1. Jill Little Diabetes Specialist Nurse Western General Hospital
Diabetes in Pregnancy
Jill Little
Diabetes Specialist Nurse
Western General Hospital

2. Number of pregnancies in England
The size of the problem
2-5% of pregnancies involve women with diabetes
Edinburgh ‘05-’08: 52% GDM, 37% T2DM, 13% T1DM
Prevalence
Number of pregnancies in England
Total singleton
pregnancies
600,200
Type 1 diabetes
0.3%
1,800
Type 2 diabetes
0.2%
1,200
Gestational diabetes
3.5%
20,400
Total diabetes in
pregnancy
23,400

3. Risks of diabetes (fetus)
Pre-existing diabetes
Gestational
miscarriage
neonatal hypoglycaemia
congenital malformation
perinatal death
stillbirth
neonatal death
fetal macrosomia
birth trauma (to mother and baby)
induction of labour or caesarean section
transient neonatal morbidity
obesity and/or diabetes developing later in the baby’s life

4. Pregnancy outcomes in Scotland (Type 1 Diabetes)
273 pregnancies during 1998
40 (14.7%) ended in miscarriage
20 (7.3%) ended in termination
13 (5%) babies had congenital anomalies
4 (2%) babies were stillborn
6 (3%) babies died in the peri-natal period
Penney et al BJOG 2003: 110,

5. Risks of diabetes (maternal)
Miscarriage
Pre-eclampsia
Preterm labour
Intrapartum complications
Progression of microvascular complications
Severe hypoglycaemia
Ketoacidosis
Death – approx one mother per year

6. CMACE (CEMACH) Centre for Maternal and Child Enquiries
“improving the health of mothers, babies and children”

7. CMACE (CEMACH)
Identified factors associated with poor pregnancy outcomes in patients with diabetes:
Social deprivation
No folic acid intake
Suboptimal self-management
Suboptimal preconception care
Suboptimal glycaemic control before/during pregnancy
Suboptimal diabetes/maternity care
Suboptimal fetal surveillance
Pre-existing complications

8. CMACE (CEMACH) Conclusions:
Majority of women did not achieve a good preparation for pregnancy
Only 37% of women had HbA1c recorded in 6 months prior to pregnancy
Only 27% of HbA1c values were <7% 53mmolls

9. Publication of National Guidelines
CEMACH NICE SIGN 2010

10. Preconception care in patients with pre-existing diabetes
Pre-pregnancy planning for all patients with diabetes
Structured education
Dietetic, weight, exercise advice
Folic acid 5mg daily (until 12 weeks)
Renal and retinal assessment
Optimise glycaemic control
Monthly HbA1c
HbA1c as low as possible and <7% 53mmolls as minimum (SIGN), <6.1% 43mmolls (NICE)
Blood glucose meter, ketone testing in T1DM
Review medications
stop statins, ACEi/ARB, oral hypoglycaemics
Continue metformin, glibenclamide, commence insulin if required

11. Metformin is safe in pregnancy
GDM women randomised to MF or insulin
46% of MF group needed supplemental insulin
No difference between groups in composite outcome (neonatal hypoglycaemia; prematurity; reduced APGAR; phototherapy; resp distress; birth trauma)
Less neonatal hypoglycaemia with MF; more preterm births (7% vs 4%)
MiG trial
Rowan et al, NEJM 2008

12. Retinopathy
43% of women with retinopathy show progression during pregnancy
Sight-threatening retinopathy rare (2%)
Risk factors are poor glycaemic control and uncontrolled hypertension
Pre-pregnancy screening, and during each trimester in pre-existing diabetes; early referral to opthalmology

13. “Help me prepare for a pregnancy!”
38 year old woman; para 0+0
T2DM 4 years, obesity – dietetic, weight, exercise advice
Background retinopathy – retinal screening at baseline
Microalbuminuria – renal assessment
Drugs: Metformin, Lisinopril, Simvastatin – stop ACEi, statin, start folic acid
BP 138/84 mmHg – consider safe alternative antihypertensive agents
HbA1c 9.1% 76mmolls - consider insulin

14. Gestational Diabetes

15. Gestational diabetes
Defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy”
Includes women with undiagnosed type 1, type 2 or monogenic (MODY) DM
Primarily refers to women with abnormal glucose tolerance which normalises post partum
Usually develops after 28 weeks gestation
Complications (all reduced by intensive management)
Crowther NEJM 2005
Macrosomia/shoulder dystocia (3%)
Neonatal hypoglycaemia (from neonatal hyperinsulinaemia)
61% neonates admitted to SCBU
Neonatal death (1%)
Late intra-uterine death (1%)

16. Screening for GDM Controversial – tidal wave of GDM is here !!
Current SCRH screening programme:
Urinalysis at every ante-natal visit
Random venous plasma glucose if glycosuria detected
Random venous plasma glucose at book-in and at 28 weeks
SIGN 116: Assess for risk factors for GDM at first antenatal visit
BMI > 30kg/m2
previous baby >4.5kg
previous GDM
Asian, Black Caribbean or Middle Eastern
family history of DM (first degree relative) if one risk factor then screen

17. Screening for GDM – SIGN 116
Screening in early pregnancy
All women with risk factors (incl previous GDM) should have HbA1c or fasting glucose measured:
women in early pregnancy with levels of…
HbA1c ≥6.5% (48 mmol/mol)
fasting glucose ≥7.0 mmol/l
two hour glucose ≥11.1 mmol/l
…should be treated as having pre-existing diabetes

18. Screening for GDM – SIGN 116
Screening in later pregnancy
All women with risk factors or intermediate results in early pregnancy should have a 75g OGTT at weeks
A fasting plasma glucose at weeks is recommended in low risk women

19. Diagnosis of GDM 75g OGTT: Fasting glucose ≥5.1mM 2 hour ≥ 8.5mM
SIGN 116 also has a 1 hour diagnostic value of ≥ 10mM

20. Management of GDM HBGM Dietetic input Metformin/Insulin
Fasting ≥5.5mM
Pre-prandial ≥6mM
Weekly CTG and liquor volumes from 36 weeks
Induced at term
Insulin stopped once delivered
OGTT at 12 weeks, 6-12 monthly screening for T2DM

21. Antenatal Care

22. Typical Antenatal Experience
Minimum 30 visits to hospital
Fortnightly visits until 30 weeks
Ultrasound scans (fetal anomaly, cardiac, fetal growth, liquor volumes)
Retinal scans (1st antenatal visit, 28 weeks)
Anaesthetic appointment
Weekly visits until 36 weeks
Twice weekly until weeks
Minimal GP and community midwife contact

23. Antenatal Care At each clinic visit May also be seen by Obstetrician
Diabetologist
Midwife
Diabetes Specialist Nurse
May also be seen by
Dietician
Opthalmologist
Nephrologist
Paediatrician
Radiologist/Sonographer
Anaesthetist

24. Glycaemic control SIGN NICE Lothian Pre-prandial 4-6mM
1 hour post-prandial <8mM
2 hour post-prandial <7mM
Before bed <6mM
NICE
Pre-prandial mM
1 hour post prandial <7.8mM
Lothian
FBG <5.5mM, Pre-prandial <6

25. Hypoglycaemia during pregnancy
Insulin requirements change during pregnancy due to gestational hormones
Hypoglycaemia
Common (14-45% of patients experience a severe hypo)
Occurs most often during 1st trimester
Risk factors include previous severe hypos, diabetes duration, impaired hypoglycaemia awareness, erratic control
Important that pre-pregnancy counseling includes hypoglycaemia re-education

26. Intrapartum and Neonatal Care
Labour induced before 40 weeks
Because of increased risk of IUD and other maternal/fetal complications
Increased risk of instrumental delivery and C Section (60%)
Aim to continue normal insulin
Aim for BMs 4-7mM
CSII – continue when feasible
CGMS – pilot study of feasibility during labour

27. Immediate Postnatal Care
Neonatal care
Hypoglycaemia
Macrosomia
Jaundice
Respiratory distress syndrome
Maternal care
Reduce insulin to pre-pregnancy doses
Stop insulin in patients with GDM
Avoid hypoglycaemia
Breast feeding

28. Postnatal Care Pre-pregnancy planning for next pregnancy!
Encourage breastfeeding
Adjust treatment regimen when necessary
GDM: 50% 5 year risk of T2DM
Diet, weight, exercise advice
12 week OGTT
Annual screening for T2DM

29. Summary
Diabetes confers significant risks on pregnancy outcomes for mum and baby
Risk reduction involves a multidisciplinary approach and intensive input from the patient
A tidal wave of GDM and T2DM is coming
Pre-pregnancy planning is crucial
Contraception, contraception, contraception!