Diabetes in pregnancy Dr Mairead O’Riordan Norma Wing Diabetic Midwife Specialist Mobile 0867872434

Diabetes in pregnancy Pregestational Gestational 75% type 1, 25% type 2 Varies with ethnic mix Local figures 2012 ~40 pregestational Gestational Carbohydrate intolerance of varying severity first manifest or diagnosed in pregnancy Atlantic DIP study 12.4% Dx of DM 2011-2014 increasing (241, 315, 389, 426) O'Sullivan EP, Avalos G, O'Reilly M, Dennedy MC, Gaffney G, Dunne FP; Atlantic DIP collaborators. Atlantic DIP: the prevalence and consequences of gestational diabetes in Ireland. Ir Med J. 2012 May;105(5 Suppl):13-5

GDM Complications for Mother and Infant Maternal: PIH/PET, labor interventions DM2, Obesity, Metabolic syndrome and CVD. Infants: Macrosomia, hypoglycaemia, RDS, hyperbilrubinaemia- NNU admission DM (DM2, GDM), Obesity, Fatty liver. DIABETES BEGETS DIABETES

BACKGROUND Prevalence is increasing …due to increasing obesity advancing maternal age Treatment is effective …lifestyle modification for majority (MNT & Exercise) …pharmacological treatment thereafter Future maternal Type 2 DM can be prevented …promotion of breastfeeding, post-partum testing for DM risk, lifestyle modification post-natal Screening and diagnosis- remains controversial …Universal or Risk factor based screening & what glycaemic thresholds to use to diagnose GDM

23,316 participants Birth weight >90th centile, OR 1.38 (95% CI (1.32 to 1.44), Cord-blood serum C-peptide level 90th percentile, 1.55 (1.47 to 1.64) Primary cesarean delivery, 1.11 (95% CI, 1.06 to 1.15) Neonatal hypoglycemia, 1.08 (95% CI, 0.98 to 1.19), There were no obvious thresholds at which risks increased. Significant associations were also observed for secondary outcomes, although these tended to be weaker.

Screening and Diagnosis of GDM

Who to screen? Universal Risk based Family history of diabetes in a first degree relative Body mass index ≥30kg/m2 Maternal age ≥ 40years Ethnicity associated with a high prevalence of diabetes Women on long term steroids Current glycosuria Previous unexplained perinatal death Previous delivery of a baby weighing ≥4.5kg Polycystic Ovary Syndrome Polyhydramnios and/or macrosomia in existing pregnancy

A review our services (Linda Culliney Senior Dietitian) The mean gestational age for the diagnosis of GDM was 28.3 weeks + 5.77 weeks (6-39weeks). Management 65% of cases Diet/lifestyle 9% were on MNT and metformin, 9% were on MNT metformin and insulin 14 % were on MNT and insulin 2.6% received treatment elsewhere. Our endocrinology service saw 29% of patients (n= 124), of these 83% went on insulin (82 basal only, 1 bolus only, 20 on both).

Findings Our mainly caucasian population are heavier and older and have a strong family history of diabetes- consistent with ATLANTIC DIP Under-diagnosing Treatment with insulin was high at 23% Highest rate of pre-term deliveries at 10% (vs 5.6% background population) Labor interventions- induction 48% (vs 34% background population), C/Section 43% (vs 31%) Our babies are heavier, 12 % Macrosomic- 41 % LGA

Findings Neo-natal admission rates of 18.9% Infant outcomes similar if not better Low breast feeding rates 54.5% breastfeeding on discharge (Irish stats show 47% initiate feeding only 24% continue after 6 weeks) Post partum screening poor consistent with other studies- strong screening program needs to be established Post partum dysglycaemia is high at 18%

Pregestational Diabetes Preconceptual Antenatal care Neonatal care Postnatal care

Preconception GPs and practice nurses should consider Actively trying to get pregnant Actively using contraception Preconception counselling Folic acid 5mg

Preconceptual management Appropriate multidisciplinary approach Optimise condition Review and optimise drug treatment Genetic counselling if appropriate Discontinue drugs with teratogenic potential Advise re what to do in early pregnancy Early medical / antenatal visit

Risk of congenital abnormalities Guerin A, Nisenbaum R, Ray JG. Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancydiabetes. Diabetes Care. 2007 Jul;30(7):1920-5.

Additional Risk factors Obesity Hypertension Increased parity Age Diabetic retinopathy Diabetic nephropathy

Treatment Some individual variation,but 3 key elements 1. Achieve normoglycaemia 2. Monitor fetal well-being 3. Appropriate timing of delivery

Nicola 39 year old lady, G3 P2. H/o previous big baby 1st pregnancy, 2nd baby GDM Dx; diet controlled. 2000 Dx type 2 diabetes 2006: Diet controlled. BMI 42.1 HbAic = 56mol/mol. 1st visit to hospital is a routine booking visit/scan.

Treatment Commence blood glucose monitoring x7 /day, prescription for stripes and needles; apply for LTI if pt has not got one. Dietary advice and referral to dietician. Give prescription for high dose folic acid. Bloods to lab FBC, TFT, HbAic, LFT. Referral to diabetes clinic and endocrinologist.

Maria 33 year old lady African origin G4 P2, BMI 40.1 HbAic-36mol/mol. OGTT @28/40. F-5.1mol/l 2Hr -6.4mol/l.

Treatment Growth scan on the 7TH CENTILE. Bloods, TFT, HbAic, LFT, FBC. Education regarding GDM. Dietician Blood glucose monitoring x7 per day. Weekly telephone contact. Pre-meal glucose levels 5.2-6.2 mol/l after 2/52 testing. Referral to endocrinologist. Insulin requiring

Aoife 37 year old lady, G2 P1, Previous h/o GDM 2014, treated with Insulin. Family h/o GDM, sister HbAic-35 BMI 23.2 3rd OGTT this pregnancy F-5.4 mol/l, 2HR 5.3mol/l t@ 32/40 gestation.

Treatment Growth scan- 78th centile, AC 78th Centile. Education regarding GDM. Monitor blood glucose levels x7/day, weekly phone contact. Dietician Referral. Pre-meal BGL’S 5.9mol/l- 6.5 mol/l. Referral to Endocrinologist, Levimer commenced.