9: DM Flashcards
Risk factors for GDM include ?
Hispanic, Asian American, Native American, and African American ethnicity, obesity, family history of diabetes, and prior pregnancy complicated by GDM, macrosomia, shoulder dystocia, or fetal death.
All pregnant women should be screened for diabetes between weeks ?
what about high risk women?
weeks 24-28
High-risk women should also be screened at their first prenatal visit.
Fetal complications of GDM include ?
macrosomia, shoulder dystocia, and neonatal hypoglycemia
GDM Patients should generally be induced between ?? weeks’ gestation.
39 and 40 wga
? and ? are used to maintain tight control btw ? and ?during delivery
Intrapartum insulin and dextrose
100-120mg/dL
Cesarean section is offered if fetal weight is over ?
4,500g
Maternal complications of diabetes during pregnancy
hyperglycemia, hypoglycemia, urinary tract infection, worsening renal disease, hypertension, and retinopathy.
Fetal complications of diabetes during pregnancy
spontaneous abortion, congenital anomalies, macrosomia, IUGR, neonatal hypoglycemia, respiratory distress syndrome, and perinatal death.
glucose screening test
positive if the 1-hour glucose level is ?
next step?
giving a 50-g glucose load and then measuring the plasma glucose 1 hour later. Positive if the 1-hour glucose level is >140 mg/dL
glucose tolerance test (GTT) is indicated if positive
GTT
given 100 g of oral glucose after an 8-hour overnight fast preceded by a 3-day special carbohydrate diet. Measure fasting and at 1, 2, and 3 hours after the load. If >2/4 values are elevated, a diagnosis of GDM is made.
GTT normal value upper limits
Fasting 90 (venous blood) 105 (whole plasma)
1 h 165 190
2 h 145 165
3 h 125 145
ADA diet recommendations for women with diabetes during pregnancy: calories, carbs
2,200 calories per day (30 to 35 kcal/kg)
200 to 220 g of carbohydrates per day-30 and 45 g of carbohydrates at breakfast, 45 to 60 g for lunch/dinner, and 15 g for snacks
glucose target ranges
if within range, classified as ?
fasting values
usually insulin or an oral hypoglycemic agent is indicated if ?
pt classified as ?
if more than 25% to 30% of a patient's blood glucose vaclass A2 or medication-controlled gestational diabetic patients. class A2 or medication-controlled
Insulin regimen
- short-acting insulin (Humalog (lispro) or NovoLog) in combo with an intermediate-acting insulin (NPH) in the morning (to cover breakfast and lunch)
- short-acting insulin at dinner
why Humalog (lispro) instead of regular insulin?
lispro: faster onset of action and shorter length of action. Humalog’s profile better represents normal physiology and leads to better control of postprandial blood glucose with less hypoglycemia.
oral glycemics?
glyburide or metformin
ACOG still considers the use of oral hypoglycemic agents during pregnancy to be experimental.
how to monitor fetus of A2 GDM pt
NST, BPP btw 32-36 wga continued until delivery on a weekly or biweekly basis
-US for an estimated fetal weight (EFW) between 34 and 37 weeks (due to risk of macrosomia)
fetal monitoring of A1 GDM?
not common to offer fetal monitoring to A1 GDM patients who are well-controlled on diet alone.
plan for A2GDM delivery
risk if goes longer?
IOL at 39 wga (37-39 if poor glycemic control)
-may be an increased risk of hypoglycemia as their placental function decreases toward the end of pregnancy.
Among patients with GDM, over ? will experience GDM in subsequent pregnancies and ? to ? will go on to develop overt diabetes within 5 years
50%
25-35%
-screened for T2DM at the postpartum visit and every year thereafter, most commonly with a fasting serum blood glucose or a 75 g, 2-hour GTT
Maternal Complications of Diabetes During Pregnancy
Obstetric complications: Polyhydramnios, PreE, Miscarriage, Infection, Postpartum hemorrhage, Increased C section
Diabetic emergencies: Hypoglycemia, DKA, coma
Vascular/end organ involvement: cardiac, renal, ophthalmic, peripheral vascular
Neurologic: peripheral neuropathy, GI disturbance
Fetal Complications of Diabetes Mellitus
macrosomia: traumatic delivery, shoulder dystocia, erb palsy
delayed organ maturity: pulm, hep, neuro, pit-thyroid axis
congenital: CV defects, NTDs, caudal regression syndrome, situs inversus, duplex renal ureter, IUGR, intrauterine death
Glucose Monitoring and Insulin Dosing During Pregnancy
Evening NPH Fasting 70–90
Morning Humalog Postbreakfast 100–139
Morning NPH Postlunch 100–139
Evening Humalog Postdinner 100–139
Instructions for Adjusting Insulin Dosage
- Establish a fasting glucose level between 70-90 mg/dL
- Adjust only one dosing level at a time
- Do not change any dosage by more than 20% per day
- Wait 24 h between dosage changes to evaluate the response
In the patient with pregestational diabetes, antenatal testing to evaluate the growth and well-being of the fetus usually begins at ? wga
32 wga (earlier testing is recommended in the setting of poor glycemic control)
testing pregestational diabetic pts
antenatal fetal assessment consisting of weekly NSTs until 36 weeks, during which time biweekly testing is implemented, including weekly NST alternating with weekly modified BPP to assess amniotic fluid measurement
- an ultrasound to assess fetal growth is usually obtained between 32 and 36 wga
- IOL at 39 wks
After delivery, maternal insulin requirements decrease significantly because of ?
removal of placenta, which contains insulin antagonists
postpartum f/u of GDM pts
avoid oral hypoglycemics in pregnancy? (cause neonatal hypoglycemia)
- if renal disease: 24-hour urine collection for creatinine clearance and protein: 6 weeks
- ophthalmologic appointment: 12 to 14 weeks postpartum.
- back to PCP or endocrinologist at 6-8 wks
White Classification for Diabetes During Pregnancy
Class A1 Gestational diabetes; diet controlled
Class A2 Gestational diabetes; insulin controlled
Class B Onset: age 20 or older Duration: 20 y
Class F Diabetic nephropathy
Class R Proliferative retinopathy
Class RF Retinopathy and nephropathy
Class H Ischemic heart disease
Class T Prior renal transplantation
