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Diabetes In Pregnancy

Diabetes in Pregnancy

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Introduction

Poor control of diabetes before and during pregnancy in women with previously diagnosed diabetes is associated with a significantly higher risk of:

congenital anomalies

miscarriage

macrosomia

intrauterine death.

deterioration of complications of diabetes especially microvascular

Obstetric complications, including operative delivery

Good control of diabetes before and during pregnancy has been shown to reduce the risks associated with pregnancy.

Gestational diabetes is usually defined as: ‘diabetes diagnosed during pregnancy’ and may be either pre-existing or new Type 1 or Type 2 diabetes presenting during pregnancy or a transient abnormality of glucose tolerance which returns to normal after the pregnancy. Recent evidence has confirmed the benefit of intervention in gestational diabetes.

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Pre-conception Counselling

Good control of diabetes before conception reduces the risk of congenital anomalies and therefore all women of childbearing age should receive education regarding the issues about diabetes and pregnancy before they become pregnant. This should be a routine part of diabetes care and education. The increasing prevalence of Type 2 Diabetes in women of childbearing age means that preconception advice needs to be included in their basic education.

CEMACH (GP Information Leaflet)

SAFER Leaflet (NHS Diabetes Patient Leaflet)

L&D Hospital Leaflet - Diabetes and having a Baby

Patients who are planning or considering a pregnancy should be referred to the specialist diabetes team for assessment, counselling and management.

Pre-conception counselling should cover:

Education about the interactions between diabetes and pregnancy, the management of diabetes in pregnancy and the need to plan and prepare for pregnancy.

Review of medical, gynaecological and obstetric history to highlight general issues such as smoking, alcohol, rubella immune status.

Advice on to optimise glycaemic control to achieve HbA1c <53 mmol /mol for 3 months prior to conception. NICE recommend a target of <43 mmol /mol, if safe with individualised blood glucose targets. NICE advise that women with an HbA1c of >86 mmol/mol should avoid pregnancy.

If diabetes is managed with oral hypoglycaemic agents other than metformin treatment should be reviewed and a switch to insulin should be considered prior to conception.

  Metformin in Pregnancy Leaflet

Review of other medication eg ACE inhibitors or statins which are not safe in pregnancy.

Screening for complications. Check retinal screening has been performed.

Dietary review.

Advice on high dose folic acid (5mg not 400mcg) supplementation prior to conception and for the first 12 weeks of pregnancy

Advice on Vitamin D3 10mcg daily

Need for effective contraception until optimal glycaemic control is achieved

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Management of diabetes in pregnancy

Women with diabetes should be seen in a combined diabetic/ antenatal clinic regularly during pregnancy. Referral should be made to the antenatal clinic and the diabetes team informed once pregnancy is confirmed.

Women on oral hypoglycaemic agents should be transferred onto insulin as soon as pregnancy is confirmed if not already done prior to conception.

Tight glycaemic control should be continued / instituted. Aim for HbA1c < 53 mmol/ mol with pre-meal capillary glucose levels of 3.5-5.9mmol/l and postprandial < 7.8 mmol/l. Advise about management of hypoglycaemia with prescription of glucagon if necessary.

Vitamin D3 (10 mcg od) is recommended throughout pregnancy and breastfeeding.

Retinal Screening should be done as soon as possible after the first contact in pregnancy and at 28 weeks if the first assessment is normal or at 16–20 weeks if any diabetic retinopathy is present. Referral should be made to an ophthalmologist if there is significant or deteriorating retinopathy.

Nephropathy may deteriorate during pregnancy: blood pressure should be managed without the use of ACE inhibitors or A2 blockers: methyldopa or labetolol may be used.

Obstetric complications should be managed conventionally but the pregnancy will need to be monitored more closely than normal.

Aim for delivery by 38-40 weeks: earlier if complications of pregnancy or diabetes.

NICE Guidance is that all women having a caesarean section before 39 week should receive steroid preparation: this will impact on the mother’s glucose control and will normally necessitate admission to control the blood glucose levels with intravenous insulin.

Early feeding will reduce risk of neonatal hypoglycaemia.

Breast feeding is encouraged in mothers with diabetes although attention needs to be paid to the risk of maternal hypoglycaemia - breast feeding leaflet. Metformin may be continued during breast feeding.

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Gestational Diabetes

Screening

Women at higher risk of diabetes due to historical risk factors should have an oral glucose test arranged for 28 weeks.

BMI > 30 kg/m2

Previous big baby (>4.5kg)

First degree relative with diabetes

Family origin with a high prevalence of diabetes

 

South Asian

 

Black Caribbean

 

Middle East

Also consider screening if other clinical suspicion such as previous unexplained obstetric disaster

Luton | Screening for Gestational Diabetes Mellitus (GDM)

Bedford | Screening for Gestational Diabetes Mellitus (GDM)

Women with Previous Gestational Diabetes

Women with previous gestational diabetes should be restarted on home blood glucose monitoring at booking.

In Luton monitoring will be discontinued if monitoring is normal after 2 weeks and a glucose tolerance test booked for 26-28 weeks.

In Bedford monitoring will be continued throughout the pregnancy.

Women with possible new Diabetes presenting in Pregnancy

Women with a suspicion of diabetes due to problems in the current pregnancy (symptoms, glycosuria on two occasions, accelerated growth rate or polyhydramnios) should have blood taken for blood glucose estimation.

If glucose 10 mmol/l or more refer for treatment

If glucose 8.0-9.9 mmol/l; arrange OGTT and consider repeat at 28 weeks

If glucose 7.9 mmol/l or lower arrange OGTT at 28 weeks or immediately if already > 28 weeks.

Diagnosis and Management

The WHO recommends that Gestational Diabetes should be diagnosed in women who meet their criteria for either Diabetes Mellitus or Impaired Glucose Tolerance. WHO have issued new guidance on diagnosis in pregnancy (August 2013) and revised NICE guidance is awaited but this will predate the WHO report!

In practice this would mean that any woman with 120-minute blood glucose in a 75gm oral glucose tolerance test of 7.8 mmol/l or more would be treated as having gestational diabetes.

Women with gestational diabetes should be referred to the diabetes specialist team. Blood glucose monitoring should be commenced.

Mild cases can be managed by diet alone but if satisfactory blood glucose levels cannot be maintained then metformin or insulin should be commenced for the remainder of the pregnancy.

  Metformin in Pregnancy Leaflet

If symptomatic diabetes occurs during pregnancy the patient should be referred to the diabetes specialist team without delay so that treatment can be instituted.

In most cases of gestational diabetes the abnormality of glucose tolerance will subside after delivery. A fasting plasma glucose should be arranged at the six weeks postnatal check.

Even if glucose tolerance returns to normal the patient should be advised to continue with a healthy diet and to avoid weight gain. The abnormality of glucose tolerance may return in future pregnancies; women who have had gestational diabetes are at greater risk of developing NIDDM in later life.

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Useful External Links & Resources

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NICE | NG3 Diabetes in pregnancy (2015)

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National Patient Safety Suite - Safe management of diabetes in pregnancy - e-learning module

PDF File

CEMACH | Women with Type 1 & 2 Diabetes

PDF File

SAFER leaflet

PDF File

Luton and Dunstable Hospital Diabetes and having a baby leaflet

PDF File

Metformin in Pregnancy Leaflet

PDF File

Luton and Dunstable Hospital Breast Feeding Leaflet
PDF File NICE | Diabetes in Pregnacy - CG63 (2008)
PDF File Luton | Screening for Gestational Diabetes Mellitus (GDM)

PDF File

Bedford | Screening for Gestational Diabetes Mellitus (GDM)

PDF File

EASIPOD leaflet - English

PDF File

EASIPOD leaflet - Urdu
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