Complications in Pregnancy

Question 1

Carbohydrate/glucose intolerance of a variable severity that is first diagnosed during pregnancy?

Answer 1

Gestational Diabetes (GDM).

Question 2

Type 1 or 2 DM diagnosed BEFORE pregnancy?

Answer 2

Pregestational Diabetes.

Question 3

A weakening of the cervix that causes premature shortening or dilation and miscarriage?

Answer 3

Incompetent Cervix

Question 4

What does Incompetent cervix cause?

Answer 4

Recurrent 2nd trimester miscarriages.

Question 5

What is the problem during pregnancy that an incompetent cervix causes?

Answer 5

The cervix will not remain completely closed during pregnancy, placing the baby at risk for premature birth.

Question 6

What are some causes and risk factors (5) for an incompetent cervix?

Answer 6

1. Past trauma to the cervix, such as from surgery or D&C.
2. Previous traumatic deliveries to the cervix.
3. Genetic anomalies that cause a malformed cervix, such as Ehlers-Danlos Syndrome or other CT disorders.
4. Cervical conization.
5. DES (synthetic estrogen) exposure in utero.

Question 7

What is an unfortunate thing involved with the diagnosis of an incompetent cervix?

Answer 7

Usually diagnosed after a second or third-trimester miscarriage occurs.

Question 8

Diagnosis of an Incompetent Cervix?

Answer 8

Transvaginal U/S – funneling of the cervix, which means the opening of the internal cervical os with protrusion of the amniotic sac into the cervical canal.

*Cervical funnelling is a sign of cervical incompetence and represents the dilation of the internal part of the cervical canal and reduction of the cervical length.

Question 9

What are some signs/symptoms of an incompetent cervix?

Answer 9

1. May or may not have some bleeding in the second or third trimester
   - Vaginal bleeding, mild cramping, backache.
2. Can usually be detected on routine prenatal ultrasound or pelvic exam.

Question 10

What is a normal cervix length?

Answer 10

At least 30 mm in length?

Question 11

What length of the cervix defines incompetent cervix?

Answer 11

Cervical weakness is variably defined. However, a common definition is a cervical length < 25 mm before 24 wks.

Question 12

What is the treatment for an incompetent cervix?

Answer 12

Treated with CERVICAL CERCLAGE which involves placing purse-string sutures in the cervix to draw it closed:

• -Placed at 14-16 weeks and removed at 36 weeks to allow for delivery
• -This effectively sutures the cervix closed to prevent premature dilation-
• -These sutures are usually removed in the last few weeks of pregnancy to prevent tearing of the cervix as it tries to dilate.

Question 13

What is a common presentation of a pt with an incompetent cervix.

Answer 13

A 32-year-old, G7P0A3, is in her thirteenth week of pregnancy. She has lost three consecutive normally formed fetuses before 20 weeks gestation, and she has had three spontaneous first-trimester abortions.

Question 14

What are the two categories that Gestational Diabetes is divided into?

Answer 14

1. Pregestational DM (PGDM).

2. Gestational DM (GDM) – glucose intolerance w/onset or first detection during pregnancy.

Question 15

Epidemiology of GDM?

Answer 15

1. 2-5% of pregnancies

- -most of which are true GDM (80-90%), but some are pregestational diabetes (10%).

Question 16

What aspect of GDM or PGDM will cause complications?

Answer 16

Higher rate of maternal and fetal complications when DM is UNCONTROLLED.

Question 17

What is hPL?

Answer 17

Human Placental Lactogen (hPL), which promotes lipolysis to increase levels of circulating free fatty acids and decreases maternal glucose metabolism.

–It is produced by the growing placenta that prevents the body from using insulin effectively.

Question 18

Describe the pathogenesis of GDM?

Answer 18

The growing placenta is a source of insulin antagonists associated with progressive insulin resistance of pregnancy.

Glucose crosses the placenta easily facilitated by diffusion, causing FETAL HYPERGLYCEMIA that stimulates pancreatic beta cells and results in FETAL HYPERINSULINISM.

Question 19

What is the simple patho of GDM?

Answer 19

A woman’s cells naturally become slightly more resistant to insulin’s effects, which increases the mother’s blood glucose level to make more nutrients available to the fetus. The mother’s body makes more insulin to keep the blood sugar levels down, but not enough to keep their blood glucose levels in the normal range.

In a small number of women, even this increase is out of range leading to gestational diabetes.

Question 20

What are the risk factors (6) for GDM?

Answer 20

1. Advanced maternal age (35+).
2. Overweight/Obese women.
3. Previous Hx of GDM.
4. FH of DM.
5. AA, American Indian, Asian american, Hispanic, Pacific Islander.
6. PCOS.

Question 21

What are some important factors or complications associated with GDM/PGDM?

Answer 21

1. GDM is a strong risk factor for the development of permanent DM II later in life (40% w/in subsequent 10 yrs).
2. Maternal DM contributes to obesity and DM of child later in life.

Question 22

What are some maternal complications associated with PGDM?

Answer 22

1. Spontaneous abortion.
2. Premature labor.
3. Vascular and end-organ involvement/deterioration:
   - -CV, Renal, Ophthalmic (Diabetic Retinopathy), Peripheral vascular, GI issues, Peripheral neuropathy.

Question 23

What are some maternal complications associated with GDM?

Answer 23

Mortality, premature delivery, complicated delivery/cesarean delivery, PREECLAMPSIA, UTI/Candidiasis, Polyhydramnios.

Question 24

What is the most concerning consequence of DM on the fetus?

Answer 24

Fetal Hyperglycemia is TERATOGENIC; leads to spontaneous abortion.

*Also, HgA1c >9.5% has a >22% risk of fetal malformations.

Question 25

What are the most common fetal complications associated with DM in pregnancy?

Answer 25

1. Intrauterine growth restriction (IUGR) – fetus does not grow at normal rate.
2. Intrauterine fetal demise (IUFD) – due to hypoxia from increased metabolism coupled w/inadequate placental O2 transfer.
3. Macrosomia – a fetus larger than 4000-4500 grams (9-10 lbs).
4. Birth trauma – shoulder dystocia, erb palsy, genital trauma.

Question 26

When and why is early glucose screening completed?

Answer 26

For all women before 13 weeks of gestation (or asap) for women at increased risk of overt diabetes.

• -BMI >25.
• -Physical inactivity.
• -1st degree relative with DM.
• -Previous GDM, HTN.

Question 27

What is the mainstay screening for GDM?

Answer 27

OGTT at 24-28 weeks – 1-hr, 50 gm oral glucose tolerance test.

• Normal <130 mg/dL.
• Abnormal >130 mg/dL.
• If >200 mg/dL, the diagnosis is rendered and the 3 hr OGTT is aborted.

Question 28

If Screening OGTT is abnormal (>130 mg/dL), then which test is next?

Answer 28

A 3-hr 100 gm OGTT test is completed.

• -Pt fasts overnight and fasting glucose taken.
• -Pt consumes 100 gm glucola.
• -Repeat glucose testing at 1, 2, 3 hrs.
• • > 2 abnormal levels detected in the 4 results above, the pt is diagnosed with GDM.

Question 29

What and who is involved in the mgmt of a pt with GDM or PGDM?

Answer 29

1. Pt education, counseling, self-monitoring of glucose levels (Fasting and post-prandial).
2. Team: pt, OB, MFM specialist (maternal fetal medicine), Clinical nurse specialist, nutritionist, social worker, neonatologist, endocrinologist.

Question 30

Why is an A1C not a valuable test for managing GDM?

Answer 30

A1C is slightly lower in normal pregnancy than in normal non-pregnant women due to an increased RBC turnover.

*A1C takes a measure of glucose attached to hemoglobin over the past 3 months; RBC lifetime is 120 days.

Question 31

What are the glycemic targets in GDM?

Answer 31

GOAL blood sugars:

• Fasting BS < 95.
• 1 hr postprandial levels < 140.
• 2 hr postprandial levels < 120.

Question 32

What is the mainstay in managing GDM/PGDM?

Answer 32

Lifestyle modifications – 70-85% of women diagnosed with GDM can be controlled with lifestyle mgmt alone.

• EXERCISE: moderate exercise for 30 mins per day; keep HR under 140 bpm.
• Dietary Mgmt: sm, frequent meals.

Question 33

What is the 1st line treatment for managing GDM/PGDM if lifestyle changes fail?

Answer 33

Insulin – it does not cross the placenta.

• -Rapid-acting insulin (bolus) + Intermediate or long-acting (basal)
• NPH 1st line for basal insulin.

Question 34

What is the dosing schedule for insulin?

Answer 34

2/3 in AM and 1/3 in PM.

• Before breakfast: 2/3 NPH, 1/3 regular insulin or lispro.
• Before dinner: 1/2 NPH, 1/2 regular or lispro.

Question 35

What fetal complication warrants a C-Section?

Answer 35

Macrosomia, fetus > 4500 grams; to avoid birth trauma to the infant and mom.

Question 36

What should NOT be initiated during pregnancy in a pt diagnosed with GMD/PGDM?

Answer 36

Insulin pump therapy.

Question 37

What is part of the Antepartum OB Mgmt?

Answer 37

1. Routine prenatal screening in women with PGDM.
2. 2nd trimester, esp if A1C >8.5%.
   - -OB US, Fetal ECHO, Maternal serum alpha-fetoprotein.
3. Monitor maternal renal, cardiac and ocular fxn.
4. Serial antepartum testing and fetal growth monitoring in 3rd trimester.
   - -At 36 weeks for well-controlled glucose levels, sooner if poorly controlled, wkly U/S.
   - -IUGR is confirmed in 3rd trimester.

Question 38

What happens to insulin levels postpartum?

Answer 38

Once fetus and placenta are delivered, insulin demands DROP DRAMATICALLY and quickly.

Question 39

Why does a postpartum mother who was diagnosed with GDM/PGDM undergo a 75g OGTT test after delivery and when should that happen?

Answer 39

Needs to happen at 4-12 weeks postpartum to assess the conversion to T2DM.

*6 wk after vaginal delivery or 8 wks after cesarean.