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BSMS203 Repro (Theme 2) > 19. Pregnancy and diabetes > Flashcards

19. Pregnancy and diabetes Flashcards

1
Q

Is maternal hyperglycaemia good

A

Maternal Hyperglycemia during pregnancy is bad / very bad for the Fetus

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2
Q

Why does diagnosing maternal hyperglycaemia matter?

A

It affords an opportunity to Prevent:

  • Morbidity In the offspring “from the uterus to the grave”
  • An exacerbation of the obesity & Type 2 diabetes epidemic
  • Future Type 2 diabetes in the mother
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3
Q

ANC booking groups

A

At ANC booking there are 2 groups

Women with Normal Glucose tolerance
Women with Abnormal Glucose tolerance
- Known Diabetes or IGT
- Unknown Diabetes or IGT

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4
Q

Types of hyperglycaemic scenarios during pregnancy

A 
Pre-gestational Hyperglycaemia
Type 1 Diabetes
Type 2 Diabetes
Known
Unknown
Monogenic Diabetes
Impaired Glucose Tolerance (IGT)
“Gestational Diabetes” (GDM)
 Any newly found Abnormal GTT after the
    1st trimester of pregnancy ( i.e.  Diabetes or IGT )
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5
Q

Practical definitions of gestational diabetes

A

WHO criteria ( and NICE)
Diabetes OR Impaired Glucose Tolerance
Fasting glucose =/ > 5.6 mmol/l
2 hour GTT glucose =/ > 7.8 mmol/l

International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria
Outcome based (HAPO study)

75 g Glucose Tolerance test

 Fasting  5.1  mmol/l
 1 hour  10.0  mmol/l
 2 hours  8.5  mmol/l

Diagnose if 1 or more abnormal

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6
Q

What is the problem with hyperglycaemia in pregnancy?

A

Any degree of Maternal Hyperglycaemia during pregnancy can cause serious problems for the fetus

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7
Q

Stages of pregnancy

A 
1st Trimester
Organogenesis
Carefully design the essential components
Avoid Mistakes ( Teratogenesis)
Construct & programme the placenta
2nd Trimester
Further complex development & linkage
3rd Trimester
Accelerated growth
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8
Q

How does maternal metabolism change as pregnancy progresses?

A 
Early pregnancy = Facilitated Anabolism
Increased Insulin sensitivity
Glucose concentration  slightly lower
Increased maternal energy stores
Later Pregnancy = Facilitated Catabolism
Increased Insulin resistance
Increased transplacental passage of nutrients
->
Rapid fetal growth
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9
Q

How does maternal hyperglycaemia mess with the system?

A 
1st trimester
Increased Fetal abnormalities
Fuel Mediated Teratogenesis
Abnormal placental programming
Increased risk of Pre-eclampsia
Excessive glucose transport
3rd Trimester
Excessive fat deposition
Adverse Fetal programming ( epigenetics )
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10
Q

Possible feotal malformations as a result of first trimester maternal hyperglycaemia

A 
Hydrocephalus
Meningomyelocoele
Congenital heart disease
Single ventricle and sacral dysgenesis
Renal agenesis
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11
Q

Preventing foetal malformation in hyperglycaemia of pregnancy

A

Start preconception for known diabetes

Good Diabetes Control in 1st Trimester
Prepregnancy counselling
Lifestyle Modification
Intensive glucose monitoring
Optimize Insulin Regimen
If not on Insulin commence Insulin
Folic Acid 5mg / day
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12
Q

Primary care & prevention of fetal malformation due to maternal hyperglycaemia

A 
Identify Unknown cases of Diabetes / IGT by checking women with risk factors
Previous Gestational Diabetes
Obesity
Polycystic ovarian syndrome
Family history of type 2 diabetes
High risk racial group
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13
Q

Problems in third trimester

A

Macrosomia & associated problems
Pre-eclapsia
Fetal or Neonatal death

Macrosomia
->
Difficult Birth
Shoulder Dystocia
Breathing Problems
Jaundice
Hypoglycaemia
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14
Q

Risk of increased perinatal mortality for women with diabetes vs no diabetes

A

Type 2 diabetes - x 9

type 1 diabetes - x2

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15
Q

Lifelong foetal sequele of hyperglycaemia in pregnancy?

A 
Obesity
Insulin resistance 
Type 2 diabetes
Dyslipaemia
Hypertension
Vascular disease
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16
Q

Who’s screened for for undiagnosed diabetes?

A 
high risk women:
Previous GDM
Obesity ( BMI > 30)
Family history
High risk racial group
Older age
Polycystic ovary syndrome
   THEN
Universal or Targeted Screening at 26 weeks
To Detect GDM
17
Q

Treatment of any pregnancy hyperglycaemia

A 
Good maternal  glucose control
- Intensive blood glucose monitoring 
- Fasting + 1 hour post prandial minimum
Appropriate nutrition
Reasonable exercise
Utrasound monitoring of Fetal abdominal girth
- Monthly from 28 weeks 
Maternal observation of Fetal movements
18
Q

Targets for hyperglycaemia of pregnancy

A

Fasting glucose < 5.1 mmo/l
1 hour postprandial glucose < 7 mmol/l
Fetal Abdominal girth < 70th centile
Less in Asians

19
Q

Drug treatment to achieve good maternal glucose control in pregnancy

A 
Prepregnancy /1st trimester hyperglycaemia
Basal bolus Insulin regimen
“Gestational” diabetes
Metformin 
Basal Insulin
Basal bolus Insulin
Glibenclamide (Uncommon in UK)
20
Q

Diabetes/GDM - post partum

A 
Maintain good Glycaemic control
- To prevent excess glucose in milk
- Reduce maternal weight gain
Advice re next pregnancy
Contraception advice
Encourage  long term glycemic control 
Encourage Breast Feeding
21
Q

breastfeeding and obesity

A 
Child
Any reduces  risk by 30-50%
- 19 studies 3-19 years
-  6 studies 4-18 years
 Prolonged exclusive reduces by 67%

Mother
Reduces postpartum weight gain

Women who lactated for either 6–12 months or 12 months or longer had half the risk for diabetes

22
Q

“Specific GDM” Management Post Partum

A

Screen for diabetes at 12 weeks post partum
- HbA1c +/- Fasting glucose, or GTT

Review GAD ect. antibody status if done

Lifestyle advice

Advice re next pregnancy

  • Optimize exercise & Nutrition
  • Pre pregnancy GTT

Annual glucose screening
- 50% develop type 2 diabetes at 10 years

23
Q

GDM & Primary Care – Post PartumContraceptives & Diabetes / IGT

A

Progestagen only pill
Combined OCP ( low dose) after 6 weeks
Mirena Intrauterine system
Sterilisation / Vasectomy

24
Q

Problem of hyperglycaemia in pregnancy

A 
Maternal Hyperglycaemia
        ->   Serious fetal problems
Early - Teratogenesis   
Late    
	· Macrosomia / hypoglycaemia / lung problems
	· Pre-eclampsia
	· Late Fetal death
25
Q

Management of hyperglycaemia in pregnancy

A
  • Folic acid 5mg in 1st Trimester
  • Aspirin 75 - 150 mg/day from 12/40
  • if less than 16/40
  • Attendance at multidisciplinary one stop clinic
  • Tight glucose control throughout pregnancy
  • Fetal Ultrasound monitoring in last trimester
  • Maternal monitoring of Fetal movements
  • Appropriate delivery strategy (NO DOGMA!!)
26
Q

Screening for hyperglycaemia in pregnancy

A 
Screen  to detect “Gestational diabetes”
High risk women at 12-14 weeks
At 28 weeks
- Everyone ( Universal screening ) or
Targeted  (NICE)
Postpartum Screen “GDM women” for Diabetes
- At 12 week post Partum
- Annually for Diabetes (50% by 15 years)

BSMS203 Repro (Theme 2) (26 decks)

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