Pregnancy and Diabetes

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Pregnancy and Diabetes

• Theresa Smyth
• Lecturer / Practitioner in Diabetes

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Aims and Objectives

• The effects of diabetes on pregnancy
• Pre-conceptual care
• Anti-natal care
• Gestational diabetes
• Labour and delivery
• Neonatal management
• Post-natal care
• Breast feeding

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Rationale

• In 1921- high maternal and fetal mortality rates
  (65)
• In 1970 fetal mortality 20
• Today - incidence of congenital malformation in
  women with diabetes is 6-9 (3-4 times that of
  the general pop)

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Rationale

• Congenital Malformations
• Major cause of perinatal morbidity and mortality
• Renal, cardiac, CNS and skeletal
• Susceptibility up to end of 7th gestational week
  caused by high blood glucose levels and ketouria
• Perinatal mortality associated with well
  controlled diabetic pregnancy is not
  significantly greater than average

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Effects Of Diabetes On Pregnancy

• 1st trimester (1-12 weeks)
• Congenital abnormalities
• Increase risk of spontaneous abortion
• 2nd trimester (12-24weeks)
• Risk of premature labour
• Risk of still birth

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• 3rd Trimester (24weeks - term)
• Polyhydraminos - excess of amniotic fluid
• Pre-eclampsia
• Late intrauterine death
• Increase fetal growth
• Intrauterine growth retardation

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Aims of Preconceptual Care

• To achieve a pregnancy outcome that
• approximates to that of the women
• without diabetes i.e. a healthy
• pregnancy, and a normal healthy baby
• and mother at delivery.

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Who?

• All women with diabetes wishing to become
  pregnant
• Women of child bearing age who do not should
  understand importance
• Women with type 2 diabetes should not be
  forgotten
• Women who had previous gestational diabetes

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Preconceptual Clinic- Assessment

• Diabetes control
• Screening for diabetic complications
• Retinopathy
• Nephropathy - ACR
• Hypertension
• Medication assessed
• ACE inhibitors
• Oral hypoglycaemic agents to insulin
• Supplementation with folic acid gt1mg (5mg)
• Thyroid function type 1dm

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Preconceptual Clinic - Assessment

• Smear
• Immunity to rubella
• Contraception
• Fertility
• Assessment and education by dietitian

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Preconceptual Clinic

• Lifestyle Issues
• Smoking
• Substance abuse
• Obesity
• Ethnic / cultural considerations

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Preconceptual Clinic Educational Needs

• Diabetes preconceptually / in pregnancy
• Blood Glucose Monitoring
• Fasting 3.5 5.3 mmol/l
• 1 hour post prandial lt7.8 mmol/l
• Target HbA1c lt 6.5 (individual) (7.2 equates to
  background pop)
• Hyperglycaemia
• Ketones
• Illness
• Treatment
• Adjustment of insulin contact numbers

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Preconceptual Care Hypoglycaemia

• Improved control increases risk of severe
  hypoglycaemia episodes
• Warnings are often reduced
• Need for increase monitoring
• Does not cause fetal abnormalities
• Driving
• Hypostop and GlucaGen

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Preconception Clinic - Attendance

• Over a 2 year period 26 of women with type 1
  diabetes, and 5 with type 2 attended the
  preconception clinic.
• Neonatal mortality and morbidity were
  significantly reduced in the group that attended.
• (Dunne, Brydon, Smith et al, 1999 Q.J med
  175-176)
• An improvement in pick-up rate for at risk women
  was a need identified.

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Preconception Care - Conclusion

• Preconceptual care reduces congenital
  malformations
• A preconceptual clinic reduces neonatal mortality
  and morbidity
• Poorly attended
• ? Computerised pick-up for women at risk
• Repeated emphasis on the importance of
  preconception care and services

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Aims Of Anti-natal Care

• Decrease congenital abnormalities
• Improve prenatal mortality and morbidity
• Reduce time spent in hospital as an in-patient
• Decrease caesarean section rate

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Anti-natal Care

• Joint ante-natal / diabetic clinic visits
• Every two weeks until 34-36 weeks
• Every week from 34-36 weeks
• Adequate diet
• Folic acid, high dose, until 2nd trimester
• Avoid high risk foods
• Oral hypoglycaemic agents discontinued and
  converted to insulin

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• Insulin therapy may considerably increase during
  pregnancy - telephone advice
• Detailed blood glucose monitoring
• Aim for
• fasting and pre-meal blood glucose 3.5-5.3mmol/l
• 1 hour post prandial lt 7.8 mmol/l
• Target HbA1c lt 6.5 (individual)
• (risk of congenital abnormalities same as
  background population at 7.2, less if HbA1c
  lower)

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• Diabetes update and education
• Glucogen for those on insulin
• Ultra sound scans to assess fetal growth and
  health
• at booking
• 20 weeks
• every 4 weeks - 2nd trimester
• every 2 weeks - 3rd trimester
• Fetal biophysical profile weekly from 36 weeks

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Retinopathy

• No retinopathy - every trimester
• Background retinopathy review monthly
• Pre-proliferative changes do not usually require
  therapy
• New proliferation requires prompt
  photocoagulation / caesarean section
• Associated with
• Rapid improvement in glycaemic control
• Poor glycaemic control
• Hypertension

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Gestational Diabetes

• Diabetes developed in pregnancy
• Affects up to 2.5 pregnant population
• Screening by glucose tolerance test
• Previous gestational diabetes
• 1st degree relative with diabetes
• Previous large baby (gt90th centile)
• Previous stillbirth
• Recurrent miscarriages

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• Glucosuria on 2 or more occasions
• previous congenital abnormality
• obesity (over 120 of ideal body weight)
• Polyhydraminos or macrosomic foetus
• Impaired glucose tolerance / impaired fasting
  glucose is treated the same as diabetes
• 50 chance or more of developing diabetes
  permanently later in life
• Glucose tolerance test performed at or around 6
  weeks post natal

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Labour And Delivery

• Intravenous infusion of insulin and glucose
• 1 hrly blood glucose monitoring - aim to keep
  blood glucose 4-6mmols
• Continuous foetal monitoring available
• Paediatrician should be present at delivery

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Neonatal Management

• If maternal diabetes is poorly controlled baby
  may have signs of macrosomia
• Obese
• Plethoric - red in appearance
• Lethargic and sleepy
• At risk of
• Hypoglycaemia
• Respiratory distress syndrome
• Polycythaemia

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• hypocalcaemia
• neonatal jaundice
• Post delivery neonatal blood glucose monitoring
• 3hrly for 24hrs
• then 6hrly for 24hrs
• discontinue when stable
• Three hourly feeds
• Complimentary feeds may be necessary until
  lactation occurs
• naso gastric feeding may be necessary if blood
  glucose is low and baby lethargic

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Post-natal Care

• Carbohydrate metabolism returns to normal very
  quickly after delivery of the placenta
• Women with pre-existing diabetes will return to
  their pre-pregnancy doses of insulin
• Women with gestational diabetes will
• Discontinue any insulin therapy
• Repeat GTT 6 weeks post natal

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Breast Feeding

• Need to increase carbohydrate intake
• Need to decrease insulin therapy by approx 25
  whilst breast feeding
• Poor diabetic control may interfere with
  lactation
• Should not return to ACE inhibiters or oral
  hypoglycaemic agents until after breast feeding

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• Women previously on oral hypoglycaemic agents
  will go back to them unless breast feeding
• All women will have a diabetic review 6 weeks
  post natal