DIABETES IN

PREGNANCY
CONSULTANT DR MANASE
REGISTRAR DR DZVEYA
SHO DR DHORO
INTRODUCTION
• Diabetes in pregnancy is associated with risks to the mother and
developing fetus
• The incidence of type 1 and type 2 has increased in recent years
• Gestational hypertension has increased as well mainly due to high
rates of obesity and more pregnancies in older women
Classification
RISK FACTORS
• BMI >30Kg/m2
• Previous macrosomic baby > 4,5kg
• Previous gestational diabetes
• First degree relatives with diabetes
• High risk race or ethnicity
• Physical inactivity
• HDL less than 35mg/dl
• Triglyceride level greater than 250mg/dl
• HBA1c >5,7%
• Women with polycystic ovarian syndrome
pathophysiology
• Hormomes such as cortisol,estrogen and human placental lactogen
produced by the placenta alters and modifies insulin receptors
• There is diminished glucose uptake at the peripheral tissues due to
1. Molecular alteration of the beta subunit insulin receptor
2. Diminished phosphorylation of tyrosine kinase
3. Remodeling in the insulin receptor substrate-1 and
phosphatidylinositol 3 kinase
Pathophysiology
Screening and diagnosis
• Women offered the OGTT
• How is it done
• 75g glucose with 300ml of water
• Ingestion to be complete within 5-10mins
• Measure blood sugar after 2hrs
• If patient vomits repeat the test the next day
Interpretation

• 2015 Nice guidelines

• Fasting plasma glucose 5.6mmol/l or
• A 2hour plasma glucose level of 7.8mmol/l or above
Management

• Preconception
• Antenatal
• Intrapartum
• postnatal
preconception
• Inform the diabetic women that they should establish a good glucose control before
conception and throughout pregnancy
• This reduces the risk of miscarriages ,congenital malformations, stillbirths and neonatal
deaths
• They should try and avoid unplanned pregnancies
• The choice of contraception is their own
• Inform the patient that the risks involved increase with how long they have had diabetes
• Blood glucose targets, glucose monitoring, medicines for treating diabetes
and its complications will need to be reviewed before and during pregnanc

• Extra time and effort is needed to manage diabetes during pregnancy

Preconception
• Diabetic women planning to get pregnant should be offered
individualized dietary advise
• Women with a BMI>27kg/m should be given advise on how to loose
weight
• Diabetic women should be advised to take 5mg/day of folic acid
before conception till 12 weeks of gestation to reduce the risk of
neural tube defects
Preconception
• Offer women with diabetes who are planning to become pregnant
monthly measurement of their HbA1c level
• This should be in addition to self monitoring at home
• This should include fasting levels,pre meal as well as post meal
glucose levels
• Targets should be as for everyone with type 1 diabetes
1. a fasting plasma glucose level of 5–7mmol/l on waking
2. a plasma glucose level of 4–7 mmol/l before meals at other times of
the day
Preconception
• The patient should advised to keep their HBA1c below 6.5% to reduce
the risk of congenital malformations
• Strongly advise women with diabetes whose HbA1c level is above
10% not to get pregnant because of the associated risks
• Women with diabetes may be advised to use metformin as an adjunct
or alternative to insulin in the preconception period and during
pregnancy
• All other oral blood glucose-lowering agents should be discontinued
before pregnancy
Preconception
• Isophane insulin should be used as first choice in pregnancy
• ACE inhibitors and ARB should be stopped before pregnancy or as
soon as pregnancy is confirmed
• Statins should also be discontinued before pregnancy
• Preconception care for women with diabetes is given in a
supportive environment, the woman's partner or other family
members should be encouraged to attend.
Preconception
• Retinal assessment should be offered to all women seeking
preconception care
• They should defer rapid optimization of glucose control until after
retinal assessment and treatment has been completed
• Renal assessment should also be done before stopping contraception
• A creatinine of > 120micromol/l,albumin:creatine ratio>
30mg/mmmol or an eGFR <45ml/minute/1.73m refer to a
nephrologist before stopping contraception
Antenatal
• Pregnant women with type 1 diabetes should test their fasting, pre
meal ,1 hour post meal and bedtime glucose levels daily
• Pregnant woman with type 2 diabetes or gestational diabetes who are
on multiple daily insulin regimen should do the same
• Pregnant women with type 2 diabetes or gestational hypertension
should test their fasting and 1 hour post meal glucose levels if
a) They are on diet or exercise therapy
b) They are taking oral therapy or single dose intermediate or long
acting insulin
Target blood glucose levels
• There should be agreed individualized targets for self monitoring
• They should maintain their blood glucose below the following targets
if they are achievable without problematic hypoglycemia
1. Fasting 5.3 mmol/l
2. 1hour after meals 7.8mmol/l
3. 2 hours after meals 6.4mmol/l
• For patients on insulin or glibenclamide they should maintain their
blood glucose levels above 4mmol/l
Monitoring HBA1c
• Measure in all pregnant women with pre-existing diabetes at the
booking appointment to determine the level of risk for the pregnancy
• Measure in the 2nd and 3rd trimester for women with pre existing
diabetes mellitus
• Measure those with gestational diabetes at the time of diagnosis to
identify those with preexisting type 2 diabetes
Managing diabetes during pregnancy
• Rapid acting insulin analogues have advantages over soluble human
insulin in pregnancy
• Women with insulin-treated diabetes have a risk of hypoglycemia and
impaired awareness of hypoglycemia in pregnancy, particularly in the
first trimester.
• Women with insulin-treated diabetes should always have available a
fast-acting form of glucose or glucagon on hand
• For those with type 1 diabetes on insulin therapy they should be
offered continuous subcutaneous infusion(insulin pump) if they have
poor glucose control
Continuous glucose monitoring
• Not routinely offered
• Only offered for those
1. who have problematic severe hypoglycemia (with or without
impaired awareness of hypoglycemia) or
2. who have unstable blood glucose levels or
3. to gain information about variability in blood glucose levels
Ketone testing and diabetic ketoacidosis
• Offer pregnant women with type 1 diabetes blood ketone testing strips
and a meter, and advise them to test for ketonaemia and to seek
urgent medical advice if they become hyperglycaemic or unwell.
• Advise pregnant women with type 2 diabetes or gestational diabetes to
seek urgent medical advice if they become hyperglycaemic or unwell.
• Test urgently for ketonaemia if a pregnant woman with any form of
diabetes presents with hyperglycaemia or is unwell, to exclude diabetic
ketoacidosis
• Any woman suspected as having diabetic ketoacidosis should be
admitted immediately
Retinal assessment during pregnancy
• Women with pre-existing diabetes should be offered retinal assessment with
mydriasis using tropicamide on their first visit
• If any diabetic retinopathy is present at booking, perform
an additional retinal assessment at 16–20 weeks
• Diabetic retinopathy should not be considered a contraindication to rapid
optimization of blood glucose control in women who present with a high
HbA1c in early pregnancy.
• Women who have diabetic retinopathy or any form of retinopathy diagnosed
during pregnancy should have ophthalmological follow-up for at least
6months after the birth of the baby
• Diabetic retinopathy is not a contraindication to vaginal birth
Renal assessment during pregnancy
• Arrange for renal assessment at first visit if not done in the last 3
months
• If the serum creatinine is abnormal >120 micromol/l, the urinary
albumin:creatinine ratio is> 30 mg/mmol or total protein excretion
exceeds 0.5 g/day, referral to a nephrologist should be considered
• eGFR should not be used during pregnancy.
• Thromboprophylaxis should be considered for women with nephrotic
range proteinuria above 5 g/day (albumin:creatinine
ratio greater than 220 mg/mmol)
Detecting congenital malformations
• Ultrasound should be offered at 20weeks to detect structural
malformation including a 4 chamber view of the heart
and 3 vessel view as well
• Offer ultrasound monitoring of fetal growth and amniotic fluid volume
every 4 weeks from 28 to 36 weeks.
• Provide an individualized approach to monitoring fetal growth and
wellbeing for women with diabetes and a risk of fetal growth
restriction
Organization of antenatal care
• Offer immediate contact with a joint diabetes and antenatal clinic to
women with diabetes who are pregnant and follow up every 1-2 wks
APPOINTMENT CARE GIVEN
Booking appointment Discuss information, education and
(joint diabetes and antenatal care) advice about how diabetes will affect
ideally by 10 weeks the pregnancy, birth and early parenting
Confirm viability of pregnancy and
gestational age at 7–9 weeks.
16 WEEKS Offer retinal assessment at 16–20 weeks
to women with pre-existing diabetes if
diabetic retinopathy was present at their
first antenatal clinic visit.
Offer self-monitoring of blood glucose or
a 75 g 2-hour OGTT as soon as possible
for women with a history of gestational
diabetes who book in the
second trimester
Organization of antenatal care
APPOINTMENT CARE GIVEN
20 weeks Offer an ultrasound scan for detecting fetal structural
abnormalities, including examination of the fetal heart
28 weeks Offer ultrasound monitoring of fetal growth and
amniotic fluid volume.
Offer retinal assessment to all women with pre-
existing diabetes.
Women diagnosed with gestational diabetes as a
result of routine antenatal testing at 24–28 weeks
enter the care pathway.
32 weeks Offer ultrasound monitoring of fetal growth and
amniotic fluid volume.
Organization of antenatal care
APPOINTMENT CARE GIVEN
36 weeks Offer ultrasound monitoring of fetal growth and
amniotic fluid volume
Provide information and advice about:
• timing, mode and management of birth
• analgesia and anaesthesia
• changes to blood glucose-lowering therapy during
and after birth
• care of the baby after birth
• initiation of breastfeeding and the effect of
breastfeeding on blood glucose control
• contraception and follow-up.
37+0 weeks to Offer induction of labour, or caesarean section if
38+6 weeks indicated, to women with type 1 or type 2 diabetes;
otherwise await spontaneous labour
Organization of antenatal care
APPOINTMENT CARE GIVEN
38 weeks Offer tests of fetal wellbeing
39 weeks Offer tests of fetal wellbeing.
Advise women with uncomplicated gestational
diabetes to give birth no later than 40+6 weeks.
Preterm labour in women with diabetes
• Diabetes should not be considered a contraindication to antenatal
steroids for fetal lung maturation or to tocolysis
• In women with insulin-treated diabetes who are receiving steroids for
fetal lung maturation, give additional insulin according to an agreed
protocol and monitor them closely
• Do not use betamimetic medicines for tocolysis in women with
diabetes
Intrapartum care
• Discuss the timing and mode of birth with pregnant women with
diabetes during antenatal appointments, especially during the third
trimester
• For a macrosomic fetus explain about the risks and benefits of vaginal
birth, induction of labour and caesarean section
• Offer women with diabetes and comorbidities such as obesity or
autonomic neuropathy an anaesthetic assessment in the third trimester
of pregnancy
• If general anaesthesia is used monitor blood glucose every 30 minutes
from induction of general anaesthesia until after the baby is born and
the woman is fully conscious.
Blood glucose control during labour
• Monitor capillary plasma glucose every hour during labour and birth
in women with diabetes, and ensure that it is maintained between 4
and 7 mmol/l
• Intravenous dextrose and insulin infusion should be considered for
women with type 1 diabetes from the onset of established labour
whose capillary plasma glucose is not maintained between 4 and
7mmol/l
Neonatal care
• Diabetic women should give birth in hospital with advanced neonatal
resuscitation skills
• Routine blood tests should be done in the babies 2-4hrs post delivery
to assess for polycythaemia,hyperbilirubinaemia, hypocalcaemia and
hypomagnesaemia
• an echo should be done if there are any abnormal cardiovascular
signs
Criteria for admission into the NNU
• hypoglycaemia associated with abnormal clinical signs
• respiratory distress
• signs of cardiac decompensation from congenital heart disease or cardiomyopathy
• signs of neonatal encephalopathy
• signs of polycythaemia and are likely to need partial exchange transfusion
• need for intravenous fluids
• need for tube feeding (unless adequate support is available on the postnatal ward)
• jaundice requiring intense phototherapy and frequent monitoring of bilirubinaemia
• been born before 34 weeks
Neonatal hypoglycemia
• All maternity units should have a written policy for the prevention,
detection and management of hypoglycaemia
• Babies should be fed within 30minutes of delivery then every 2-3hrs
to maintain a minimum of 2mmol/l
• If plasma glucose levels remain low on 2 consecutive readings despite
maximum support for feeding,feed via NGT or give IV dextrose
Postnatal care
• Women with insulin-treated pre-existing diabetes should reduce their
insulin immediately after birth and monitor their blood glucose levels
carefully to establish the appropriate dose
• women with insulin-treated pre-existing diabetes should know that
they are at increased risk of hypoglycaemia in the postnatal period,
especially when breastfeeding
• They should take snacks before and after feeds
• Women who have been diagnosed with gestational diabetes should
discontinue blood glucose-lowering therapy immediately after birth.
Postnatal care
• Women with pre-existing type 2 diabetes who are breastfeeding can
resume or continue to take metformin and glibenclamide only
immediately after birth
• Medicines discontinued in the preconception period should be
avoided during breastfeeding
Follow up after birth
• Women with preexisting diabetes should be referred back to their
routine diabetes care arrangements
• They should use contraception and should come for preconception
visits for their next pregnancies
• Those diagnosed with gestational diabetes should be screened for
persistent hyperglycemia before discharge
• Women who were diagnosed with gestational diabetes have a risk of
gestational diabetes in future pregnancies, and should be offered
testing for diabetes when planning future pregnancies
Follow up after birth
• Women with gestational diabetes and whose blood glucose levels returned
to normal after the birth
1. Offer lifestyle advice (including weight control, diet and exercise).
2. Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude
diabetes
3. If a fasting plasma glucose test has not been performed by 13 weeks, offer
a fasting plasma glucose test, or an HbA1c test if a fasting plasma glucose
test is not possible after 13 weeks.
4. Do not routinely offer a 75 g 2-hour OGTT.
5. Offer an annual HbA1c test to women who were diagnosed with
gestational diabetes who have a negative postnatal test for diabetes
•THANK YOU