Gestational diabetes
• Intro: |
- One of the most common conditions of pregnancy, which can have serious complications for the parent and baby if not identified and managed
- Usually goes away again after giving birth
- It's usually diagnosed from a blood test 24 to 28 weeks into pregnancy
- Less common than Type 1 & 2 diabetes (increasing prevalence tho)
- Affects 4-5 in 10o women during pregnancy, or 1 in 20 pregnancies in the UK |
• Causes: |
- Hormonal difficulty to use insulin (increased risk of insulin resistance)
- Cells don't respond properly to insulin by not producing enough, making it difficult to use glucose properly for energy (stays in body & blood sugar level rises), leads to gestational diabetes |
• Risk factors: |
- Living with overweight or obesity
- Having had it before in a previous pregnancy
- Having had a very large baby in a previous pregnancy (4.5kg / 10lbs or more)
- Having a fHx of diabetes (at least one parent or sibling)
- Having a South Asian, Black or African Caribbean or Middle Eastern background
- Increasing age (NHS recommends screening if pregnant and over 40yrs or older) |
• Prevention: |
- Some people can't prevent it{{nl]}- Get support to manage weight, healthy diet and keeping active before and during pregnancy |
• What after diagnosis? |
- Care team informs GP
- Within 1 week you should be referred to a joint diabetes and antenatal clinic
- Team will work on targeting blood sugar levels with you (will reduce risks of complications) |
• What happens if mom has GD? |
- Can affect how well the placenta works
- Can make baby unwell and affect their movements
- If baby movements have slowed, stopped or are different to normal, contact midwife or maternity unit immediately |
• Complications: |
- Baby growing larger than normal (more painful or difficult birth & possible distress)
- Neonatal hypoglycaemia (baby has low blood sugar after birth)
As well as the above, continuous high blood sugar levels can also lead to:
- Induced labour
- Caesarean section
- Baby having higher risk of being overweight or obesity & developing Type 2 diabetes
- Baby having yellow skin & eyes (jaundice) after birth |
• Symptoms: |
- Going for a wee a lot, especially at night
- Being really thirsty
- Feeling more tired than usual
- Genital itching or thrush
- Blurred eyesight
Many women have no noticeable symptoms |
• Tests: |
Oral glucose tolerance test (OGTT)
Doesn't harm mom or baby
1. You'll need to fast (no food or drinks) for 8-10 hours the night before & the morning of the test
2. Blood test to measure blood glucose level
3. Will be given a glucose drink
4. Rest for 2 hours, another blood test to see how the body is dealing with the glucose
Results: Diagnosed with GD if fasting blood sugar level is 5.6mmol/l or above, or if your 2hr post glucose blood sugar level is 7.8mmol/l or above
- GD can develop at any time during pregnancy, if you develop any symptoms (despite -ve OGTT), talk to midwife |
• Treatments: |
- Checking blood sugar levels regularly (pricking w/ lancet)
- Levels outside targets discuss with healthcare team, can cause problems for mom and baby
- Very common to need glucose lowering medication, including insulin
- Regular physical activity
- Healthy diet |
• Medications: |
- Metformin: tablet that helps to reduce the amount of glucose produced by the liver, & to make insulin work more effectively; taken with, or after, a meal
- Insulin: Allows glucose to enter the cells and to be used for energy; injection that goes in just undertake skin (can't be taken orally because the stomach will digest it) |
• What should I aim for? |
- Going for regular walks after lunch or dinner
- Pregnancy yoga
- Swimming or water aerobics
- Dancing in the kitchen
- Try not to sit after a meal (being active for 15-20min within 30 min of a meal) |
• Blood sugar level aims: |
- Fasting: below 5.3mmol/l
- 1hr after meals: below 7.8mmol/l
- If not able to check until 2hr after a meal: below 6.4mmol/l |
Gestational hypertension
• Intro: |
- BP readings of ≥140/90 mmHg on 2 occasions at least 4hr apart after 20 weeks' gestation in a previously normotensive woman
- Must be w/o the presence of proteinuria (<300mg in 24hr) or other clinical features (thrombocytopenia, impaired renal or kidney function, pulmonary oedema, or new-onset headache) suggestive of pre-eclampsia |
• Key diagnostic factors: |
-Presence of risk factors
- Previously normotensive
- BP ≥140/90 mmHg
- <20 weeks' gestation
- Absence of Ssx that suggest pre-eclampsia |
• Risk factors: |
- Nulliparous (hasn't given birth before)
- Black or Hispanic ethnicity
- Obesity |
• 1.3 Management of chronic hypertension in pregnancy: |
Referral & discussion:
- Offer referral to a specialist in hypertensive disorders for women with chronic hypertension to discuss treatment risks & benefits
- For those taking ACE inhibitors or ARBs, highlight the increased risk of congenital abnormalities during pregnancy
- Emphasise discussing alternative antihypertensive treatment with healthcare professionals if planning pregnancy or taking these medications for other conditions
Medication safety update:
- Note the MHRA's drug safety update on ACE inhibitors and angiotensin II receptor antagonists, advising against use in pregnancy unless absolutely necessary
Antihypertensive treatment adjustment:
- Promptly discontinue ACE inhibitors or ARBs if pregnancy is confirmed, preferably within 2 working days, & provide alternative options
- For thiazide or thiazide-like diuretics, inform about potential risks of congenital abnormalities & neonatal complications during pregnancy
- Encourage discussion of alternative antihypertensive treatment with healthcare professionals for those planning pregnancy
Limited risk with other antihypertensive treatments:
- Assure women taking antihypertensive treatments other than ACE inhibitors, ARBs, thiazide, or thiazide-like diuretics that limited evidence suggests not increased risk of congenital malformation |
• 1.4 Management of gestational hypertension: |
Assessment & risk factors:
- Full assessment in 2° care by a trained healthcare professional
- Consider additional risk factors: nulliparity, age >40 or older, pregnancy interval >10 yrs, fHx of pre-eclampsia, multi-feral pregnancy, BMI 35kg/m2 or more, gestational age at presentation, previous Hx of pre-eclampsia or gestational hypertension, pre-existing vascular disease, pre-existing kidney disease
Tests & treatment:
- Hypertension (BP 140/90 - 159/109 mmHg): offer pharmacological treatment ig BP remains above 140/90 mmHg
- Severe hypertension (BP 160/110 mmHg or more): admit to hospital; if BP falls below 160/110 mmHg, manage as for hypertension
- Antihypertensive treatment: offer to all women; target BP of 135/85 mmHg or less
- BP measurement: 1 or 2x / week until BP is 135/85 mmHg or less
- Dipstick proteinuria testing: 1 or 2x /week (w/ BP measurements)
- Blood tests: measure full blood count, liver function, & renal function at presentation & then weekly
- Placental growth factor (PLGF)-based testing: if suspicion of pre-eclampsia
- Fatal assessment: offer fatal heart auscultation at every antanatal appointment; ultrasound assessment at diagnosis & repeat every 2-4 weeks if normal; cardiotocography (CTG) if clinically indicated
Additional metal monitoring (severe hypertension):
- Ultrasound assessment every 2 weeks if severe hypertension persists
- CTG at diagnosis & then only if clinically indicated |
Pelvic girdle pain (PGP) in pregancy
• Intro: |
- Pelvis has 3 joints that normally move slightly & work together
- PGP is caused by uneven movement of these joints, resulting in less stability & pain
- Factors contributing to PGP include changes in weight & posture during pregnancy |
• Signs & symptoms: |
- Px in pubic region, lower back, hips groin, thighs or kness
- Clicking or grinding in the pelvic area
- Pain made worse by movement: walking on uneven surfaces / rough ground or for long distances; moving your knees apart (getting in/out of the car); standing on one leg (climbing the stairs, dressing, getting in/out of bath); rolling over in bed; during sexual intercourse |
• Risk factors: |
- Hx of back problems
- Hx of pelvic injuries
- Hypermobility syndrome |
• Management options: |
- Avoiding aggravating movements / changing positions
- Exercises for pain relief & mobility: focus on strengthening abdominal & pelvic floor muscles for improved balance, posture, & spine stability; incorporate routines that facilitate easier movement while minimising strain
- Mobs, drops, SMT
- Warm baths, or heat, or ice packs
- Hydrotherapy
- Acupuncture / dry needling
- Support belt or crutches |
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