43. Gestational Diabetes Flashcards
T/F: pregnancy is an insulin resistant state
True
It is mediated by GH, CRH, placental lactogen
Increase in prolactin, progesterone, cortisol
Glucose intolerance diagosed in pregnancy
Gestational diabetes
Gestational diabetes is typically diagnosed based on ________ Classification System
White’s
Compare/contrast type A1 vs. type A2 based on White’s classification system
Type A1 = gestational diabetes; diagnosed in pregnancy and controlled with diet alone (no meds)
Type A2 = gestational diabetes; diagnosed in pregnancy and controlled with diet and glyburide or insulin
Risk factors for gestational diabetes
Overweight (BMI >25) and…
- FH of diabetes
- High risk race/ethnicity
- Previous LGA infant
- Previous GDM
- HTN
- PCOS
- A1c >5.7%
- Hx of CVD
When do you typically screen for gestational diabetes?
24-28 weeks
T/F: physicians should screen on risk factors for GDM alone
False, then we would miss 50% of cases
What are the current screening recommendations for GDM?
Screen ALL patients between 24-28 wks
2 step approach: 1 hr glucola (50g glucose tolerance test) — abnormal result is 130-140 mg/dL, if abnormal proceed to 3 hr GTT
If initial result is >200 mg/dL proceed to diabetic education
What is the difference between the 1 hr glucola and 3 hr GTT?
1 hr glucola does not need to be fasting as result is not dependent on prior oral intake
3 hr GTT must be fasting, requires 2 abnormal values to be diagnostic
What are some alternative screening regimens for GDM?
2 hr GTT (75 g load)
HgA1c
Fasting glucose
Random glucose monitoring
What are the 2 first line antepartum guidelines for GDM?
Dietary changes: caloric intake based on weight - baseline 30 kcal/kg, 50% carbs, 25% protein, 25% fat
Exercise: moderate exercise 3-5x/week with goal of 150 min/week, walking after meals which greatly improves glucose control
What is the testing regimen like for GDM?
Daily monitoring — fasting and 1 or 2 hr postprandial
[peak postprandial glucose occurs at 90 min]
may not need to test as much for well controlled pts
Fasting glucose should be ______
1 hr postprandial should be ____
2 hr postprandial should be ____
<95 mg/dL
<140 mg/dL
<120 mg/dL
T/F: with dietary changes, 70-80% of those with GDM can achieve euglycemia
True
What are examples of oral hypoglycemic agents?
Glyburide
Metformin
In terms of medication, what is first line tx for GDM? Why?
Insulin; bc it does not cross placenta
MOA of metformin
Inhibits hepatic gluconeogenesis and glucose absorption
Stimulates glucose uptake in peripheral tissues
Why is metformin chosen less frequently than insulin for GDM?
It crosses the placenta, although there are no recorded long term data on neonatal effects
Adverse effects of metformin
Diarrhea, abdominal pain
26-46% will still require tx with insulin
Benefits of metformin
Good option for cost, administration, and compliance
MOA of glyburide
Binds pancreatic beta cell ATP/K receptors
Increases insulin sensitivity in peripheral tissues
Studies are mixed about glyburide, but placental crossing is likely minimal. However, fetal _____ may be a side effect
Hypoglycemia
Maternal risks associated with GDM
Preeclampsia
LGA
Delivery trauma
Mothers with GDM have a 4x higher likelihood of developing _____ in the first 5 years
T2DM
[also 10x more likely in first 10 years, 60% of latin american women develop within 5 yrs of pregnancy]
Fetal risks of GDM
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
Shoulder dystocia
Birth trauma
Stillbirth
Increased risk of childhood and adult onset obesity and diabetes
When and how do you monitor a mother with GDM?
Monitoring of fetus begins at 32 weeks with NST and biophysical profiles
Serial amniotic fluid measurements
US for growth
Which form, A1 or A2, has lower risk with less monitoring required?
A1
When is delivery recommended for mothers with GDM?
A1DM = deliver after 39 wks
A2DM = deliver after 39 wks
Preexisting diabetes = 38-39 wks
Poorly controlled = 37-39 wks
In terms of intrapartum management, the goal of identification and management are reduction of fetal risks of what 3 conditions?
Preeclampsia
LGA
Shoulder dystocia
What are other goals of intrapartum management in mothers with GDM?
Optimal glycemic control during labor, which allows effective contractions/labor progression, and optimal environment for infant at delivery
Goals for postpartum GDM management
2 hr oral GTT after 6 wks postpartum
PCP f/u
Preventative therapy — impaired fasting glucose, impaired glucose tolerance, diabetes
Repeat screening every 1-3 years after delivery
