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Practice bulletins > #190 Gestational Diabetes Mellitus > Flashcards

#190 Gestational Diabetes Mellitus Flashcards

1
Q

What class is diet-controlled gestational diabetes?

A

GDMA1

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2
Q

What class is gestational diabetes that requires medication to achieve euglycemia?

A

GDMA2

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3
Q

Approximately what percent of pregnancies are complicated by any type of diabetes?

A

7%

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4
Q

What percent of cases of pregnancies complicated by any type of diabetes are women with gestational diabetes?

A

86%

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5
Q

What race/ethnic group has the lowest rate of gestational diabetes?

A

Caucasian women

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6
Q

Is the prevalence of gestational diabetes increasing, decreasing, or staying the same?

A

Increasing.

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7
Q

What is the prevalence of preeclampsia in women with GDM with fasting <115 vs >115?

A

9.8% in those with fasting <115; 18% in those with fasting >115

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8
Q

Are women with gestational diabetes more likely to wind up with a cesarean section?

A

Yes

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9
Q

Are women with gestational diabetes at increased risk of developing diabetes?

A

Yes

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10
Q

How many women with gestational diabetes will go on to develop diabetes within 22-28 years after pregnancy?

A

70%

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11
Q

What % of Latin American women with gestational diabetes will develop T2DM within 5 years of their index pregnancy c/b GDM?

A

60%

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12
Q

What complications are offspring of women with gestational diabetes at increased risk for?

A

Macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, and birth trauma, increased risk of stillbirth. Increased risk of childhood and adult-onset obesity and diabetes in offspring.

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13
Q

The use of historic factors (family or personal hx of diabetes, previous adverse preg outcome, glycosuria, and obesity) will fail to identify what % of women with GDM?

A

About 50%

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14
Q

What is the screening test for gestational diabetes?

A

50g, 1 hour oral glucose tolerance test

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15
Q

When should pregnant women be screened for gestational diabetes?

A

Between 24 and 28 weeks

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16
Q

For pregnant women with a positive early 1 hour test (50 g oral glucose), with negative 3 hour, what should be done at 24-28wks?

A

Skip the 1 hour and do the 3 hr gtt

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17
Q

In which patients should you consider screening for detecting pregestational diabetes or early GDM?

A

All overweight or obese women with 1+ of the following:

  • Past Ob: previous GDM, previous infant >4kg
  • PMH: BMI >40kg, HTN, PCOS, cardiovascular dx, acanthosis nigricans
  • Soc Hx: high-risk race or ethnicity
  • FHx: 1st degree relative w/ DM,
  • Labs: HDL < 35mg/dL; triglyceride >250dmg/dL; HgbA1C => 5.7%
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18
Q

How do you diagnose GDM based on 3 hour 100g OGTT?

A

Most often diagnosed with two or more abnormal values

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19
Q

What is the threshold for the 1 hour OGTT?

A

Vary by institution, typically 130-140mg/dL

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20
Q

True or false, women with single elevated value on 100g, 3-hour OGTT have significantly increased risk of adverse perinatal outcomes compared to women without GDM?

A

True.

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21
Q

What are the cut offs for the 3hr OGTT?

A 
Fasting 95-105mg/dL
1h 180-190 mg/dL
2h 155-165mg/dL
3h 140-145mg/dL
(lower is Carpenter and Coustan Criteria; higher is National diabetes data group)
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22
Q

What is the one-step approach for establishing diagnosis of gestational diabetes mellitus? How is it diagnosed, what are cut off values?

A

75-g 2-hr OGTT. Diagnosed with any single threshold value (fasting 92, 1h 180, 2h 153)

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23
Q

Does use of the 2h OGTT increase or decrease the prevalence of GDM?

A

Increase, would identify approx 18% of pregnant women in US as having GDM

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24
Q

Does ACOG recommend the one-step or two-step process for diagnosing gestational diabetes?

A

Two Step. 1h followed by 3h.

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25
Q

What are the benefits of treating gestational diabetes?

A

Decreased rate of shoulder dystocia, preeclampsia, LGA infant, birth weight >4kg

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26
Q

What is the risk of preeclampsia in women with GDM, untreated vs treated?

A

18% in untreated. 12% in treated

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27
Q

What is the risk of LGA infant in women with GDM in untreated and treated?

A

22% and 13%

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28
Q

What is the risk of birth weight >4kg in women with GDM untreated and treated?

A

21% to 10%

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29
Q

What is the recommended surveillance of blood sugars in women with gestational diabetes?

A

General recommendation is 4x/day: fasting and after each meal (1 or 2h). Insufficient evidence to define optimal frequency

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30
Q

What does fasting glucose measure predict in women with GDM?

A

Predictive of increased neonatal fat mass

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31
Q

When does glucose peak posprandial?

A

90 minutes after meal

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32
Q

Can you reduce the number of fingersticks during monitoring of GDM?

A

Yes, once glucose well controlled by diet and low likelihood for future adjustments to care, can decrease. Unusual to recommend fewer than 2 measures per day

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33
Q

What are the goal fasting and postprandial blood glucose values in GDM?

A

Fasting <95mg/dL
1h pp <140mg/dL
2h pp <120mg/dL

34
Q

With gestational diabetes controlled by diet, what % of diet should have calories from carbs, protein, fat?

A

Carbs 33-40%
Protein 20%
Fat 40%

35
Q

What is the exercise recommendation for pregnant women with GDM?

A

Aim for 30 min of moderate-intensity aerobic exercise at least 5d/wk or minimum of 150mins per week

36
Q

What is the recommended first-line pharmacotherapy for GDMA2?

A

Insulin

37
Q

Does insulin cross the placenta?

A

No

38
Q

What is the typical starting total dosage of insulin in units/kg daily for women with GDM with fasting and pp hyperglycemia present after most meals?

A

0.7-1.0units/kg daily. Divided into regimen of multiple injections using long-acting or intermediate-acting insulin in combo with short-acting.

39
Q

What is the onset of action for insulin lispro?

A

1-15 min

40
Q

What is the peak of action of insulin lispro?

A

1-2h

41
Q

What is the duration of action of insulin lispro?

A

4-5h

42
Q

What is the onset of action for insulin aspart?

A

1-15min

43
Q

What is the peak of action of insulin aspart?

A

1-2h

44
Q

What is the duration of action of insulin aspart?

A

4-5h

45
Q

What is the onset of action of regular insulin?

A

30-60min

46
Q

What is the peak of action of regular insulin?

A

2-4h

47
Q

What is the duration of action of regular insulin?

A

6-8h

48
Q

What is the onset of action of NPH (isophane insulin suspension) insulin?

A

1-3h

49
Q

What is the peak of action of NPH (isophane insulin suspension) insulin?

A

5-7h

50
Q

What is the duration of action of NPH (isophane insulin suspension) insulin?

A

13-18h

51
Q

What is the onset of action of insulin glargine?

A

1-2h

52
Q

What is the peak of action of insulin glargine?

A

no peak

53
Q

What is the duration of action of insulin glargine?

A

24h

54
Q

What is the onset of action of insulin determir?

A

1-3h

55
Q

What is the peak of action of insulin determir?

A

Minimal peak at 8-10h

56
Q

What is the duration of action of insulin determir?

A

18-26h

57
Q

Has the FDA approved use of any oral agents for use with GDM?

A

No

58
Q

What is metformin, and how does it work?

A

Biguanide that inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissues

59
Q

Does metformin cross the placenta?

A

Yes, levels can be as high as maternal concentrations

60
Q

How do outcomes in women with GDM treated with insulin vs metformin compare?

A

Lack of superiority of metformin compared to insulin (similar outcomes). No long-term data in metformin-exposed offspring.

61
Q

What % of women taking metformin for GDM will eventually require insulin?

A

26-46%

62
Q

What are the most common adverse effects of metformin?

A

Abdominal pain and diarrhea (reported in 2.5-45.7%)

63
Q

What is the maximum daily dose of metformin?

A

Usually 2,500-3000mg in two or three divided doses

64
Q

How should you start a patient on metformin?

A

Usually: 500mg nightly for 1 week, then 500mg BID

65
Q

What type of medication is glyburide and how does it work?

A

Sulfonylurea that binds to pancreatic beta-cell adenosine triphosphate potassium channel receptors to increase insulin secretion and insulin sensitivity of peripheral tissues

66
Q

With what type of allergy can you not use glyburide?

A

Sulfa allergy

67
Q

How does glyburide use compare to insulin for management of GDM?

A

Worse outcomes. Higher rates of neonatal hypoglycemia. Higher rates of PEC, hyperbilirubinemia, and stillbirth.

68
Q

What % of women receiving glyburide for GDM will require additional of insulin?

A

4-16%

69
Q

Does glyburide cross the placenta?

A

yes

70
Q

When would you start antenatal fetal testing in women with pregestational diabetes, well-controlled GDMA1, poorly controlled GDMA1, GDMA2?

A

Well-controlled GDMA1 does not typically necessitate antenatal fetal testing, but can consider after 32wk. For all others, usually initiate testing at 32wks

71
Q

When do you recommend delivery of GDMA1 with good glycemic control?

A

39-40w6d

72
Q

When do you recommend delivery of GDMA2 with good glycemic control?

A

39w0d to 39w6d

73
Q

When should you deliver a GDM patient with poor glycemic control?

A

37w and 38w6d. Delivery in late preterm 34w to 36w6d may be justified for those who fail in-hospital attempts to improve glycemic control or who have abnormal fetal testing

74
Q

What % of infants identified LGA on ultrasound were LGA at birth?

A

22%, according to one study

75
Q

At what EFW for women with GDM should you counsel about risks and benefits of scheduled CS?

A

When EFW >4500g

76
Q

What proportion of women with GDM will have diabetes or impaired glucose metabolism at postpartum screening?

A

One third

77
Q

What % of women with GDM will go on to develop DM later in life? What fold increased risk is it for a women with GDM to develop DM later in life compared to someone without GDM?

A

15-70%. 7-fold increased risk

78
Q

When should a woman with GDM be screened postpartum for DM, impaired fasting glucose levels, or impaired glucose tolerance?

A

4-12wks postpartum

79
Q

What is the recommended test for detecting issues with postpartum glucose control?

A

75-g 2h OGTT

80
Q

How do you interpret the results of a 75-2h OGTT postpartum test?

A

fasting >125mg/dL or 2h >199mg/dL = Diabetes

81
Q

How often should you repeat glucose testing for women who had gestational diabetes during pregnancy with normal postpartum testing?

A

Every 1-3 years

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