#201 Pregestational Diabetes Mellitus Flashcards
What % of pregnancies are complicated by pregestational diabetes?
1-2%
What is the prevalence of diabetes mellitus in women of reproductive age?
3.1-6.8%
What causes type 1 diabetes?
Autoimmune process that destroys the pancreatic beta cells
Does type 1 diabetes typically present earlier or later in life?
Earlier
What is the mainstay of treatment for Type 1 diabetes?
Insulin
What is the most common form of pregestational diabetes?
Type 2
What characterizes type 2 diabetes mellitus?
Onset later in life, peripheral insulin resistance, relative insulin deficiency, and obesity.
What % of cases of diabetes during pregnancy are gestational diabetes (vs pregestational)?
90%
What proportion of women with gestational diabetes will go on to develop type 2 diabetes later in life?
More than one half
What races/ethnicities have higher rates of pregestational diabetes?
Black, Native American, Hispanic
How and when can you diagnose pregestational diabetes during pregnancy?
Can be diagnosed in first or early second trimester with the diagnostic criteria of hemoglobin A1C (6.5% or greater) or fasting plasma glucose of 126 mg/dL or greater, or a 2-hour glucose of 200mg/dL or greater w/ 75g oral glucose
When is insulin resistance greatest during pregnancy?
Third trimester
Why does insulin resistance increase during pregnancy?
Increasing placental hormones including human chorionic somatomammotropin (human placental lactogen), progesterone, prolactin, placental growth hormone, and cortisol. Additionally tumor necrosis factor alpha and leptin.
Why should maternal glucose control be maintained near physiologic levels before and throughout pregnancy?
Decrease complications hyperglycemia: include spontaneous abortion, fetal malformation, fetal macrosomia, fetal death, and neonatal morbidity
How often should you review glucose logs for pregestational diabetics during pregnancy?
At least every 1-2 weeks during the first two trimesters, and weekly after 24-28wks. In someone with excellent control, this can be individualized
What is the change in caloric requirement during pregnancy?
Additional 300 kcal/day during the second and third trimesters.
What is the general dietary approach to glycemic control during pregnancy (what in particular is focused on and wht is the recommendation)?
Careful carbohydrate counting and allocation to meals and snacks.
30-45g at breakfast, 45-60g at lunch and dinner, and 15g snacks approx 2-3 hrs after each meal
Are simple or complex carbohydrates recommended with diabetes during pregnancy? Why?
Complex, digested more slowly and are less likely to produce significant postprandial hyperglycemia
What are the average insulin requirements per kg/day per trimester for diabetic patients?
1st trimester: 0.7-0.8 units/kg/day
2nd trimester: 0.8-1.0 units/kg/day
3rd trimester: 0.9-1.2 units/kg/day
What are the fasting and postprandial glycemic goals during pregnancy?
Fasting: 95mg/dL or less
1 hour pp: 140mg/dL or less
2 hours pp: 120mg/dL or less
During the night, glucose levels should not decrease to less than how many mg/dL (pregestational diabetes)?
60mg/dL
In 2nd and 3rd trimesters, a hemoglobin A1C less than what has the lowest risk of LGA infants?
Less than 6%
What is the role of short- or rapid-acting insulin analogues? When are they administered?
Administered right before meals to reduce glucose elevations associated with eating.
Which insulins should be administered with a meal?
Short or rapid-acting (eg, lispro, aspart); not regular insulin
What is onset of action, peak of action, and duration of action for insulin lispro?
onset 1-15 min
peak 1-2 hrs
duration 4-5 hrs
What is onset of action, peak of action, and duration of action for insulin aspart?
Onset 1-15mins
Peak 1-2hrs
Duration 4-5hrs
What is onset of action, peak of action, and duration of action for regular insulin?
Onset 30-60 min
Peak 2-4 hrs
Duration 6-8 hrs
What is onset of action, peak of action, and duration of action for isophane insulin suspension (NPH)?
Onset 1-3hrs
Peak 5-7 hrs
Duration 13-18hrs
What is onset of action, peak of action, and duration of action for insulin glargine?
Onset 1-2 hrs
Peak: no peak
Duration 24h
What is onset of action, peak of action, and duration of action for insulin detemir?
Onset 1-3hrs
Peak: minimal peak at 8-10hrs
Duration: 18-26hrs
What are the purpose of longer acting or basal insulins?
Maintain euglycemia between meals and in the fasting state
When is NPH insullin typically dosed?
Before breakfast with a rapid-acting insulin and before the evening meal or at bedtime. Bedtime preferred d/t less risk of nocturnal hypoglycemia
How are glargine and detemir produced?
Recombinant DNA
What is the name of the phenomena where nocturnal hypoglycemia can cause elevated fasting glucose levels?
Somogyi effect
How often can you check HbA1c levels during pregnancy?
Monthly
In women with pregestational diabetes, at what glucose level should you check urine ketones, why?
When glucose levels exceed 200mg/dL due to risk of diabetic ketoacidosis
If a pregnant patient identifies an episode of hypoglycemia, what should you direct them to do?
Instruct them to consume 15g of carbohydrates (glucose tablets or fruit juice or milk) and then wait 15 minutes for their glucose level to correct before taking in additional glucose
What should you administer to a diabetic patient with a severe hypoglycemic episode and loss of consciousness?
Glucagon
How does pregnancy affect progression of diabetes?
Associated with an exacerbation of diabetes-related complications, particularly retinopathy and nephropathy
What is the leading cause of blindness in the US aged 24-74yrs
Diabetic retinopathy
What kind of retinopathy is diabetic reinopathy? What characterizes it?
Nonproliferative retinopathy and proliferative retinopathy. Nonproliferative: Characterized by retinal microaneurysms and dot-blot hemorrhages
Proliferative: Neovascularization
True or false, improved glycemic control decreases the rate or progression of retinopathy in diabetic patients?
False, pregnant and nonpregnant diabetic individuals experience progression with improved glycemic control
How do you treat proliferative retinopathy?
Pan-retinal photocoagulation, ideally before the patient becomes pregnant
True or false, women with diabetes who become pregnant should delay their eye exam until postpartum
False, should have a comprehensive eye examination in the first trimester and be monitored closely throughtout pregnancy
Diabetic nephropathy is estimated to be present in what % of diabetic pregnancies?
5-10%
Does pregnancy lead to permanent deterioration in renal function in women with mild-to-moderate diabetic nephropathy?
most studies fail to demonstrate permanent deterioration
What are women with preexisting diabetic nephropathy are higher risk for during pregnancy?
Hypertensive disorders, uteroplacental insufficiency, and iatrogenic preterm birth because of worsening renal function
What % of pregnant patients with pregestational diabetes mellitus have chronic hypertension?
5-10%
How does gastroparesis from diabetes affect pregnancy?
Increased risk of hyperemesis. Affects the interaction between diet and diabetes management. Increases risk of hypoglycemic episodes.
What can be used for gastroparesis during pregnancy?
Metoclopramide
Does pregnancy increase the risk of diabetic neuropathy in women with pregestational diabetes?
No, does not appear to increase risk
What is the incidence of diabetic ketoacidosis in patients with pregestational diabetes mellitus?
5-10%
Is the incidence of diabetic ketoacidosis higher or lower during pregnancy, why?
Thought to be due to enhanced insulin resistance. Higher incidence, propensity for DKA to develop more rapidly and less severe levels of hyperglycemia and even normal glucose levels
What are the common risk factors for diabetic ketoacidosis during pregnancy?
New onset diabetes; infections (influenza, UTI); poor patient compliance; insulin pump failure; treatment with beta-mimetic tocolytic medications and antenatal corticosteroids
What lab findings are commonly present during diabetic ketoacidosis during pregnancy?
Low arterial pH (<7.3), low serum bicarb (<15mEq/L), elevated anion gap, positive serum ketones
What does a fetal heart rate tracing look like during diabetic ketoacidosis?
Commonly with minimal variability and may have late decelerations in the setting of contractions; typically improves with maternal condition improvement
What is the mainstay treatment for diabetic ketoacidosis during pregnancy (broadly)?
Aggressive hydration and intravenous insulin
What should be monitored during treatment of DKA in preganancy (labs)?
arterial blood gas, hourly glucose levels, serum ketones q1-2h. Potassium.
How should IVF be managed for a pregnant patient with diabetic ketoacidosis?
Isotonic sodium chloride, with replacement of 4-6L in first 12h. [1-2L/hr for the first hour; 250-500ml/h depending on hydration state (if sodium elevated, use 1/2 normal)]
When gluc reaches 200mg/dL, change to 5% dextrose 1/2 NS at 150-250ml/hr. After 8 hours use 1/2NS at 125ml/hr
How do you manage/monitor potassium during treatment of DKA during pregnancy?
Establish adequate renal function.
- If K<3.3, hold insulin and give 20-30mEq K+/h until K+ >3.3mEq/L or is being corrected
- If 3.3mEq/L < K+ < 5.3mEq/L, given 20-30mEq K+ in each 1L of IVF to keep K between 4-5mEq/L
- If serum K+ >5.3mEq/L, do not give K, check q2h
How do you manage/monitor insulin/glucose during treatment of DKA during pregnancy?
Use regular insulin intravenously.
- Consider loading dose 0.1-0.2units/kg
- continuous 0.1u/kg/hr insulin
- if gluc does not fall by 50-70mg/dL in first hour, double the insulin infusion every hour until steady decline achieved
- When gluc 200mg/dL, reduce infusion to 0.05-0.1u/kg/hr
- keep gluc between 100-150mg/dL until resolution of DKA
How do you manage/monitor bicarbonate during treatment of DKA during pregnancy?
Provide based on pH.
pH >7.0, no HCO3
pH 6.9-7.0: dilute NaHCO3 (50mmol) in 200mL H2O w/ 10mEq KCl and infuse over 1hr. Repeat NaHCO3 every 2h until pH is 7.0. monitor K+
- pH <6.9-7.0: Dilute NaHCO3 (100mmol) in 400mL H2O w/ 20mEq KCl and infuse for 2hr. Repeat NaHCO3 admin q2h until pH is 7.0, monitor serum K.
Does length of time that patient has pregestational diabetes change the risk of pregnancy complications?
Yes, those with diabetes for a longer time have higher rate of problems
What is the risk of major congenital anomalies in women with pregestational diabetes?
6-12%
What is the association between hypoglycemic episodes during pregnancy and adverse fetal outcomes (in women with pregestational diabetes)?
Clinical studies have not demonstrated an association
During which gestational age range is hyperglycemia most concerning?
Organogenesis, 5-8 wks after LMP, thought to play a critical role in abnormal development
What is the risk of congenital anomalies according to HgbA1C level?
<1% elevation in HbA1C = 5-6% fetal malformation rate [close to that seen in normal pregnancy (2-3%)]
HbA1C near 10% association with fetal anomaly rate of 20-25%
What are the most common fetal anomalies seen with pregestational diabetes?
Complex cardiac defects, CNS anomalies (anencephaly and spina bifida), and skeletal malformations (sacral agenesis)
True or false, higher levels of HvA1C are associated with higher risk of stillbirth
True
Why does the fetus of a woman with uncontrolled diabetes have increased risk of macrosomia?
Glucose passes placenta, stimulate insulin release in fetus. Insulin is a potent growth hormone, particularly in adipose tissue
What are the neonatal consequences of poorly controlled pregestational diabetes mellitus during pregnancy?
Profound hypoglycemia, higher rate of respiratory distress syndrome, polycythemia, organomegaly, electrolyte disturbances, and hyperbilirubinemia
What are long-term outcomes for offspring of women with type 1 diabetes mellitus?
Obesity and carbohydrate intolerance
Are women with type 1 or type 2 diabetes at greater risk for pregnancies c/b congenital malformations, stillbirth, or neonatal mortality?
Same risk
True or false, women with pregestational diabetes are at greater risk for primary cesarean section?
True
True or false, women with pregestational diabetes are at increased risk for spontaneous labor?
True
What is the rate of preeclampsia in women with type 1 diabetes without nephropathy vs those with nephropathy?
15-20% if no nephropathy.
50% if have nephropathy
What work up is recommended for women with type 1 or type 2 DM at preconception visit?
Retinal exam by ophthalmologist, a 24-hr urine collection for protein excretion and creatinine clearance, lipid assessment and electrocardiography. Thyroid studies for T1DM.
What is the risk of thyroid dysfunction in women with T1DM?
Up to 40%
What medications should be recommended to patients with pregestational diabetes preconception/during pregnancy (apart from glucose management meds)?
All women should have at least 400mcg folic acid; can consider higher in this population d/t higher risk of neural tube defects, but no evidence to support this.
Low dose aspirin started between 12 and 28wks (optimally before 16wks) and continued until delivery
At what gestational age can you start aspirin prophylaxis and when should you stop?
Start between 12 and 28 wks (preferably before 16wks) and continued until delivery
What additional ultrasounds should be performed for women with pregestational diabetes?
Growth ultrasound (commonly 34w0d to 38w6d), consider fetal echo; antenatal testing starting at 32wks (NST/AFI)
For women with pregestational diabetes without vascular complications, who are well controlled, when should you deliver?
Between 39w0d and 39w6d
For women with pregestational diabetes, at what EFW would you consider offering cesarean delivery?
4500g or greater
What type of insulin is in an insulin pump?
Rapid-acting insulin (such as lispro) is most appropriate
When using an insulin pump, what % of total daily insulin is given continously as basal rate and what % are boluses before meals and snacks?
50-60% continuous basal rate
40-50% as boluses before meals and snacks
For patients with insulin pump, if insulin is interrupted or impaired, what is risk of DKA or high ketones?
DKA may develop rapidly, 9.8% of pump adverse events lead to high ketones or DKA
What is the onset of action and duration of action of glyburide?
Onset: 4hrs
Duration: 10hrs
What is the preferred medication for women with Type 2 DM during pregnancy if glucose is not controlled?
Insulin
How should you counsel women with T2DM on metformin about management during pregnancy?
insulin is the preferred therapy in pregnancy and that oral antidiabetic medications are not approved by the U.S. FDA for treatment of diabetes during pregnancy because they cross the placenta and lack long-term neonatal safety data
In women with pregestational diabetes with vasculopathy, nephropathy, poor glucose control, or prior stillbirth, when should you deliver them?
Consider early delivery 36w0d to 38w6d
Is ultrasound more accurate at EFW than clinical assessment?
Has not been proven to be more accurate
Does induction of labor for suspected macrosomia reduce birth trauma in diabetic women?
No
For how long after corticosteroid administration for fetal lung maturity in patients with pregestational diabetes, should you anticipate increased insulin requirement?
5 days
How do you management insulin during labor and delivery?
Usual intermediate-acting or long-acting insulin at bedtime.
Hold morning insulin or reduce dose based on timing of admission or delivery.
Start IVF NS. Switch to D5 when gluc <70 or in active labor (rate 100-150cc/hr) w/ goal of gluc of ~100mg/dL.
Check gluc q1h.
Regular insulin IV infusion rate of 1.25u/h if gluc >100mg/dL.
For pregestational diabetics on insulin, how should you manage them after delivery?
Start 1/3 to 1/2 predelivery dose of intermediate or long-acting insulin. After starting regular food, 1/3 to 1/2 of short or rapid acting insulin.
If insulin pump, decrease by 50%
What contraceptives are contraindicated in diabetics?
None, unless patient has vasculopathy cannot have estrogen containing methods
