Antenatal Problems 3

Question 1

Of women who have diabetes during pregnancy, what % have:

1) Gestational diabetes
2) Type 1 diabetes
3) Type 2 diabetes?

Answer 1

1) Gestational = 87.5%
2) Type 1 = 7.5%
3) Type 2 = 5%

Question 2

What are the effects of diabetes on pregnancy?

Answer 2

• Maternal hyperglycaemia leads to fetal hyperglycaemia which is potentially harmful to the fetus = leads to hyperinsulinaemia through beta cell hyperplasia in fetal pancreatic cells
• Insulin in fetus acts as a growth promoter = macrosomia, organomegaly and increased erythropoiesis
• Fetal polyuria = polyhydraminos (esp in poor control)
• High levels of insulin in fetus + removal of glucose supply after birth = neonatal hypoglycaemia
• Early feeding and regular blood glucose monitoring should be performed to minimise the risk of cerebral damage
• Surfactant deficiency occurs through reduced production of pulmonary phospholipids = clinically manifests as respiratory distress syndrome (more common in babies born to diabetic mothers)

WHAT ABOUT SGA??
NB diabetes also associated with SGA ??

Question 3

What happens to insulin requirements during pregnancy?

Answer 3

Insulin requirements increase throughout pregnancy and are maximal at term

A normal woman can increase the amount of insulin she produces to counteract diabetogenic hormones
(human placental lactose, cortisol, glucagon, oestrogen and progesterone) to maintain BG at 4-4.5mmol/L

Diabetic women are unable to do this

Question 4

What may be associated with ketoacidosis in those with diabetes in pregnancy? (4)

Answer 4

(Rare)

• Hyperemesis gravidarum
• Infection
• Tocolytic agents eg terbutaline (used to suppress premature labour)
• Steroid therapy

Question 5

What effect may pregnancy have on retinopathy in those who are pregnant and have diabetes?

Answer 5

• 2x risk of development / progression of existing disease
• Paradoxically rapid improvement in Glycaemic control leads to increased retinal blood flow which can cause retinopathy
• All diabetic women should have retinopathy assessment and proliferative retinopathy requires treatment
• Early changes usually revert after delivery

Question 6

What effect may pregnancy have on nephropathy in those who are pregnant and have diabetes?

Answer 6

• Renal function and proteinuria may worsen during pregnancy
• This is usually temporary
• Maternal risk of pre-eclampsia and fetal risk of IUGR in this population
• Increased surveillance required

Question 7

What effect may pregnancy have on IHD in those who are pregnant and have diabetes?

Answer 7

• Pregnancy increases cardiac workload
• Women who have had a previous MI should avoid pregnancy (50% mortality)
• Women with symptoms should be assessed by a cardiologist before conception

Question 8

What are some maternal complications of diabetes during pregnancy? (8)

Answer 8

• UTI
• Recurrent vulvovaginal candidiasis
• PIH / pre-eclampsia
• Obstructed labour
• Operative deliveries (CS or assisted vaginal deliveries)
• Retinopathy
• Neuropathy
• Cardiac disease

Question 9

What are some fetal complications of diabetes during pregnancy? (7)

Answer 9

• Miscarriage
• Congenital abnormalities
• Preterm labour
• Polyhydramnios (25%)
• Macrosomia (25-40%)
• IUGR
• Unexplained intrauterine death

Question 10

What are some neonatal complications of diabetes during pregnancy? (5)

Answer 10

• Polycythaemia (macrosomia leads to inc oxygen demand increasing erythropoiesis)
• Jaundice (also from macrosomia and impaired hepatic conjugation of bilirubin)
• Birth trauma: shoulder dystocia, fractures, erb’s palsy, asphyxia
• Respiratory distress syndrome (due to lower fetal lung maturity)
• Increased perinatal mortality