anaemia in pregnancy + gestational diabetes

Question 1

anaemia in pregnancy screening

Answer 1

low Hb in blood

screened twice in pregnancy

i) booking clinic
ii) 28 weeks gestation

booking bloods >110
28 week gestation >105
post partum >100

Question 2

why does anaemia happen in pregnancy?

Answer 2

plasma volume increases which results in a reduction of haemoglobin concentration. blood is diluted due to the higher plasma volume

Question 3

presentation of anaemia

Answer 3

Shortness of breath
Fatigue
Dizziness
Pallor

Question 4

what is the haemoglobinopathy screening in pregnancy?

Answer 4

thalassemia (ALL WOMEN)
sickle cell disease (WOMEN AT RISK)

additional (not routinely)
ferritin
b12
folate

Question 5

how to manage anaemia in pregnancy?

Answer 5

iron- ferrous sulphate 200mg three times per day

b12: pernicious anaemia (check for intrinsic factor antibodies)
IM hydroxocobalamin
oral cyanocobalamin

Question 6

folate

Answer 6

all women should already be taking folic acid 400mcg per day. if deficient then start on folic acid 5mg daily

Question 7

thalassaemia and sickle cell anaemia

Answer 7

manage jointly with specialist
high dose folic acid (5mg)
close monitoring
transfusion

Question 8

gestational diabetes

Answer 8

diabetes triggered by pregnancy due to reduced insulin sensitivity (resolves after birth)

if risk factors, screen with OGTT at 24-28 weeks gestation and if previous gestational diabetes then do OGTT sooner (after the booking clinic)

Question 9

what are the complications of gestational diabetes?

Answer 9

large for dates fetes and macrosomia *shoulder dystocia

women are at risk of developing T2DM after pregnancy

Question 10

what is OGTT?

Answer 10

oral glucose tolerance test

used in patients with risk factors for GD or features suggestive of GD

• Large for dates fetus
• Polyhydramnios (increased amniotic fluid)
• Glucose on urine dipstick

peformed after fasting
patient drinks 75g glucose at the start of their test
blood sugar is measured before and after 2 hours

normal result
fasting <5.6
at 2 hours <7.8
*anything higher is GD
5-6-7-8

Question 11

management of gestational diabetes

Answer 11

1. four weekly USS to monitor fatal growth and amniotic fluid from 28-36 weeks

2.

if fasting glucose <7 trial diet and exercise for 1-2 weeks followed by metformin then insuin

if >7 insulin + metformin

if >6 plus macrosomia (or other complications) start insulin + metformin

*if decline/cannot tolerate insulin or metformin offer glibenclamide (sulfonylurea)

Question 12

target levels

Answer 12

Fasting: 5.3 mmol/l
1 hour post-meal: 7.8 mmol/l
2 hours post-meal: 6.4 mmol/l
Avoiding levels of 4 mmol/l or below

Question 13

pre-existing diabetes

Answer 13

aim for good glucose control before pregnancy
take 5mg police acid preconception - 12 weeks

aim for target insulin levels same as women with GD
type II +metformin +insulin

retinopathy screening

Question 14

delivery and GD / pre-existing diabetes

Answer 14

GD: can give brith up to 40+6

pre-existing diabetes:
planned delivery 37 and 38+6 weeks if existing diabetes

Question 15

post natal care

Answer 15

GD improves after birth
can stop diabetes meds immediately afterbirth and follow up fasting glucose at least 6 week after.

loer doses of insulin
wary of hypoglycaemia

Neonatal hypoglycaemia
Polycythaemia (raised haemoglobin)
Jaundice (raised bilirubin)
Congenital heart disease
Cardiomyopathy

Question 16

neonatal hypoglycaemia

Answer 16

regular BM and frequent feeds
maintain BM >2mmol/L
IV dextrose
nasogastric feeding