4.3 - Diabetes in Pregnancy Flashcards
What are the top 2 complications of Type 1 Diabetes on obstetric outcomes?
1) 5x risk of perinatal mortality (e.g. shoulder dystocia)
2) 10x risk of congenital malformations
Diabetes in pregnancy carries a 10x risk of congenital malformations. What are these malformations? Give 5
1) CNS - Spina Bifida, anencephaly
2) CVS - VSD, transposition, hypoplastic left heart
3) Renal agenesis
4) GI - Anal atresia
5) MSK - Caudal regression, Sacral agenesis
What is the pathophysiology of gestational diabetes
The placenta produces “Anti-insulin” hormones including B-hCG, Human placental lactogen, progesterone, and cortisol. These increase insulin resistance.
If the maternal pancreatic islet cells are unable to produce sufficient insulin to balance this out
=> Hyperglycemic state => Gestational Diabetes (which would only be compunded with pre-existing DM)
What can pass the placenta? Glucose, Insulin, or both?
Glucose only
How does GDM affect foetal growth
How would this impact delivery
Maternal hyperglycemia leads to foetal hyperglycemia => foetus increases insulin production to balance out the high glucose => Hyperinsulineamia => Accelerated growth and macrosomia
This leads to a prolonged 2nd stage of delivery which may necessitate the use of operative delivery which comes with its own risks for the mother and the foetus. In addition to that there is an increased risk of obstetric emergencies including shoulder dystocia and PPH
If the mother has GDM, is the neonate more likely to have hypo or hyperglycemia?
Hypoglycemia
Patients at risk of GDM receive more specialised pre-conception counselling e.g. previous hx or pre-existing or PCOS). What are important changes to the normal care in pregnancy that you would need to inform the patient about? Give 5
1) Switch from oral to insulin injections (SC).
2) Increased frequency of insulin injections + glucose monitoring
3) Referral and care with specialise diabetic clinic
4) Check for signs of nephropathy, retinopathy, and neuropathy including monitoring for proteinuria.
5) Increased folic acid dose of 5mg/day instead of 0.4
6) MDT care
7) Glucagon Kit for treatment of hypoglycemic episodes.
8) Avoid smoking and drinking (referral for cessation)
What is the significance of measuring proteinuria in pregnancy in patients at risk of GDM?
Diabetic nephropathy which increases the risk of
1) renal failure
2) superimposed Pre-eclampsia
3) foetal growth restriction
4) Pre-term labour
5) Stillbirth
You are asked to inform the family members as to how to monitor for hypoglycemic episodes in the pregnant wife. What will you say
1) Symptoms: Rapid loss of conciousness, diaphoresis, tremor, palpitation
2) treatment IM Glucagon from glucagon kit
You are asked to inform the family members as to how to monitor for Diabetic ketoacidosis in the pregnant wife. What will you say
1) Preceded by drowsiness and gradual onset polyuria
2) Sx: Dehydration, tachypnea, hypotension, ketotic (sweet smell)
3) Main cause is infection so watch for signs of infection (pyrexia)
What is the general format of emergency management of DKA?
Fluids -> Antibiotics -> Insulin
Define Gestational Diabetes
Carbohydrate intolerance/insulin resistance of varying severity with onset or first recognition in pregnancy via 75g glucose tolerance test @ 24-28 weeks GA
What is the normal range of glucose levels are we aiming to achieve?
What level would indicate hypoglycemia
5-7mmol/L
Hypoglycemia 3.9
Who receives the oral glucose test for GDM? When is it screened for?
75g oral glucose test given at 24-28 weeks for patients with RF for GDM. This includes:
1) Age >40
2) PCOS
3) Obesity BMI>30
4) Family Hx of diabetes/GDM
5) Pre-gestational DM
6) GDM in previous pregnancy
7) Previous macrosomic infant
8) Index polyhydramnios or LGA
9) Steroids/antipsychotics
When is the expected peak after giving a patient the 75g oral glucose test?
1 hour later
