1. Miss M Maitra Consultant O&G UHCW 29 April 2015

2. What is Diabetes Mellitus? Metabolic disorder Multiple aetiology Chronic hyperglycaemia Defects in insulin secretion, insulin action or both

3. Physiological changes in pregnancy  Insulin resistance Altered glucose homeostasis Insulin Vs Glucagon/Cortisol/HPL/Progesterone/hCG Placental barrier  fetal consequences

5. Consequences

6. Complications Maternal Miscarriage Polyhydramnios Shoulder dystocia Birth trauma PET/HTN Caesarean section DM in future

7. Fetal Miscarriage Premature delivery Stillbirth/ NND Birth trauma Neonatal consequences Future obesity & diabetes

8. Diabetes in pregnancy Pre-existing diabetes Gestational diabetes 87.5% Type 1 7.5% Type2 5% African, Black Caribbean, South Asian, Chinese, Middle Eastern

9. Group work! 1. AB is a 28 yr old teacher who is known to have Type 1 DM since childhood. She is planning to have a baby. What will you advise? 2. CD is a 32 yr old housewife who has a h/o PCOS and is on metformin for Type 2 DM. She has a BMI of 35 and has recently found out that she is pregnant. She is currently 16 weeks of gestation. What is your management plan? 3. EF is a 40 yr old G3P2 – with a h/o GDM in the last pregnancy. She is now 7 weeks pregnant. Outline your management plan.

10. Management

11. Pre-conception care Optimise control! Avoid unplanned pregnancy! Discuss risks Lifestyle advice Folic acid Retinal and renal assessments

12. Medical Management Near-normoglycaemia ↑ self monitoring Adjustment of Rx doses Target capillary BG = 3.5-5.3 mmol/L fasting and < 7.8 mmol/L 1 hr PP

13. Management – Type 1 DM  requirement/monitoring Hypoglycaemia awareness

14. Management – Type 2 DM

15. Antenatal Care Scans Baseline renal functions / retinal checks Folic acid/Vitamin D Antihypertensives/aspirin

16. Timing of delivery INSULIN? DIET? ORAL RX CONTROL? 38-40 WEEKS

17. Intra-partum Management Hourly capillary blood glucose levels Variable rate insulin infusion* Target range: 4-7 mmols

18. What happens postnatally? Return to pre-pregnancy doses (Type 1 & 2) Breastfeeding implications Lifestyle modification

19. Neonatal care Check BMs within 2-4⁰ to NNU if: - Hypoglycaemia/RDS/Polycythaemia/Jaundice - Congenital cardiac abnormalities - Need for tube feeding/IV fluids - Preterm (< 34/40)

20. Gestational Diabetes (GDM) ‘Carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy’ – National Diabetes Data Group (1985)

21. NICE 2015  a fasting plasma glucose level of 5.6 mmol/litre or above or  a 2-hour plasma glucose level of 7.8 mmol/litre or above. [new 2015]

22. Risk factors for GDM BMI above 30 kg/m2 Previous macrosomic baby ≥ 4.5 kg / 90 th centile Previous GDM 1  relative with diabetes Ethnic origin Maternal age > 35 yrs PCOS Long term steroids Previous unexplained SB / recurrent miscarriage Polyhydramnios / Macrosomia / persistent glycosuria

23. GDM - Advice

24. HBGM: Glycaemic targets Fasting blood glucose = 3.5 – 5.3 mmol/L 1hr PP blood glucose <7.8 mmol/L INDIVIDUALISED targets

25. Antenatal Care Multidisciplinary care

26. Timing of Delivery 40 to 40+12

27. Postnatal care Stop Rx Check FBS after 6 weeks and then annually Life style modifications

28. Further reading http://www.nice.org.uk/nicemedia/pdf/cg063guidance.pdf