Complicated Pregnancy 4

Question 1

Pathophysiology of GDM [3]

Answer 1

• Maternal insulin requirements increase
• Maternal glucose crosses placenta leading to fetal hyperinsulinemia > macrosomia
• Fetus cannot utilize all Glc so it returns to mother

Question 2

What hormones cause insulin requirements to rise by 30% during pregnancy? [2]

Answer 2

Production of certain anti-insulin hormones:

• Human Placental Lactogen
• Placental growth hormone
• Estrogen and progesterone

Question 3

By what mechanism do you get foetal hyper-insulinaemia in pre-existing diabetics? [2]

Answer 3

• 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

Question 4

What risks does pre-existing DM hold for the mother? [4]

Answer 4

• Miscarriage
• Pre-eclampsia
• Worsening of diabetic complications e.g. nephropathy, retinopathy or hypos
• Infections, pre-term labour

Question 5

Fetal complications of GDM [6]

Answer 5

• 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

Question 6

Its useful to split obstetric management of pre-existing DM into 3 “phases”

Answer 6

• Pre-conception
• Pregnancy
• Labour

Question 7

What actions should we take prior to a diabetic actually getting pregnant? (pre-conception) [4]

Answer 7

• 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

Question 8

What 2 aspect of medications can we provide diabetics during pregnancy? [2]
What are 2 oral diabetic medication?

Answer 8

• Tighten glucose control by changing from oral rx to insulin
• Provide glucagon injections or concentrated glucose sol for hypoglycemic episodes

Metformin and glibenclamide

Question 9

What should we monitor in a pregnant diabetic during the actual pregnancy phase?

Answer 9

• 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

Question 10

Things to consider in labour management of GDM patient [3]

One post-natal aspect of management to avoid neonatal hypo

Answer 10

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

Question 11

What are the risk factors for developing gestational DM? [5]

Answer 11

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

Question 12

Screening criteria for GDM in NHS Grampian [4]

Answer 12

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

Question 13

How do we manage a mother with GDM? [3]

Answer 13

Overall: tighten and optimize glucose control

• Lifestyle mods: diet and exercise
• Insulin and Metformin

Question 14

How is GDM managed after the delivery? [2]

Answer 14

Check OGTT 6-8wks PN - glucose should return to normal

Check HbA1C yearly due to the high risk of developing overt DM now

Question 15

GDM - give 2 definitions

Increased of developing…

Answer 15

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.

Question 16

Macrosomia
Risks to infant [2]
Risks to mother [4]
Future risks to mother [2]

Answer 16

Risks to Infant: causes increased risk of birth trauma, neonatal hypoglycemia
Risks to Mother: c- section, pre-eclampsia, polyhydramnios, preterm labour
Future risks to mother: Recurrent GDM pregnancies
Risk of developing Type II DM

Question 17

Neonatal hypoglycemia
How does it happen? [2]
Presentation of neonate [1]

Answer 17

Post-delivery, fetus still is hyperinsulinemic but glucose supply cut off
Jittery and irritably infant

Question 18

OGTT indications and at what stages should u offer these?

Answer 18

If previous GDM, offer at booking
If RF present 24-48 weeks
If 2+ glycosuria on one occasion or 1+ on two occasions - offer irregardless of GA

Question 19

Contraindications to pregnancy in GDM patients
3 conditions
5 bio indicators from examination, lab tests

Answer 19

IHD
Active untreated proliferative retinopathy
Renal insufficiency

• Creatinine clearance <50 mL/minute
• Serum creatinine > 200 µmol/L
• Proteinuria >2 g/24 hours
• Blood pressure >130/80 mm Hg despite treatment
Severe gastroparesis – inability/unwillingness to use insulin

Question 20

Rapid normalisation of blood glucose during pregnancy can trigger retinopathy progression. How to manage this in pregnant woman? [3]

Answer 20

• A preconception dilated eye exam should be performed by an ophthalmologist
• Retinal status should be stabilised
prior to conception
• Reassess retinal status each trimester (more frequently
if retinopathy is present)

Question 21

Management of infusion during labour and delivery [3]

Answer 21

Sliding scale infusion
T1: Halve the rate of insulin infusion after placental delivery
T2: STOP insulin after placental delivery

Question 22

Postnatal care for GDM

Answer 22

Check fasting glucose 6w post-partum