Complicated Pregnancy 2- Diabetes

Question 1

There are 2 mechanisms by which pre-existing diabetes causes a problem

Answer 1

• Raised insulin requirments of the mum

- Hyper-insulinaemia of the foetus

Question 2

What causes insulin requirements to rise during pregnancy?

Answer 2

Production of certain anti-insulin hormones:

• Human Placental Lactogen
• Progesterone
• HCG
• Cortisol

This causes problems for mum if insulin doses aren’t adjusted well enough

Question 3

By what mechanism do you get foetal hyper-insulinaemia in pre-existing diabetics?

Answer 3

High maternal glucose crosses placenta to bairn
–> Increase in foetal insulin production
–> Problems
E.g. Macrosomia, neonatal hypoglycaemia & respiratory immaturity

Question 4

What risks does pre-existing DM hold for the mother?

Answer 4

• Miscarriage
• Pre-eclampsia
• Worsening of diabetic complciations e.g. nephropathy, retinopathy or hypos
• Infections
• Shoulder dystocia on delivery

Question 5

What risks foes pre-existing DM hold for the baby?

Answer 5

• Macrosomia & Shoulder Dystocia
• Polyhydramnios
• Stillbirth
• Neonatal Hypoglycaemia and resp distress
• Prematurity

Question 6

Its useful to split obstetric management of pre-existing DM into 3 “phases”

Answer 6

• Pre-conception
• Pregnancy
• Labour

Question 7

What actions should we take prior to a diabetic actually getting pregnant?

Answer 7

• Optimise the Glycaemic control till its in 4-7mmol/l
• Give folic acid
• Give Dietary Advice
• Do Retinal & Renal Assessments

Question 8

What medications can we provide diabetics during pregnancy?

Answer 8

• Insulin (increased dose or replacing oral drugs) to optimise control
• Conc glucose solution or glucagon injections in case of hypos

Question 9

What should we monitor in a pregnant diabetic during the actual pregnancy phase?

Answer 9

• Blood glucose
• BP & urine protein= watch pout for Pre-eclampsia
• Look out for Ketonuria & Infections
• Foetal Growth
• Retinal Assessment at 28 & 34 wks

Question 10

Do diabetic women deliver by normal delivery?

Answer 10

Most are induced around 38-40wks due to macrosomia

You should always consider C-section if the baby is large to avoid complications such as shoulder dystocia or tears

Question 11

What else should we do during and after labour to ensure a diabetics mothers (and foetuses) health?

Answer 11

• Use insulin during labour to maintain the sugar level
• Continuous CTG

Feed the baby early to avoid hypos

Question 12

What is Gestational DM?

Answer 12

Carb intolerance in pregnancy and abnormal glucose tolerance reverting to normal after delivery

Its risky but not nearly as dangerous as Type 1 or 2 DM

Question 13

What are the risk factors for developing gestational DM?

Answer 13

Any H/o GDM or FH of DM

A previous macrosomic baby

Polyhydramnios, large foetus or recurrent glycosuria in the current pregnancy

Increased BMI >30

Coming from a high risk group for DM e.g. Asian origin

Question 14

Who do we screen for GDM?

Answer 14

Any women with risk factors

Question 15

How do we screen for GDM?

Answer 15

If risk factor present- offer Hb1Ac estimation :
o If >6% offer oral glucose tolerance test of 75mgs
o If normal OgTT repeat at 24-28 weeks
o Offer OGTT again at 16 and 28 weeks if there is more than 1 risk factor present

Question 16

How do we manage a mother with GDM?

Answer 16

Sugar control!:

• Start with Diet
• Insulin & Metformin

Question 17

How is GDM managed after the delivery?

Answer 17

Glucose should return to normal, check with OGTT 6-8wks PN

Yrly HbA1C due to the high risk of developing overt DM now

Question 18

What size baby is considered to be macrocosmic?

Answer 18

any baby over 4.5kg