Complicated Pregnancy 4 Flashcards
Pre-existing Type 1 or 2 DM Gestational (GDM)
Pathophysiology of GDM [3]
- Maternal insulin requirements increase
- Maternal glucose crosses placenta leading to fetal hyperinsulinemia > macrosomia
- Fetus cannot utilize all Glc so it returns to mother
What hormones cause insulin requirements to rise by 30% during pregnancy? [2]
Production of certain anti-insulin hormones:
- Human Placental Lactogen
- Placental growth hormone
- Estrogen and progesterone
By what mechanism do you get foetal hyper-insulinaemia in pre-existing diabetics? [2]
- Fetus exposed to hyperglycemia and may be stimulated to secrete insulin leading to excess fetal growth.
- Maternal insulin is metabolized by placenta and cannot cross fetal circulation
What risks does pre-existing DM hold for the mother? [4]
- Miscarriage
- Pre-eclampsia
- Worsening of diabetic complications e.g. nephropathy, retinopathy or hypos
- Infections, pre-term labour
Fetal complications of GDM [6]
- Intrauterine demise eg spontaneous abortion, still birth
- Congenital malformations eg cardiac, MSK, sacral agenesis
- Macrosomia > labour complications > birth injuries
- Organomegaly eg cardio, cardiac arrest
- Metabolic abnormalities, erythrocytosis
- Neonatal hypoglycemia, convulsions
Its useful to split obstetric management of pre-existing DM into 3 “phases”
- Pre-conception
- Pregnancy
- Labour
What actions should we take prior to a diabetic actually getting pregnant? (pre-conception) [4]
- Optimise the Glycaemic control till its 4-7mmol/l and Hb1Ac < 6.5%
- Give folic acid 5mg
- Give dietary advice, weight loss if BMI >27
- Retinal and renal assessments
What 2 aspect of medications can we provide diabetics during pregnancy? [2]
What are 2 oral diabetic medication?
- Tighten glucose control by changing from oral rx to insulin
- Provide glucagon injections or concentrated glucose sol for hypoglycemic episodes
Metformin and glibenclamide
What should we monitor in a pregnant diabetic during the actual pregnancy phase?
- Blood glucose
- BP and urine protein (PE)
- Look out for ketonuria and infections
- Monitor fetal growth 4 weekly from 28-36w
- Retinal Assessment at 28 and 34 wks
Things to consider in labour management of GDM patient [3]
One post-natal aspect of management to avoid neonatal hypo
Labour induced around 37w and 38+6w
Consider C-section if the baby is large to avoid complications leading to birth injuries
Continuous CTG monitoring
Feed the baby early to avoid hypos
What are the risk factors for developing gestational DM? [5]
Any H/o GDM or FH of DM
Previous macrosomia
Current pregnancy: polyhydramnios, large fetus or recurrent glycosuria
Increased BMI >30, age >25
Coming from a high risk group for DM e.g. Asian origin
Screening criteria for GDM in NHS Grampian [4]
If risk factors are present, offer HbA1c estimation at booking
If >6%, 75gms OGTT to be done
If OGTT is abnormal > diagnose with GDM
If OGTT is normal repeat it again at 24 wks
How do we manage a mother with GDM? [3]
Overall: tighten and optimize glucose control
- Lifestyle mods: diet and exercise
- Insulin and Metformin
How is GDM managed after the delivery? [2]
Check OGTT 6-8wks PN - glucose should return to normal
Check HbA1C yearly due to the high risk of developing overt DM now
GDM - give 2 definitions
Increased of developing…
Defined as any degree of glucose intolerance with onset or first recognition during pregnancy
Abnormal glucose tolerance that reverts to normal after delivery
More at risk of developing Type II DM in later life.
