#190 Gestational Diabetes Mellitus Flashcards by Angela Nolin

What class is diet-controlled gestational diabetes?

GDMA1

How well did you know this?

Not at all

Perfectly

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

GDMA2

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

86%

How well did you know this?

Not at all

Perfectly

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

Caucasian women

How well did you know this?

Not at all

Perfectly

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

Increasing.

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

Yes

How well did you know this?

Not at all

Perfectly

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

Yes

How well did you know this?

Not at all

Perfectly

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

70%

How well did you know this?

Not at all

Perfectly

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

60%

How well did you know this?

Not at all

Perfectly

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

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.

How well did you know this?

Not at all

Perfectly

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?

About 50%

How well did you know this?

Not at all

Perfectly

What is the screening test for gestational diabetes?

50g, 1 hour oral glucose tolerance test

How well did you know this?

Not at all

Perfectly

When should pregnant women be screened for gestational diabetes?

Between 24 and 28 weeks

How well did you know this?

Not at all

Perfectly

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?

Skip the 1 hour and do the 3 hr gtt

How well did you know this?

Not at all

Perfectly

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

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%

How well did you know this?

Not at all

Perfectly

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

Most often diagnosed with two or more abnormal values

How well did you know this?

Not at all

Perfectly

What is the threshold for the 1 hour OGTT?

Vary by institution, typically 130-140mg/dL

How well did you know this?

Not at all

Perfectly

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?

True.

How well did you know this?

Not at all

Perfectly

What are the cut offs for the 3hr OGTT?

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)

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

Two Step. 1h followed by 3h.

How well did you know this?

Not at all

Perfectly

What are the benefits of treating gestational diabetes?

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

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

18% in untreated. 12% in treated

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

22% and 13%

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

21% to 10%

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

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

What does fasting glucose measure predict in women with GDM?

Predictive of increased neonatal fat mass

When does glucose peak posprandial?

90 minutes after meal

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

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

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

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

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

Carbs 33-40% Protein 20% Fat 40%

What is the exercise recommendation for pregnant women with GDM?

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

What is the recommended first-line pharmacotherapy for GDMA2?

Insulin

Does insulin cross the placenta?

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?

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

What is the onset of action for insulin lispro?

1-15 min

What is the peak of action of insulin lispro?

1-2h

What is the duration of action of insulin lispro?

4-5h

What is the onset of action for insulin aspart?

1-15min

What is the peak of action of insulin aspart?

1-2h

What is the duration of action of insulin aspart?

4-5h

What is the onset of action of regular insulin?

30-60min

What is the peak of action of regular insulin?

2-4h

What is the duration of action of regular insulin?

6-8h

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

1-3h

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

5-7h

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

13-18h

What is the onset of action of insulin glargine?

1-2h

What is the peak of action of insulin glargine?

no peak

What is the duration of action of insulin glargine?

24h

What is the onset of action of insulin determir?

1-3h

What is the peak of action of insulin determir?

Minimal peak at 8-10h

What is the duration of action of insulin determir?

18-26h

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

What is metformin, and how does it work?

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

Does metformin cross the placenta?

Yes, levels can be as high as maternal concentrations

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

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

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

26-46%

What are the most common adverse effects of metformin?

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

What is the maximum daily dose of metformin?

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

How should you start a patient on metformin?

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

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

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

With what type of allergy can you not use glyburide?

Sulfa allergy

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

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

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

4-16%

Does glyburide cross the placenta?

yes

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

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

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

39-40w6d

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

39w0d to 39w6d

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

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

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

22%, according to one study

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

When EFW >4500g

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

One third

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?

15-70%. 7-fold increased risk

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

4-12wks postpartum

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

75-g 2h OGTT

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

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

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

Every 1-3 years