Essay 282: Diabetes

The assessment should aim to determine the current glycemic status of the woman.She should be seen at a joint diabetic clinic involving a Diabetologist,an Obstetrician with special interest in diabetes,specialist midwife and dietician. Her notes have to be reviewed to see if her pattern of glycemic control. She must be counselled that if her HbA1C value which reflects sugar control in the last 3 months is <6.1%, it is safe to embark on a pregnancy. Any history of hypoglycaemic episodes in the past must be asked perceived as giddiness,chillness,relieved with eating something. A Feeling unwell sensation at any time could point to a ketoacidosis  though more common in type1 DM .She should be asked if she was doing home glucose testing and what were the values like.A postprandial 1hour value of <7.8mmol/l is more reflective of good control and is preferred to a fasting which must be 3.5 to 5.9mmol/l. Whether she is controlled on diet or takes oral hypoglycemics must be noted. Biguanides like Metformin is recommended by NICE as a safe alternative to insulin and can be continued in pregnancy.Thiazolidinediones like rosiglitazone not safe in pregnancy.A careful note is made to see if the woman has any complications like Nephropathy,Retinopathy and Neuropathy.If she has not had a renal and retinal screen in last months she must undergo one now. If serum creatine is >120mmol/l or proteinuria>2+ Nephrologist opinion is needed and pregnancy has to be deferred. A History of coexisting high blood pressure to be asked and if on ACE inhibitors ,to be changed as they are contraindicated in pregnancy.Her diet and exercise pattern has to be looked into.Any sudden weight loss over a short span of time may suggest a poor control.S ocial habits like smoking can worsen sugars ,must be stopped.she should be asked if she is on folic acid prophylaxis 5mg daily as it prevents neural tube defects.A check is made on her immunity status to rubella,HbSAg .An examination is done to note her blood pressure,  any leg ulcers,retinal screen by fundoscopy. Investigations include           HbA1C,   sugars fasting and postprandial,FBC,Urine for proteins,microscopy,LFT ,Renal function tests, HIV screen.
                         The woman should first be reassured that if her glycemic control is good prior to and during pregnancy,often  the outcome is good.In  this woman as she is 40,she must be told about the age related risks of aneuploidy.Risk of Downs syndrome is around 1 un 140.She must have an early dating scan to calculate gestational age accurately.Serum markers like beta HCG,PAPP-A,MSAFP are all low in a diabetic pregnancy and must be interpreted with caution .Ideal would be a Combined Test taking Nuchal transluscency(NT) done at 11 to13 weeks and first trimester markers beta HCG and PAPP-A. The fetus is also at 5 times increased risk for congenital malformations compared to nondiabetics.Neural tube defects (NTD),cardiac anamolies are common. Prophylaxis with Folic Acid 5mg for 12 weeks preconception nd continuing through first trimester prevents NTD,along with a tight glycemic control. The risk of miscarriage is increased ,but there is no evidence to recommend bed rest,progesterone support.Again good diabetic control helps.Increased risk of pretermlabour is due to infections  urinary or pelvic.Hence infections must be promptly diagnosed and treated.Polyhydramnios can also cause preterm labour and can be prevented by good sugar control.Serial growth scans from 28 weeks onwards helps in detecting macrosomia and also liquor volume .IUGR can rarely occur if mother has vasculopathy, can be prevented by optimising sugars.If detected,umbilical artery Doppler is useful to detect fetal compromise.   Risk of sudden unexplained IUD  at term, due to hypoglycemia  avoided by careful induction of labour at 38 weeks.         Baby is  also at risk of intrapartum morbidity due to shoulder dystocia,difficult delivery ,increased risk of operative delivery or caesarean section.  Can be minimised by    avoiding difficult deliveries,keeping a low threshold for caesarean and EFW >4.5kg ,caesarean preferred over vaginal delivery.Other newborn complications are hypoglycaemia,prevented by frequent feeds,hypocalcemia,polycythemia,jaundice.These must be promptly watched for by a neonatologist,detected and treated. So, the delivery must be at a hospital with facility for newborn care. She should be given Information leaflets and details of websites like www.patient.co.uk
 

a.       I will take a history enquiring about the medications she takes, as metformin and insulin are not contraindicated in pregnancy but glibenclamide may need to be discontinued as soon as pregnancy occurs as safety is uncertain. I will ask about use of ARBs and ACE inhibitors which should be discontinued before conception or as soon as pregnancy occurs due to possible teratogenicity. I will ask about use of statins, and advise herto stop prior to conception.

I will ask about compliance with her  diabetes care advise, compliance with medications and ability to maintain good glycaemic control. I will enquire about her lifestyle including smoking, excessive alcohol intake and lack of exercise, and if present  I will advise smoking cessation to improve general health, reduce the risk of ectopic pregnancy, preterm delivery ,placenta praevia, placental abruption and FGR.

I will advise about the risk of Fetal alcohol spectrum disorders and recommend reduction in alcohol intake if excessive, to no more than 1-2 units 1-2 times a week.

I will ask about any medical disorders eg hypertension, and advise optimal control prior to conception as this reduces maternal and fetal complications.

I will ask about her smear history and if due offer her one.

I will ask about any renal function tests, microalbuminuria/protenuria  assessments  and repeat these.

I will enquire about symptoms of autonomic neuropathy eg loss of sensation on feet, recurrent episodes of diarrhoea, which would reflect poor glycaemic control. This will require more intensive effort to optimise glycaemic control prior to conception.

I will ask about recent screening for diabetic retinopathy, and if not done within preceding year I will refer her to an ophthalmologist for fundoscopy and retinal photography, to allow preconcetual treatment if retinopathy is present.

I will ask about her menstrual history, LMP, contraceptive use and compliance to exclude current pregnancy. I will ask about any past pregnancies, TOPs,miscarriages and ectopic pregnancies, fertility problems and treatments to assess the need for additional referrals.

I will check her blood pressure to exclude hypertension.

I will send a 24 hour urine sample for microalbuminuria and protenuria, blood for u&Es to assess renal function tests. I will refer to a nephrologist if she has significant microalbuminuria or protenuria >500mg/24 orcreatinine >125mmol/L.

I will send blood for HbA1c. If this is elevated I will advise her to delay conception until she achieves a target of <6.1%, due to increased risk of congenital anomalies associated with elevated HbA1c.

I will offer her serology for rubella immunity and if negative I will offer rubella vaccine, with advise to delay pregnancy for at least 1month.

b.      I will explain that Pregnancy in poorly controlled diabetes is associated with increased risks of miscarriage, congenital anomalies including NTDs and cardiac defects, fetal macrosomia and polyhydramnious, spontaneous and iatrogenic preterm delivery, prematurity, birth trauma including shoulder dystocia, IUGR,IUFD and perinatal death. There is also and increased risk of neonatal hypoglycaemia, hypothermia, jaundice and hypo calcaemia, hypokalaemia and hypomagnesemia.

I will explain that most of these complications are reduced to population level by achieving optimal glycaemic control preconcetually,  fasting 3.5-5.9mmol/L,1hour postprandial blood sugar of <7.8mmol/L and HbA1c <6.1%, and maintaining this throughout pregnancy. I will advise her that taking high dose folic acid 5mg/day from 12weeks preconception and continuing throughout pregnancy will further reduce the risk of NTDs and supplement increased requirement in pregnancy. I will advise her to avoid excessive weight gain in pregnancy, through a dieticians advise and regular basic exercise, as this enhances glycaemic  control.

I will advise her that conception with a high HBA1c of 10% or more is associated with a very high risk of congenital anomalies that termination of pregnancies is adviseable.

I will explain that care under the joint care of a diabetologist, obstetrician, diabetes midwife, and dietician in pregnancy, with hospital based antenatal care and delivery  reduces fetal complications and improves pregnancy outcome.

I will explain that she will be offered fetal echocardiography at 18-20+6 weeks to check for cardiac anomaly, in addition to a detailed anomaly scan. She will also be offered serial growth scans at 24,28,32 and 36week gestation, to exlude IUGR, identify macrosomia and polyhydramnious for appropriate management.

I will advise her that aiming to deliver her at 38 weeks gestation reduces the risk of unexplained stillbirth, which increases at this stage of pregnancy.

If there is macrosomia >4.5kg EFW then offering caesarean delivery reduces the risk of shoulder dystocia.

I will advise her that intrapartum insulin within an agreed protocol, with maternal glycaemic monitoring, and electronic fetal monitoring reduces fetal distress and perinatal morbidity and mortality.

I will advise that keeping the newborn warm, early frequent feeding will prevent hypothermia and hypoglycaemia respectively.

I will provide written information about diabetes and pregnancy and introduce her to a support group for diabetic pregnant women.

a)- I'll like to see her in a joint clinic with an endocrinologist who has experience in diabetes in pregnancy. i'll ask about the drugs she's taking for Diabetes mellitus(DM).Metformin and glibenclamide are safe in pregnancy but not licensed, hence need informed consent. I'll do HbA1c to assess control of glucose. Aim is to keep HbA1c < 6.1% , if safe, and to avoid pregnancy if HbA1c > 10 %. She should avoid unplanned pregnancy.

I'll see if she has had recent ( in last year) renal and retinal assessment, and if thats normal, else,if serum creatinine > 125 mmol/l,or eGFR < 45%  will refer her to  nephrologist, and a retinal assessment.i'll examine her Bloodpressure and urine for proteinuria. she may have comorbities like hypertension, and if on Angiotensin converting enzyme inhibitors,or angiotensin receptor blockers, will need changing prepregnancy.

i'll check for rubella immunity. i'll prescribe folic acid 5 mg/d to be started prepregnancy and first trimester.

b)- Fetal risks associated with pregnancy are spontaneous miscarriage, congenital anomalies like neural tube defects, heart defects, skeletal structural defects,renal defects, sacral agenesis. i'll inform of the risk of fetal macrosomia, birth trauma, erb's palsy, unexplained stillbirth. I'll also tell her about neonatal hypoglycemia, NICU stay, obesity in adulthood.

i'll counsel her that these risks can be reduced by good control of blood sugars. the importance on avoiding unplanned pregnancy will be emphasised. Aim is to keep HbA1c < 6.1%. That reduces her risk of congenital anomalies. Folic acid 5 mg/d helps reduce risk of neural tube defects.

management in joint diabetic/obstetric clinic, frequent monitoring for glucose control, Blood pressure and proteinuria at each visit helps glucose management, and early detection of preeclampsia. Growth scans to detect macrosomia, and consider elective cesarean section if estimated fetal weight > 4.5 kg at term. elective delivery by induction or cesarean section after 38 weeks to reduce risk of stillbirth. continuous fetal heart rate monitoring in labour. strict blood glucose monitoring in labour to avoid maternal hyperglycemia .

A)     Assessment should be in a multidisciplinary clinic with a diabetologist, dietitian and obstetrician. I would ask her about her glycaemic control and what hypoglycaemic treatment she is taking, because if gylamic control is not good advice againt pregnancy is recommended until good optimization of her blood glucose. Her oral hypoglcaemic drugs nead modification if become pregnant. I would ask her about complications of diabetes, like vision complication from retinpathy, autonomic neuropathy like diarrhea or peripheral neuropathy and leg ulcers. I would ask her about hypertension, whether she is taking anti hypertensive treatmet or not  because some treatment likr ACE inhibitors ARBS are teratogenic and need modifications. I would ask about cardiac disease symptoms and treatment. I would ask if she is using Statin treatment because it need to be stoped if become pregnant. I would examine the patient starting with blood pressure, and systemic examination, cardiovascular system, leg for ulcers. Eye examination and fundoscopy is important. CNS examination for neuropathy need to be done. regarding investigation, I would do 75 gm 2hour OGTT, and HbA1C level to see how blood sugre controlled, FBC and urine analysis,  because risk of UTI is increased. Renal investigation like serum creatinine and eGFR to assess the renal function because the risk of nephropathy, and also 24 hour protein should be done and  if more than 2gm, refer the patient to renal physician . LFT and lipid profile are important to be done.

B)      I would tell the patient that miscarriage in early pregnancy can occur. I woud tell her that hyperglycaemia and hyperinsulinaemia can cause  big baby( macrosomia) which may cause birth injuries during labour, and may increase the possibility of caesarean section with its complications of haemorrhge and anaesthesia. Shoulder dystocia can results from macrosomia if vaginal delivery is the choice. Assisted vaginal delivery can result in maternal and fetal morbidity and mortality. I would tell her that still birth may occur from hypoxia, that results from  anaerobic metabolism due to  hyperglycaemia. Polyhydromnios can occur which may result in preterm delivery. In some cases of diabetes with  vascular complications IUGR can results. Congenital malformations like cardiac anomalies may occur. Hypoxia in uterus can result in polythycaemia due to excessive erythropoisis ,  neonatal hypoglycaemia can occur due to neonatal hyperinsulinimia and removal of glucose from mother after delivery. Hypocalcaemia ,hypomgnesaemia and jaundice due hyperbiluribinamia all may occur. Respiratory distress syndrome (RDS) can occur in baby delivered to diabetic mother. Neonatal admission is increased in diabetic mother. I have to tell the patient sensitively that there is an increased risk of down syndrome due to her age.

Most of these risk can be decreased by good glycaemic control in prepregnancy period.  Advice against pregnancy if HbAIC is more than 10% and if achievable keep level less than 6.1%. rubella vaccine is recommended before pregnancy and folic acid must be given. If she become pregnant, antenatal follow up  in joint clinic, including diabetic physician and dietian, blood glucose level should be individualized, and if possible keep in range 3.5 to 5.9 mmol\l , 2hour post prandial 7.8mmol/l. Revise oral hypoglycaemic treatment and change it to actrapid analogues insulin, ACE inhibitors changes to labetolo if patient is hypertensive. Antenatal care visits must include retinal assessment and renal assessment at booking and at 24-28 weeks. OGTT at 24-28weeks. Anomaliy scan at 18-20 weeks and cardiac scan, 4 chamber need to be done. Growth monitoring and amniotic fluid assessment done every 4 weeks from 28 to 36 weeks. At 36 planning the delivery and offer birth after 38 weeks if growth is normal and may be earlier if macrosomia is suspected. Delivery by caesarean section is advised if estimated fetal weight more than 4.5 kg. Screening for Down syndrome is better to be done with NT because serm marker are not reliable in diabetes, CVS and amniocentesis can be done to cofirm down syndrome. Neonatologist is to better to attend the  delivery. Neonate blood sample taken for close monitoring of glucose and to keep level more than 2mmol\l and recheck at 2-4 hours. Do not transfer baby to communities care until after 24 hours. Leaflet information must be provided to the mother.     

A 40 year old nulliparous woman with a 3 year history of Type II diabetes mellitus has been referred for pre-pregnancy counselling. Her BMI is 23kg/m2. (a) Discuss your assessment [8 marks].

I would like to check her last HbA1c to check if her blood glucose level is adequately controlled, as HbA1c >10 is associated with high risk of congenital anomalies and ideally it should be <6% before conception. I will need to review her medical treatment whether she is using an ACE inhibitor or ARB for blood pressure control or for protection of kidney from development of microalbuminuria, as these medications should be stopped before or once pregnancy is diagnosed as they may affect the fetal kidneys. Statins used for treatment of hyperlipedemia are also contraindicated with pregnancy and should be stopped before conception. Oral hypoglycemics except metformin should be changed before or once pregnant.Her BP and urine should be tested for proteinuria. A blood test for HbA1c and lipid profile should be ordered if no recent blood test available. U&E , creatinine, liver transaminases should be done to check for liver and kidney function as they are affected by disease progression or by adverse effect of medications. Urine should be test for microalbuminuria to detect nephropathy. Similarly a retinal digital imaging should be ordered if not done within the past year to check for retinopathy. 

 (b) What will you tell her about the fetal risks associated with pregnancy and how these can be minimised? [12 marks]

Fetal outcomes are worse in pregnant patient having diabetes as compared to those who don't. The risks can be significatly reduced with proper control of blood glucose level, but cannot be eliminated.Fetal risks include increased risk of miscarriage, congenital anomalies especially neural tube defects especially with HbA1c >10%. This can be minimised by advising against pregnancy and offering adequate contraception for patients having poor glycemic control until adequate control is achieved .Aim is HbA1c <6%.Fasting blood glucose targets should be 3.5- 5.9mmol/l. one hour post prandial <7.8mmol/l.High dose folic acid 5 mg should be advised to be taken 1-3 months prior to conception and continued for first 12 weeks as this was shown to decrease incidence of neural tube defects by 70%. The fetus is also at risk of major cardiac anomalies and this should be screened by an echocardiogram at 18-20 weeks of gestation. Fetal macrosomia, polyhydramnios are also potential risks and are associated with preterm labour and delivery. The fetus is also at increased risk of delayed lung maturity. Adequate blood glucose control, admnistration of antenatal corticosteroids, planning of delivery in a tertiary care center with ability to deal with fetal complications. Serial growth scan are undertaken starting 28 weeks to detect macrosomia and polyhydramnios. The risk of stillbirth and neonatal death is also increased and it is due to increased maternal insulin requirements especially in last trimester. There is increased risk of hypoglycemia postnatally along with electrolytes disturbance eg hypocalcemia, hypomagnesemia. Polycythemia and increased riks of jaundice is also present. These can be minimised by adequate glycemic control antepartum and intrapartum to keep an euglycemic state thus preventing fetal hyperinsulinemia and subsequent hypoglycemia. Also frequent feeding with monitoring of fetal blood glucose levels and electrolytes will be needed to deal with these complications. Phototherapy is needed to treat hyperbilirubinemia and prevent kernicterus.The baby is also at  increased  of fetal trauma due to macrosomia.This can be minimised by anticipating shoulder dystocia, by delivering in a tertiary care center and by elective cesarean delivery if estimated fetal weight >4500g. Her baby is at increased risk of developing childhood obesity and diabetes later in his life. This is reduced by careful surveillance of excessive weight gain, excersise advice and screening for diabetes.

 A] She should have a multidisciplanary approach involving obstretician, endocrinologist, dietician, GP . pre pregnancy meeting must involve her partner or family member. take history of diabetic complications such as leg ulcers, peripheral neuropathy, visual loss, and drug therapy . advice against pregnancy if her diabetes is poorly controled and presence of complications . Do general physical examination and calculate BMI . do fundoscopy , investigations such as FBC, Urea and electrolytes, LFT ,HBa1c . urine for protiens, glucose, nitrates, leukocytes. advise against pregnancy if HBa1c is more than 10grm % , give effective contraception until diabetes is controlled. assess her renal and retinal status if it is not done during the previous year by the appropriate specialist. discuss the importance of glycemic control prepregnancy and through out the pregnancy . modify the antihypertensive drugs such as ACE inhibitors and ARBS to Beta blockers by the specialist physician . explain the effects of  diabetes on pregnancy such as miscarriage, fetal anamolies , FGR, polyhydromnia, fetal macrosomia , unexplained IUFD, preterm delivery and ceasarean section . need to change oral hypoglycemic drugs to insulin as insulin is not terratogenic. There is increase risk of hyperglycemic or hypoglycemic episodes , increased insulin resistance during pregnancy and decreases after delivery of placenta . there may be deterioration of nephropathy and retinopathy during pregnancy . if patient has good glycemic control advice her to take folicacid 5 mg prepragnancy upto end of first trimester. modify her life style habits such as smoking,  recreational drugs and  alcohol. check for rubella immunisation and if not immune , immunise the patient and advice against pregnancy till one month . provide information leaflet and contact details of the support group .

B] THis patient needs Multidisciplinary approach involving obstretician, diabetologist, dietician, diabetic nurse. diabetic control through out pregnancy has good out come both  to the mother as well as the baby. there is increased risk of neural tube defect such as sacral agenesis and downs syndrome at risk  of 1:150 due to the womens age and diabetes.she should have a nuchal translucency scan between 11-14 weeks  and screening for downs syndrome by combined test in the first trimester . combined test consist of nuchal translucency scan and biochemical test such as free BHCG, Pappa proteins . if positive can go for further confirmation test  . this can be reduced by advising her to take folic acid 5 mg until end of first trimester . aneuploidy can be screened by invasive test such as CVS or amniocentesis , there is slight increase in rate of miscarriage about 1-2%. bed rest and progesterone support is not helpful . the fetus is at risk of congenital anamolies so a detail anamoly  scan is needed at 20 weeks gestation .cardiac anamoly is also increased ,so should have a cardiac scan and cardiac echo between 20-22 weeks. adequate glycemic control reduces this risk  . there is increased risk of fetal growth restriction , fetal macrosomia , and poly hydromnia so  fetal monitoring is done by regular growth scan  in the form of biophysical profile , and umbilical artery doppler every 2-4 weeks from 24 weeks onwards.risk of antenatal still birth in the  late third trimester  due to altered blood sugar levels  and increased need of insulin , so the fetus is delivered after 38 weeks . there is risk of preterm delivery , fetal prematurity and respiratory distress is reduced  by delivering under cover of  corticosteroides and tocolysis . if good glycemic control and no evidence of fetal macrosomia anticipate vaginal delivery but senior obstetrician must be present if there is macrosomic baby  as risk of shoulder dystocia . in case of significant macrosomia > 4.5kg baby   deliver by ceasearean section . neonatologist must be present at the time of delivery for neonatal assessment . this complications can be minimised by maintaining her  diabetes in control . teach the patient self monitoring  of blood glucose level, pre meal ,post meal and before going to bed . try and keep the preprandial  blood sugar level between 3.5 - 5.9 mmol per lt  and post prandial below 7.8 mmol per lt. no need to test HBa1c in second and third trimester . educate her  and her relatives about  hypoglcemic episodes and to take glucose drink or glucagon  in the event of hypoglycemia . if the patient feels unwell she should check her urine for protiens and ketones and any risk of diabetic ketoacidosis should be managed by admission to critical level 2 . urine protein and BP should be checked regularly  .regular and frequent anc is needed . diet control and early identification of complication and early intervention has a good out come both for the mother and the baby. provide her information leaflet and  24 hrs hospital contact number.

 i would  ask her about how she controls the DM by diet and excerises,

take hypoglycemic drugs or insulin.

if she has regular visit with diabetologist to control DM.moreove if she

has had fundoscopy and retinal examination recently.iwould ask her

about any complications arise from dm as nephropathy or

neuropathy ,and if present what is the medications. I would check her

blood presure to detect hypertension.iwould request fudoscopy and

retinal examination if she did not make it in the previous 6

monthes.iwould request investigations such as renal fuction test,if

serum creatinine > 120 micromole/litre or estimated glomular

filitration rate is less than 45ml/min i will refere her to nephrologist

and i will advise against discontinuation of the contraception .iwould

request HbA1c and if the level >10% as this is associated with increase

the  risk of congenital malformation. i would advice  her to continue

contraception until it reach  6.1% to reduce but not eleminates risk of

congenital malformation.

)iwould tell her that her fetus has increased risk of congnital malformation  if her d.m not controlled before conception. and to minimize this risk she should keep her HbA1c < or equal to 6.1%.i would inform her that the risk of  down syndrom would be increased due to her age and not related to DM.the risk according to her age about 1:80.moreover screenig test for down syndrome are affected by dm such as maternal serum alpha fetoprotine which are decreased in DM.Also the risk of miscarriage is also increased if the DM is  not well controlled,but also it increases up to 50%  due to her age.neural tube defect is increased with dm and this can be minimized by taking folic acid 5mg before conception and up to 12 weeks of gestation.Also,congenital cardiac diseases are increased with DM and detalied cardiac scan at 18-20 wk should be done.if she is not controlled her DM through glycemic control this would increase risk of fetal hypoxia and acidosis,hydraminos due to fetal polyuria,feta macrosomia and still birth.hydraminos will increase risk of preterm labour and abruption placenta.macrosomia is associated with increase risk of shoulder dystocia and its sequale such as erb,s palsy and increase risk of ceaserean section.good glycemic control during pregnancy coul be achevied by frequent monitior by her self at home of fasting and 1 hour post prandial.targeted blood suga level  is recommended to be 3.5-5.9mmole/l fasting and to be below 7.8mmo.le/l 1 hour post prandial.the woman should be informed that if there is risk of preterm labour that corticosteroids to enhance lung matuartion of her fetus are not contraindictaed. and nifidpine will be the drug of choice.more over she will need to have regular serial scan of liqour and fetal growth every4 wks from 28wk.also induction of labour will be recommended at 38 wk of gestation to decrase risk of perinatal morbidity and mortality.if her wishes to continue pregnancy byond this date she shoud have weeky test for fetal wellbeing.vaginal delivery is the aim for uncomplicated pregnancy and cs for obstetric indictions and for macrosomic baby>4500gm.she should informed also that her neonate is at increase risk of hypoglycemia and hypothermia and this can be minimizd by erly and regular feeding.she should be also informed that the risk of addmission to NICU is incrased.moreover there is increased future risk of obesit yand dm for her baby.finally i would  tell her that good glycimic control and regular ANC visit with obstetricain and diabetic joint clinic will decrease risk to her fetus Then.I would give her written information about DM and pregnancy and also written information about down syndrome. 

a) Diabetic pregnany women are classifiied as high-risk pregnancies and should receive pre-pregnancy counselling as good diabetic control can reduce the risk to herself and to the pregnancy. She should be advised to take 5mg of folic acid pre-conceptually and her rubella status should be established. She should be taking effective contraception until the suggested changes to her management are in place. Ideally counselling should be provided by a multidisciplinary team which includes an obstetrician and diabetologist. A history should be taken to include current medication and the presence of diabetic complications. If she is taking oral hypoglycaemic agents then she can continue metformin in pregnancy; although other hypoglycaemic agents e.g. glibecamide and glitzaones are not recommended. She should be advised she may need to switch to insulin during the pregnancy if she cannot achieve good control with metformin. She should also be advised to stop any additional medication which is not advised in pregnancy e.g. statins or ACE inhibitors. Baseline investigations include HbA1c, FBC, U&Es and blood pressure. Her HbA1c should be <6 and any hypertension should be treated with methyldopa. The date of her last retinopathy screening should be established and if not within the last 12 months should be scheduled pre-pregnancy. She should be counselled that pregnancy can cause worsening of retinopathy.

b) She should be advised that diabetic patients are at higher risk of birth defects, fetal macrosomia, IUGR, stillbirth and pre-eclamspia. She should be advised that these complications can be reduced with good pre-pregnancy control. She should be advised to take low-dose aspirin to improve placental growth and reduce the risk of IUGR and pre-eclampsia. She should be offered regular growth scans from 24 weeks every four weeks which should detect macrosomia or growth restriction. Macrosomia has implications for the fetus in the form of shoulder dystocia at delivery. She should be offered a 20 week detailed anatomy scan. She should be advised that high dose folate (5mg) will reduce the risk of neural tube defects. She should be advised that babies of diabetic mothers are may experience hypoglycaemia in the early post natal period and may require care in the neonatal unit. They are also more likely to suffer from jaundice.