Camden Diabetes Education Day June 2014

In England and Wales: 650,000 deliveries each year 2-5% pregnancies involve women with diabetes 87.5% gestational diabetes 7.5% type 1 diabetes 5% type 2 diabetes Type 2 increasing and may be higher here – ethnically diverse population

Key clinical issues Adequately prepare women with pre-existing diabetes for pregnancy Take appropriate steps during the pregnancy to minimise adverse outcomes

Risks discussed, started on folic acid 5mg Termination discussed LM 30 year old type 1 diabetes 1994, gastroparesis Known ACR 82, HbA1c 14% On ACE, statin Levemir, Novorapid Hospital admission with vomiting, found to be pregnant, discharged out of hours, ANC appt made for 2 weeks Risks discussed, started on folic acid 5mg Termination discussed

Made significant changes to insulin BGL rapidly improved PCR 512 Miscarried at 20 weeks

Risks: pre-existing diabetes Miscarriage Congenital anomalies

Maternal Risks: Hypoglycaemia Loss of hypo awareness (increased risk of seizures, trauma) Acceleration of complications (retinopathy and nephropathy)

Late complications (pre-existing diabetes / GDM) Fetal macrosomia or IUGR Shoulder dystocia Preterm labour Stillbirth Neonatal hypoglycaemia Pre-eclampsia

Factors associated with poor pregnancy outcome Maternal social deprivation Not using contraception Suboptimal diabetes control pre & during pregnancy Not taking Folic Acid 5mg No preconception care

Pregnancy in type 1 & type 2 diabetes All of those of us working in diabetes/ANC clinic know how difficult it is for women with diabetes… particularly type 1. Women have to carry the burden of guilt of knowing that lapse of good control can cause irretrieveable damage to their developing baby. We expect to see them weekly in busy clinics at a time that they don’t want anyone to know they are pregnant (especially their work). Difficult balancing act

Experiences of professional support during pregnancy and childbirth – a qualitative study of women with t1. Explored the experience of professional support during pregnancy in women with t1 diabetes. Results: Mothers concern about jeopardizing the baby’s health Women felt that HCP concern was towards the baby and not them Felt that they were used as messengers between hc providers Data analysis was directed towards discovering qualitative meanings by identifying and clustering meaning units in the text. Further analysis identified eight themes of meaning, classified under pregnancy or childbirth, forming a basis for a final whole interpretation of the explored phenomenon. Results: The women felt worry about jeopardizing the baby's health and this was Berg et al 2009

Pre-conception Planned pregnancy (discuss with all women of child-bearing age) Review contraception Refer to pre-conception clinic Aim HbA1c <7%, use contraception until good glycaemic control, offer monthly measurement HbA1c All hcp who come into contact with women (of child-beaing range) should provide adequate preconception counselling Always discuss contraception Convey the possibility of good pregnancy outcomes Support mothers-to-be in a holistic way Programs customise to comply with culture and ethnic background

Type 1 – intensive support with control, pump therapy Medication Folic Acid 5mg (start preconception until 12 weeks) Continue Metformin Stop all other oral anti-diabetes drugs/substitute insulin Stop ACE-I/ARBs Stop Statins Type 1 – intensive support with control, pump therapy Retinal screening /Urine ACR and eGFR

Screening for Gestational Diabetes Screening 28 weeks 50g glucose challenge test Random BGL Diagnosis 75g oral glucose tolerance test

Antenatal Care Regular appointments 1-3 weekly BGM 4 x/day Fasting (target < 5.5) 1 hour post prandial (target <7.5) Regular growth scans 4weekly (from 28wks) Delivery – based on scan, glycaemic control

Postnatal Care GDM Annual HbA1c High risk – address lifestyle measures Postnatal GTT at 6 weeks Annual HbA1c High risk – address lifestyle measures

What support can you get? For women with type 2 diabetes: Vanessa Sawmynaden Preconception counselling Improve glycaemic control prior to pregnancy Transfer onto insulin when necessary

Miranda Rosenthal (Diabetologist) Royal Free

UCLH Jakki Berry - preconception clinic Antenatal clinic UCLH (Monday mornings) Jo Modder / Nikki Lack (Consultant Obstetricians) Jakki Berry / Lydia Chinyerere (DSNs) Sarita Naik (Diabetologist)

To summarise…..