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Diabetes Flashcards

1
Q

What is metabolism? What two process allow for metabolism?

A

chemical process by which cells produce the substances and energy needed to sustain life

Catabolism
Anabolic process

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2
Q

What is catabolism? What does it provide? What hormone are involved?

A

Organic compounds are broken down to provide heat and energy

Provides energy for anabolism; excess stored in fat or as glycogen

Catabolic hormones: Cortisol, glucagon, adrenalin, cytokines

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3
Q

What is anabolic process? Where does the energy come from? What hormones are involved?

A

Simpler molecules are used to build more complex compounds like proteins for growth and repair of tissues

Source of energy comes from catabolism

Anabolic hormones: Insulin, estrogen, testosterone, & growth hormones

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4
Q

What metabolic changes occur in pregnancy?

A

Lower glucose tolerance
Higher blood glucose levels
Progressive insulin resistance
Increased insulin production

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5
Q

How does the placenta provide a sustained supply of glucose to the developing fetus in early pregnancy?

A

Estrogen and progesterone stimulate insulin production & cellular responses

Results in ANABOLIC state that increases the storage of glycogen for future maternal-fetal demands

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6
Q

What causes progressive insulin resistance in late pregnancy? When is maternal fat metabolized? How are maternal glucose needs met?

A

hPL, prolactin, cortisol, and glycogen lead to resistance to insulin

Maternal fat metabolized in pregnancy during periods of fasting (nighttime)

Maternal glucose needs met by lower peripheral uptake of glucose

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7
Q

How is glucose transported to the fetus in late pregnancY?

A

Glucose actively transported across the placenta to fetus and used as a fuel source; increases as fetus grows and needs more (diabetogenic effect on pregnancy)

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8
Q

What is type 1 diabetes?

A

“Can’t make it”

Inadequate production of insulin by ß cells (Islets of Langerhans) of the pancreatic gland

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9
Q

What is type 2 diabetes?

A

“Can’t use it”

Cell membrane receptor site failure causes inability to utilize insulin

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10
Q

What are the two types of gestational diabetes (GDM)?

A

A1GDM- diet controlled
A2GDM- requires medications to control it

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11
Q

A1GDM is controlled by…

A

diet controlled

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12
Q

A2GDM is controlled by… what type?

A

medications

insulin first line but some providers use Metformin, Glyburide

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13
Q

What is GDM?

A

Carbohydrate intolerance of varying degrees

Onset or 1st recognition during pregnancy

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14
Q

What are the risk factors for GDM? (8)

A

Overweight/obesity
Lack of physical activity
Previous GDM, pre diabetes
Polycystic ovary syndrome
Diabetes in 1st degree relatives
Previous delivery of >9lb baby
Black, hispanic, American Indian, Asian, Pacific Islander
Older maternal age (especially over 40)

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15
Q

Do you need to screen or testing for GDM for a patient with Type 1 or Type 2 diabetes?

A

No glucose screeening is needed

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16
Q

What is the goal with pre-existing type 1 or type 2 diabetes? What should be monitored? What is recommended?

A

Critical to maintain tight blood sugar control, adjust meds, prn

Monitor Hgb A1C levels

Recommend healthy diet, daily exercise, stay within recommended weight parameters in pregnancy

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17
Q

An A1C level of _______ is associated with _______

A

Hgb A1C of >/=6.5% associated with higher risk of congenital anomalies (5x increase in heart, skeletal, CNS congenital defects if hyperglycemia in 1st trimester)

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18
Q

When should the universal screening for GDM be done? Who is screened? What are the methods of screening?

A

Universal screening at 24-28 weeks gestation

All pregnant patients who do not have pre-existing DM or have an early diagnosis

Either 1-hour GCT or 2-hour GTT

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19
Q

Which patients undergo early screening at initiation of prenatal for undiagnosed type 2 DM? (8)

A

Patients with a BMI > 25 (23 in Asian American) and 1 or more of the following:

Previous GDM, macrosomia, stillbirth
Physical inactivity
1st degree relative with diabetes
High risk race or ethnicity (AA, Latino, Native American. Asian American, Pacific Islander)
HTN, h/o CVD
Low HDL or high triglycerides
PCOS, acanthosis nigricans, morbid obesity and other conditions associated with insulin resistance
A1C greater than 5.7% on previous testing, impaired glucose tolerance or impaired fasting glucose

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20
Q

What happened if early screening is negative?

A

RETEST at 24-28 weeks with universal screening

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21
Q

What occurs if early screening is positive? What happened based on those results?

A

Confirm with 3-hr GTT

Negative 3-hr GTT- repeat 3-hr GTT at 24-28 weeks
Positive 3-hr GTT–treated as GDM; Do not repeat testing at 24-28 weeks

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22
Q

What is used to screen the patient for GDM? What is a positive screening? What happens if its positive?

A

1-hour 50g oral glucose challenge test, non fasting

Positive screen: blood glucose >130-140mg/dL (institutional)

Proceed to diagnostic testing with 3-hour 100g GTT

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23
Q

What is the one step method to diagnose a patient with GDM? What is a positive test?

A

2-hour 75 g GTT

≥ fasting: 92, ≥ 1 hour: ≥ 180, 2 hour: ≥ 153

Need 1 abnormal for GDM diagnosis

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24
Q

What is the normal glucose range for a 1-hour GCT screening? What value wouldd be diagnostic and not require any further testing?

A

< 130 mg/dL to 140 mg/dL (practice dependent)

If 1-hour 50g GCT is ≥ 200, patient is diagnosed with GDM (likely pre-existing); no further testing needed

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25
Q

What patent teaching should occur prior to a 3 hour GTT?

A

Have patient eat normal unrestricted diet prior to day of testing

No food, smoking, exercise for 8-12 hours before first blood draw

Procedure can take up to 4 hours

26
Q

What is the 3 hour GTT procedure? What should be restricted during this time?

A

Fasting glucose drawn
Give 100-gram glucose drink
Glucose levels drawn q 1 hour for 3 hours following glucose load

NPO except water, no smoking, minimal activity

27
Q

What is an abnormal 3 hour GTT? What is needed for diagnosis? What value would stop the test after just the fasting level?

A

Abnormal if fasting: ≥ 95; 1 hour: >180; 2 hour: ≥ 155; 3 hour: ≥ 140

Need 2 abnormal values for GDM diagnosis

28
Q

If the fasting blood glucose is ______ on a 3 hour GTT then the patient has GDM and testing can be stopped

A

If fasting is ≥ 126 the patient has GDM, most likely pre-existing. The test can be stopped

29
Q

What should the diet of a patient with GDM be?

A

Eat 3 meals and 2 snacks/day (one at bedtime) to limit glucose fluctuations; each meal and snack should include some protein with a high-protein bedtime snack

Diet should consist of 35-40% of calories from carbohydrates; 20% from protein; 40% from fats with saturated fats comprising <7% of total calories

Fiber 28 g per day

30
Q

Should a patient with GDM exercise? What s/s should they be aware of? How often should they be monitoring/documenting their glucose?

A

Exercise for 30 minutes daily

Signs and symptoms of hypoglycemia and hyperglycemia

Blood glucose monitoring/documentation 4 times per day (fasting and 1-hour postprandial).

31
Q

What is the target blood glucose ranges for GDM?

A

Fasting < 95
1-hour postprandial <140

32
Q

Is GDM typically well managed by diet and exercise?

A

No, despite compliance with diet and exercise, 25-50% still need medication

33
Q

When is medical management of GDM indicated? What is used first line? What can be used orally?

A

Indicated if > 30% of glucose values in one week are above the target thresholds (fasting- 95 mg/dL and 1-hr postprandial 140 mg/dL)

Insulin preferred agent

Oral hypoglycemic agents (Metformin/Glyburide—not FDA approved in pregnancy) may be used if individual is unwilling/unable to take Insulin or provider preference

34
Q

What are the immediate maternal complications with GDM?

A

Pre-eclampsia, GHTN, abruption, postpartum hemorrhage
Hydramnios-related to high fetal glucose levels causing excessive urination
Poor healing, infections (UTIs/yeast infections)
Ketoacidosis- untreated lead to maternal/fetal death
Increased risk of a c-section
Increased risk of forceps/vacuum assisted births
Increased risk of a shoulder dystocia

35
Q

What are the late maternal complications of GDM?

A

Within 20 years > 70% develop overt Type 2 DM
Increased risk of cardiovascular disease and early atherosclerosis

36
Q

What are the immediate fetal/neonatal complications r/t GDM? (8)

A

Increased perinatal mortality/stillbirth
Macrosomia (EFW > 4,000 grams)
Pre-term birth
Hypoglycemia
Birth trauma
Hyperbilirubinemia
Polycythemia
Respiratory distress syndrome

37
Q

What are the later fetal/neonatal complications r/t GDM?

A

Obesity- born with more body fat (even when nl weight at birth)
Evidence of female children developing GDM in their own pregnancies.
Impaired intellectual development
Impaired glucose tolerance

38
Q

What additional complications does pre-existing diabetes pose in pregnancy?

A

Thyroid dysfunction
Increased risk of maternal mortality
Related to poor glucose control in the first trimester (Increased risk of miscarriage
and 5X greater risk of congenital malformations)

39
Q

What are the goals for antepartum care for patients with GDM or pre-existing DM?

A

Maintain balance between glucose and insulin
Optimize health of mom and baby and prevent complications
Monitor for maternal and fetal well-being with visits, fetal assessments and education
Q 1-2 week prenatal appointments- watch BPs, weight, glucose levels
Refer to nutritionist/diabetic educator

40
Q

A1GDM will receive expectant management until? Delivery is indicated when?

A

Expectant management acceptable until 40 6/7 weeks
Delivery no earlier than 39 weeks unless other indications

41
Q

A2GDM with well controlled sugars should consider induction when?

A

Consider induction of labor between 39 weeks and 39 6/7 weeks

42
Q

A2GDM with poorly controlled sugars should consider induction when?

A

Consider induction of labor between 37 weeks and 38 6/7 weeks

43
Q

A patent with pre-existing type 1 or 2 DM w/o vascular disease should consider induction when?

A

Consider induction at 39 weeks with well controlled blood sugars

44
Q

When should early delivery be considered? What should be done before early delivery? When should a c-section be considered?

A

Consider earlier delivery if poor control, coexisting HTN, or non-reassurring fetal testing

Amniocentesis to check for fetal lung maturity if delivery prior to 38 weeks

Offer cesarean section if EFW >4,500 gram

45
Q

What is labor management for patients with GDM or type1/2 DM?

A

Monitor labor progress and descent
Continuous fetal monitoring
Prepare for shoulder dystocia
Monitor for s/s of preeclampsia
A1GDM random glucose on admission

46
Q

What additional care is needed for those whose diabetes are managed with medications (Type 1, Type 2, A2GDM)?

A

Hourly glucose levels once in labor (goal: 70-129)
Start insulin drip if sugars > 130; Regulated by sliding scale
IV fluids (D5LR, normal saline, LR)
Sometimes NPO
Type I with insulin pump may sometimes use their own pump in labor

47
Q

What is the blood glucose level goal for those with medication managed diabetes once in labor?

A

70-129

48
Q

What blood sugar would indicate that an insulin drip should be started?

A

> 130

49
Q

When does insulin resistance of pregnancy go away? What does this lead to?

A

rapidly dissipates after delivery of the placenta

Insulin requirements drop dramatically

50
Q

What is the postpartum care for GDM?

A

Resume normal diet
A2 GDM– stop diabetes medications after delivery
Screen at 4-12 weeks postpartum for type 2 DM - 2-hour 75 g GTT for screening is recommended

51
Q

What is the postpartum care for type 1 and type 2 DM?

A

Insulin will need to be adjusted; monitor closely for hypoglycemia (type 1 DM)
Metformin preferred oral agent
After 24-48 hours resume standard diabetes management

52
Q

Do you need to preform antenatal testing for an A1GDM?

A

No

53
Q

When does antenatal testing start for A2GDM controlled? What testing is done?

A

32 weeks

Weekly NST
Weekly assessment of amniotic fluid volume
US at 28-32 weeks, 36 weeks

54
Q

When does antenatal testing start for A2GDM poorly controled? What testing is done?

A

32 weeks

Twice weekly NST
Weekly assessment of amniotic fluid volume
US at 28-32 weeks, 36 weeks

55
Q

When does antenatal testing start for type 1/2 DM? What testing is done?

A

32 weeks

Twice weekly NST
Weekly assessment of amniotic fluid volume
Fetal ECHO for early A1C > 6.5%
US 26-28 wks then q 4 wks

56
Q

After having GDM when is an FPG/ 2 hour GTT preformed?

A

4-12 weeks PP

57
Q

If FPG >125mg/dl or 2 hour GTT >199 mg/dl what occurs?

A

Diabetes

Refer to diabetic management

58
Q

If FPG 100-125 mg/dl or 2 hour GTT 140-199 mg/dl what occurs?

A

Impaired fasting glucose or IGT or both

Consider referral to management
Weight loss and physical activity consult
Consider metformin if combined IGT and impaired fasting glucose
Medical nutrition therapy
Yearly assessment of glycemic status

59
Q

If FPG <100 mg/dl or 2 hour GTT <140 mg/dl what occurs?

A

Normal

Assess glycemic status every 1-3 years
Weight loss and physical activity counseling PRN

60
Q

What effect can the glucose test have on women?

A

Can make them feel sick/nausea

61
Q

What are diet recommendations for a patient with GDM?

A

Don’t skip meals – trying to maintain glucose levels by eating small meals every few hours will help extreme fluctuation
Decrease simple sugars and saturated fats in their diet – explain foods that have simple sugars like juice, soda, white rice, syrup, potatoes. Educate on better choices like brown rice increase. Higher sat fats can worsen insulin resistance so lean protein sources recommended
Increase protein - talk out food with protein and a high protein snack at night will decrease risk of hypoglycemia at night
Increase exercise to 30 minutes of moderate exercise – helps with weight gain, helps to utilize glucose —> decrease insulin and medication needs, assess barriers to exercise

62
Q

Why would you give D5LR to a diabetic patient in labor? What should you never do?

A

Need sugar because labor may not progress b/c labor is a marathon

Do not bolus with D5LR because more at risk for fetus hypoglycemia

OB (16 decks)

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