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(Pre-)Pregnancy in Primary Care

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(Pre-)Pregnancy in Primary Care Diabetes and (pre-)pregnancy in primary care Kate Hunt, Diabetes Consultant, KCH Rita Forde, DSN, KCL Lambeth CCG Diabetes Learning Event 4th October 2018 Learning objectives • Why (pre-)pregnancy and diabetes is relevant in primary care • Key messages about pregnancy and diabetes • Opportunities and approaches for discussing pregnancy with women with diabetes • When and how to refer • Sources of information Pregnancy in women with diabetes • Increased risk of adverse pregnancy outcomes: – ↑Congenital malformation, ↑ Miscarriage, – ↑ Pre-eclampsia, – ↑ Fetal macrosomia, ↑ Birth trauma (to mother & baby), – ↑ Induction of labour or caesarean section, – ↑ Stillbirth, – ↑ Neonatal morbidity (SCBU/NICU admission, hypoglycaemia, hyperbilirubinaemia, respiratory distress, neonatal death) • Increased risk of maternal hypoglycaemia (1st trimester), DKA and deterioration of maternal diabetes complications • Increased risk of obesity and/or T2DM in offspring Pregnancy in women with diabetes Establishing good blood glucose control (and other measures) BEFORE conception and continuing throughout pregnancy will reduce the risk of adverse pregnancy outcomes (miscarriage, congenital malformation, stillbirth and neonatal death) NICE: pre-pregnancy in women with diabetes • Information about outcomes and risks for mother and baby • Diet and body weight if BMI >27 kg/m2 • Folic acid 5mg (to reduce risk of neural tube defect) • Self monitoring of blood glucose • HbA1c <48mmol/mol (6.5%) if achievable without problematic hypoglycaemia • Blood glucose lowering agents – Metformin and insulin only – all others should be stopped and replaced with insulin • Statins should be discontinued before pregnancy or as soon as pregnancy confirmed • Alternative antihypertensives suitable for use during pregnancy should be substituted – Labetolol, Nifedipine, Methyldopa • Screening (retinal and renal) • Contraception NICE Guideline 3 2015 National Pregnancy in Diabetes Audit - 2016 Enrolled in audit Live births after 24 Enrolled in audit weeks 1689 (51%) 1517 1689 (51%) 1608 (49%) 1521 NDIP 2017 Folic acid 5mg prior to pregnancy 7 National Pregnancy in Diabetes Audit 2017 At least one of the following: Folic Acid 5mgs statins/ACE I / ARB /adverse DM medication Type 1 DM 41.8% 1.8% Type 2 DM 22.8% 13.0% NDIP 2017 Adverse DM medication - sulphonylurea or glitinide, gliptin, GLP-1 analogue and pioglitazone, irrespective of whether the woman was also taking metformin and/or insulin. First contact with antenatal diabetes team <8/40 9 First HbA1c in pregnancy 10 Case 1 & Case 2 5 mins Case 1: tables 1-3 Case 2: tables 4-6 Case 1 38 year old woman Wants to get pregnant and has heard that diabetes might be a problem PMH: T2DM diagnosed (Δ age 34) BMI 32 kg/m2 Hypertension (Δ age 34) Obstetric: G0 Meds: Metformin 1000mg bd, Gliclazide 160mg bd, Sitagliptin 100mg od Atorvastatin 40mg od Bendrofluazide 2.5 mg od, Ramipril 10mg od Recent investigations: HbA1c 58 mmol/mol (7.5%), BP 132/78 mmHg, TC 3.4 mmol/l, LDL 1.8 mmol/l, Retinal screening normal, uACR <2.5 mg/mmol Questions: What are the issues? What would you discuss with her? What would you do? Case 1 What are the issues • HbA1c higher than ideal • Sitagliptin, gliclazide, atorvastatin, bendrofluazide, ramipril should be avoided in pregnancy What would you discuss with her? • Congratulate her for making an appointment to discuss this • Explain that her risks of adverse outcome are higher BUT risks can be reduced. • Explain HbA1c is higher than ideal & she is on several medications not safe in pregnancy • Explore if any other diet/exercise measures she might be able to introduce • Ask about smoking and alcohol • Advise her to avoid pregnancy until these issues are sorted out (need to explore this) • Advise her to let practice know immediately if she gets pregnant before this What would you do? • Refer to Diabetes Pre-pregnancy clinic (eRS) • Diabetes UK Information Prescription / websites • Start folic acid 5mg od • In PCC or in primary care: – Stop bendrofluazide and ramipril, change to labetolol – Consider stopping atorvastatin (stop when trying for pregnancy, or if not avoiding) – Consider stopping sitagliptin (stop when trying for pregnancy, or if not avoiding) – Continue metformin – Continue gliclazide until switched to insulin – Teach SMBG Referral-thinking about pregnancy (in next 12 months)=eRS Providing information Diabetes UK Information Prescription https://www.diabetes.org.uk/profession als/resources/resources-to-improve-yo ur-clinical-practice/information-prescrip tions-qa Providing information Diabetes UK website https://www.diabetes.org.uk/guide-t o-diabetes/life-with-diabetes/pregn ancy Providing information NHS website https://www.nhs.uk/conditions/pregn ancy-and-baby/diabetes-pregnant/ Case 2 38 year old woman, Pregnant. LMP 8 weeks ago PMH: T2DM diagnosed (Δ age 34) BMI 32 kg/m2 Hypertension (Δ age 34) Meds: Stopped all medication with positive pregnancy test 10 days ago Metformin 1000mg bd, Gliclazide 160mg bd, Empagliflozin 25mg od Atorvastatin 40mg od Amlodipine 10mg od Recent investigations: HbA1c 58 mmol/mol (7.5%), TC 3.4 mmol/l, LDL 1.8 mmol/l, uACR <2.5 mg/mmol Retinal screening normal Today: BP 132/78 mmHg, capillary blood glucose 12.5 mmol/l Questions: What are the issues? What would you discuss with her? What would you do? Case 2 What are the issues • HbA1c higher than ideal • She has stopped all her medications and BG 12.5 mmol/l (pregnancy targets pre meals <5.3mmol/l, 1 hour post meal < 7.8 mmol/l) but BP ok • Empagliflozin, sitagliptin, gliclazide, atorvastatin, amlodipine, should be avoided in pregnancy What would you discuss with her? • Explain HbA1c is higher than ideal & she was on several medications not safe in pregnancy • Explain she will need to be seen urgently by the diabetes pregnancy team and will be taught how to test BG and started on insulin What would you do? • Refer to Diabetes Pregnancy team immediately (phone call). (Should be seen within 24-48 hours, taught SMBG and started on full basal bolus insulin) • Start folic acid 5mg od • Restart metformin. Stay off empagliflozin, gliclazide • Stay off amlodipine (as BP ok). (if concern start nifedipine) • Stay off atorvastatin Referral-pregnant • We aim to see within 24-48 hours • Please DON’T use eRS (as turnaround too slow) • Please include patient’s mobile number, HbA1c, medication in referral King’s College Hospital Denmark Hill • Email referral: [email protected] AND • Phone call (email only sufficient if HbA1c <48 mmol/mol on diet/metformin/insulin only & no other concerns) – Switchboard 02032999000, bleep Diabetes SpR – OR Consultant Connect Guy’s & St Thomas Hospital Consultant connect • Email referral: [email protected] AND • Phone call (email only sufficient if HbA1c <48 mmol/mol on diet/metformin/insulin only & no other concerns) – Diabetes department St. Thomas’ 0207188 1981 – OR Consultant Connect Medications in (pre) pregnancy Blood glucose lowering agents Metformin and insulin only all others should be stopped and replaced with insulin Statins should be discontinued before pregnancy or as soon as pregnancy confirmed Alternative antihypertensives suitable for use during pregnancy should be substituted Labetolol (to replace other b-blockers, diuretics, ACEi, ARB-local guidance) Nifedipine (to replace other Ca channel blockers--local guidance) rd Methyldopa (3 line) (NB: if microalbuminuria/proteinuria consider continuing ACEi/ARB until confirmed pregnancy) Case 3 & Case 4 5 mins Case 4: tables 1-3 Case 3: tables 4-6 Case 3 22 year old woman, Follow up appointment. Seen 2 weeks ago after doing fingerstick test using grandmother’s BG meter and found CBG 12.2mmol/l. Assymptomatic. PMH: nil Family history: mother has diabetes on tablets and grandmother diabetes on insulin Meds: nil Other: BMI 34 kg.m2, black African Recent investigations: CBG in clinic 10.5 mmol/l, urine ketones negative HbA1c 53 mmol/mol (7.1%), repeated 55 mmol/mol (7.2%) Questions: What is the diagnosis? Is diabetes and pregnancy information relevant here? What would you discuss with her, when and how? Case 3 What is the diagnosis? • Type 2 diabetes Is diabetes and pregnancy information relevant here? • Yes What would you discuss with her, when and how? • Straight away! • ‘What are your thoughts on having a baby in the next couple of years?’ • ‘Do you think you might (want to) have a baby in the next couple of years?’ • (Probably avoid ‘Are you planning pregnancy?) Talking about pregnancy with women with diabetes What are your thoughts on having a baby in the next couple of years? Yes/Maybe/ No Unsure Do you know why we discuss pregnancy Do you know why we discuss pregnancy in diabetes? in diabetes? Discuss: Increased risk of adverse pregnancy outcomes in women with diabetes Correct medications, good BG control, folic acid 5mg, lifestyle measures PRIOR to pregnancy reduces risk Inform PN/GP IMMEDIATELY if pregnant Signpost information How are you planning / preventing How are you preventing pregnancy? pregnancy? Refer Diabetes PPC Signpost reliable contraception Advise avoid pregnancy until diabetes Advise to discuss with PN/GP BEFORE trying to get pregnant/discontinuing care optimised contraception Case 4 36 year old woman, attending for diabetes annual review PMH: T2DM diagnosed (Δ age 32) (attended DESMOND) BMI 36 kg/m2 Hypertension (Δ age 32) Obstetric history: G3P2+1 miscarriage (1st trimester), 2 children aged 12 and 10 Meds: Metformin 1000mg bd, Gliclazide 160mg bd, Liraglutide 1.2 mg od Atorvastatin
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