6.2.1 - Diabetes - exam Flashcards
Pregnancy management of diabetes
Multidisciplinary team.
1 diet and exercise
2 metformin
3 insulin injection
Regular monitoring of glucose levels Ultrasound Size of baby Fetal anatomy Blood flow Heart activity
Management of baby post delivery
RDS - may need o2 Glucose infusion Monitor sugars Bilirubin Glucose Calcium
Explain the pathophysiology of gestational diabetes mellitus
Patho of GDM
an increase in insulin resistance and beta cell hyperplasia
Explain the risk factors for gestational diabetes mellitus.
Advanced maternal age >35 or 40 depends on literature Family hx of diabetes Previous GDM Macrosomic baby > 4500 or 90th centile Non Caucasian race/ethnicity Being overweight or obese BMI >30 Smoking Polycystic ovarian syndrome Previous elevated BGL Previous perinatal loss Medications (corticosteroids - antipsychotics
Describe the testing and define the diagnostic criteria for gestational diabetes mellitus.
OGTT 75g
one elevated plasma glucose level is sufficient for a diagnosis
If a fasting glucose has been preforms for other reasons and shows an elevated value, this may be accepted as a diagnostic of GDM
HbA1c - 48 - 48 mmol/mol > 6.5%) if the woman can not tolerant the drink in early pregnancy may be sufficient to diagnose pre-exciting diabetes and requires review by an endocrinologist
Type 1 diabetes can be present in pregnancy
Criteria for diagnosis of GDM with a Oral Glucose tolerance test (OGTT) 75g glucose drink - usually down 24-28 gestation
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Fasting for at least 8 hours before test
Fasting range >5.1 mmol/ml
1h glucose > or equal 10.00 mmol/ml
2h glucose >8.5
values vary according to local protocols
HbA1c <6.5%
What 4 tests may be used in screening for GDM?
How and when are women tested for gestational diabetes, describe the diagnostic criteria in Australia.
- oral glucose tolerance test (diagnostic)
- non fasting plasma glucose
- HbA1c (not reimbursed by medicare)
Describe normal glucose metabolism in pregnancy and why it is altered.
see ph
What is the procedure for a GTT?
- fasting for 10-12 hours
- baseline plasma glucose measured
- 75g glucose drink within 5 mins
- plasma glucose measured at 1 hour and 2h
- no food, smoking, drinks other than water or exercise during test
Describe maternal glucose metabolism when the woman has diabetes and the potential effects on the fetus.
Describe insulin resistance, and the impact for obese women (elevated BMI) in pregnancy, link this to risk for gestational diabetes.
What women are at increased risk of developing gestational diabetes (aside from high BMI).
Advanced maternal age >35 or 40 depends on literature
Family hx of diabetes
Previous GDM
Macrosomic baby > 4500 or 90th centile
Non Caucasian race/ethnicity
Smoking
Polycystic ovarian syndrome
Previous elevated BGL
Previous perinatal loss
Medications (corticosteroids - antipsychotics
What is gestational diabetes?
any degree of glucose intolerance with onset or first recognition in pregnancy
When is GDM usually tested for?
routinely at 24-28 weeks gestation
early for high risk women at 12-16 weeks
at 6-8 weeks postpartum in women diagnosed with gestational diabetes
List the topics you need to cover with a newly diagnosed woman with GDM.
- modification of diet refer to a dietitian
- regular & gentle exercise 30 mins per day
- home blood glucose monitoring at least 4 times a day
- Less than or equal to 5.0 mmol/l fasting
- Less than 6.7mmol/L two after a meal
- increased frequency of antenatal visits
- lactation consultant ie if clinically appropriate ante natal expressing
- cease smoking
- timing of birth
- interdisciplinary team (midwife, obstetrician, diabetes educator, dietition, other specialists)
What are the associated risks of gestational diabetes?
- polyhydramnios
- preeclampsia
- C/S
- PPH
- perinatal death
- macrosomia (shoulder dystocia, perineal trauma)
- birth trauma
- neonatal hypoglycaemia, hypocalcaemia, magnesaemia
- respiratory distress syndrome
- hyperbilirubinaemia
- neonatal polycythaemia
What long term risks exist for women that have had gestational diabetes?
50% risk of developing type 2 DM within 20 years
What drugs may be used to treat women with gestational diabetes that isn’t controlled sufficiently with diet?
- insulin
- metformin
- glibenclamide (caution)
What are the postnatal recommendations for women with gestational diabetes?
GTT at 6-12 weeks postpartum
diabetes testing 1-2 yearly
List 5 important considerations providing labour care for women and fetus with GDM?
- timing of birth (some facilities induce, c/s at 38-39/40, particularly if macrosomic, persistant hyperglycaemic or other complications)
- glucose levels in labour - 4/24 monitoring
- fetal monitoring (continuous CTG in labour for GDM on insulin, blood glucose outside optimal range or ? macrosomic)
- ? shoulder dystocia
- active management of third stage
List 4 means of assessing fetal wellbeing where mum has GDM?
- fetal movements
- fundal height
- ultrasound
- regular CTG if IUGR or macrosomia
What are the three different types of diabetes?
- type 1 insulin deficient
- type 2 insulin resistant
- gestational
What other medicines interact with insulin?
decrease insulin requirements - oral hypoglycaemic agents - monoamine oxidase inhibitors - non selective beta adrenergic blockers - ACE inhibitors - salicylates - anabolic steroids - quinine - sulphonamides increase insulin requirements - oral contraceptives - glucocorticoids - thyroid hormones - sympathomimetics - nicotinic acid other - betablockers - alcohol
Explain the Pathophysiology of Normal pregnant woman of insulin and glucose homostatis
Normal pregnant woman
- Beta cells produce/secretes insulin from the pancreas (Beta Cell Hyperplasia in pregnancy)
- When the woman eats >hyperglycamia>beta cells produce insulin
- binds to target cells to allow glucose from the blood
- reduces blood glucose level
- there is still enough blood glucose for the fetus
- Fetus requires adequate glucose for energy and growth
- normal fetal growth
- in pregnancy - insulin sensitivity decreases
- effect on maternal tissue is reduce
- more glucose in the blood
- factors from the fetus for maternal body to feed it
