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Maternal Medicine > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Define gestational diabetes mellitus (GDM)

A

Carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy.

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2
Q

What are the plasma glucose cut offs for diagnosing GDM?

A

Fasting: >5.1 mmol/L
OGTT 1 hr post: >=10.0 mmol/L
OGTT 2 hr post: >8.5 mmol/L

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3
Q

What are the plasma glucose cut offs for diagnosing DM in pregnancy?

A

Fasting: >= 7.0 mmol/L
*No OGTT 1 hr post criteria.
OGTT 2 hr post: >=11.1 mmol/L
Random: >=11.1 mmol/L

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4
Q

What are the plasma glucose cut offs for diagnosing impaired glucose tolerance?

A

Fasting: >=6.1 but <7.0 mmol/L
*No OGTT 1 hr post criteria.
OGTT 2 hr post: >=7.8 but <11.1 mmol/L

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5
Q

What congenital malformations are associated with pre-existing DM?

A

Congenital heart disease
Anencephaly
Microcephaly
Neural tube defects

Sacral agenesis - specific to diabetes, but rare

Directly proprotional to HbA1c during first 10/40

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6
Q

In the first trimester, what maternal risks are present with pre-existing DM?

A
  • Hypogclyaemia (with nausea and vomiting / hyperemesis in pregnancy)
  • Impaired hypoglycaemia awareness during pregnancy
  • Diabetic ketoacidosis
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7
Q

For women with pre-existing DM, how often should the HbA1c be tested?

A

At least once a trimester

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8
Q

What are the treatment goals for women with pre-existing DM?

A

Fasting: 4.0 - 5.3
1 hour: 5.5 - 7.8
2 hours: 5.0 - 6.7

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9
Q

How do insulin requirements change during pregnancy?

A

Insulin requirements increase steadily through pregnancy - T1DM may need a 2 fold increase in pre-pregnancy insulin; T2DM may require insulin in addition to metformin.

Decline slightly towards term
Small reductions 5-10% are common

HOWEVER, marked decreases > 15% raise concern regarding placental function

  • limited evidence
  • indication for surveillance rather than delivery
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10
Q

If EFW > 4.5kg with DM, there is a _____ risk of shoulder dystocia

A

20%

Therefore, consideration should be given to El LSCS
But NNT to prevent one permanent BPI is 443

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11
Q

How are monogenic diabetes disorders inherited?

A

Autosomal Dominant

Fetus has 50% chance of inheriting it

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12
Q

What are risk factors for developing GDM?

A

BMI > 30
AMA 40+
Previous GDM
Family history of diabetes (first degree relative with DM or sister with GDM)
Ethnicity: Asian, Indian subcontinent, Aboriginal and Torres Strait Islander, Maori, Pacific Islander, Middle Eastern, non-white African
Previous baby > 4.5kg
PCOS
Medications: corticosteroids, antipsychotics

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13
Q

When should women have diabetes testing in pregnancy, and how?

A

All women:

  • Booking HbA1c
  • 75g OGTT at 26-28/40

Women with risk factors:

  • early pregnancy OGTT
  • repeat OGTT at 24-28 weeks if not diagnosed in early pregnancy

2 step procedure with polycose no longer recommended.

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14
Q

What is the recommended timing of delivery for a woman with T1DM or T2DM

A

At the latest, 38+6/40

Because after 39/40, risk stillbirth goes up (RR with DM is 7.2)

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15
Q

What are the signs and symptoms of DKA?

A 
Nausea, vomiting
Abdominal pain
Thirst, dry mouth
Reduced urine output
Unusual, fruity smelling breath
Rapid breathing, dyspnoea
Tachycardia, palpitations
Drowsiness, confusion, disorientation
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16
Q

What is the Pederson hypothesis?

A

Maternal hyperglycaemia leads to fetal hyperglycaemia which causes fetal pancreatic ß cells hyperplasia, and increased circulating insulin.
Insulin is an anabolic growth promoting hormone, which causes increased neonatal fat deposition and abdominal girth with increased birth weight.

17
Q

Briefly describe the MIG Trial

A

Aim: To rule out a 33% increase in a composite of perinatal complications in infants of women treated with Metformin as opposed to Insulin

Randomised: to Metformin up to 2500mg / day (+Insulin if required to achieve glycaemic control), or Insulin

Primary outcome: Composite measure of neonatal outcome including neonatal hypoglycaemia, RDS, PTB, low APGARS etc

Results: No difference in the primary outcome between both groups
I.e Metformin safe in pregnancy
Less SEVERE neonatal hypoglycaemia in the Metformin Group
Of women in the Metformin group, 46% needed Insulin as well
Women referred metformin treatment to taking insulin

18
Q

What was the only intervention that was found to PREVENT women from developing GDM

Cochrane 2020

A

Diet and exercise (combined)

19
Q

What are the OGTT values used to diagnose GDM?

A

fasting >/= 5.1
1 hour >/= 10
2 hour >/= 8.5

20
Q

What HbA1c levels indicate insulin resistance and diabetes mellitus?

A 
IR = 42-47
DM = >/=48
21
Q

Who requires GDM screening at earliest opportunity after pregnancy confirmed? And how is this screening conducted?

A

2 moderate OR 1 major risk factor:

High risk factors for GDM
• Previous GDM
• Previously elevated blood glucose level
• Maternal age ≥40 years
• Family history DM (1st degree relative with diabetes or a sister with GDM)
• BMI > 35 kg/m2
• Previous macrosomia (baby with birth weight > 4500 g or > 90th centile)
• Polycystic ovarian syndrome
• Medications: corticosteroids, antipsychotics

Moderate risk factors for GDM
• Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non‐white African
• BMI 25 – 35 kg/m2

Screening:
HbA1c AND 75g 2h OGTT at earliest opportunity after pregnancy confirmed. Repeat OGTT at 24-28 weeks if not diagnostic in early pregnancy.

22
Q

What is the risk of PET in GDM, T1DM, T2DM and DM with nephropathy?

A

GDM - 10%
T1DM, T2DM - 15-20%
DM with nephropathy - up to 50%

23
Q

What should occur at the initial visit for women with pre-existing DM?

A

Booking bloods
HbA1c
Creatinine
ACR
retinopathy screening (if not within last 3 months)
Ensure taking higher dose 5mg folic acid and iodine
Check height, weight, BMI and BP
Screen for CVD risk factors
Review medications - change to metformin +/- insulin
Counselling around risks of adverse obstetric outcomes, and potential disease progression in pregnancy

Also: TFTs and consider coeliac serology screening in T1DM

24
Q

When should delivery be planned for T1DM/T2DM and GDM?

A 
T1DM/T2DM = 37-38+6 (risk stillbirth increases dramatically from 39wk) 
GDM = Delivery by 40+6; earlier dependant on risk factors
25
Q

What are the risks and what is the counselling for a woman with diabetes and LGA baby >/= 4.5kg?

A

20% risk of shoulder dystocia.

Offer ElCS.

NB. NNT 443 to prevent 1 permanent brachial plexus injury.

26
Q

What are the diagnostic levels for pre-existing DM?

A

fasting >/= 7.0
2 hour >/= 11.1

Random glucose >/= 11.1

27
Q

What are the glycemic targets for women checking BSLs?

A

Fasting = 5.3
1 hour post meals = 7.4
2 hours post meals = 6.7

Pre- existing diabetes - aim to maintain HbA1C = 48 if possible without risk of hypoglycaemic episodes

28
Q

How to initiate treatment in new diagnosis GDM

A

If fasting glucose < 7:

  • Diet and lifestyle for up to 2 weeks
  • If BSLs not controlled, commence metformin
  • If metformin not successful or not tolerated, commence insulin

If fasting glucose >/= 7; macrosomia; diabetic complications (retinopathy/nephropathy)
- Commence insulin

29
Q

When should BSLs be checked?

A

T1DM
- Fasting, pre-meal, 1 hour post-meal, evening

T2DM/GDM on bolus short-acting insulin
- Fasting, pre-meal, 1 hour post-meal, evening

T2DM/GDM on diet, metformin or single dose long acting insulin:
- Fasting, 1 hour post-meal

30
Q

What is the perinatal mortality rate for women with pre-existing diabetes T1DM/T2DM?

A

28 per 1000 births

31
Q

How does diabetes affect the risk of congenital abnormality?

A

The risk of congenital abnormality doubles.
(Background risk roughly 2.5%)

Commonest abnormality:

  • Congenital heart malformation
  • Neural tube defects (incl: micro-/anencephaly)

Risk highest if HbA1c >/= 86 - women should be advised to use contraception until diabetic control improved.

Dose dependent relationship between risk of abnormality and HbA1c levels prior to 10 week pregnancy.

32
Q

What are the long term complications of GDM? What follow-up is required postpartum?

A

30% recurrence risk in future pregnancies
50% risk of developing T2DM in later life
Increased risk of high BMI and diabetes in the fetus

Recommend HbA1c at 12 wks

  • If pre-diabetic repeat after further 12 weeks
  • If >/=48 requires initiation of management for diabetes

Annual HbA1c screening

33
Q

Describe the HAPO 2008 study.

A

Large blinded cohort study.
Aiming to find out if hyperglycaemia less than the threshold for diabetes mellitus had adverse pregnancy effects
Inclusion: OGTT by 32 weeks fasting <5.8, 2hr <11.1.

FINDINGS:
- Even below threshold for Dx overt DM, increasing serum glucose levels correlated with several adverse obstetric outcomes
- Increased risk of:
1st outcome = LGA >90th, neonatal hypoglycaemia, CS delivery, cord blood c-peptide
2nd outcome = PET, shoulder dystocia, birth injury, preterm birth, NICU admission, hyperbilirubinemia

34
Q

What are the effects of pregnancy on pre-existing diabetes?

A
  • Increasing insulin requirements
  • Risk of deterioration of diabetic nephropathy (most likely if mod/severe renal impairment)
  • Deterioration in diabetic retinopathy
  • Increased risk of hypoglycaemia
  • hypoglycemia unawareness
  • DKA is rare, but can be exacerbated by hyperemesis, sepsis or prolonged labour
  • Deterioration in autonomic neuropathy and gastric paresis
35
Q

What are the additional obstetric risks for women with pre-existing diabetes?

A

Maternal:

  • PET
  • Shoulder dystocia
  • CS delivery

Fetal:

  • Miscarriage
  • Stillbirth
  • Perinatal/neonatal death increased 5-10 fold
  • Congenital anomalies increased 2-3 fold (NTD, heart defects, sacral agenesis)
  • Macrosomia
  • Polyhydramnios
  • Birth injury
  • Neonatal hypoglycemia
  • jaundice
  • RDS
36
Q

Why are babies of diabetic mothers prone to jaundice?

A

Hyperinsulinemia and increased fetal growth creates a state of relative hypoxia, driving extra medullary erythropoeisis and polycythemia.

37
Q

What additional antenatal care is required in pre-exisitng diabetes?

A
  • Pre-preganncy evaluations and counselling
  • Management under tertiary centre, with MDT input
  • Medication optimisation
  • Close serum glucose onitroing with glucometer
  • Ketone testing strips (if become hyperglycaemic or if unwell)
  • 5mg folic acid through 1st trimester
  • Early dating and viability scan
  • Routine nuchal scan
  • Detailed tertiary anatomy scan and cardiac echo
  • Growth scans through third trimester
  • PET assessment at each visit
  • Planning around timing of delivery - IOL before 39 weeks
38
Q

Intrapartum considerations for women with T1DM.

A
  • Insulin-dextrose sliding scale
  • Potassium replacement
  • Hourly BSL - aim 4-7 g/L
  • CTG
  • CS only for obstetric indications
  • After delivery of placenta reduce insulin rate by half
  • Once E&D can restart SC insulin at pre-pregnancy dose, or 25-40% reduction

Maternal Medicine (18 decks)

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