Transcript Diabetes in pregnancy

Diabetes in
pregnancy- an update
Seema Chakravarti
MRCOG, MRCPI
Consultant Obstetrician BHR
Trust
CEMACH DIABETES REPORT
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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
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Type 1
Type 2
Gestational Diabetics
SOME WOMEN WITH
GDM WILL HAVE PRE
EXISTING DIABETES!!
Factors associated with poor
pregnancy outcome
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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
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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
Pregnancy putcome by booking
HbA1c
100%
80%
60%
40%
20%
0%
SB
<7.8 >7.8- >14
14
Hb A1c
Cong
abnormality
Normal
Solutions
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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
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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
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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
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Retinopathy digital
pictures and mydriasis
If retinopathy need preconception advice and
possible treatment
Percentage of women developing
sight threatening DR in pregnancy
60
50
40
30
20
10
0
No retinopathy
Minimal
retinopathy
Mod to severe
retinopathy
Nephropathy
1.
2.
3.
Warn risk of PET/IUGR/SB
Refer for hospital PPC if creatinine more
than 120micromole/litre and 24 hr urine
protein >2gm
Consider asprin/clexane especially if
proteinuria as increased thromboembolic
risk
General advice
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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
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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
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Metformin safe NICE
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Thank you