Diabetes Mellitus in Pregnancy

Last updated 03.11.12

 

Index

 

Definition

-   

 

Features

-  80% DM seen in pregnancy is GDM

 

Associated S/S

-   

 

Complications

-  Type 1 DM

-  Risks ass w poor glycaemic control x10 risk

-  Congenital defects

-   Related to HbA1c, if <7 no increased risk

-   NTD x10

-   Caudal regression x200

-   Cardiac x5

-  Miscarriage

-  Preterm labour

-  Pre-eclampsia

-  IUGR

-  Operative delivery

-  Shoulder dystocia

-  PPH

-  Type 2 DM

-   

 

Mx

-  BSL

-  See Mx of GDM

-  Preconception

-  R/V all meds if appropriate in pregnancy

-  Change from oral hypoglycaemics to Insulin BD or basal bolus

-  Optimise glycaemic control: aim for HbA1c 6%

-  Screen for DM complications

-  Diabetes educator & dietician R/V

-  Obstetrician referral +/- Physician

-  Commence Folic acid

-  First Trimester

-  R/V every 4 weeks+

-  Routine antenatal screening +

-  Repeat HbA1c

-  U&E

-  TFTs

-  Urine MCS for protein & casts

-  Monitor for weight gain

-  Beware increased Insulin sensitivity & risk of hypoglycaemia weeks 6-16 (esp 10-14)

-   Insulin may need to be decreased

-  If not already done prior to pregnancy

-   Opthalmic assessment

-   24hr urine protein & Cr clearance, U&E

-   Assess for neuropathy (incl autonomic)

-   BP R/V

-   US at 12/40 (+/- NT)

-  If hyperemesis

-   Adjust Insulin dose according to BSL

-   Maintain fluid intake

-   Maintain carbohydrate intake with fluids if not tolerating solids

-   Pt for medical R/V if

-   BSL >12 for 24hrs

-   Unable to tolerate oral fluids

-   Vomiting > 24hrs

-  Second Trimester

-  R/V every 2 weeks (depending on BSL)

-   Aim for <5.5 fasting, <7 at 1.5hrs post prandial

-  Repeat HbA1c

-  Insulin sensitivity decreases after 20/40

-   Insulin will need to be increased progressively

-  Repeat screening for complications if detected prior

-  Ongoing BP R/V

-  Third Trimester

-  Repeat HbA1c

-  Repeat screening for complications if detected prior

-  Ongoing BP R/V

-  US at 34/40 +/- at 37/40 if LGA

-  Increased fetal surveillance (CTG..)

-   Esp Type 1 DM or vascular complications of Type 2 DM

-  Delivery

-  Type 1 DM: aim for IOL 38/40

-  Type 2 DM: aim for IOL/delivery 40/40 unless complications

-  Labour

-  Chart sliding scale for Insulin

-   BSL <7 = 0 units

-   BSL 7 – 9 = 1 unit

-   BSL 9 – 11 = 2 units

-   BSL 11 – 15 = 3 units

-   BSL >15 = 5 units

-  Consider Insulin dextrose infusion for Type 1 DM

-  Post Partum

-  Immediate post partum reduce Insulin by 50%

-  Diabetes educator R/V

-  Post Natal

-  If DM2 continue Insulin until ceased breast feeding then R/V by Endo for return to previous Rx

-  Neonatal Care

-  BSLs: hypoglycaemia

-  Referral to Paedatrician whilst in hospital if available

 

 

 

References

 

Managing Pregnancy & Labour for Patients with Type 1 & Type 2 Diabetes Protocol, Southern Health 05/04/06