Type 1 diabetes
absolute deficiency of insulin production by the pancreas, usually autoimmune.
- usually diagnosed in childhood
- nearly always requires insulin
- life threatening complications
- cannot be prevented/cured
Type 2 diabetes
relative deficiency of insulin production by the pancreas.
- usually diagnosed in adulthood
- often managed without insulin
- familial association, BMI, ethnicity, hypertension
- no cure, possible prevention
Maternal complications of type 1/ 2
- hypoglycaemia
- ketoacidosis
- hypertension and increased risk of PET
- diabetic retinopathy
- diabetic nephropathy
- shoulder dystocia
- c section
- infection + impaired wound healing
- polyhydramnios
Fetal complications of type 1 / 2
- congenital malformation
- macrosomia
- SGA
- stillbirth / perinatal mortality
- preterm
- neonatal hypoglycaemia
- polycythaemia
- jaundice
- RDS
Preconception care
- folic acid 5mg OD from 3/12 pre-conception
- r/v medications (ACE-I, statin)
- check HBA1c (< 6.5% prior to pregnancy)
Antenatal care
- MDT (diabetologist, dietician, obstetrician, diabetes midwives)
- folic acid 5mg OD + vit D 1000iu OD
- optimise blood glucose control, diet and weight
- r/v medications (ACE-I, statin)
- HbA1c with booking bloods
- ketone monitoring
- glucagon pen –> anyone on insulin in case of hypo
- early dating scan, then at 12, 20, 28, 32 and 36 weeks for fatal growth and dopplers
- may need fetal echo around 16-18 weeks if HbA1c >8% –> higher risk of abnormalities
- monitor for PET
- retinal assessment
- IOL between 37- 38+6
Postnatal care
- adjust insulin (and/or metformin) dose according to feeding (insulin for pre-existing diabetes should be lowered to 2/3rd of their pre-pregnancy dose)
- blood glucose 6 x a day
- observe for neonatal hypos
- contraceptive advice
Gestational diabetes
relative deficiency of insulin production by the pancreas, which cannot match the demands required for glycemic control in pregnancy.
often managed without insulin
associated with Fox of diabetes, raised BMI and some ethnicities
Screening for GDM
GTT 24-28 weeks
- prev GDM
- BMI > 30
- prev baby > 4.5kg
- 1st degree family relative with diabetes
- PCOS
- any ethnicity at higher risk
additional criteria developed through pregnancy:
- glycosuria
- polyhydramnios
- macrosomic baby
Abnormal results for GTT for fasting and post 2 hours
Fasting: > 5.6
2 hrs: > 7.8
Antenatal care
- commence blood glucose monitoring
- aspirin from 12/40, vit D/calcium supplementation, folic acid 5mg
- HbA1c, FBC, renal and liver function
- baseline urine PCR
- regular contact with obstetric diabetes team
- additional USS at 32/40
- anaesthetic r/v if BMI > 40
- if uncomplicated, offer IOL at 40+6
Postnatal care
- 24 hr of blood glucose monitoring
- discontinue metformin/insulin
- fasting plasma glucose 6-13 weeks after birth
- annual HbA1c with GP to detect T2DM
- lifestyle + diet advice –> reduce chance of T2DM
- neonatal hypoglycaemia monitoring
VRII
women on insulin therapy (GDM or pre-existing) might be best to start VRII (variable rate intravenous infusion) however some might be best to continue with insulin pump.
Intrapartum care
- birth in obstetric unit
- maintain maternal blood glucose between 4-8 mmol/L. Monitoring every 1-2 hrs depending on plan.
- test on the finger of the arm with no IV running
- pressure areas monitoring
- VRII for type 1, most type 2 and some GDM women. Stop immediately after delivery of the placenta.
- not able to use fibre device in established labour
GDM treatment
Diet + exercise –> reduce carbs, low glycemic index food
Metformin –> treats insulin resistance, better for T2 or GDM. Can be used instead of or as well as insulin
Insulin –> rapid short acting (novo rapid), intermediate long acting (Lantus)
Hypoglycaemia figures
mild hypoglycaemia: < 4mmol/L
severe: < 3 mmol/L
S+S of hypoglycaemia
- sweating
- shaking
- pale/grey
- speech difficulty
- convulsions
- drowsiness
- feeling of hunger
- anxiety/irritability
- incoordination
- palpitations
- tingling of lips/extremities
- odd behaviour
- vague and confused
- nausea
- headache
Management of hypoglycaemia
if BG between 3.5-4 + asymptomatic –> bring a meal forward or have a snack
otherwise:
1st line: BG 3-3.5 or 3.5-4 + symptoms
- oral glucojuice / dextrose tablets
2nd line: if unconscious/unable to tolerate oral treatment
- 1mg IM glucagon injection
(should not be used for recurrent hypoglycaemia)
3rd line:
- IV glucose 75ml of 20% glucose over 15 mins
check BG every 10 mins until increased. Stop insulin infusion if on
Diabetic Ketoacidosis
acute, major, life-threatening complication of diabetes characterised by:
hyperglycaemia
ketosis –> capillary ketones > 3 mmol/L or urinary ketones ++
acidemia –> pH < 7.3
S+S of diabetic ketoacidosis
- vomiting
- polyuria and polydipsia (excessive thirst)
- dehydration
- tachycardia
- tachypnoea
- coma
- ketotic smell on breath
- nausea
- leg cramps
- blurred eyesight
- confusion
Management of DKA
- urgent r/v
- obs
- iv access
- take FBC, U+E, clotting, CRP, VBG and lactate
- measure capillary ketone levels
- CEFM
- IV fluids to resolve acidosis
- IV insulin
- If BG < 14 mmol/L start 10 % glucose using second cannula
Macrosomia definition
> 4 or 4.5kg, > 90th centile
What causes fetal macrosomia? and what else does it lead to?
maternal hyperglycaemia –> fetal hyperglycaemia –> fetal pancreatic beta-cell hyperplasia –> fetal hyperinsulinaemia. = macrosomia
+ organomegaly, polycythaemia (jaundice), RDS
Birth complications of macrosomia
- shoulder dystocia
- instrumental/operative delivery
- 3/4th degree tear
- PPH due to damage of the uterine muscle
