Pregnancy and Diabetes

Question 1

Maternal Hyperglycemia during pregnancy … for the fetus

Answer 1

Maternal Hyperglycemia during pregnancy is bad / very bad for the Fetus

Question 2

Why does Diagnosing Maternal Hyperglycemia matter?

• It affords an opportunity to prevent
  
  • … in the offspring “from the uterus to the …”
  • An exacerbation of the … & … epidemic
  • Future … in the mother

Answer 2

• It affords an opportunity to Prevent
  
  • –Morbidity In the offspring “from the uterus to the grave”
  • –An exacerbation of the obesity & Type 2 diabetes epidemic
  • –Future Type 2 diabetes in the mother

Question 3

Hyperglycemia of Pregnancy

• At Ante Natal Care booking there are 2 groups:
  
  • 1. Women with …
  • 2. Women with …
       * Known …
       * Unknown … or …

Answer 3

• At ANC booking there are 2 groups
  
  • 1. Women with Normal Glucose tolerance
  • 2. Women with Abnormal Glucose tolerance
       * Known Diabetes
       * Unknown Diabetes or IGT (impaired glucose tolerance)

Question 4

Hyperglycaemia during Pregnancy - Possible Scenarios

• Pre-… Hyperglycaemia
  
  • Type 1 Diabetes
  • Type 2 Diabetes
    
    • Known
    • Unknown
  • … Diabetes
  • … (IGT)
• “… Diabetes” (GDM)
  
  • Any newly found Abnormal GTT after the … trimester of pregnancy ( i.e. Diabetes or IGT )

Answer 4

• Pre-gestational Hyperglycaemia
  
  • –Type 1 Diabetes
  • –Type 2 Diabetes
    
    • Known
    • Unknown
  • Monogenic Diabetes
  • Impaired Glucose Tolerance (IGT)
• “Gestational Diabetes” (GDM)
  
  • Any newly found Abnormal GTT after the 1st trimester of pregnancy ( i.e. Diabetes or IGT )

Question 6

What is “Gestational Diabetes” (GDM)? - Practical Definitions

• WHO criteria ( and NICE)
  
  • Diabetes OR Impaired Glucose Tolerance
    
    • Fasting glucose =/ > … mmol/l
    • 2 hour GTT glucose =/ > … mmol/l
• International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria
  
  • Outcome based (HAPO study)

Answer 6

• WHO criteria ( and NICE)
  
  • Diabetes OR Impaired Glucose Tolerance
    
    • Fasting glucose =/ > 5.6 mmol/l
    • 2 hour GTT glucose =/ > 7.8 mmol/l
• International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria
  
  • Outcome based (HAPO study)

Question 7

WHO criteria for Gestational Diabetes:

• Fasting glucose =/ > … mmol/l
• 2 hour GTT glucose =/ > … mmol/l

Answer 7

• Fasting glucose =/ > 5.6 mmol/l
• 2 hour GTT glucose =/ > 7.8 mmol/l

Question 8

International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria - Gestational Diabetes

• Outcome based (HAPO study)
• What numbers in a glucose … test were associated with increased … for the fetus

Answer 8

• Outcome based (HAPO study)
• What numbers in a glucose tolerance test were associated with increased risk for the fetus

Question 9

Hyperglycaemia of Pregnancy IADPSG Criteria

• 75 g Glucose Tolerance test
  
  • Fasting … mmol/l
  • 1 hour … mmol/l
  • 2 hours … mmol/l
• Diagnose if 1 or more abnormal

Answer 9

• 75 g Glucose Tolerance test
  
  • Fasting 5.1 mmol/l
  • 1 hour 10.0 mmol/l
  • 2 hours 8.5 mmol/l
• Diagnose if 1 or more abnormal

Question 10

Hyperglycaemia in Pregnancy : The Problem

Answer 10

• Any degree of Maternal Hyperglycaemia during pregnancy can cause serious problems for the fetus

Question 11

Hyperglycemia during pregnancy - Consider management

• .. pregnancy
• .. pregnancy
• .. pregnancy

Answer 11

• Before pregnancy
• During pregnancy
• After pregnancy

Question 12

Stages of Pregnancy - Simple Endocrinologist’s view!

• 1st Trimester
  
  • O…
    
    • Carefully design the … components
    • Avoid Mistakes (T..)
    • Construct & programme the …
• 2nd Trimester
  
  • Further … development & linkage
• 3rd Trimester
  
  • Accelerated …

Answer 12

• 1st Trimester
  
  • Organogenesis
    
    • Carefully design the essential components
    • Avoid Mistakes ( Teratogenesis)
    • Construct & programme the placenta
• 2nd Trimester
  
  • Further complex development & linkage
• 3rd Trimester
  
  • Accelerated growth

Question 13

Maternal Metabolism changes as Pregnancy progresses

• Early pregnancy = Facilitated A…
  
  • Increased Insulin …
  • Glucose concentration slightly …
  • … maternal energy stores
• Later Pregnancy = Facilitated C…
  
  • Increased Insulin …
  • Increased … passage of nutrients
  • -> Rapid fetal …

Answer 13

• Early pregnancy = Facilitated Anabolism
  
  • Increased Insulin sensitivity
  • Glucose concentration slightly lower
  • Increased maternal energy stores
• Later Pregnancy = Facilitated Catabolism
  
  • Increased Insulin resistance
  • Increased transplacental passage of nutrients
  • -> Rapid fetal growth

Question 14

Maternal Hyperglycaemia - How does this mess with the system?

• 1st Trimester
  
  • Increased Fetal …
    
    • Fuel Mediated T…
  • Abnormal … programming & development
    
    • Increased risk of Pre-…
    • Excessive … transport
• Late Second & 3rd Trimester
  
  • Excessive … deposition
  • Adverse Fetal … ( epigenetics )

Answer 14

• 1st Trimester
  
  • Increased Fetal abnormalities
    
    • Fuel Mediated Teratogenesis
  • Abnormal placental programming & development
    
    • Increased risk of Pre-eclampsia
    • Excessive glucose transport
• Late Second & 3rd Trimester
  
  • Excessive fat deposition
  • Adverse Fetal programming ( epigenetics )

Question 15

First Trimester Maternal Hyperglycaemia leads to fetal malformation- , such as:

• Hydro…
• Meningo…
• … … in Congenital Heart Disease
• Single … and Sacral …
• … Agenesis

Answer 15

• Hydrocephalus
• Meningomyelocoele
• Central Cyanosis in Congenital Heart Disease
• Single Ventricle and Sacral Dysgenesis
• Renal Agenesis

Question 16

This graph is showing the percentage of … … in diabetes vs women without diabetes

Answer 16

Congenital Malformations

Question 17

Congenital Malformations due to Maternal Hyperglycemia

• … tube defects
• Congenital … abnormalities
• … Agenesis
• … problems

Answer 17

• Neural tube defects
• Congenital cardiac abnormalities
• Sacral Agenesis
• Renal problems

Question 18

Preventing Fetal Malformation in Hyperglycaemia of Pregnancy
- Start Preconception for known Diabetes

• Good Diabetes Control in … Trimester
  
  • … counselling
    
    • … Modification
    • Intensive … monitoring
    • If not on … commence …
    • Optimize … Regimen
      
      • B… Bolus or Pump
      • Freestyle … or continuous … monitoring
• … Acid 5mg / day

Answer 18

• Good Diabetes Control in 1st Trimester
  
  • Prepregnancy counselling
    
    • Lifestyle Modification
    • Intensive glucose monitoring
    • If not on Insulin commence Insulin
    • Optimize Insulin Regimen
      
      • Basal Bolus or Pump
      • Freestyle Libre or continuous glucose monitoring
• Folic Acid 5mg / day

Question 19

Primary care & Prevention of Fetal Malformation due to Hyperglycaemia of Pregnancy

• Identify Unknown cases of Diabetes / IGT by checking women with risk factors
  
  • Previous … Diabetes
  • O…
  • … … syndrome
  • Family history of …
  • High risk … group

Answer 19

• Identify Unknown cases of Diabetes / IGT by checking women with risk factors
  
  • Previous Gestational Diabetes
  • Obesity
  • Polycystic ovarian syndrome
  • Family history of type 2 diabetes
  • High risk racial group

Question 20

Prevention in Primary care
DPP - Mean Weight Change

• Green = ?
• Yellow = ?
• Blue = ?

Answer 20

• Green = Placebo
• Yellow = Metformin
• Blue = Lifestyle

Question 21

What is Macrosomia?

Answer 21

Macrosomia is a term that describes a baby who is born much larger than average for their gestational age, which is the number of weeks in the uterus.

Question 22

Hyperglycaemia in the third trimester = lead to …

Answer 22

Macrosomia (larger than average baby)

Question 23

Macrosomia - Hyperglycaemia in 3rd Trimester - leads to…

• Difficult …
• … Dystocia
• … Problems
  
  • • J…
  • …glycaemia
  • Hypo…
  • Poly…

Answer 23

• Difficult birth
• Shoulder Dystocia
• Breathing Problems
  
  • + Jaundice
  • Hypoglycaemia
  • Hypocalcaemia
  • Polycythaemia

Question 24

• Women with Diabetes vs No Diabetes - Increased … Mortality
• T2 Diabetes = x …
• T1 Diabetes = x …

Answer 24

• Increased Perinatal Mortality = T2 Diabetes x 9, T1 Diabetes x 4

Question 25

_Hyperglycaemia in Pregnancy - Lifelong Fetal Sequele_ * O... * ... resistance * ... diabetes * Dys... * ...tension * ... disease * Adverse ... outcomes?

Answer 25

* **Obesity** * **Insulin resistance** * **Type 2 diabetes** * **Dyslipaemia** * **Hypertension** * **Vascular disease** * **Adverse neurodevelopmental outcomes?**

Question 26

_Compounding the Problem - Pregnancy and Diabetes_ * The number of women with diabetes during pregnancy giving birth has more than ... recently, * a finding that raises health concerns for both mothers-to-be and babies. * USA Today 28/04/2008​

Answer 26

* The number of women with diabetes during pregnancy giving birth has more than **Doubled** recently, * a finding that raises health concerns for both mothers-to-be and babies. * USA Today 28/04/2008​

Question 27

“One in ... women in the United Kingdom is obese at antenatal booking”, * BMJ 2013

Answer 27

“One in **five** women in the United Kingdom is obese at antenatal booking”, * BMJ 2013

Question 28

_Detecting Hyperglycemia of Pregnancy - Early Screening for high risk women_ * Previous ... or M.. * Obesity ( BMI \> ...) * ... history * High risk ... group * ... age * ... ... syndrome * + Universal or Targeted Screening & ...-... weeks

Answer 28

* Previous **GDM** or **MACROSOMIA** * Obesity ( BMI \> **30**) * **Family** history * High risk **racial** group * **Older** age * **Polycystic ovary** syndrome * + Universal or Targeted Screening & **26-28** weeks

Question 29

_Treatment of any Pregnancy Hyperglycaemia_ * Good maternal ... control * Intensive blood ... ... * ... prick tests * Fasting + 1 hour post ... minimum * Fasting + 1 hr post ... + pre... * ... Libre (or continuous monitoring system) * Appropriate n... * Reasonable e... * Utrasound monitoring of Fetal ... girth * Monthly from ... weeks * Maternal observation of Fetal ...

Answer 29

* Good maternal **glucose** control * Intensive blood **glucose** monitoring * **Finger** prick tests * Fasting + 1 hour post **prandial** minimum * Fasting + 1 hr post **prandial** + **preprandial** * **Freestyle** Libre (or continuous monitoring system) * Appropriate **nutrition** * Reasonable **exercise** * Utrasound monitoring of Fetal **abdominal** girth * Monthly from **28** weeks * Maternal observation of Fetal **movements**

Question 30

_Targets for Hyperglycaemia of Pregnancy_ * Fasting glucose \< ... mmo/l * 1 hour postprandial glucose \< ... (...) mmol/l * Fetal Abdominal girth \< ...th centile * Less in A...

Answer 30

* Fasting glucose \< **5.1** mmo/l * 1 hour postprandial glucose \< **7** (7.8) mmol/l * Fetal Abdominal girth \< **70th** centile * Less in **Asians**

Question 31

_Drug treatment to achieve good Maternal Glucose control in pregnancy_ * Prepregnancy /1st trimester hyperglycaemia * ... ... Insulin regimen * “Gestational” diabetes * M... * Basal ... * Basal ... Insulin * G... (ONLY IF NO ALTERNATIVE)

Answer 31

* Prepregnancy /1st trimester hyperglycaemia * **Basal bolus** Insulin regimen * “Gestational” diabetes * **Metformin** * Basal **Insulin** * Basal **bolus** Insulin * **Glibenclamide** (ONLY IF NO ALTERNATIVE)

Question 32

_Diabetes / GDM – Post Partum_ * Encourage ... ... * Maintain good ... control * To prevent excess ... in ... * Reduce maternal ... ... * Advice re next pregnancy * C.. advice * Encourage long term ... control

Answer 32

* Encourage **Breast Feeding** * Maintain good **Glycaemic** control * To prevent excess **glucose** in **milk** * Reduce maternal **weight gain** * Advice re next pregnancy * **Contraception** advice * Encourage long term **glycemic** control

Question 33

_Breast Feeding & Obesity_ * Child * Any reduces risk by ...-...% * 19 studies 3-19 years * 6 studies 4-18 years * Prolonged exclusive reduces by ...% * Mother * Reduces postpartum ... ...

Answer 33

* Child * Any reduces risk by **30-50**% * 19 studies 3-19 years * 6 studies 4-18 years * Prolonged exclusive reduces by **67**% * Mother * Reduces postpartum **weight gain**

Question 34

What did this study show?

Answer 34

**Women who lactated for either 6–12 months or 12 months or longer had half the risk for diabetes**

Question 35

_“Specific GDM” Management - Post Partum_ * Screen for diabetes at ... weeks post partum * HbA1c +/- Fasting glucose, ( or GTT ) * Review GAD ect. antibody status if done * Lifestyle advice * Advice re next pregnancy * Optimize exercise & Nutrition * Pre pregnancy GTT * ... glucose screening * ...% develop type 2 diabetes at 10 years

Answer 35

* Screen for diabetes at **12** weeks post partum * HbA1c +/- Fasting glucose, ( or GTT ) * Review GAD ect. antibody status if done * Lifestyle advice * Advice re next pregnancy * Optimize exercise & Nutrition * Pre pregnancy GTT * **Annual** glucose screening * **50**% develop type 2 diabetes at 10 years

Question 36

_GDM & Primary Care – Post Partum - Contraceptives & Diabetes / IGT_ * ... ... pill * ... ... ( low dose) after ... weeks * Mirena ... system * Sterilisation / Vasectomy

Answer 36

* **Progestagen only pill** * **Combined OCP ( low dose) after 6 weeks** * **Mirena Intrauterine system** * **Sterilisation / Vasectomy**

Question 37

_Hyperglycaemia in Pregnancy - Summary 1 – The Problem_ * Maternal Hyperglycaemia leads to Serious ... problems * Early - T... * Late * M... / hypo... / lung problems * Pre-... * Late Fetal ... * Perinatal J..., poly...

Answer 37

* Maternal Hyperglycaemia leads to Serious **fetal** problems * Early **- Teratogenesis** * Late * **Macrosomia / hypoglycaemia / lung problems** * **Pre-eclampsia** * **Late Fetal death** * **Perinatal Jaundice, polycythemia**

Question 38

_Hyperglycaemia in Pregnancy Summary 2 - Management_ * Folic acid ...mg in 1st Trimester * Aspirin ... - ... mg/day from 12/40 * if less than 16/40 * Attendance at ... one stop clinic * Tight ... control throughout pregnancy * Fetal ... monitoring in last trimester * Maternal monitoring of Fetal ... * Appropriate delivery strategy (NO ...!!)

Answer 38

* Folic acid **5mg** in 1st Trimester * Aspirin **75 - 150** mg/day from 12/40 * if less than 16/40 * Attendance at **multidisciplinary** one stop clinic * Tight **glucose** control throughout pregnancy * Fetal **Ultrasound** monitoring in last trimester * Maternal monitoring of Fetal **movements** * Appropriate delivery strategy (NO **DOGMA**!!)

Question 39

_Hyperglycaemia in Pregnancy - Summary 3 - Screening_ * Screen to detect “... diabetes” * High risk women at ...-... weeks * At ... weeks * Everyone (Universal screening ) or * Targeted (NICE) * Postpartum Screen “GDM women” for Diabetes * At ... week post Partum * Annually for Diabetes (...% by 15 years)

Answer 39

* Screen to detect “**Gestational** diabetes” * High risk women at **12-14** weeks * At **28** weeks * Everyone (Universal screening ) or * Targeted (NICE) * Postpartum Screen “GDM women” for Diabetes * At **12** week post Partum * Annually for Diabetes (**50**% by 15 years)