Ch 9 Diabetes During Pregnancy Flashcards
during pregnancy, human chorionic somatomammotropin aka human placental lactogen, and other hormones produced by placenta act as
anti-insulin agents leading to increased insulin resistance and generalized carbohydrate intolerance.
women with GDM are generally not at increased risk for congenital anomalies like women with pregestational diabetes. Further, these women have a 4-10 fold incrased risk of developing type 2 diabetes mellitus during their lifetime.
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gdm ranges from 1-12% of pregnant women.
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best tim to screen for diabetes during pregnancy is
24-28 weeks in women with low risk for GDM.
however, to identify women with preexisting t2DM, patients with one or more risk factors for developing GDM should be screened at their first prenatal visit. if negative, patients are screened for GDM again 24-28 weeks
if more than 30% of patients blood glucose values are elevated, medication - usually insulin or oral hypoglycemic agent is indicated. these indivudlais are then considered class A2 or medication controlled gestational diabetic patients
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short acting in combination with intermediate acting insulin in th emorning ( to cover breakfast and lunch)
and short acting insulin at dinner
short acting insulin - humalog (lispro) or novolog
intermediate acting insulin -nph
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glyburide ( oral ) should not be first line treatment of GDM. comparing metformin and insulin demonstrated no differences in outcomes. because oral agents cross the placenta and long-term outcomes have not been adequately assessed, metformin should be used as a second line agent only in those women who will not take insulin.
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GDMA2 patients who are on insulin /oral hypoglycemic agent need
fetal monitoring via NST or modified bpp starting between 32 and 36 weeks and continued weekly until delivery
it is NOT common to offer fetal monitoring to GDMA1 patients who are well controlled on diet alone. decision varies among practitioners
scheduled delivery at 39 weeks is common in patients on insulin / hypoglycemic agent gdma2
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gdma2 have increased risk of hypoglycemia because their placental function decreases toward end of pregnancy.
their long acting hypoglycemic agents are discontinued and blood glucose monitored every hour. dextrose and insulin drips are used if necessary to maintain blood glucose <120mg/dl
patients with efw > 4000 g have increased risks of shoulder dystocia
some clinicians offer elective c/s
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among pts with GDM, over 50% will experience GDM in subsequent deliveries and 25-35% will go on to develop overt diabettes within 5 years
35% will develop overt diabetes within 5 years
screen for T2d for women with GDM at postpartum visit and every year thereafter most commonly with fasting serum blood glucose or 75g 2 hr gtt
every year thereafter most commonly with fasting serum blood glucose or 75g 2 hr gtt
women with diabettes are 4x more likely to develop preeclampsia or eclampsia than women without diabetes. they ar ealso twice as likely to have a spontaneous abortion. in addition , the risks of infection, polyhydramnios, postpartum hemorrhage, and cesarean delivery are all increased for diabetic mothers. diabetes can have adverse effects on the fetus including 5x increase in perinatal death and 2-3x increase in risk of congenital malformations depending on glycemic control
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in older studies, minimal glycemic management in gravid diabetic woman perinatal mortality was as high as
30%
however, with careful managemetn by specialists, risk can be reduced to < 1%
fetus of diabetic mothers are more likely to develop congenital anomalies including both cardiac anomalies and neural tube defects, and most dramatically, caudal regression syndrome
fetus also at risk for fetal growth abnormalities and sudden intrauterine fetal demise (IUFD)
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