1 / 38

Diabetes and (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 4 th October 2018. Learning objectives. Why (pre-)pregnancy and diabetes is relevant in primary care Key messages about pregnancy and diabetes

deleond
Download Presentation

Diabetes and (pre-)pregnancy in primary care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Diabetes and (pre-)pregnancy in primary care Kate Hunt, Diabetes Consultant, KCH Rita Forde, DSN, KCL Lambeth CCG Diabetes Learning Event 4th October 2018

  2. 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

  3. 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

  4. 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)

  5. 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

  6. National Pregnancy in Diabetes Audit - 2016 NDIP 2017

  7. NPID Audit, 2013-2015, Published October 2016 Folic acid 5mg prior to pregnancy

  8. National Pregnancy in Diabetes Audit 2017 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.

  9. NPID Audit, 2013-2015, Published October 2016 First contact with antenatal diabetes team <8/40

  10. NPID Audit, 2013-2015, Published October 2016 First HbA1c in pregnancy

  11. Case 1 & Case 2 5 mins Case 1: tables 1-3 Case 2: tables 4-6

  12. 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 1000mgbd, Gliclazide160mgbd, Sitagliptin100mg 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?

  13. 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

  14. Referral-thinking about pregnancy (in next 12 months)=eRS

  15. Providing information Diabetes UK Information Prescription https://www.diabetes.org.uk/professionals/resources/resources-to-improve-your-clinical-practice/information-prescriptions-qa

  16. Providing information Diabetes UK website https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/pregnancy

  17. Providing information • NHS website • https://www.nhs.uk/conditions/pregnancy-and-baby/diabetes-pregnant/

  18. 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?

  19. 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

  20. 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: kch-tr.diabetessupplies@nhs.net 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: gst-tr.DiabetesAndEndocrine@nhs.net 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

  21. 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) • Methyldopa (3rd line) • (NB: if microalbuminuria/proteinuria consider continuing ACEi/ARB until confirmed pregnancy)

  22. Case 3 & Case 4 5 mins Case 4: tables 1-3 Case 3: tables 4-6

  23. Case 3 22 year old woman, Follow up appointment. Seen 2 weeks ago after doing fingerstick test using grandmother’s BG meter and found CBG12.2mmol/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?

  24. 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?)

  25. Talking about pregnancy with women with diabetes What are your thoughts on having a baby in the next couple of years? Yes/Maybe/ Unsure No Do you know why we discuss pregnancy in diabetes? Do you know why we discuss pregnancy 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 pregnancy? How are you preventing pregnancy? Signpost reliable contraception Advise to discuss with PN/GP BEFORE trying to get pregnant/discontinuing contraception Refer Diabetes PPC Advise avoid pregnancy until diabetes care optimised

  26. 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 1000mgbd, Gliclazide160mgbd, Liraglutide 1.2 mg od Atorvastatin 40mg od Ramipril 10mg od, amlodipine 10mg od Mirena coil Recent investigations: HbA1c 48 mmol/mol (6.5%), TC 3.4 mmol/l, LDL 1.8 mmol/l, uACR <2.5 mg/mmol Retinal screening normal BP 125/74 mmHg Questions: Is diabetes and pregnancy information relevant here? What are the issues/possible assumptions? What would you discuss with her and how?

  27. Case 4 Is diabetes and pregnancy information relevant here? • Yes! What are the issues/possible assumptions? • Just because she has 2 older children and has a Mirena coil, does not mean she does not want further pregnancies • Her pregnancies were before she developed diabetes so she may not realise there are any issues • DESMOND does not cover diabetes and pregnancy • If thinking about pregnancy gliclazide, liraglutide, atorvastatin, ramipril not suitable If not thinking about pregnancy, could consider SGLT2i What would you discuss with her (and how)? • ‘You have the Mirena coil at the moment. What are your thoughts on having a baby in the next couple of years/do you think you might want to have another baby in the future?’

  28. Pregnancy as part of annual review Woman <50 years old attending for diabetes annual review What are your thoughts on having a baby in the next couple of years? Yes/Maybe/ Unsure No Do you know why we discuss pregnancy in diabetes? Do you know why we discuss pregnancy 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 pregnancy? How are you preventing pregnancy? Signpost reliable contraception Advise to discuss with PN/GP BEFORE trying to get pregnant/discontinuing contraception Refer Diabetes PPC Advise avoid pregnancy until diabetes care optimised

  29. What happened to this lady?

  30. Case 4-missed opportunities Over the following year: • Mirena coil removed December 2017 (no discussion about diabetes and pregnancy) • Self-started folic acid 400 mcg od • Pregnant March 2018. Missed miscarriage at 8/40 with ERPC. (no discussion about diabetes and pregnancy) • Pregnant Oct 2018. Self referred for maternity care at 8/40

  31. Healthcare professionals perspectives about pre-pregnancy care for women with type 2 diabetes I hadn’t thought about it until you asked me - we don’t talk about pregnancy when women are newly diagnosed, there isn’t anything in there [DESMOND] about it at all, which is interesting ‘cause we do stuff for men. (DSN PC1) I don't give them support until they come to me and say, ‘Actually, we’re thinking of trying for a family,’ which is interesting – it’s more reactive, really. (GP 03)

  32. Healthcare professionals perspectives about pre-pregnancy care for women with type 2 diabetes • Asking them about their contraception or planning doesn't enter my thought process, and that’s just mainly down to timing issues ‘cause you know if you go there it takes time, and you just don't have time to deal with everything (GP5). • Well I think obviously the time is pressure for us. I mean we have our fingers in an awful lot of pies in general practice. And we have to cover a lot of areas (PN2). • Pre-conceptual and planning tends to go lower on your prioritisation list because you're dealing with the here and now, so to start a conversation like that… it’s time(GP1). • Well if we got paid for it I would remember to do it (PN 4) Pre-pregnancy care for women with type 2 diabetes – Rita Forde, PhD thesis KCL.

  33. Healthcare professionals perspectives about pre-pregnancy care for women with type 2 diabetes • I’m not going to do the specialised pre-conception care, it would be a specialist nurse that would do that - so it really is about me identifying them [women with T2DM] and flagging them up (GP2). • I don't deal with it [pre-pregnancy care]. So I would pass it on to someone who would be the appropriate person to do it, because we’re so specialised in certain areas (DSN SC1). • I’m specialised in other fields of diabetes, whereas my other colleagues are more specialised in pre-pregnancy care, so I would ask their advice and help, but I think it’s important for us to have an understanding of it, but I could happily give people general information about it and help them (DSN SC2). • You can't expect every GP to know everything there is to know about everything (CE1). • I don't think across the board between secondary and primary care, there's a lot of interface (PN2). Pre-pregnancy care for women with type 2 diabetes – Rita Forde, PhD thesis KCL.

  34. Pregnancy as part of annual review Woman <50 years old attending for diabetes annual review What are your thoughts on having a baby in the next couple of years? Yes/Maybe/ Unsure No Do you know why we discuss pregnancy in diabetes? Do you know why we discuss pregnancy 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 pregnancy? How are you preventing pregnancy? Signpost reliable contraception Advise to discuss with PN/GP BEFORE trying to get pregnant/discontinuing contraception Refer Diabetes PPC Advise avoid pregnancy until diabetes care optimised

  35. EMIS

  36. Women's views on pre-pregnancy care Just talk to people, let them know. It was never spoken about to me and I never knew, not even when I went on that course to learn when I started with diabetes. Even since then, no one ever mentioned pregnancy or even asked me. (Danni) When I go to the GP, I see a lot of posters on the wall but nothing about type 2 and pregnancy related, not even in their leaflets they give you. (Carol)

  37. Raising awareness -Mailshot to women aged 18-50 on DECS mailing list Oct 2018 -A4 posters available to display in primary care (please!) -Any other ideas?

  38. 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

More Related