Guidelines

2008: Diab in Pregn: CG63 | pdf (full) | QuickRef

• 650k births (Eng&Wal)/yr, 2-5% with DM (87.5% GDM + 7.5% T1DM + 5% T2DM)
• Icrd risk of miscarriage, pre-eclampsia, preterm labour, rapid worsening of diab retinopathy
• Icrd risk of stillbirth, congen malformations, macrosomia, birth injury (b/o macrosomia), perinat mort, postnatal adaption problems (hypoglycaemia)
• Only Insulin Aspart has marketing authorisation for pregnant women, others: informed consent

Preconception care:

• good glycaemic control before [aim HbA1c<6.1%] and during pregnancy dcrs risk of
• fetal macrosomia
• birth trauma (to mother and baby)
• induction of labour or caesarean section
• miscarriage
• congen malform
• stillbirth
• transient neonatal morbidity
• neonatal death
• obesity and/or diabetes developing later in the baby's life
• avoid unplanned pregnancy (esp if HbA1c>10%, no retinal assessment<6mths)
• folic acid 5mg od until 12/40
• stop OHA (+- except Metformin)
• stop ACEI, ARB (substitute with alternatives), Statins
• Isophane Insulin as 1st choice long-acting (insuff. data on long-acting analogues)
• retinal assessment and treatment if necessary
• consider renal referral if Crea>120 or eGFR<45mL/min/1.73m2 before discont contraception

Gestational DM:

• Risk factors and indication for screening for GDM:
• BMI>30
• prev macrosomic baby>4.5kg
• prev GDM
• 1st deg relative with DM
• family origin (South Asia; black Caribbean, Middle East)
• icrd risk of macrosomia (& shoulder dystocia, birth trauma), induction of labour, C-section, icrd monitoring during pregn and labour
• GDM screening by 75g 2h oGTT at 24-28 wks (16-18 wks and 28wks if prev GDM, then also early SMBG): GDM: FPG>=7.0 or 2h>=7.8
• Aim for low GI carbohydrates, lean proteins incl oily fish and poly-/mono-unsaturated fats
• Restrict calorie intake to <=25kcal/kg/d and moderate exercise >=30min/d
• Hypoglyc agents if diet & exercise don't achieve targets within 1-2 weeks, or incipient macrosomia (abdo circumf>70th cent): regul insul*, aspart, lispro*, metformin*, glibenclamide*

Antenatal care:

• aim (if safe) 3.4<FBG<6, 1hppBG <7.8 [HbA1c<6.1% in first Trimester]
• HbA1c in 1st trimester: each 1% above 7% a/w 5.5% icr in adverse outcome (congen abnlty, morbidity of baby dxd within 5/12 and mortal); 6-fold icr in risk between lowest and highest quintile;
• no evidence to support the clinical utility of HbA1c measurements in 2nd/3rd trimester;
• contact with diabetes care team q1-2/40
• warn icrd risk of hypo unawareness in insulin treated DM (esp 1st Trimester)
• if suspected DKA: admit HDU
• antenatal fetal heart US at 18-20/40
• SMBG: fasting + 1hpp, if on insulin also: pre-bed and ketone testing if unwell
• concentrated glucose if on insulin, and glucagon if T1DM
• consider CSII if multiple injections fail
• retinal assessment in pre-existing DM ~10/40 [or ASAP if not within 12/12 pre-conception], [+at 16-20/40 if retinopathy], and at 28/40
• renal referral if Crea>120 or U-Prot>2g/d [consider thromboprophylaxis if >5g/d]; don't use eGFR;
• US monitoring of fetal growth and amniotic fluid volume at 28, 32, 36/40
• consider monitoring of fetal well-being after 38/40 if macrovasc dis/nephropathy

Other Guidance

• GDM: 5th International Workshop Recommendations (2007) Diab Care: free pdf

Timetable