2.  Paradigm of medical diseases in pregnancy  Effect of pregnancy on disease  Short-term  Long-term  Effect of disease on pregnancy  Mother vs. fetus  Disease vs. its treatment  Prepregnancy vs. gestational

3.  Approximate prevalence 0.5%  Increasing  In Australia 75% type 1, 25% type 2  Varies with ethnic mix

4.  Pregnancy is diabetogenic  HPL, progesterone antagonize insulin  Glucose is major energy substrate for fetus  Pregnancy causes insulin resistance

6.  Nephropathy  None if mild-moderate  If severe (creatinine > 0.25 mmol/L), may exacerbate renal failure  Retinopathy  Seems to make it worse, but probably due to tight control (DCCT)

7.  Treatment  OHAs rarely used  Sulphonylureas ?teratogenic  Troglitazone hepatotoxic  Acarbose not effective, side effects  Metformin ok, but rarely adequate  Insulin  Only problem if too much or not enough!

8.  Miscarriage  Polyhydramnios  Preeclampsia (more if diabetic nephropathy)  Infection (UTI, candidiasis, chorioamnionitis)  Operative delivery (CS rate 50%)  PPH

9.  Miscarriage  Congenital Malformations  2 - 3 times background rate  minimized by good control around the time or conception and organogenesis  commonest are neural tube and cardiac defects  Caudal regression (sacral agenesis) rare  Perinatal Death  Late “unexpected” FDIU  perinatal mortality rate doubled

10.  Macrosomia (40%)  Birth trauma  Hypoglycaemia  Hypocalcaemia/magnesaemia  Respiratory distress syndrome  Hypertrophic Obstructive CardioMyopathy (HOCM)  Hyperbilirubinaemia  Hyperviscosity/ polycythaemia  The risk of type 1 diabetes mellitus in the child of a woman with the condition is 2%.

11.  Education about diabetes and pregnancy  Investigation for complications of diabetes  Microalbuminuria, ophthalmoscopy  Optimize glycaemic control  Excellent control minimizes congenital anomalies  Switch OHA to insulin  Hb A1c  Importance of fetal surveillance  Lifestyle disruption  Folic acid  Rubella

12.  TEAM APPROACH  Unified clinic  Obstetrician, endocrinologist, diabetes educator, dietitian, neonatal paediatrician (itfot)  Increased frequency of visits  4-weekly to 20 weeks  2-weekly to 28 weeks  Weekly thereafter

13.  Routine management PLUS  Repeat prepregnancy counselling steps  Urinary protein/ microalbumin excretion  Ophthalmoscopy each trimester  Glycaemic control  Organize fetal surveillance

14.  Home blood glucose monitoring qid  Goals are 5.5 mmol/L fasting and 7 mmol/L 2 hours postprandial  Hb A1c monthly  Dietary management  Appropriate energy intake  50-60% CHO, 25% fat, 15% protein  Even distribution  Exercise - 30 minutes walk a day  Insulin  Basal-bolus: 1 dose medium-long acting insulin (e.g. isophane), short-acting with each meal  Hypo management

15.  Ultrasound  12 weeks  gross morphology, dates, plurality, nuchal translucency  18-20 weeks  detailed morphology  30 and 34 weeks  growth  Other scans, Dopplers as indicated  Prevention of FDIU  CTG weekly from 30 weeks, 2/week from 36 weeks

16.  RCT suggests advantage in delivery at 38 - 39 weeks  Decreased macrosomia, shoulder dystocia  40 weeks if perfect control, no complications  ?Role of elective CS for macrosomia  Diabetes is independent risk factor for shoulder dystocia  Recommend if estimated fetal weight > 4.5 kg  Consider if EFW 4 - 4.5 kg

17.  Notify endocrinologist  Omit morning insulin the day of induction.  Measure blood glucose on admission and every 2 hours.  50 U insulin in 50 mL 0.9% NaCl (1U/mL) via syringe pump  Start at 1mL/hour  Adjust to keep glucose 4-7 mmol/L  Simultaneous 5% dextrose at 100 mL/hour

18.  Usual obstetric management PLUS  Continuous CTG  Epidural analgesia is encouraged  End should be in sight in 12 hours  2nd Stage - Anticipate Shoulder Dystocia  Experienced accouchouer and paediatrician must be present.  Prepare to re-position patient (over edge of bed and exaggerated lithotomy)  Active Management of 3 rd Stage  If elective CS, do first on list

19.  Cease insulin infusion at delivery (unless Caesarean section)  Often reduced needs for 24 hours  Then back to prepregnancy dose  Type 2 may need no treatment in puerperium  OHAs discouraged in lactation

21.  Carbohydrate intolerance of varying severity first manifest or diagnosed in pregnancy  The definition applies irrespective of the need for insulin treatment and the result of any postnatal glucose tolerance test

22.  Was noted that women with diabetes in pregnancy had high perinatal mortality rate without treatment  This sometimes preceded recognition of diabetes  Pregnancies also characterized by fetal macrosomia  Pregnancy is diabetogenic

23.  Pregnancy can induce a temporary hyperglycaemic state in susceptible women  This can lead to the typical sequelae of diabetes in pregnancy  Macrosomia, preeclampsia, perinatal mortality  Recognition and treatment of these women can avert these problems  Marker for later development of diabetes mellitus

24.  Test of carbohydrate metabolism at 24 - 28 weeks in all pregnant women  Earlier if high-risk, esp. previous GDM  Most convenient is glucose tolerance test  Fasting glucose, 75 g load, 2-hour glucose  GDM = fasting  5.5 mmol/L OR 2-hour  8.0 mmol/L  Sometimes preceded by glucose challenge test  Non-fasting 75 g glucose load, 1-hour blood glucose  Positive test  8.0 mmol/L leads to GTT

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

26.  Monitor blood glucose  Aim for fasting < 5.5 mmol/L and 2-hour postprandial < 6.5 - 7 mmol/L  Initiate carbohydrate modified diet with balanced intake during day  Exercise - 30 minutes walk per day  Insulin as required in 25%  Usually 1-2 doses per day sufficient

27.  Timing of investigations variable  Most perform some test in late pregnancy  Commonest test is CTG  Start 30 - 36 weeks depending on other features  Ultrasound to determine fetal size

28.  If well-controlled, not on insulin, no other problems, deliver at term  Recommend elective Caesarean section if estimated fetal weight > 4.5 kg  Consider if EFW 4 - 4.5 kg  If suspected macrosomia, poor control, deliver at 38 weeks

29.  If not on insulin, usual management + 4-hourly blood glucose  Notify if > 7mmol/L  If on low-dose insulin (< 20 U/day) may not need any  If on higher-dose insulin, insulin and glucose infusions as for prepregnancy diabetes  50 U insulin in 50 mL 0.9% NaCl  Start at 1mL/hour  Adjust to keep glucose 4-7 mmol/L  Simultaneous 5% dextrose at 100 mL/hour

30.  Prepare for shoulder dystocia  Cease insulin if used at delivery  Monitor infant’s blood glucose after delivery  Measure mother’s blood glucose BD for 2 days

31.  Recall at 6 weeks postpartum for GTT  2% will have diabetes  10% will have IGT  Long-term risk of diabetes mellitus 50% over 10 years  Long-term follow-up  Lifestyle modification  50% recurrence in future pregnancy