1. Camden Diabetes Education Day June 2014

2. In England and Wales: 650,000 deliveries each year
2-5% pregnancies involve women with diabetes
87.5% gestational diabetes
7.5% type 1 diabetes
5% type 2 diabetes
Type 2 increasing and may be higher here – ethnically diverse population

3. Key clinical issues
Adequately prepare women with pre-existing diabetes for pregnancy
Take appropriate steps during the pregnancy to minimise adverse outcomes

4. Risks discussed, started on folic acid 5mg Termination discussedLM
30 year old type 1 diabetes 1994, gastroparesis
Known ACR 82, HbA1c 14%
On ACE, statin
Levemir, Novorapid
Hospital admission with vomiting, found to be pregnant, discharged out of hours, ANC appt made for 2 weeks
Risks discussed, started on folic acid 5mg
Termination discussed

5. Made significant changes to insulin
BGL rapidly improved
PCR 512
Miscarried at 20 weeks

6. Risks: pre-existing diabetes
Miscarriage
Congenital anomalies

8. Maternal Risks: Hypoglycaemia Loss of hypo awareness
(increased risk of seizures, trauma)
Acceleration of complications (retinopathy and nephropathy)

9. Late complications (pre-existing diabetes / GDM)
Fetal macrosomia or IUGR
Shoulder dystocia
Preterm labour
Stillbirth
Neonatal hypoglycaemia
Pre-eclampsia

10. Factors associated with poor pregnancy outcome
Maternal social deprivation
Not using contraception
Suboptimal diabetes control pre & during pregnancy
Not taking Folic Acid 5mg
No preconception care

11. Pregnancy in type 1 & type 2 diabetes
All of those of us working in diabetes/ANC clinic know how difficult it is for women with diabetes… particularly type 1.
Women have to carry the burden of guilt of knowing that lapse of good control can cause irretrieveable damage to their developing baby.
We expect to see them weekly in busy clinics at a time that they don’t want anyone to know they are pregnant (especially their work).
Difficult balancing act

12. Experiences of professional support during pregnancy and childbirth – a qualitative study of women with t1.
Explored the experience of professional support during pregnancy in women with t1 diabetes.
Results:
Mothers concern about jeopardizing the baby’s health
Women felt that HCP concern was towards the baby and not them
Felt that they were used as messengers between hc providers
Data analysis was directed towards discovering qualitative
meanings by identifying and clustering meaning units
in the text. Further analysis identified eight
themes of meaning, classified
under pregnancy or childbirth, forming a basis for a final whole
interpretation of the explored phenomenon.
Results:
The women felt worry about jeopardizing the
baby's health and this was
Berg et al 2009

13. Pre-conception
Planned pregnancy (discuss with all women of child-bearing age)
Review contraception
Refer to pre-conception clinic
Aim HbA1c <7%, use contraception until good glycaemic control, offer monthly measurement HbA1c
All hcp who come into contact with women (of child-beaing range) should provide adequate preconception counselling
Always discuss contraception
Convey the possibility of good pregnancy outcomes
Support mothers-to-be in a holistic way
Programs customise to comply with culture and ethnic background

14. Type 1 – intensive support with control, pump therapy
Medication
Folic Acid 5mg (start preconception until 12 weeks)
Continue Metformin
Stop all other oral anti-diabetes drugs/substitute insulin
Stop ACE-I/ARBs
Stop Statins
Type 1 – intensive support with control, pump therapy
Retinal screening /Urine ACR and eGFR

15. Screening for Gestational Diabetes
Screening 28 weeks
50g glucose challenge test
Random BGL
Diagnosis
75g oral glucose tolerance test

16. Antenatal Care Regular appointments 1-3 weekly BGM 4 x/day
Fasting (target < 5.5)
1 hour post prandial (target <7.5)
Regular growth scans 4weekly (from 28wks)
Delivery – based on scan, glycaemic control

17. Postnatal Care GDM Annual HbA1c High risk – address lifestyle measures
Postnatal GTT at 6 weeks
Annual HbA1c
High risk – address lifestyle measures

18. What support can you get?
For women with type 2 diabetes:
Vanessa Sawmynaden
Preconception counselling
Improve glycaemic control prior to pregnancy
Transfer onto insulin when necessary

19. Miranda Rosenthal (Diabetologist)
Royal Free

20. UCLH Jakki Berry - preconception clinic
Antenatal clinic UCLH (Monday mornings)
Jo Modder / Nikki Lack (Consultant Obstetricians)
Jakki Berry / Lydia Chinyerere (DSNs)
Sarita Naik (Diabetologist)

21. To summarise…..