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

2. 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 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 May;105(5 Suppl):13-5

3. 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

4. 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

7. 23,316 participants
Birth weight >90th centile, OR (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.

8. Screening and Diagnosis of GDM

9. 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

11. A review our services (Linda Culliney Senior Dietitian)
The mean gestational age for the diagnosis of GDM was weeks 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).

12. 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

13. 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%

14. Pregestational Diabetes
Preconceptual
Antenatal care
Neonatal care
Postnatal care

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

16. 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

17. 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 Jul;30(7):

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

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

20. 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.

21. 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.

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

23. 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 mol/l after 2/52 testing.
Referral to endocrinologist.
Insulin requiring

24. 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 32/40 gestation.

25. 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.