Bread & Butter Flashcards
What are the S/Es of methyldopa?
There are CNS, CVS and haematological effects:
CNS: sedation, headache, nightmares, depression/mild psychosis, Bell’s palsy, parkinsonism
CVS: postural hypotension, bradycardia, worsening of angina, myocarditis, pericarditis, oedema
Haematological: haemolytic anaemia (positive direct Coombs test); bonemarrow suppression
What is the increase in perinatal and neonatal mortality that is assoc with PGDM?
Can be increased 5-10 fold
CEMACH study showed a perinatal mortality rate of 3% (for both PGDM & GDM)
What is the fetal mortality rate assoc with maternal ketoacidosis?
10-25%
As pregnancy progresses, how does the mother’s body compensate for the increased insulin resistance?
- Hyperplasia of the islet cells of Langerhaans in the pancreas increases insulin production.
What are the placental diabetogenic hormones?
HCG PP
Human placental lactogen
Cortisol; Corticotrophin-releasing hormone
Glucagon; growth hormone
Progesterone
Prolactin
Crh (hypothalamus)- acth( ant. Pituitary) - cortisol + sex steroids (adrenal Zona reticularis)
Glucagon (alpha pancreatic cells) - increased hepatic gluconeogenesis and glycogenolysis + growth hormone secretion
Target GMR during labour and delivery?
4-6mmol/L
T/F. No oral hypoglycaemic agents are licensed sedation for use in pregnancy? What FDA class is metformin? Most serious s/e of metformin?
True.
Metformin is Class B. No animal studies have shown harm to the fetus.
Most serious s/e of metformin is lactic acidosis - but this is a RARE complication.
What is the HAPO study?
Hyperglycemia and Adverse Pregnancy Outcome study
—- looked at >23,000 ethnically diverse women who had a 75g OGTT
–AIM: to clarify the risk of adverse outcomes assoc with degrees of glucose intolerance, that are less severe than overt diabetes.
—- the FOUR primary outcomes of the study were:
1) Macrosomia (bt>90th centile for GA, gender, Parity, ethnicity and field center)
2) Primary caesarean delivery
3) Clinical neonatal hypoglycaemia
4) Hyperinsulinaemia (cord c-peptide >90th centile for the study group
Secondary outcomes considered:
- preterm birth
- shoulder dystocia/birth injury
- skinfold thickness >90th centile for GA, gender, Parity, ethnicity, field center
- percent body fat >90th centile for GA
- admission for neonatal intensive care
- hyperbilirubinaemia
- pre-eclampsia
RESULTS:
Strong, continuous association of between maternal hyperglycemia (below levels diagnostic of diabetes) and increased birth weight, increased serum C-peptide levels and the other primary outcomes.
- the link with secondary outcomes were present but not as strong.
What is the Pederson hypothesis?
This hypothesis states that maternal hyperglycaemia results in transplacental glucose transfer which stimulates the fetal beta islet cells of langerhaans to secrete excess insulin/Hyperinsulinaemia, which produces adiposity and macrosomia, amongst other things.
The HAPO study concluded that this hypothesis is correct.
What is the IADPSG criteria?
The International Association of Diabetes and Pregnancy Study Groups used the HAPO study as the basis for new GDM thresholds.
To diagnose GDM:
Fasting: 5.1
1hr: 10
2hr: 8.5
To diagnose overt diabetes in pregnancy:
Fasting: 7/more
HbA1C: 6.5% or more
Random blood glucose: 11/more
What are pre-existing factors for the development of type 2 DM?
3 strongest are:
1. Ethnicity!!! (South Asians very high risk, Afro-Caribbean)
2. Maternal age
3. BMI
Others include:
4. Prev GDM
5. Family h/o diabetes
6. H/o stillbirth or congenital anomaly
What is the increased risk of a pulmonary embolism is a pt with a BMI >30?
3-5 times increased
(Odds ratio 2.7-5)
35 y.o, 33 wks, BP 180/110. 3+ proteinuria urinalysis. Elevated BP and proteinuria are new onset. Which drug will u administer INITIALLY?
Iv betamethsone, iv mgso4, iv furosemide, iv diazepam, oral methyldopa?
Iv mgso4
MgSO4 is the first line anticonvulsant.
(also acts to reduce BP a little as it is a competitive inhibitor of Ca😉)
-BP every 15mins until stable then every 30mins.
- measure O2 sats continually, maintain above 95%, chart with BP
- if present measure CVP and arterial lines continuously and chart w/ bP.
- Ivf at 80cc/hr
Hourly checks:
- neurological assessment using GCS or AVPU scales.
- respiratory rate
4 HOURLY checks:
- -strict I/O charting//urine output
- clinical r/v to assess for s/e (motor paralysis, absent deep tendon reflexes, respiratory depression, cardiac artythmia).
What is significant proteinuria using:
1. Protein:creatinine ratio
2. Albumin:creatinine ratio
3. Dipstick
4. 24 hr urine collection?
- > 30mg/mmol
- > 8mg/mmol
- > 1g/L (1+ or more)
- > 300mg/24hrs
30 y.o, P2, 16/40, BP- 155/105 mmHg, 1mth prior was 150/100mmHg. Urinalysis 1+ protein. Spot urinary prot:creat ratio is 35mg/mmol, 24hr urine is 0.35g protein. Likely diagnosis?
cHTN
- unlikely to have preeclampsia at 16 weeks, as second wave of placental invasion is only just occurring.
- likely has chtn with renal disease (hence the proteinuria)
—will require further renal assessment.
How long should pregnancy be delayed after bariatric surgery?
12-18mths to:
1. allow stabilisation of body weight
2. Identify and correct any nutritional deficiencies
What is the acceptable weight gain in obese women?
No acceptable weight. Focus on healthy diet instead
How should women with bariatric sx be managed?
- Pregnancy is HIGH risk and should be managed in a consultant lead clinic.
- Screening and surveillance for nutritional deficiencies
- Dietician referral for advice w.r.t their specialized nutritional needs.
What type of nutrient deficiencies are pts at risk of post bariatric sx?
Folate
Vitamin B12
Iron and
Fat soluble vitamin
Macronutrients fat and protein
Can lead to an SGA fetus
Benefits assoc with bariatric sx?
Reduced risks of:
- GDM
- HTNsive disorders
- fetal macrosomia
T/F. 75g OGTT can provoke dumping syndrome in pts with bariatric sx?
True
Prevent by limiting Gestational weight gain to 5-7kg whilst doing test
Incidence of asthma in pregnancy?
10%
T/F. Asthma exacerbations increase postpartum?
False
Advice for patient with fasting glucose of >7.1? (OGTT)
- As per the IADPSG criteria, this pt has GDM.
- Start insulin +/- metformin
+ diet and exercise