1. Diabetes in pregnancy James Penny Consultant Obstetrician & Gynaecologist Surrey & Sussex NHS Trust

2. Diseases Gestational Diabetes Pre-existing Diabetes Definition: Disorder of carbohydrate metabolism. It is an organ specific autoimmume disease with a genetic component Prevalence: 650,000 pregnancies-UK and Wales of which 2-5% are diabetic pregnancies. The prevalence is increasing in both types. Type 2 is increasing in certain minority ethnic groups. Pregnancy complicated by diabetes ---Gestational diabetes accounts for 87.5%,7.5% type 1 and 5% type 2. Types: Type 1-0.27% of births Type 2-0.10% of births

3. Recent focus St Vincent declaration NICE document on prenatal care NICE document on diabetes Cemach report on diabetes in pregnancy

6. Risks of diabetes Pedersen hypothesis Unexplained stillbirth Congenital malformation Caesarean section Miscarriage Long term effect of infant/child health

7. This talk Prepregnancy care for established diabetics Early pregnancy care Gestational diabetes Third trimester and delivery

8. The size of the problem

9. Prepregnancy Care Maternal health –Weight –Folate –Smoking –Long term health –contraception

10. Extremely tight control of blood sugar

11. Prepregnancy Care Maternal health –Assess for Risk of miscarriage

12. Prepregnancy Care Congenital anomalies –Comparison of % depending of timing of care

13. Prepregnancy Care Congenital anomalies If the HbA1c is >10% then ~ 30% of babies may have a congenital anomaly

14. Prepregnancy care Allows a detailed risk assessment Should be performed opportunistically Diabetic women should plan their pregnancy

15. Maternal risks Diabetic ketoacidosis is rare in pregnancy Hypoglycaemia accounts for most death in pregnant diabetics

16. Early pregnancy Multidiscplinary care Obstetrician Physician Midwife Dietician Diabetic nurse Patient

17. Management Diet to allow ideal weight gain Change oral hypoglycaemics to insulin Tight control of blood sugars –Fasting < 6 –Postprandial < 8 Q.D.S. insulin regime Post prandial levels are important

18. Downside –Hypoglycaemia –Morning sickness

19. Gestational Diabetes Definition –Carbohydrate intolerance that arises during pregnancy and disappears after delivery Is gestational diabetes an important condition

20. Trends in insulin resistance and insulin production with age Insulin resistance Insulin production

21. Trends in insulin resistance and insulin production with age Pregnancy

22. Insulin Resistance

23. Gestational Diabetes Screening Random glucose - booking + 28 weeks Timed random glucose - booking + 28 weeks Urinary dipstick Risk factor screening 50g mini GTT - booking or 28 weeks 50g mini GTT for women over 25 HbA1c

24. Gestational Diabetes Diagnosis 100g GTT (5.0, 9.2, 8.1, 6.9) 100g GTT (5.8, 10.6, 9.2, 8.1) 75g GTT 75g mini GTT Serial capillary blood sugar 50g GTT (AUC)

25. GDM – Screening LOW RISK –Routine random sugar at 16 and 28 weeks HIGH RISK –28 week simplified GTT

26. Gestational Diabetes Management

27. Obstetric management. Early referral to offer advice and support and review medication. Medical review for retinal and renal assessment Scans- 7-9 wks viability,NT scans –refer Tertiary unit, 20-22wks anomaly and cardiac scan, serial growth scan at 28,32.36 weeks. Dopplers liquor and fetal well being look for IUGR. Regular antenatal visits monitoring insulin req and scans. BP/ proteinuria Induction of labour -38-39wks on insulin. 40 wks if well controlled or diet control Wellbeing screening at ADU C/S at 39 weeks Post natal care..

28. Third trimester and fetal risks Fetal size Cardiac hypertrophy Stillbirth

29. Fetal Complications Macrosomia-63% vs 10% Caesearean sections-56% vs 20% Premature delivery-425 vs 12% Preecclampsia-18% Nronatal jaundice-18% RDS-17% Congenital anomlies-5% Perinatal mortality-5%

31. Macrosomia

33. Fetal Monitoring Serial growth scans Biophysical profile Cardiotocography Doppler

34. Delivery At 38 - 40 weeks gestation High incidence of caesarean Shoulder dystocia

35. Postnatal Care Breasting not to continue previous drugs which were contraindicated. advice on contraception and planning future pregnancy. Risk of hypos in the breast fed food before or during and establish control pre pregnancy insulin doses. GM stop insulin. Advise on diet exercise contraception, watch for hyperglycaemia. Subsequent screening. FBs -6 weeks postnatal and annually ophthalmology follow up inthose with proliferative dis.

36. Early neonatal risks Fetal hypoglycaemia Polycythaemia - jaudice Respiratory distress syn Birth trauma

37. Postnatal Insulin requirements return to normal immediately GTT at 6-12 weeks post partum Long term F/U - mother and baby

38. Contraception?

39. Barkerism

40. Summary