Makindo Medical Notes

Related Subjects: Type 1 DM |Type 2 DM |Diabetes in Pregnancy |HbA1c |Diabetic Ketoacidosis (DKA) Adults |Hyperglycaemic Hyperosmolar State (HHS) |Diabetic Nephropathy |Diabetic Retinopathy |Diabetic Neuropathy |Diabetic Amyotrophy |Maturity Onset Diabetes of the Young (MODY)

🤰 Around 1 in 20 women giving birth in the UK each year either have pre-existing diabetes or develop gestational diabetes (GDM). These pregnancies require multidisciplinary care involving obstetricians, diabetes specialists, midwives, dietitians, and the GP.

🧩 Diabetes in Pregnancy

• Pre-existing diabetes:
  • Type 1 → insulin dependent, autoimmune, usually diagnosed in youth.
  • Type 2 → insulin resistance ± relative deficiency, associated with obesity.
• Gestational diabetes (GDM):
  • Diabetes diagnosed during pregnancy (not overt pre-existing).
  • Typically detected in 2nd–3rd trimester via OGTT.
  • Risk factors: age >25, BMI >30, previous GDM, macrosomic baby (>4.5kg), family history, non-Caucasian background, HIV positive.

⚠️ Risks in Pregnancy

• For the Mother:
  • Hypertension, pre-eclampsia, miscarriage, preterm labour.
  • Hypoglycaemia unawareness (esp. in T1DM).
  • Progression of retinopathy and nephropathy.
  • Higher caesarean section rates.
  • Increased lifetime risk of T2DM (esp. after GDM).
• For the Baby:
  • Macrosomia → shoulder dystocia, birth trauma.
  • Congenital malformations (if poor control at conception).
  • Neonatal hypoglycaemia (due to fetal hyperinsulinism).
  • ↑ risk of obesity and T2DM in later life.

🛠️ Management Strategies

• Preconception:
  • Optimise HbA1c (<48 mmol/mol if safe).
  • Weight optimisation, lifestyle advice.
  • Stop unsafe meds (ACEi, statins, some oral hypoglycaemics).
  • Folic acid 5 mg/day until 12 weeks.
• During pregnancy:
  • Frequent CBG monitoring (≥4x/day) or CGM/flash monitoring.
  • Eye and renal screening early in pregnancy.
  • OGTT at booking if risk factors.
  • Insulin is mainstay (oral agents avoided except metformin if risk-benefit considered).
  • Ultrasound & growth scans to monitor macrosomia/polyhydramnios.
• Targets (NICE):
  • Fasting: 5.0–7.0 mmol/L.
  • Pre-meal: 4.0–7.0 mmol/L.
  • Test blood ketones if hyperglycaemic or unwell.
• If Type 1 Diabetes:
  • Offer CGM (continuous glucose monitoring).
  • Alternative: Flash glucose monitor (Libre).
• If non–Type 1 Diabetes:
  • CGM may still be offered if poor control.
  • Increase monitoring if meds adjusted.

🍼 Postpartum Care

• Mother:
  • Insulin needs usually fall rapidly after delivery.
  • Check fasting glucose at 6 weeks postpartum (esp. after GDM).
  • Half of women with GDM develop T2DM long-term → lifelong screening needed.
• Baby:
  • Monitor for neonatal hypoglycaemia and respiratory distress.
  • Ongoing paediatric review for growth and metabolic risk.
• Breastfeeding:
  • Encouraged – improves maternal glycaemia and reduces child’s diabetes risk.
  • May require reduced insulin doses due to increased energy demands.

📚 Teaching Pearls

• Poor glycaemic control at conception → highest risk of congenital malformations.
• ACE inhibitors & statins are teratogenic – must be stopped preconception.
• Metformin sometimes continued in GDM or T2DM, but insulin is gold standard.
• Always think macrosomia → shoulder dystocia risk in OSCE stations.
• Women with GDM require lifelong annual diabetes screening.

🔗 References

• NICE NG3 – Diabetes in Pregnancy