANCY

• GESTATIONAL DIABETES ACHOIS
• 1000 pregnancies 510 intervention versus control
  (FG lt7.8, 7.8-11IGT)
• 1 v 4 rate of delivery complications
• Increase in Induction
• Same C/S rate
• QOL PN better

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DIABETES AND PREGNANCY

• GESTATIONAL DIABETES
• Who to test? Universal or Selective
• 26-28 weeks
• Family history
• Older and more obese
• Big babies
• IUD

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DIABETES AND PREGNANCY

• GESTATIONAL DIABETES
• Glucose Tolerance Test
• FBG gt5.6
• 2 Hour gt 8.5
• Target BG 4-6 fasting , 6-8 2 hours
• Treat With BGM and diet
• if above target treat with insulin

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Hyperglycaemia and Pregnancy Outcome (HAPO)

• 23,235 pregnancies
• 4 gestational diabetes
• Large for dates
• C/S rates
• Neonatal hypoglycaemia
• Presented at ADA 2007

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DIABETES AND PREGNANCY

• 27 year old female primagravida, type 1 15
  years.
• HbA1c 9
• Microalbuminuria on ACE
• Hypercholesterolaemia on Statin
• Hypothyroid on thyroxine
• Wants to become pregnant
• What Advice does she need ?

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DIABETES AND PREGNANCY

• 35 year old type 2 for 5 years
• Gravida 2 (68 years old) BMI 35
• Gestational diabetes in first pregnancy
• HbA1c 8.5 on Metformin 850mg bd
• On antihypertensives, statin and aspirin
• Wants another baby
• What do you advise?