diabetes and pregnancy
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on Jul 26, 2012 Says :
nice ppt on pregnancy planning.
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Slide 1 :
Diabetes and pregnancy Great Expectations! Sister Lesley Mowat Dr Shirley Copland
Slide 2 :
Pregnancy -the ideal outcome As normal a pregnancy as possible Healthy mother and baby Aiming to reduce the rates of miscarriage, congenital anomaly and perinatal mortality to the same levels as the background population
Slide 3 :
Topics Prepregnancy planning Care during pregnancy Gestational diabetes
Slide 4 :
Pre-pregnancy planning All patients with type 1, type 2 or secondary diabetes who are in the child bearing years should be made aware of the importance of planning for any pregnancy Discuss during routine review along with contraception issues
Slide 5 :
Pre-pregnancy planning Key message is that excellent glycaemic control prior to conception and during pregnancy results in the optimal outcome for mother and baby Self management of diabetes and issues of hypoglycaemia need to be discussed e.g. insulin adjustment, glucose targets, driving, teach use of hypostop/glucogon to partner
Slide 6 :
Pre-pregnancy planning Diabetes complications need to be recognised and managed optimally Review medications NB Ace inhibitors are teratogenic Rubella status to be checked Commence folic acid 5mg Review other health issues, menstrual status and gynaecological factors
Slide 7 :
Pre-pregnancy planning SIGN guidelines strongly recommend that pre-pregnancy care is provided by a mutli-disciplinary specialist team Advise early attendance at specialist clinic for pre-pregnancy advice i.e. Combined Diabetes/Obstetric Clinic, AMH (weekly Tues pm)
Slide 8 :
Why need to plan? Pregnancy in Type 1 diabetes is a high risk state for both the mother and the foetus Increased risks of diabetes complications Increased risk of obstetric complications Increased foetal and neonatal hazards
Slide 9 :
Why need to plan? Patients with type 2 diabetes are also at increased risk of obstetric complications and their babies are equally at risk of malformation and neonatal problems Type 2 diabetes increasing in young women Tight glycaemic control prior to and during pregnancy is essential and insulin therapy likely to be required
Slide 10 :
Maternal risks with Type 1 diabetes Severe hypoglycaemia with loss of hypoglycaemic awareness (30%) Ketoacidosis can develop more rapidly Worsening of pre-existing retinopathy - laser treatment can be required Worsening of pre-existing renal dysfunction and hypertension
Slide 11 :
Obstetric risks in diabetes Increased rates of miscarriage Higher incidence of pre-eclampsia Obstructed labour and polyhydramnios now less common High caesarean section rates (71%)
Slide 12 :
Foetal and neonatal risks Congenital malformation rates remain greater than the background population e.g. cardiac defects, sacral agenesis Late intrauterine deaths and increased foetal distress - aim to deliver between 38-40 weeks Macrosomia(most >50th centile, many 95th) Neonatal hypoglycaemia is common
Slide 13 :
Slide 14 :
Aims prior to conception Blood glucose levels between 4 - 7 mmols HbA1c target of 7.0% or less Avoiding disabling hypoglycaemia ?How
Slide 15 :
Patient commitment Home glucose monitoring 4 -6 times daily (or more!) Multiple injection insulin regime i.e. basal bolus regime with self adjustment Address lifestyle issues and review diet Clinic visits 6-8 weekly and telephone support
Slide 16 :
Pregnant at last! Patients should attend combined obstetric /diabetes ante-natal clinc as soon as pregnancy is confirmed May need admission for stabilisation of control early or at any time during the pregnancy - open door policy in Ashgrove Ward, AMH Routine 2- 4 weekly review schedule followed but seen as often as required
Slide 17 :
Pregnancy Patients strive for near normal glycaemia throughout the pregnancy i.e. blood sugar 4-7 mmols Self titration of the insulin dose is essential Insulin doses at least double by the end of pregnancy Encouraged to check for ketones if bs greater the 10 mmols and seek immediate advice if present (risk of foetal death)
Slide 18 :
Delivery Ideally vaginal delivery between 38 and 40 weeks gestation Neonatal intensive care facilities required During labour iv insulin/10 % dextrose regime used to maintain euglycamia High ceasarean section rate Post delivery insulin doses return to pre- pregnancy level in type 1 patients. Type 2 often diet alone initially if breast feeding
Slide 19 :
Gestational Diabetes Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy Usually seen in the third trimester and glycaemic control returns to normal immediately after pregnancy May be the first presentation of type 1 or type 2 diabetes
Slide 20 :
Gestational Diabetes Screening - by a random venous glucose if glycosuria ++ is detected and routinely at 28 weeks gestation If greater than 5.5 mmols/l two hours or more after food or greater than 7.0 mmols/l within two hours of eating then requires further investigation by a 75g OGTT
Slide 21 :
Gestational diabetes Diagnosis confirmed if fasting bs is greater than 5.5 mmols/l or two hour OGTT level greater than 9 mmols/l Associated with macrosomia and treatment by diet and/or insulin may cause a modest reduction in birth weight Initial management is dietary - if blood glucose remains elevated and if evidence of macrosomia then insulin treatment started
Slide 22 :
Gestational diabetes Marker for increased risk of future diabetes OGTT arranged 6 months post partum, majority are normal at that stage Up to 50% may go on to develop later diabetes mainly type 2 Should be advised on lifestyle and weight reduction to reduce risk Protocol for follow up in primary care
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