Chapter 25 Endocrine Disorders in Pregnancy

Question 1

diagnostic criteria for type 2 diabetes mellitus:

Answer 1

added hemoglobin A1c of >= 6.5

Question 2

are there differences in pregnancy outcomes / glycemic control when pregestational diabetes is treated with subcutaneous insulin or insulin pump?

Answer 2

no

Question 3

Lagner and colleagues found

Answer 3

glyburide and insulin equally efficacious in treatment of gestational diabetes mellitus (GDM) in all severity levels.

Question 4

PTU may be rarely associated with

Answer 4

liver toxicity; therefore, liver function tests should be monitored during pregnancy

Question 5

levothyroxine requirements have been seen to increase as early as 5th week of gestation. thyroid hormone important for cognitive development. it is recommended that levothyroxine be increased ___ upon a +pregnancy test

Answer 5

increase levothyroxine by 30% after a +pregnancy test

Question 6

American Diabetic Association outlined 4 criteria for dx of type2 diabetes in nonpregnant :

Answer 6

1. casual plasma glucose of >= 200 mg/dL
2. fasting plasma glucose of >= 126mg/dl
3. 2 hr glucose value of >= 200mg/dL on 75g, 2-h gTT
4. hemoglobin a1c>= 6.5%

Question 7

management of pregestational diabetes:

Answer 7

retinal and renal health; any meds being taken, esp antihypertensive or thyroid medications. assessment of patient’s risk of complications during pregnancy, including worsening of renal or ophthalmologic function.

Question 8

gestational diabetes:

Answer 8

risk of fetal structural anomaly FOURFOLD to EIGHTFOLD higher.

Question 9

the major congenital anomalies in DM preg pts occured in ___% for type1 DM and ___% for type2DM

Answer 9

4.8% for type1 diabetes and
4.3% for type2 diabetes
for congenital anomalies

Question 10

Neural tube defects in insulin dependent diabetics increased ___, and congenital heart disease increased ___.

Answer 10

NT defects insulin dependent 4.2fold

congenital heart defect increased 3.4fold.

Question 11

use of REGULAR insulin before each meal helps limit postprandial hyperglycemia.

Answer 11

true

Question 12

to provide basal insulin levels between feedings, a longer-acting preparation is necessary such as isoprostane insulin (NPH) or insulin zinc (Lente)

Answer 12

true

Question 13

dosing for DM

Answer 13

2/3 of total insulin in the morning, of which 2/3 are intermediate acting and 1/3 is regular insulin.

remaining 1/3 of the total insulin dose is given in the evening: 50% short acting insulin given prior to dinner, and 50% intermediate acting insulin given at bedtime.

Question 14

elective c-s for suspected fetal macrosomia (US of greater than ____) would require 443 c/s to avoid one permanent brachial plexus injury

Answer 14

4500g.

Question 15

preeclampsia is more common among women with diabetes, 2-3x more likely in women with pregestational diabetes.

Answer 15

true

Question 16

renal function assessment should be performed EVERY TRIMESTER in women with evidence of pregestational diabetes

Answer 16

creatinine, blood urea nitrogen (bun), uric acid, 24 hr urine collection.

Question 17

polyhydramnios

Answer 17

any single verticle pocket of amniotic fluid deeper than 8cm. or when sum of 4 pockets exceeds 24cm.

Question 18

main clinical problems associated with hydramnios are

Answer 18

fetal malposition and preterm labor.

Question 19

the nondiabetic fetus achieves pulmonary maturity at what gestational age?

Answer 19

34-35 weeks.

Question 20

fetal lung maturity assay by presence of more than ……. in amniotic fluid from amniocentesis specimen

Answer 20

> 3% phosphatidyl glycerol

Question 21

Gestational Diabetes definition:

Answer 21

glucose intolerance that begins or is first recognized during pregnancy.

Question 22

risk factors for GDM:

Answer 22

1. maternal age of 35 yrs or more
2. BMI > 22kg/meter squared
3. asian, latin

Question 23

diagnosis of GDM:

Answer 23

screening with 50g glucose at 24-28 weeks.

Question 24

definitive diagnosis of gestational diabetes:

Answer 24

100g GTT; 2 or more values must be met or exceeded for diagnosis of GDM. overnight fasting.

Question 25

management of GDM:

Answer 25

glubyride: 2nd generation SULFONYLUREA. has been shown to cross placenta minimally .
Lagner and associates (2000) compared glyburide and insulin with GDM. showed equivalently excellent maternal glycemic control and perinatal outcomes.

Question 26

Metformin

Answer 26

frequently employed in pts with PCOS and type2 DM to improve insulin resistance and fertility.
-Metformin therapy has been demonstrated to improve success of ovulation induction and may reduce 1st trimester loss in women with PCOS.

Question 27

Dysregulation of local follicle regulatory systems by androgens and other factors impedes normal follicular growth, resulting in follicular arrest at the 4 to 8 mm diameter size [6]. A dominant follicle (ie, 18 to 25 mm in diameter) does not develop and, therefore, ovulation does not occur. Thus, the combination of elevated LH, hyperinsulinemia, ovarian androgen overproduction, and disruption of follicle growth produces the PCOS phenotype of oligoovulation and hyperandrogenism.

Answer 27

true

Question 28

metformin’s major effect is

Answer 28

DECREASE hepatic GLUCOSE production thus REDUCING the need for insulin secretion; it also decreases intestinal absorption of glucose and modestly improves insulin sensitivity. PRIMARILY used for type2 DM but also used for PCOS. Unlike sulfonylureas, it does not produce hypoglycemia in either normal subjects or patients with type 2 diabetes

Question 29

The most common side effects of metformin are gastrointestinal:

Answer 29

diarrhea, nausea or vomiting, flatulence, indigestion, and abdominal discomfort.

Question 30

dose of metformin:

Answer 30

500mg daily if ER, take at dinner time with meals.

Question 31

Although it might be preferable to treat only insulin-resistant women with PCOS, there is currently no readily available, reliable test to evaluate the presence of insulin resistance. Some clinicians do not test at all; others perform an oral glucose tolerance test to look for impaired glucose tolerance and check for elevated insulin levels.

Answer 31

true

Question 32

Maternal thyroid diseases.

Answer 32

estrogen dependent increase in thyroid-binding globulin. results in an increase in total thyroxine (TT4) and total triiodothyronine (TT3) levels throughout pregnancy.

Question 33

HCG has a stimulatory effect on the thyroid, such that

Answer 33

TSH can be NORMAL or DECREASED in 1st and early second trimester.

Question 34

Maternal TSH does NOT cross placenta

Answer 34

true

Question 35

maternal thyroid hormones and thyrotropin-releasing hormone (TRH) are transferred to the fetus throughout gestation.

Answer 35

true

Question 36

transplacental transfer of thyroid-stimulating immunoglobulin (TSI) may occur, causing fetal

Answer 36

thyrotoxicosis.

Question 37

other substances that may be transferred from maternal compartment to fetal compartment and affect fetal thyroid function are

Answer 37

iodine, radioactive isotope of iodine, propylthiouracil (PTU), and methimazole.

Question 38

HYPERTHYROIDISM results in increase of

Answer 38

low birth weight delivery

trend toward higher neonatal mortality.

Question 39

most common causes of thyrotoxicosis (85%)

Answer 39

is Graves disease.
other causes are acute thyroiditis, Hashimoto disease, hydatiform mole, choriocarcinoma, toxic nodular goiter, toxic adenoma.

Question 40

dx of hyperthyroidism

Answer 40

intolerance to heat, nerousness, irritability, emotional lability, increased perspiration, tachycardia and anxiety.

Question 41

lab difficult to eval because total serum thyroxin (T4) levels are normally elevated during pregnancy as a result of estrogen induced increases in thyroxine-binding globulin

Answer 41

true

Question 42

diagnostic lab:

Answer 42

low TSH, high free thyroxine T4

Question 43

methimazone thought to be associated with aplasia cutis in offspring. however, this causal relationship hasn’t been proved

Answer 43

true

Question 44

PTU crosses placenta more slowly than methimazole, and has become drug of choice during pregnancy.

Answer 44

PTU drug of choice in pregnancy. may be associated with liver toxicity, need to monitor liver function tests during pregnancy.

Question 45

Once hyperthyroid under control, important to keepPTU dose as low as possible, preferably <100mg daily. because

Answer 45

drug crosses placenta and blocks fetal thyroid function, possibly producing hypothyroidism in fetus.

Question 46

Hypothyroidism leading cause is

Answer 46

hashimoto’s thyroiditis - chronic autoimmune thyroiditis, characterized by painless inflammation and enlargement of thyroid gland.

Question 47

other causes of primary hypothyroidism, include iodine deficiency, thyroidectomy, ablative radioiodine therapy for hyperthyroidism

Answer 47

true

Question 48

2ndary causes of hypothyroidism:

Answer 48

sheehan’s syndrome.

Question 49

sheehan’s syndrome caused by

Answer 49

obstetric hemorrhage leading to pituitary ischemia, necrosis, and abnormalities in all pitituary hormones, lymphocytic hypophysitis, and hypophysectomy.

Question 50

signs and sx of hypothyroidism:

Answer 50

fatigue, cold intolerance, cramping, constipation, weight gain, hair loss, insomnia, mental slowness.

Question 51

def of hypothyroidism in labs:

Answer 51

high tSH, low free T4

Question 52

subclinical hypothyroidism

Answer 52

high TSH, freeT4normal.

Question 53

goal of therapy is normalization of TSH. TSH checked at

Answer 53

4-6 week increments and dose of levothyroxine adjusted by 25-50 increments.

Question 54

levothyroxine requirements have een seen to increase as early as 5th week. it is important for __ development and is recommended that doses of levothyroxine are increased 30% upon a + pregnancy test

Answer 54

levothyroxine requirements are important for cognitive development of the fetus, it is recommended an increased dose of 30%

Question 55

levels of vitamin D increase

Answer 55

2-3 fold.