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1999 Obstetrics & Gynaecology By Duy Thai

MANAGEMENT OF DIABETES IN PREGNANCY •

A 25 year old woman with IDDM wants to get pregnant. She comes to you for pre pregnancy advice. What do you do?

1. History • How long have you had the diabetes? • Any complications of diabetes • Eyes • Renal function, any hypertension • Cardiovascular system (unlikely at this age to have problems) • What diabetic medications • Any other medications (e.g. antihypertensives) • Level of control • Frequency of BSL monitoring • Any episodes of hypo or hyperglycemia – any 2. Examination • BP • Check eyes – fundoscopy • Urinalysis – if proteins, do 24 hour urine collection and MSU M/C/S 3. Investigations • ECG if over 35 • RFT/U&E • FBE • BSL • HBA1c • 24 hour urine collection 4. Advice/education • Folate 5mg/day (NOT 0.5mg) as she is at increased risk of having baby with NTD • Sensible diet, exercise • Educate on: • Effect of diabetes on pregnancy • Increased risk of fetal malformations • Risk of pre ecclampsia • Effect of pregnancy on diabetes • Insulin requirements may be increased • Prognosis She is now pregnant. What do you do? 1. Team approach – endocrinologist/physician, dietician, obstetrician, nurse educator, paediatrician 2. Dietician advice • High complex carbohydrates • Distribute food evenly throughout day • Exercise, 30 min/day 3. Strict diabetes control • BSL 4 times daily • Basal bolus regime of insulin 4. Increased frequency of antenatal visits • 2 weekly until 28 weeks • Weekly thereafter 5. Increased frequency of fetal wellbeing assessment (to detect abnormalities and risk of FDIU) • Ultrasound 12 weeks – may see anencephaly 18 weeks – spina bifida 28 weeks 30 weeks – fetal growth 34 weeks – check fetal growth, looking for evidence of macrosomia • CTG – start at 32 weeks: once a week until 38 weeks, twice thereafter • May consider to deliver at 38 weeks due to risk of macrosomia (obstructed labour) and FDIU Page 1 of 2

1999 Obstetrics & Gynaecology By Duy Thai

Case 2 • Primigravida, 25/40, has GTT result: fasting 5.4, 120min 9.5 (N<8) • What do you do? 1. Tell her that she has gestational diabetes 2. How did she get it • Due to raised HPL from placenta • No need to worry 3. Refer to dietician for dietary control • Control diet • Regular exercise 4. Home glucose monitoring • Levels should be < 6.5 2 hours post prandial • If levels persistently > 7 should advise start on insulin 5. Fetal monitoring • Ultrasound at 30 and 34 weeks to detect presence of macrosomia • CTG weekly from 32 weeks at PDSU 6. If well controlled, can delivery at term 7. Post partum counselling • Don’t need to be on insulin • 50% chance of developing GDM in next pregnancy • 50% chance of developing NIDDM within 20 years • If she gets pregnant again, need to do a GTT (rather than GCT) earlier on (at 2nd visit). If normal, repeat at 28 weeks

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MANAGEMENT OF DIABETES IN PREGNANCY