DIABETES PREGNANCY
Improved diabetes control in early pregnancy can reduce the incidence of congenital malformations and early spontaneous fetal loss.
Pre-pregnancy Assessment
ee patients with their partner if possible and provide with written information
- Take a full medical, obstetrical and gynaecological history
- Review current medication. Note ACE Inhibitors, Statins and other teratogenic drugs should be discontinued
- Prescribe Folic Acid 5mg daily for at least a month pre-conception and during first trimester. The usual “over the counter” dose is 400mcg daily and this is insufficient in women with diabetes because of an increased risk of neural tube defects.
- Assess for presence of diabetes complications and treat blood pressure if required
- Check rubella antibody status, thyroid biochemistry and urinalysis
- Advise on diet and weight reduction if relevant and strongly discourage smoking
- Educate on the importance of good glycaemic control and avoidance of ketoacidosis
- Aim to obtain HbA1c near to the non-diabetic range, while avoiding hypoglycaemia
- Instruct partners to recognise and manage hypoglycaemia
- In women with type 2 diabetes, initiate insulin in those receiving oral hypoglycaemic agents or where it is not possible to obtain good control with diet alone and exercise, since OHA's are contra-indicated in pregnancy,
Women who are well-controlled and free of complications can be advised to stop contraception and to keep a record
of periods. Other women may require additional time to optimise glycaemic control or to have investigation and
treatment of complications.
Advise patients to perform a pregnancy test if there is a lapse of five weeks between periods and contact a
Diabetes Specialist Nurse soon after obtaining a positive result
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Ante-natal Care
- Ante-natal care should be hospital-based, from a multi-disciplinary team
- Individualise insulin regimens and recommend 4-times daily glucose monitoring.
- Aim to maintain glucose 4-7 mmol/L and HbA1c within the normal non-diabetic range
- Remember insulin requirements increase progressively from the 2nd trimester until the last month of gestation, when a slight fall-off may be noted
- Hypoglycaemia and loss of awareness is common in early pregnancy. Women who lose awareness of hypoglycaemia in pregnancy sould be advised to stop driving until their warning symptoms return to normal. Hypoglycaemia does not appear to have long-term adverse effects on fetal development
- Ketoacidosis can cause fetal death at any stage. All women should test urine for ketones if their blood glucose is high (>10), if vomiting occurs or if they are unwell. They should be advised to contact their Diabetes Specialist Nurse, hospital antenatal team or GP if persistent ketonuria is present as admission for intravenous fluid and insulin may be required.
- All women should have regular retinal screening and measurement of blood pressure and renal function, as retinopathy and nephropathy may deteriorate during pregnancy.
- Patients generally attend for ante-natal care at intervals of 2-4 weeks from booking up to 28 weeks, every 2 weeks until 34 weeks and thereafter weekly until delivery.
Delivery
The timing of delivery is individualised; in women with good diabetes control and no complications,
the pregnancy may be continued to 39-40 weeks.
Caesarian section rates are often higher than in non-diabetic women.
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