Diabetes In Pregnancy

Question 1

Define Gestational diabetes mellitus (GDM)

Answer 1

‘Carbohydrate intolerance resulting in hyperglycaemia with variable severity… during pregnancy’ (WHO, 2013)

Affects 4-5% of pregnant women (RCOG, 2021)

Question 2

Type 1 diabetes:

Answer 2

-lack of insulin as beta cells are damaged by immune system
-abrupt onset, non-obese/no family history , young
-weight loss, nausea, polydipsia/uria
-8% of diabetics

Question 3

Type 2 diabetes:

Answer 3

-inability to produce sufficient insulin, reduced insulin sensitivity
-obesity, PCOS, Asian backgrounds, prev GDM
-90% of diabetics

Question 4

Indications for GTT:

Answer 4

-BMI > 30
-prev GDM
-family history/ ethnicity
-glycosuria of 1X 2+ or 1+ 2X
-prev macrosomic baby >4.5kg

(NICE, 2020)

Question 5

Method for GTT:

Answer 5

-Fast from midnight
-obtain fasting blood sample
-drink (75g glucose and rest for 2 hours
-obtain 2nd blood sample
-document

Question 6

When and ranges:

Answer 6

-24-28 weeks
-at booking and 28/40 if prev GDM, BMI > 45
-1st: <5.6mmol/L
-2nd: <7.8 mol/L

Question 7

Advice:

Answer 7

-exercise
-diet
-dietician, diabetic team and consultant referral
-growth scans
-IOL, neonatal hypoglycaemia

Question 8

Monitoring GDM:

Answer 8

-1 hour before and after feeds
-before: 5.3mmol/L
-after: 7.8mmol/L
-metformin if exercise and diet unaffective
-insulin if metformin unaffective

Question 9

Polyhydramnios:

Answer 9

-increased amniotic fluid
-caused by fetal polyuria due to high blood glucose levels

Question 10

Birth plan for women with GDM:

Answer 10

-offer IOL 40+6
-offer IOL before 40/40 if other complications present
-CS if IOL contraindicated
-if IOL declined, offer more monitoring

Question 11

Maternal risks with diabetes:

Answer 11

-retina damage
-damage to kidneys nephrons
-harmful ketone build up

Question 12

Fetal risks due to diabetes

Answer 12

-miscarriage and stillbirth
-LGA, shoulder dystocia
-neonatal hypoglycaemia
-diabetes and obesity in later life

Question 13

Pre-conception diabetic care:

Answer 13

-good control of blood sugars will reduce risk of fetal harm
-use contraception until BMI 18-27 and diet control
-5mg follic acid

Question 14

Antenatal care for diabetic women:

Answer 14

-refer to consultant led care
-75mg PO aspirin from 12/40 - delivery
-growth scans from 28/40

Question 15

Diabetic ketoacidosis

Answer 15

Normal ketone level- <1.5
High: 3 (possible DKA)
Fetal mortality up to 35%
Care in HDU: fluids, monitoring

Question 16

Labour care:

Answer 16

-offer birth on D/S with CTG
-monitor blood glucose

Question 17

Postnatal care:

Answer 17

—stop insulin if GDM or reduce if prev diabetic
-health promotion
-fasting glucose test 6-13 weeks postnatal

Question 18

Testing for neonatal hypoglycaemia:

Answer 18

Pre feed BMs for 2nd and 3rd feed
-should be above 2.0mmol/L