NICE: Diabetes in Pregnancy

This post is a summary of NICE guideline NG23 “Diabetes in Pregnancy” which was published in 2015. This guideline contains recommendations for managing diabetes & its complications in women who are planning pregnancy /already pregnant.

This is one of ‘the must’ guideline for the MRCOG exams. I have extracted only the main points. It is recommended to read the full guideline to ensure that no important points are missed.

I hope this is helpful. Your feedback and suggestions to improve further posts are welcome.

Thanks

To download full guideline Click Here

To download all NICE guidelines Click Here

INTRODUCTION

• 5% pregnancies are complicated by diabetes
• 87.5% → gestational diabetes
• 7.5% → type1
• 5% → type 2
• Risks to woman & fetus
• Miscarriage, pre-eclampsia & preterm labour are more common with pre-existing diabetes
• Diabetic retinopathy can worsen rapidly during pregnancy
• Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality & postnatal adaptation problems are more common in babies born to women with pre-existing diabetes

PRECONCEPTION PLANNING AND CARE

• Good blood glucose control before conception & continuing it throughout pregnancy reduces the risk of miscarriage, congenital malformation, stillbirth & neonatal death
• Risks can be reduced but not eliminated
• Important to avoid unplanned pregnancies & effective contraception
• Provide information about how diabetes affects pregnancy and how pregnancy affects diabetes
• Make sure woman enters pregnancy in best optimum health in order to avoid complications
• BMI ≥27 offer advice on weight loss
• Prescribe folic acid 5 mg/day to reduce risk of baby with neural tube defects

Monitoring of blood glucose & ketones in the preconception period

• Offer monthly HbA1c to those diabetics planning to become pregnant
• Teach self-monitoring of blood sugar levels& use of glucometer

Target blood glucose and HbA1c levels

• Aim for same capillary plasma glucose target ranges as recommended for all people with type 1 diabetes
• Aim to keep HbA1c levels below 48 mmol/mol (6.5%)
• Advise against pregnancy if HbA1c level above 86 mmol/mol (10%)

Safety of medicine for diabetes before and during pregnancy

• Metformin can be used
• All other oral blood glucose-lowering agents should be discontinued before pregnancy & insulin substituted

GTG# 38 Management of Gestational Trophoblastic Disease

This post is the summary of green-top guideline GTG 38 “Management of Gestational Trophoblastic Disease” which was published in September 2020.  The new version of the guideline has some changes, so it is important to cover it. There are some important numbers which are tested repeatedly in exams. It is strongly encouraged to go through the original guideline to make sure that no point is missed. 

I hope this post is helpful. Suggestions to improve future posts are welcome.

To Download the Guideline 38: Click Here

All GreenTop Guidelines: Click Here

Definitions

Gestational trophoblastic disease (GTD) is a group of disorders ranging from premalignant (complete & partial mole also called hydatidiform mole) to malignant (invasive mole, choriocarcinoma, placental site specific trophoblastic tumour (PSTT) and epithelium trophoblastic tumour (ETT)

Gestational trophoblastic neoplasia (GTN): persistence of GTD after primary treatment (persistent elevation of HCG)

Histological confirmation for diagnosis

• Required for complete/partial mole
• Not required for GTN

Introduction & Background

Molar pregnancy subdivided into complete and partial mole 

Complete Mole	Partial Mole
Diploid & androgenic in origin	Triploid 90% Tetraploid or mosaic occasionally
No fetal tissue	Fetus or fetal RBCs present
75-80% arise due to duplication of single sperm after fertilisation of an ‘empty’ ovum	2 sets of paternal haploid & 1 set of maternal haploid chromosomes
20-25% due to dispermic fertilization of an ‘empty ovum’	Not all triploid or tetraploid pregnancies are partial moles Must have histopathological evidence of trophoblast hyperplasia for dx

GTD (Hydatidiform mole, Invasive mole, Choriocarcinoma, PSTT)

• Uncommon in UK
• Incidence 1 in 714 live births
• Ethnic variation Asian 1 in 387 live births Non-Asian 1 in 752 live births
• Associated with age at conception, higher in extremes of age
• <15 yrs 1 in 500 pregnancies >50 yrs 1 in 8 pregnancies 

GTN 

• May develop after molar/non-molar pregnancy or a live birth
• 1 in 50 000 after live birth 
• On average, a consultant O &G will deal with one new case every 2 years

Registration & Treatment Program UK

• Effective with cure rates of 98-100% 
• Chemotherapy Needed in 
• 0.5-1.0% after partial mole 
• 13-16% after complete mole
• Registration with GTD is a minimum standard of care

Presentation of Molar Pregnancy

• Most common presentation is irregular vaginal bleeding (60%), positive pregnancy test & supporting USG evidence (12%)
• Less common hyperemesis, excessive uterine enlargement, hyperthyroidism, early-onset pre-eclampsia (PET) & abdominal dissension due to theca lutein cysts
• Very rarely: haemoptysis or seizures— metastasis in lungs or brain

Role of USG

• USG use has lead to earlier diagnosis of molar. Reduction in mean gestation age of diagnosis from 16 to 9 weeks (over 1988- 2013)
• Majority of histologically proven molar → associated with USG diagnosis of delayed miscarriage or an-embryonic pregnancy
• Pre-removal accuracy of diagnosis increases with gestational age 
• 35-40% before 14wks
• 60% after 14 wks 
• USG correctly identified 56% of molar pregnancies with suspected missed miscarriage
• Unrecognised GTD prior to removal → 2.7%