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Diabetes in pregnancy Fiona McKeeman-Credentialled Diabetes Educator 1 Diabetes In Pregnancy Gestational Diabetes Pre-Existing Diabetes- Type 1 Diabetes Type 2 Diabetes The Endocrine Unit The advanced trainee/ Reg Pager


  1. Diabetes in pregnancy Fiona McKeeman-Credentialled Diabetes Educator 1

  2. Diabetes In Pregnancy  Gestational Diabetes  Pre-Existing Diabetes-  Type 1 Diabetes  Type 2 Diabetes

  3. The Endocrine Unit  The advanced trainee/ Reg  Pager 464 or through switch during working hours  The consultants -  Drs Renouf, Matthiesson & Dutta  After hours -Contact the endocrinologist on call through switch  The DNEs (Diabetes Nurse Educators)  Sue, Fiona, Kylie, Debbie, Fadwa  Page 506 or ext 7625 (working hrs Mon-Fri) 3

  4. Gestational Diabetes 2-3 times Pancreas Carbohydrate Insulin glucose Muscle cell g g g g g g g g g g g g g Hormones Placenta

  5. What is GDM?  Gestational Diabetes Melitis is glucose intolerance with onset or first recognition in pregnancy  Usually a temporary form of diabetes that occurs during pregnancy.  Rising levels of placental hormones (HPL and progesterone) have opposite action to insulin causing release of glucose from cells into the bloodstream. These Hormones also cause insulin resistance.  Insulin production from the pancreas needs to increase (2-3 times more) to match the effect of these placental hormones.  Women who develop GDM have deficient insulin production and/or significant insulin resistance .

  6. Foetal and maternal risks of GDM  Risks to Baby  Risks to Mother  Macrosomia  Pre-eclampsia  Neonatal Hypoglycaemia  Polyhydramnios  Birth Trauma  Caesarean Birth  Shoulder dystocia  Future risk of GDM 50% next pregnancy 70% if you  Respiratory Distress have had it in first two  Hypocalcaemia pregnancies.  Polycythemia  Future risk of Type 2- 50%  Jaundice  Obesity, abnormal glucose tolerance, GDM &Type 2 diabetes in adolescence and adulthood.

  7. Testing for GDM New recommendations ADIPS 2014 (nov) (RANZCOG Endorsed)  All women not known to have pre pregnancy diabetes or hyperglycemia in pregnancy should undergo 75gm OGTT at 24-28 weeks (Glucose Challenge Test (GCT) screening no longer recommended)  Those Identified as HIGHER RISK should undergo a 75gm OGTT early in pregnancy or at the fist opportunity after conception.  Women in the HIGHER RISK group who have a normal result on early pregnancy testing should have a repeat 75gm OGTT at usual time of 24- 28wks. However a OGTT should be performed at any earlier time if clinically indicated. 7

  8. GDM Risk Factors  Higher risk groups- (any of below)  Previous hyperglycaemia in pregnancy  Previously elevated BGL  Maternal age ≥40 yrs.  Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African.  Family History of Diabetes (1 st degree relative or a sister with GDM)  Pre pregnancy BMI >30kg/m 2  Previous macrosomia (baby birth wt >4500gm or >90 th centile)  Polycystic ovarian syndrome  Medications: Corticosteroids, antipsychotics 8

  9. Diagnostic Criteria RANCOG Endorsed – recommended adoption Jan 1 st 2015 Old Criteria: Fasting ≥5.5, 1hr - not considered, 2hr ≥ 8.0 GDM occurs in approx. 5-8% of Australian pregnancies (may increase to 12-14% with new diagnostic criteria) 9

  10. Pre-Existing - Type 2 Diabetes Pancreas Carbohydrate Insulin glucose Muscle cell g g g g g g g g g g g g g g g g Hormones Placenta Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

  11. Pre-Existing - Type 1 Diabetes Pancreas Carbohydrate Insulin g glucose Muscle cell g g g g ketones Fat g g g cell FA g g g g g g g g Hormones Placenta Embryo Image: library.thinkquest.org/.../glossary/Embryo.htm

  12. Foetal and maternal risks of Pre-existing Diabetes Risks to Baby  Risks to Mother   Congenital abnormalities 2-3 higher risk than gen pop Some complications of   Miscarriage/ foetal death diabetes accelerated by pregnancy eg renal damage  Intra uterine growth retardation- small for gestational age and retinopathy.  Type 1 diabetes (greater if father has Type 1 UTI’s  diabetes) 2% mother vs 5% father Hypoglycaemia   Macrosomia Ketoacidosis- Type 1 diabetes   Birth Trauma Pre-eclampsia   Shoulder dystocia Polyhydramnios  Neonatal Hypoglycaemia   Respiratory Distress  Caesarean Birth  Polycythemia  Jaundice  Hypocalcaemia  Obesity, abnormal glucose tolerance &Type 2 diabetes in adolescence and adulthood. Normal BGLs are the aim pre pregnancy and throughout pregnancy 12

  13. Type 1 & Type 2 Diabetes Congenital Abnormalities  Congenital abnormalities (heart, CNS, neural tube, kidneys, GI ) 2-3 times higher risk than general population.  Malformation rates are related to the degree of hyperglycaemia  Most congenital abnormalities occur 3-6 weeks after conception -often before pregnancy is diagnosed.  Can result in miscarriage, Foetal death in utero  Women conceiving with HbA1c less than 7% have malformation rates comparable to non – diabetic women.  Pre pregnancy counselling vital 13

  14. GDM (no DM before pregnancy) Diet and Exercise Rx Insulin Rx Pre-existing diabetes ?? Metformin Rx Type 1 Type 2 14

  15.  Treatment targets for self BG monitoring  Varies between centres around Australia.  The Following are suggested by ADIPS Based on “best available” data but need further research for RANZCOG endorsement.  Fasting ≤ 5.0 mmol/l  (1 hour BG after commencing meal ≤ 7.4 mmol/l) - if can’t wait to 2hrs  2 hour BG after commencing meal ≤ 6.7 mmol/l 15

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  17. Medtronic Paradigm pump 17

  18. On admission  Check DMR for any admission instructions from GDM clinic  Check for Diabetes Labour management plan in DMR  Refer to Clinical Practice Guideline- Diabetes in pregnancy (on intranet)  Ring to inform endocrine unit  during working hours if not urgent  at any time, if required urgently

  19. In labour- GDM and Type 2 Diabetes  Withhold insulin when in labour  Aim is to keep the BGLs 4-7 mmol  This reduces the risk of neonatal hypoglycaemia  Check BGLs Hourly in labour  Contact Endocrinology unit If BGLs >7.0 an insulin infusion may be required (stop after delivery of placenta)  GDM -NO insulin after delivery  Type 2- Endocrinology review to assess if oral agents or insulin is required. 19

  20. Type 1 DM in labour  Hourly BGLs  Require an insulin infusion  Insulin pump patients – routinely cease pump and commence infusion when in labour Type 1 After delivery  Reduce insulin infusion to 1/5 th at delivery of placenta (do not stop infusion until restarting insulin injections)  Ongoing Insulin doses will NEED TO BE REDUCED to 1/5 th of previous pregnancy doses  Do NOT withhold insulin or glucose even if not eating 20

  21. Elective Caesarean Section – On insulin Clarify plan of management for pre, peri and post  operation with endocrinology and anaesthetist. Ideally caesarean sections for patients with insulin  requiring diabetes should be scheduled early on the morning list to minimise disturbance of glucose metabolism. Normal insulin night prior to Caesarean. Withhold  morning insulin Type 2 and GDM monitor BGL early morning and pre-  op – if >7.0 insulin infusion may be required (cease infusion after delivery) Patients with Type 1 diabetes switch to insulin and  dextrose infusion in morning. Reduce rate One Fifth rate after delivery of the placenta. 21

  22. Insulin dextrose Intravenous Infusion 10% dextrose 12hrly rate Insulin Infusion 50units Actrapid in 50ml Normal saline Extra 10units Actrapid in 10ml Normal saline to prime through tubing

  23. Preparing insulin infusion Follow MR18B insulin infusion order -contact endocrinologist for or. Prepare Insulin Syringe Driver: Make up 10 units (Actrapid) in 10mls normal saline (ie 1 unit per ml) prime  infusion line with all of this solution before connecting – coats the tubing as insulin is sticky protein and will stick to plastic coating until fully coated. Make up 50ml syringe with 50 units regular insulin (Actrapid) in 50mls normal  saline (ie 1 unit per ml) Connect to same cannula as dextrose infusion using Y lumen connector  Starting rate ordered by endocrinologist  Prepare Dextrose Infusion 10% Dextrose to commence at 12hrly rate when BGL less than 15mmol  Aim is to keep BGL’s 4 -7mmol during labour- specific instructions need to be  handwritten by Dr in lower section of infusion protocol. Hourly BGL’s  Follow hypo treatment as per insulin infusion protocol MR 18B 

  24. Hypoglycaemia Treatment  Routine hypo treatment (when not on insulin infusion)  If BGL<3.9mmol  100ml lucozade (if able to swallow and conscious)  Repeat BGL 10mim  If still < 3.9 repeat lucozade 100ml  Give longer acting carb snack once >4.0mmol  If altered conscious state- 25ml IV Dextrose 50% slow push-retest in 5min- commence 8/24 10% dextrose.  (If no IV access Glucagon IM 1mg)  (Refer to hypoglycaemia treatment CPG)

  25. Care post delivery  GDM  Diabetes educator review- advise risk of subsequent risk of diabetes and GDM.  Check QID BGL 24 hrs (diet controlled) 48hrs (insulin) notify endo if above 10  75 gm OGTT 6wks post partum  Review appointment GDM clinic or GP 8-10wks postpartum  1-2 yearly OGTT if not pregnant  Early OGTT in next pregnancy – first visit or 12-14 wks gestation 25

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