Management of diabetes in

special situations
Diabetes in pregnancy
• Gestational diabetes is defined as diabetes with first onset or
recognition during pregnancy.
• This definition will include a few patients who develop type 1
diabetes during pregnancy, where prompt action and early insulin
treatment will be required, and some patients who develop type 2
diabetes, or had unknown pre-existing type 2 diabetes, in whom the
diabetes does not remit after pregnancy.
• gestational diabetes develops due to an inability to increase insulin
secretion adequately to compensate for pregnancy-induced insulin
resistance, and most women can expect to return to normal glucose
tolerance immediately after pregnancy.
• Risk factors for gestational diabetes :
• • Body mass index > 30 kg/m2
• • Previous macrosomic baby weighing ≥ 4.5 kg
• • Previous gestational diabetes
• • Family history of diabetes (first-degree relative with diabetes)
• • Family origin with a high prevalence of diabetes:
• South Asian (specifically women whose country of family origin is
India, Pakistan or Bangladesh) Black Caribbean Middle Eastern
• women at high risk for gestational diabetes should have an oral
glucose tolerance test at 24–28 weeks, and some guidelines
recommend that all high-risk women should be screened by
measuring HbA1c, fasting blood glucose or random blood glucose at
the first booking visit.
• It should be noted that measurements of HbA1c cannot reliably be
used to diagnose diabetes in early pregnancy and until 3 months
post-partum, since HbA1c levels fall due to increased red cell
turnover.
• Diagnostic criteria for GDM
• Perform a 75 g OGTT ,with plasma glucose measurement when an
individual is fasting and at 1 and 2 h ,at 24-28 weeks of gestation in
individuals not previously diagnosed with diabetes
• The OGTT should be performed in the morning after an overnight fast of at
least 8 h .
• The diagnosis of GDM is made when any of the following plasma glucose
values are met or exceeded:
• Fasting : 92 mg /dl (5.1mmol /L )
• 1 h :180 mg /dl (10.0 mg /L)
• 2h : 153 mg /dl (8.5mmol/L)
Management
• The aim is to normalise maternal blood glucose concentrations and reduce the
risk of excessive fetal growth.
• The first element of management is dietary modification, in particular by
reducing consumption of refined carbohydrate.
• Women with gestational diabetes should undertake regular pre- and post-
prandial selfmonitoring of blood glucose, aiming for pre-meal blood glucose
levels of < 5.3 mmol/L (96 mg/dL) and a 1-hour post-prandial level of < 7.8
mmol/L (142 mg/dL) or a 2-hour post-prandial level of < 6.0 mmol/L (109 mg/dL).
• If pharmacological treatment is necessary, metformin, glibenclamide or insulin
can all be used. Glibenclamide should be used rather than other sulphonylureas
because it does not cross the placenta.
• women with gestational diabetes should have a fasting blood glucose measured
at 6 weeks post-partum and have HbA1c concentrations measured annually to
screen for the development of diabetes.
Pregnancy in women with established
diabetes
• Maternal hyperglycaemia early in pregnancy (during the first 6 weeks post
conception) can adversely affect fetal development, causing cardiac, renal and
skeletal malformations, of which the caudal regression syndrome (abnormal
development of the lower Maternal hyperglycaemia early in pregnancy (during
the first 6 weeks post conception) can adversely affect fetal development, causing
cardiac, renal and skeletal malformations, of which the caudal regression
syndrome (abnormal development of the lower part of the spine) is the most
characteristic.
• The risk of fetal abnormalities is about 2% for non-diabetic women and about 4%
for women with well-controlled diabetes (HbA1c < 53 mmol/ mol) but more than
20% for those with poor glycaemic control (HbA1c > 97 mmol/mol).
• Therefore, it is important for women with diabetes to aim to achieve good
glycaemic control before becoming pregnant. In addition, high-dose folic acid (5
mg daily, rather than the usual 400 μg) should be initiated before conception to
reduce the risk of neural tube defects.
• Pregnancy is also associated with an increased risk of ketosis, particularly,
but not exclusively, in women with type 1 diabetes. Ketoacidosis during
pregnancy is dangerous for the mother and is associated with a high rate
(10–35%) of fetal mortality.
• Pregnancy is linked with a worsening of diabetic complications, most
notably retinopathy and nephropathy, so careful monitoring of eyes and
kidneys is required throughout pregnancy.
• If heavy proteinuria and/or renal dysfunction exist prior to pregnancy,
there is a marked increase in the risk of pre-eclampsia, and renal function
can deteriorate irreversibly during pregnancy.
• Perinatal mortality rates remain 3–4 times those of the non-diabetic
population (at around 30–40 per 1000 pregnancies) and the rate of
congenital malformation is increased 5–6-fold.
Hyperglycaemia in acute medical illness
• Hyperglycaemia is often found in patients who are admitted to hospital as
an emergency.
• most people this occurs in the context of a known diagnosis of diabetes; in
some individuals, however, it is a consequence of stress hyperglycaemia ,
while in others it is due to undiagnosed diabetes.
• Hyperglycaemia on admission to hospital is associated with increased
length of stay and increased mortality in a wide variety of acute medical
emergencies, including acute coronary syndrome and acute stroke.
• There is no consensus on the optimum glucose targets in acutely ill
patients but extremes of blood glucose should be avoided, and so a target
of between 6 and 12 mmol/L (105 and 180 mg/dL) seems appropriate.
Achieving such a target may require the use of intravenous insulin and
dextrose in some individuals.
Surgery and diabetes
• Patients with diabetes are reported to have up to 50% higher perioperative mortality
than patients without diabetes.
• Surgery causes catabolic stress and secretion of counter-regulatory hormones (including
catecholamines and cortisol) in both normal and diabetic individuals.
• . In diabetic patients, either there is absolute deficiency of insulin (type 1 diabetes) or
insulin secretion is delayed and impaired (type 2 diabetes), so that in untreated or poorly
controlled diabetes, the uptake of metabolic substrate into tissues is significantly
reduced, catabolism is increased and, ultimately, metabolic decompensation in the form
of DKA may develop in both types of diabetes.
• hyperglycaemia impairs wound healing and innate immunity, leading to increased risk of
infection.
• Patients with diabetes are also more likely to have underlying pre-operative morbidity,
especially cardiovascular disease.
• Finally, management errors in diabetes may cause dangerous hyperglycaemia or
hypoglycaemia.
Pre-operative assessment
• • Assess glycaemic control:
• Consider delaying surgery and refer to the diabetes team if HbA1c >
75 mmol/mol; this should be weighed against the need for surgery
• • Assess cardiovascular status Optimise blood pressure Perform an
ECG for evidence of (possibly silent) ischaemic heart disease and to
assess QTc
• • Assess foot risk Patients with high-risk feet should have suitable
pressure relief provided during post-operative nursing
• • For minor/moderate operations where only one meal will be
omitted, plan for the patient to be first on the list
Perioperative management
Post-operative management
• Patients who need to continue fasting after surgery should be maintained on
intravenous insulin and fluids until they are able to eat and drink .
• Insulin infusion necessitates dextrose infusion to maintain a supply of glucose but
this combination drives down plasma potassium, and can result in
hyponatraemia.
• Intravenous fluids during prolonged insulin infusion should therefore include
saline and potassium supplementation. UK guidelines recommend the use of
dextrose/ saline (0.45% saline with 5% dextrose and 0.15% potassium chloride).
• Once a patient’s usual treatment has been reinstated, care must be taken to
continue to control the blood glucose, ideally between 6 and 10 mmol/L (105–
180 mg/dL), in order to optimise wound healing and recovery.
• Patients normally controlled on tablets may require temporary subcutaneous
insulin treatment until the increased ‘stress’ of surgery, wound healing or
infection has resolved.