Complications of pregnancy 2 (other stuff) Flashcards
What is gestational diabetes?
What happens to this following delivery?
carbohydrate intolerance with onset (or first recognised) in pregnancy
This normally returns to normal following delivery - however - the mother is more at risk of developing type 2 diabetes later in life
How is pre-existing diabetes affected by pregnancy?
What effect can maternal diabetes have on the developing fetus?
Insulin requirements of mother increase:
- Human placental lactogen, progesterone, BhCG, cortisol - all have anti-insulin action
Fetal hyper-insuliaemia occurs:
- Maternal glucose crosses the placenta which induces increased insulin production in the fetus
- The fetal hyperinsulinemia causes macrosomia
What are the risks to the beby of maternal diabetes?
Specifically in terms of:
- Problems in utero
- Problems with delivery
- Problems actually with the neonate
problems in utero:
- polyhydramnios
- miscarriage
problems with delivery:
- shoulder dystocia
- operative delivery
- problems caused by macrosomnia
problems with the neonate:
- hypoglycaemia
- congenital abnormalities
- respiratory distress, impaired lung maturity
- stillbirth
- increased perinatal mortality
- jaundice
What congenital abnormalities are associated with maternal diabetes?
Cardiac abnormalities
Sacral agenesis
especially if blood sugars high peri-conception
How is maternal diabetes managed pre-conception?
Maintain good/better glycaemic control…
- ideally - blood sugars should be 4-7 mmol/l
- HbA1c < 48 mmol/mol
Folic acid 5mg (high dose) is given
Dietary advice
Renal assessment
Retinal assessment
How is pre-existing diabetes managed during pregnancy?
Optimise glucose control for increased insulin requirements of pregnancy…
Make aware of increased risk of hypos…
- provide glucagon injections / conc. glucose solution
Watch for ketonuria, infections, PET
Repeat retinal assessment at 28 & 34 weeks
Monitor fetal growth
Around the time of delivery, how is pre-existing diabetes managed?
Labour usually induced 38-40 weeks
If macrosomnia - consider elective C-section
Maintain blood sugar in labour:
- Insulin
- Dextrose-insulin infusion
Continuous fetal CTG in labour
Early feeding of baby post delivery - for N. hypoglycaemia
Can go back to pre-pregnancy insulin regime post delivery
What are the risk factors for gestational diabetes (GDM)?
BMI > 30
Previous macrosomic baby > 4.5 kg
Previous GDM
Family Hx of DM
High risk group for DM (eg of Asian origin)
Polyhydramnios or macrosomia in current pregnancy
Recurrent glycosuria in current pregnancy
Is GDM risky business?
GDM associated with some increase in maternal complications (eg PET) and fetal complications (macrosomia) but much less than with type I or II diabetes
When would you screen for GDM?
If a pregnant woman has a significant number of risk factors for GDM
How does screening for GDM work?
If risk factor present - offer HbA1C estimation at booking:
- if > 6% (43 mmol/mol), 75gms OGTT to be done
- if OGTT normal, repeat OGTT at 24 -28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
How is GDM managed both during & after pregnancy?
control blood sugars - trial in this order:
- Diet & exercise
- Metformin (start this immediately if fasting glu >7)
- Metformin & insulin
Post delivery – check OGTT 6 to 8 weeks PN
Yearly check on HbA1C/ blood sugars as at a higher risk of developing overt diabetes
How does the risk of thromboembolism change in pregnancy and why?
Risk of thromboembolism increases in pregnancy
Pregnancy is a hypercoagulable state:
- Increased fibrinogen, Factor VIII, VW factor, platelets
- Decreased anticoagulants - antithrombin III
- Increase in fibrinolysis
There is also increased stasis and vascular damage - both of which are causes of thromby time
How is DVT and PE investigated in pregnancy?
More or less the same as for other people…
- ECG
- Blood gasses
- Doppler US (DVT)
- CTPA - diagnostic (same as normal) - V/Q is alternative
How is PE or DVT treated in pregnant women?
Same as normal
DOACs - apixaban or rivaroxaban
If renal problems - LMWH (Dalteparin)
