43. Gestational Diabetes Flashcards

1
Q

T/F: pregnancy is an insulin resistant state

A

True

It is mediated by GH, CRH, placental lactogen

Increase in prolactin, progesterone, cortisol

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2
Q

Glucose intolerance diagosed in pregnancy

A

Gestational diabetes

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3
Q

Gestational diabetes is typically diagnosed based on ________ Classification System

A

White’s

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4
Q

Compare/contrast type A1 vs. type A2 based on White’s classification system

A

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

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5
Q

Risk factors for gestational diabetes

A

Overweight (BMI >25) and…

  • FH of diabetes
  • High risk race/ethnicity
  • Previous LGA infant
  • Previous GDM
  • HTN
  • PCOS
  • A1c >5.7%
  • Hx of CVD
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6
Q

When do you typically screen for gestational diabetes?

A

24-28 weeks

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7
Q

T/F: physicians should screen on risk factors for GDM alone

A

False, then we would miss 50% of cases

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8
Q

What are the current screening recommendations for GDM?

A

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

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9
Q

What is the difference between the 1 hr glucola and 3 hr GTT?

A

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

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10
Q

What are some alternative screening regimens for GDM?

A

2 hr GTT (75 g load)

HgA1c

Fasting glucose

Random glucose monitoring

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11
Q

What are the 2 first line antepartum guidelines for GDM?

A

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

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12
Q

What is the testing regimen like for GDM?

A

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

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13
Q

Fasting glucose should be ______

1 hr postprandial should be ____

2 hr postprandial should be ____

A

<95 mg/dL

<140 mg/dL

<120 mg/dL

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14
Q

T/F: with dietary changes, 70-80% of those with GDM can achieve euglycemia

A

True

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15
Q

What are examples of oral hypoglycemic agents?

A

Glyburide

Metformin

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16
Q

In terms of medication, what is first line tx for GDM? Why?

A

Insulin; bc it does not cross placenta

17
Q

MOA of metformin

A

Inhibits hepatic gluconeogenesis and glucose absorption

Stimulates glucose uptake in peripheral tissues

18
Q

Why is metformin chosen less frequently than insulin for GDM?

A

It crosses the placenta, although there are no recorded long term data on neonatal effects

19
Q

Adverse effects of metformin

A

Diarrhea, abdominal pain

26-46% will still require tx with insulin

20
Q

Benefits of metformin

A

Good option for cost, administration, and compliance

21
Q

MOA of glyburide

A

Binds pancreatic beta cell ATP/K receptors

Increases insulin sensitivity in peripheral tissues

22
Q

Studies are mixed about glyburide, but placental crossing is likely minimal. However, fetal _____ may be a side effect

A

Hypoglycemia

23
Q

Maternal risks associated with GDM

A

Preeclampsia
LGA
Delivery trauma

24
Q

Mothers with GDM have a 4x higher likelihood of developing _____ in the first 5 years

A

T2DM

[also 10x more likely in first 10 years, 60% of latin american women develop within 5 yrs of pregnancy]

25
Fetal risks of GDM
Macrosomia Neonatal hypoglycemia Hyperbilirubinemia Shoulder dystocia Birth trauma Stillbirth Increased risk of childhood and adult onset obesity and diabetes
26
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
27
Which form, A1 or A2, has lower risk with less monitoring required?
A1
28
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
29
In terms of intrapartum management, the goal of identification and management are reduction of fetal risks of what 3 conditions?
Preeclampsia LGA Shoulder dystocia
30
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
31
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