Episode 73 Diabetes in Pregnancy

How do we care for women with a diagnosis of diabetes when they are pregnant & why is the extra care we give so important? In this episode I  explore existing diabetes and gestational diabetes and the differences  and similarities between them and the impact they have on pregnancy experience and outcome.

Want to know more?
NICE guidance: https://www.nice.org.uk/guidance/ng3
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012327.pub2/full
GDM & the risk of stillbirth https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.15659

Help & information for pregnant women
https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/pregnancy/during-pregnancy
https://abcd.care/dtn-education/diabetes-tech-in-pregnancy
https://www.gestationaldiabetes.co.uk/gestational-diabetes-support/
https://jdrf.org.uk/news/nhs-access-to-cgm-for-pregnant-women-with-type-1-diabetes-begins-in-england/

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Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Episode 73 Diabetes in Pregnancy

Florence: [00:00:00] Hello, my name's Florence. Welcome to the obs pod. I'm an N H S Obstetrician, hoping to share some thoughts and experiences about my working life. Perhaps you enjoy, call the midwife, maybe birth fascinates you, or you'll simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth.

Perhaps you work in maternity and want to know what makes your obstetric colleagues tick or you want some fresh ideas and inspiration, whichever of these is the case, and for that matter, anyone else that's interested? The obs pod is for you,

episode 73, diabetes in Pregnancy. Why am I calling this diabetes in pregnancy, not existing diabetes [00:01:00] or gestational diabetes? I'm going to talk about both. Even though as you'll see, they are in some ways quite different. Why am I fired up to tackle this topic? Well, in part, I listened to the episodes of the Midwives Cauldron podcast on gestational diabetes from the mother's perspective and the baby's perspective, I have to say it was totally brilliant and I highly recommend listening to those episodes if you want a really good, sensible introduction to the topic.

The other reason I want to talk about this topic, What I experience every day in my clinical practice, increasing numbers of women with gestational diabetes and the interventions that come with it. Before I start talking about that, I'm going to [00:02:00] take a step back. When I was doing my specialty training and studying for my exams, one of the key things we learned was about the St.

Vincent Declaration . This was an aspiration set in 1989 that women with preexisting diabetes should have the same maternal and neonatal outcomes as women without. Seems quite reasonable, doesn't it? That was 1989. It's really quite shocking then that 32 years later, we're still a long way from this becoming reality.

and it's even more important because diagnoses of diabetes in the UK have doubled in the last 15 years with 90% of those cases being type two diabetes. So women that are pregnant who have existing diabetes as a diagnosis are on the rise. [00:03:00] In part. This may be related to maternal age. Also may be related to the rise of obesity, but it's a fact and it's a fact that we have to deal with.

When I did my exams, we had to learn that there was a direct correlation between long-term diabetic control and pregnancy outcome, both in terms of congenital abnormalities and stillbirth. Women with type one or type two diabetes need very close monitoring support throughout pregnancy, not only to mitigate the risk to the babies, but also to reduce the risk to themselves.

When I used to run a diabetic antenatal clinic, one of the important aspects was to ensure that the women were screened for long-term diabetes complications, such as retinopathy that can cause blindness, [00:04:00] nephropathy that can cause renal failure. We had to make sure that the pregnancy was not doing any damage to their long-term health screening tests.

To check for these complications that normally might be performed annually, needed to be performed more frequently in pregnancy. We would see women every two weeks. With the endocrinologist, the diabetic nurse and dietician, to try and optimize their care, and it was one of those rare situations in which there was a preconception clinic, not only in existence, but very much encouraged.

Because tight control during those first few critical weeks after conception had a big bearing on the wellbeing of the baby in terms of congenital abnormality, formation, tight control, really [00:05:00] important, but it isn't risk free. Hypoglycemia is a real possibility. And sometimes women in pregnancy lose their warning signs that they may have relied on pre-pregnancy.

And with hypoglycemia being a serious medical emergency, this is a significant potential side effect of that ti to control. So women with preexisting diabetes in pregnancy, Need a lot of care, a lot of support, a lot of input. I remember when I started my maternity experience work at one of the first whose shoes maternity pilot workshops.

A woman stood up and shared her story about the continued pressure she felt having to maintain such incredibly tight diabetic control during pregnancy. She [00:06:00] felt judged at every appointment. Remember I said we might be seeing women every two weeks? She felt guilty about her baby. Was she doing her best? And if there were problems with her baby, would it be her fault?

The surveillance intended to be helpful, just made her feel like a series of impossible hurdles to jump. . It sounds really stupid now, but despite having been both a registrar and a consultant in the Diabetic Antenatal Clinic, it had never occurred to me that it might be perceived in that way, in effect pregnancy, feeling like a long, sustained exam that one had to pass.

This seems like a problem taking a woman who's pregnant excited about becoming a mother. and then the very service that is supposed to [00:07:00] keep her and her baby safe and supported through that journey instead becoming a source of incredible stress to her. It made me wonder how it could make things easier, and it's many years since I was the consultant for the Diabetic Antenatal Clinic.

So when I was thinking about this episode, I thought I should figure out if much has changed in the meantime. I had a memory of reading something about technology, so I looked it up and indeed, nice guidance and NHS England's recommendation for women with type one diabetes is that they should have continuous glucose monitoring or C G M during pregnancy free on the N H s.

The implementation of this has been somewhat delayed by Covid. It started rolling out in November, 2020, and the [00:08:00] nice guidance was updated in December, 2020 after clear evidence suggested benefit to both women and their babies. It makes me wonder how far we've got with that Technology. Given the challenging year, we've just experienced in the uk, how many pregnant women are struggling without it, and at what cost in terms of their long-term physical and mental health, and those that do have access to it and have got it.

How are they finding it? Is it helping them gain control? Is it helping them? Feel supported? Is it taking some of the pressure off them or is it actually increasing the pressure because they're under continuous surveillance? I know at my trust we've been using an app to track women's blood [00:09:00] glucose. This means rather than carrying around the tatty little blood glucose recording book, women have an app on their phone.

And through the wonders of technology, our diabetic midwives can access the women's results, look at them with her, and do a telephone consultation. Again, that could be good. Less hospital appointments, more support, but is that app a little bit big brotherish, we are watching you even when you're at home.

We can access your blood sugars, see what you're doing, see if you're sticking to your diet, see what your control is like. I can't quite decide. Okay, so diabetes, quite clear. Cut what we need to do for good reason. [00:10:00] So I'm going to turn now to gestational diabetes. What is that? In basic terms is when your body and pregnancy can't keep up with the increasing insulin requirements your body needs.

The woman has higher than normal blood glucose levels, and this can lead to complications for the baby, such as being macrosomic. That means cherubic chubby, growing too rapidly. She can also have extra fluid known as polyhydramnios. The importance of these complications is not just for the pregnancy here and now, but it's a glimpse potentially into the future of that woman's health.

We know that women with gestational diabetes may experience it in future pregnancies and have a higher chance of developing type two diabetes in the future, so it's an [00:11:00] opportunity to talk to her about her diet exercise. Lifestyle choices to optimize her health at a point in the future, and for her GP to take over monitoring her over the years to come.

When I trained, we were clearly taught that gestational diabetes and preexisting diabetes were like chalk and cheese. They were totally different. And not to be confused with one another. Yet the care I increasingly come across does frequently seem to muddle the two. I'm not going to go into diagnosis and treatment in depth because there are far more well-equipped people than me to do so for gestational diabetes, but I am going to explore some of the issues I come across and where perhaps we might be missing the point.

We've said that diabetes has an [00:12:00] increased risk of congenital anomalies and stillbirth by its very nature, gestational diabetes doesn't carry the same risk of congenital anomalies simply because at the beginning of pregnancy, the woman's blood glucose levels are entirely normal. Tests for gestational diabetes are sometimes.

At 16 weeks and 28 weeks, but more often, the screening tests are offered at 28 weeks, so all the organ formation and development has already occurred at a time at which the woman's blood glucose is entirely normal. Right. Let's think about some of the situations I come across Situation one. The woman's had gestational diabetes diagnosed [00:13:00] through her screening glucose tolerance test at 28 weeks.

Her baby's doing fine. She's got average growth. Her blood sugars are well controlled, but then suddenly we tell a woman she needs to have an induction because of the risk of stillbirth, and we tell her this on the basis of the treatment she's taking. If she's managed to control her blood sugars on diet, we'll tell her she doesn't need to have her baby until 40 weeks and six days.

But if she starts on Metformin tablet treatment or insulin, then we tell her that she needs to have an induction earlier just on the basis of the treatment she's taking. I don't get it. We're giving her the treatment to control her blood sugars and if we've controlled her blood sugars, what is the risk [00:14:00] and are we worrying about the risk of macrosomia and therefore a difficult birth, perhaps shoulder dystocia and trauma for her, or are we thinking about it because of the risk of stillbirth

I've had women who would rather eat insufficiently to achieve so-called diet control than be started on metformin or insulin treatment simply for this reason. That way she's labeled diet control. She doesn't need to have an early induction. In my experience, women like to know facts. We can't simply wave around.

The increased chance of stillbirth, that's scaremongering. We have to tell her what is that risk? Researching this episode, I delved into it a bit deeper. [00:15:00] The risk of stillbirth in gestational diabetes might be four times higher than the background population, although there seem to be quite a lot of studies with conflicting evidence.

Let's take that as the worst case scenario. Four times higher than the background population. That sounds pretty high. Okay. Let's think about the fact that the background rate in the UK is on average maybe four per thousand. So if we say it's four times higher, are we now talking 16 per thousand? If we take a more common complication, perhaps we're trying to prevent a Macrosomic baby shoulder dystocia and trauma to the mother and injury to the baby rather than stillbirth.

Let's look at the Cochrane Review. The [00:16:00] Cochrane review on gestational diabetes says that there isn't any evidence that any of the interventions, whether that be diet or. Medication treatment have any benefit. In fact, they may actually instead cause harm by increasing induction. That's a bit of a sobering thought.

I come across many pregnant women with gestational diabetes having induction suggested at 38 weeks or even 37. If you actually read the NICE guidance, it states that induction. Should happen by 40 plus six. It doesn't mention insulin, it doesn't mention metformin or any other criteria in that timing. If you look at it, it actually says between 37 weeks to 38 weeks plus six.

Offer induction [00:17:00] of labor or if indicated cesarean section to women with type one or type two diabetes await spontaneous labor for all other women. Hang on a minute. That backs up what I just said. Women with preexisting diabetes and women with gestational diabetes are different. Women with gestational diabetes can await spontaneous labor.

So why is my antenatal ward and many others up and down the country full of women having induction for gestational diabetes? Okay, let's come back to stillbirth. Researching this episode, I found an excellent paper from the team at Manchester under Professor Hazel, [00:18:00] who does an enormous amount of research on stillbirth risk.

They looked at the stillbirth risk in gestational diabetes, and they looked at what was the impact of following the NICE guidance and treating that gestational diabetes on the rates of still birth. It was then that concluded that the risk of stillbirth may be four times higher than the background population.

But they discovered that if we treat gestational diabetes according to the NICE guidance that rate that higher risk, that higher chance of stillbirth in those women that have been treated according to NICE guidance. goes back to the background rate wait. That means women that we are treating with gestational diabetes have the background rate of stillbirth.[00:19:00] 

That's fantastic. So if there is a risk, a higher chance, we've negated that by our treatment. That is fabulous. Surely that means we can follow the nice guidance and wait for these women to go into spontaneous labor, can't we? Now, let's turn to situation two. This is a pregnant woman who's had a scan. The scan may have been for all sorts of other reasons, but the scan incidentally suggests that the baby's big.

The abdominal circumference, the tummy measurement is bigger than the 97th centile, or she's carrying extra fluid. Remember my big baby episode? If you haven't had a listen to that and you're interested, I suggest you do. For this woman, it's too late [00:20:00] in the day to diagnose gestational diabetes. Maybe she's 36 weeks.

It's a bit late to start testing her, and we feel that if we did test her, we couldn't do much to modify her blood sugar levels in the remaining weeks. So do we recommend induction to her? Paradoxically, if she was diagnosed and under control with her blood sugars, we might wait to 40 plus six. But now because it's a bit late in the day.

We might recommend induction at 37. I agree we can't have much impact on the growth of the baby at this stage, but surely if her gestational diabetes has only started now at this point, it should be less significant if she's only developed it at this late point. And what if she doesn't have it at [00:21:00] all?

It could just be that her baby is destined to be that large afterall the whole point of the 97th Centile is 3% of babies will be that large, so we may be putting the label of gestational diabetes on her when she doesn't have it at all. Does it matter? Well, yes it does, because once we've applied that label, not only may she be recommended to have an induction, but also her baby will need to have blood sugar monitoring after it's born.

We've started a whole load of intervention. Situation three is my most infuriating one. The pregnant woman is here for her routine check. There is glucose in her urine. Known as Glycosuria. If you read the nice [00:22:00] guidance according to this, she'll need further testing. The earlier section on diagnosis clearly states that Glycosuria is not sufficient to make a diagnosis.

This is because glycosuria can just simply represent the fact that she had something sugary to eat I have a morning antenatal clinic. So if someone had the audacity to have a sugary cereal for breakfast, she may test positive or maybe she had a hot chocolate. Again, if this happens late in pregnancy, we think it's too late to test, do anything, take any action.

So, ooh, let's apply that label again. And yeah, you guessed it, the solution. Induction.

Let's go back to that NICE guidance once again. 37 weeks to [00:23:00] 38 plus six offer induction of labor or if indicated, cesarean. Section two, women with type one or type two diabetes await spontaneous labor for other women. There's no mention of gestational diabetes. It couldn't be clearer. So why do we see more and more women being induced?

Antenatal wards full of women, and I know it's not just my own hospital. I see other midwives and obstetricians from other areas of the country through my networks talking about it. Now, don't get me wrong, there is a place for induction. Sometimes if the baby is hugely macrosomic, its growth is [00:24:00] accelerating or actually worse still.

A woman with preexisting diabetes or gestational diabetes whose baby is growth restricted , then that's an alarm bell, correct? These babies, these babies are the ones at risk. These are the women that need thought care, consideration and decisions about timing of birth, which brings me to

With the rise in type two diabetes and increasing numbers of pregnant women with existing diabetes and gestational diabetes, and with the national drive to reduce stillbirths, which is very laudable [00:25:00] diabetic specialists, antenatal clinics are becoming busier and busier. In our zeal to provide good care, we've developed a whole industry.

This leads to women having their continuity of care with their named midwife disrupted. They may be moved from their continuity care team to the diabetic team. In this busy clinic, there's little time to counsel them about the whys and where fors of some of these big decisions. My zesty bit this week would therefore be, we need to separate out care of women with existing diabetes from those with gestational diabetes.

Yeah. I know it's convenient for us as a service. They need many of the same professionals, but actually it doesn't take account of the [00:26:00] women's experience. And it contributes to us muddling things up and confusing the two. If you're seeing more than 20 women in a morning, is it any wonder that the boundaries between gestational diabetes and existing diabetes get blurred?

My other zesty bit for professionals is, please don't bandy about. The stillbirth word, yes, of course you can use that word, but have an intelligent conversation about it. As I mentioned in my obstetric cholestasis episode, be honest about what we know and what we don't, so that the woman understands what you're talking about, rather than just chucking in the stillbirth word and her then being terrified[00:27:00] 

it's very difficult for a woman to go against your recommendation when you mention Stillbirth word, because then she feels it's her fault if something catastrophic happens to her baby. If you are a pregnant woman with preexisting diabetes, I've put some links to some great videos about continuous glucose monitoring in pregnancy

understand what your options are. Understand that you should be offered preconceptual counseling. Know what are the important things right from the start of your pregnancy, and know that many, many women with existing diabetes have very healthy pregnancies. Know that we are there to support you, not judge.

But to try and help you through what we know is a very difficult period [00:28:00] in life.

And if you have gestational diabetes, don't be frightened to question what health professionals are telling you. I've put some links to some gestational diabetes support groups. You might find them helpful to. And understand what exactly are the risks to you and your baby? And if someone's recommending induction, is that a blanket induction?

We're just telling you this because we tell this to every woman with gestational diabetes. Or are they actually looking at your own pregnancy, your own blood sugar, control the size of your baby and applying that evidence to you? Don't be frightened to question what they're suggesting and make sure that you feel you have all the [00:29:00] answers you need to make your decision, because it is just that.

It's your decision. Having gestational diabetes doesn't necessarily mean that all your choices are automatically taken away. I do hope you've enjoyed listening to this episode of the obs. Feel free to contact me on Twitter @FWmaternity or @TheObsPod to ask me questions. Give me topics for future episodes or let me know what you think.

It's absolutely fantastic when you get in touch and I really enjoy reading your comment. As usual, I've tried to include in the program notes some extra reading about this particular topic, both for professionals working in maternity care and for pregnant women using services. [00:30:00] I'd like to reassure you that although I'm talking about my experiences working in maternity care, I take confidentiality very seriously and do not give any personal information about any of my patients.

If you've enjoyed listening, I'd love you to recommend TheObsPod to friends or colleagues. And please do leave me a review on whichever podcast directory you find my episodes. Many thanks for listening.