LFD deck 2 - diabetes in pregnancy

Question 1

What are the different types of diabetes you can having during pregnancy ?

Answer 1

All types:

• Pregestational: T1DM, T2DM, MODY
• Gestational diabetes = diabetes with onset or first recognition during pregnancy

Question 2

List the potential complications of diabetes during pregnancy and state what all these complications relate to

Answer 2

All the following complications relate to poor diabetic control:

• Congenital anomalies- related to high HBA1C at booking
• Miscarriage
• IUD
• Worsening diabetic complications eg retinopathy, nephropathy
• PET
• Polyhydramnios
• Macrosomia
• Shoulder dystocia
• Neonatal hypoglycaemia

Question 3

What pre-pregnancy counselling is needed for a pre-exisiting diabetic who wants to become pregnant ?

Answer 3

• Avoid unplanned pregnancy and to get HBA1c within acceptable levels prior to reduce risk of complications
• Offer monthly HBA1c monitoring to those trying to become pregnant
• Make sure ACEi & statins all stopped as soon as pregnancy confirmed or prior to conception
• Lifestyle & dietry advice
• Give high dose folic acid from the point of trying to concieve to 12weeks of pregnancy

Question 4

What extra antenatal management is required for someone with diabetes during pregnancy ?

Answer 4

• Early booking to diabetic antenatal clinic
• Folic Acid 5mg
• Low Dose Aspirin from 12 weeks
• Fetal anomaly scan at 18-20 weeks
• Regular eye checks for retinopathy
• If nephropathy- refer renal team
• Use Hypoglycaemic Agents: Insulin- MDI /Insulin pump or Metformin (Type 2)
• Consider continuous glucose monitoring in those with unstable BG levels
• Growth scans 4 weekly from 28 weeks
• Counsel about shoulder dystocia
• Deliver at 38 weeks (earlier if complications)

Question 5

List the risk factors for developing gestational diabetes

Answer 5

• Previous GDM
• Obesity BMI 30 or more
• FH: 1st degree relative
• Ethnic variation: South Asia (India / Pakistan / Bangladesh), Middle Eastern, Black Caribbean
• Previous big baby
• Polyhydramnios
• Big baby – AC / EFW on USS
• Glycosuria (1+ on >1 occasion or >= 2+ on one occasion)

Question 6

Describe the pathophysiology of gestational diabetes

Answer 6

Placental hormones (Human placental lactogen, cortisol) can result in relative insulin deficiency/ insulin resistance causing development of GDM

The consequences are:

• Overgrowth of insulin sensitive tissues & macrosomia
• Hypoxaemia state in utero
• Short term metabolic complications
• Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes

Question 7

How is gestational/ pre-exisiting diabetes diagnosed during pregnancy? (state the diagnostic values)

Answer 7

• 1st line = all those with risk factors (previously listed) should have their early blood glucose monitoring using HBA1c levels or do a OGTT
• 2nd line = if diagnosis remains unclear then OGTT done between 24-28 weeks

OGTT values diagnostic of GDM:

• Fasting >=5.1 mmol/l
• 2 hour >=8.5 mmol/l

If someone is symptomatic then can diagose with one test showing diabetes results but if asymptomatic you want to repeat the tests 2 weeks later

Question 8

How often should someone with diabetes during pregnancy monitor their glucose levels and what are the target levels they should achieve ?

Answer 8

Minimum total 4 times a day - premeals (sometimes 1 hr postmeal) & before bed.

Targets:

• Fasting; 3.5 -5.5 mmol/l
• 1 hr <7.8mmol/l

Question 9

What is the management of GDM

Answer 9

Hyoglycaemic control:

• 1st line = diet, weight control & excercise
• 2nd line = metformin (or glibenclamide)
• 3rd line = insulin

Note that choice is tailored also to patient preference, this is a rough guide

Also should be monitored for PET and growth scans as previously stated starting at 24 weeks gestation

Question 10

What are the advantages of using oral hypoglycaemic agents compared to insulin in pregnancy ?

Answer 10

• Avoidance of hypoglycaemia associated with insulin
• Less weight gain
• Less ‘education’ required to ensure safe / effective administration

Question 11

What is the advantage of insulin therapy during pregnancy ?

Answer 11

It does not cross the placenta like metformin

Question 12

When should delivery of the baby occur in GDM?

Answer 12

From 38weeks onwards, earlier if complications:

• Insulin treatment 38-39 weeks
• Metformin 39-40 weeks
• Diet alone 40 to 41 weeks
• If fetal macrosomia/ IUGR/ PET earlier delivery

Question 13

What mode of delivery should be opted for in GDM ?

Answer 13

• If EFW is > 4.5kg then C-section
• Otherwise it is upto maternal preference but the risks & benefits of SVD should be discussed including shoulder dystocia

Question 14

What is the risk of future development of T2DM having had GDM?

Answer 14

Upto 70%

Question 15

What is the post-natal management of pre-exisiting diabetes ?

Answer 15

Return to pre-pregnant insulin/oral regime

Question 16

What follow-up following delivery is required for someone who had GDM?

Answer 16

• Fasting blood sugar (FBS) checked 6-8 weeks postnatally
• If signs/symptoms of Type 2 DM- OGTT 6 weeks PN
• Annual FBS & lifestyle changes then required

Question 17

What is the post-natal management of GDM?

Answer 17

Stop treatment & monitor BG for 48hrs to ensure return to normal & no persistence of impaired glucose tolerance