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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
What patent teaching should occur prior to a 3 hour GTT?
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
What is the 3 hour GTT procedure? What should be restricted during this time?
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
What is an abnormal 3 hour GTT? What is needed for diagnosis? What value would stop the test after just the fasting level?
Abnormal if fasting: ≥ 95; 1 hour: >180; 2 hour: ≥ 155; 3 hour: ≥ 140 Need 2 abnormal values for GDM diagnosis
28
If the fasting blood glucose is ______ on a 3 hour GTT then the patient has GDM and testing can be stopped
If fasting is ≥ 126 the patient has GDM, most likely pre-existing. The test can be stopped
29
What should the diet of a patient with GDM be?
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
Should a patient with GDM exercise? What s/s should they be aware of? How often should they be monitoring/documenting their glucose?
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
What is the target blood glucose ranges for GDM?
Fasting < 95 1-hour postprandial <140
32
Is GDM typically well managed by diet and exercise?
No, despite compliance with diet and exercise, 25-50% still need medication
33
When is medical management of GDM indicated? What is used first line? What can be used orally?
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
What are the immediate maternal complications with GDM?
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
What are the late maternal complications of GDM?
Within 20 years > 70% develop overt Type 2 DM Increased risk of cardiovascular disease and early atherosclerosis
36
What are the immediate fetal/neonatal complications r/t GDM? (8)
Increased perinatal mortality/stillbirth Macrosomia (EFW > 4,000 grams) Pre-term birth Hypoglycemia Birth trauma Hyperbilirubinemia Polycythemia Respiratory distress syndrome
37
What are the later fetal/neonatal complications r/t GDM?
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
What additional complications does pre-existing diabetes pose in pregnancy?
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
What are the goals for antepartum care for patients with GDM or pre-existing DM?
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
A1GDM will receive expectant management until? Delivery is indicated when?
Expectant management acceptable until 40 6/7 weeks Delivery no earlier than 39 weeks unless other indications
41
A2GDM with well controlled sugars should consider induction when?
Consider induction of labor between 39 weeks and 39 6/7 weeks
42
A2GDM with poorly controlled sugars should consider induction when?
Consider induction of labor between 37 weeks and 38 6/7 weeks
43
A patent with pre-existing type 1 or 2 DM w/o vascular disease should consider induction when?
Consider induction at 39 weeks with well controlled blood sugars
44
When should early delivery be considered? What should be done before early delivery? When should a c-section be considered?
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
What is labor management for patients with GDM or type1/2 DM?
Monitor labor progress and descent Continuous fetal monitoring Prepare for shoulder dystocia Monitor for s/s of preeclampsia A1GDM random glucose on admission
46
What additional care is needed for those whose diabetes are managed with medications (Type 1, Type 2, A2GDM)?
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
What is the blood glucose level goal for those with medication managed diabetes once in labor?
70-129
48
What blood sugar would indicate that an insulin drip should be started?
>130
49
When does insulin resistance of pregnancy go away? What does this lead to?
rapidly dissipates after delivery of the placenta Insulin requirements drop dramatically
50
What is the postpartum care for GDM?
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
What is the postpartum care for type 1 and type 2 DM?
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
Do you need to preform antenatal testing for an A1GDM?
No
53
When does antenatal testing start for A2GDM controlled? What testing is done?
32 weeks Weekly NST Weekly assessment of amniotic fluid volume US at 28-32 weeks, 36 weeks
54
When does antenatal testing start for A2GDM poorly controled? What testing is done?
32 weeks Twice weekly NST Weekly assessment of amniotic fluid volume US at 28-32 weeks, 36 weeks
55
When does antenatal testing start for type 1/2 DM? What testing is done?
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
After having GDM when is an FPG/ 2 hour GTT preformed?
4-12 weeks PP
57
If FPG >125mg/dl or 2 hour GTT >199 mg/dl what occurs?
Diabetes Refer to diabetic management
58
If FPG 100-125 mg/dl or 2 hour GTT 140-199 mg/dl what occurs?
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
If FPG <100 mg/dl or 2 hour GTT <140 mg/dl what occurs?
Normal Assess glycemic status every 1-3 years Weight loss and physical activity counseling PRN
60
What effect can the glucose test have on women?
Can make them feel sick/nausea
61
What are diet recommendations for a patient with GDM?
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
Why would you give D5LR to a diabetic patient in labor? What should you never do?
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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