diabetes in pregnancy- an update seema chakravarti mrcog, mrcpi consultant obstetrician bhr trust

Diabetes in pregnancy- an update

Seema Chakravarti

MRCOG, MRCPI

Consultant Obstetrician BHR Trust

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

Subtypes

Type 1 Type 2 Gestational Diabetics SOME WOMEN WITH

GDM WILL HAVE PRE EXISTING DIABETES!!

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

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 <7 Counsel regarding risks and management

strategies

Booking HbA1c and pregnancy outcome

0%20%40%60%80%

100%

<7.8 >7.8-14

>14

Hb A1c

Pregnancy putcome by booking HbA1c

SB

Congabnormality

Normal

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

Targets

Pre conception Hb A1c <7.0% 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

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

Assess diabetes

Retinopathy digital pictures and mydriasis

If retinopathy need pre-conception advice and possible treatment

Percentage of women developing sight threatening DR in pregnancy

0

10

20

30

40

50

60

No retinopathy

Minimalretinopathy

Mod to severeretinopathy

Nephropathy

1. Warn risk of PET/IUGR/SB

2. Refer for hospital PPC if creatinine more than 120micromole/litre and 24 hr urine protein >2gm

3. Consider asprin/clexane especially if proteinuria as increased thromboembolic risk

General advice

Diet and lifestyle Optimise weight( BMI>35 independent risk

factor for maternal mortality and morbidity) Adequate contraception Folic Acid 5mg until 12 weeks gestation.

Diabetes UK and CEMACH guidance on pre preg care Leaflet

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

Breast feeding

Metformin safe NICE

Thank you