*Diabetes

Question 1

What does insulin do?

Answer 1

Acts as a key to allow glucose to enter cells

i.e. regulates carbohydrate and fat metabolism

(in the absence of insulin, glucose cannot enter the cell)

Question 2

What happens in GDM?

Answer 2

• Placental hormones prevent the body from using insulin effectively
• Increased BGLs (hyperglycaemia)
• Fetus makes more insulin to handle extra glucose
• Extra glucose gets stored as fat

Question 3

What are the diagnostic criteria for GDM following 75g OGTT?

Answer 3

Fasting venous PG >5.1
1 hour >10
2 hour >8.5

The diagnosis of GDM is made if one or more of these values are abnormal

Question 4

Non-fasting random PG?

Answer 4

> 7.8

Proceed to OGTT

Question 5

Diet and exercise management for women with GDM

Answer 5

• Increased fibre
• Reduced portion size
• 5-6 reduced fat meals/snacks
• 30mins moderate exercise
• Calorie reduced diet if BMI>30
• If insulin: evening snacks/supper

Question 6

Describe BGL monitoring

Answer 6

• Fasting <5.5 (pre-breakfast)
• 2hrs post-prandial <7 (after start of each meal)
• 2-3 days/wk unless very unstable

If diet controlled, only monitor 2-3 days per week

Question 7

What are the glucose levels for likely overt diabetes?

Answer 7

Fasting >7mmol/L
Random >11.1mmol/L
HbA1c >6.5%

Question 8

What does a HbA1c measure?

Answer 8

The amount of glycated haemoglobin

Average blood sugar levels - past 3 months

The amount of glucose attached to hemoglobin

Question 9

Maternal and fetal surveilance for women requring insulin

Answer 9

Maternal:
TFT
Spot urine albumin:creatinin ratio each trimester
Opthalmogic and vasculopathy baseline
During insulin adjustments 1-2 weekly contacts

Fetal:
FTS
Anatomy scan
3rd trimester USS
*If poor control or other complications: twice weekly CTG from 28-32 weeks

Question 10

Intrapartum and insulin

Answer 10

Give only 50% of intermediate acting dose the night before

Control GSL using glucose and insulin infusions. Inform medical staff if BGL is <5 or >6.9mmol/l

(If IOL or caesarean)

Question 11

Postnatal - baby

Answer 11

Encourage early and frequent (3hrly) breastfeeding
Skin to skin under warm blankets
Pre-2nd feed PGL (>2.6). If less than <2.6 management in SCN may require nasogastric feeding, IV glucose and/or IM glucagon.

After birth, baby still produces larger amounts of insulin but it is no longer receiving high glucose levels from mother, therefore becomes hypoglycaemic.

Question 12

Risks associated with GDM

Answer 12

 Miscarriage
 Macrosomia
 Pre eclampsia
 Intrauterine death
 Polyhydramnios
 Hypoxia
 Infection
 Preterm birth
 Preterm labour
 Respiratory Distress Syndrome
 Obstructed labour
 Hypoglycaemia
 Increased risk of child developing diabetes

Question 13

Aims of collaborative management …

Answer 13

 Maintain normal or near normal level of glycaemia by diet or insulin therapy
 Maintain fetal health
 Recognise and treat early onset of complications
 Ensure birth is timed to ensure positive outcome for mother and baby

Question 14

High risk factors for GDM

Answer 14

 Previous GDM
 Ethnicity: Asian (including Indian), Aboriginal, Pacific Islander, Maori, Middle Eastern, non-white African
 Maternal age > 40 yrs
 Family history DM (1st degree relative with DM including a sister with GDM)
 Obesity, especially if BMI > 35kg/m²
 Hypertension prior to 20 weeks
 Previous macrosomia (baby with birth weight more than 4000g)
 History of unexplained stillbirth
 Previous baby with congenital abnormalities
 Polycystic ovarian syndrome
 Medications: corticosteroids, antipsychotics

Question 15

Screening for GDM in pregnancy invovles:

Answer 15

Fasting plasma glucose: GDM diagnosed if > 5.1mmol/L

Non-fasting random plasma glucose. Proceed to a OGTT if > 7.8mmol/L

All women OGTT (75g) at 24 – 28 weeks gestation

Question 16

If diagnosed with GDM, what does the management involve?

Answer 16

 Multidisciplinary team
 Education
 Diet
 Physical activity
 Blood glucose monitoring
HbA1C each trimester

Question 17

What education is provided to women with GDM?

Answer 17

Healthy eating - it’s role in blood glucose control
Exercise - it’s role in blood glucose control
Self monitoring of blood glucose
Self-insulin administration and insulin adjustement if required

Question 18

Management for GDM woman not requiring insulin

5 areas with dot points

Answer 18

Education - healthy eating, exercise, BGL monitoring, etc

Diet and exercise:
 Increased fibre
 Reduced portion size
 5-6 reduced fat meals/snacks a
day
 30 minutes of moderate exercise
 Calorie reduced diet if BMI>30

BGL: aim for
<5.5 mmol/l fasting level
 <7 mmol/l 2 hour post prandial
 HbA1c measure each trimester

Maternal surveillance
 Opthalmologic baseline
 TFT
 Initial urine spot protein:creatinine

Fetal surveillance:
 First trimester screen
 Anatomy scan
 3rd trimester ultrasound
 CTG dependent on circumstances

Birth
 Aim for 39-40 weeks:
 IOL

Question 19

Management for GDM woman requiring insulin

Answer 19

Education - healthy eating, exercise, BGL monitoring, etc

Diet - as before plus evening snacks / supper

BGL
<5.5 mmol/l fasting level
 <7 mmol/l 2 hour post prandial
 HbA1c measure each trimester

Oral Hypoglycaemic Agents may ONLY be considered in women resistant to large doses of insulin (use in pregnancy still under review)

Exercise - 30 mins per day

Insulin
- Individualise

Fetal surveillance
 First trimester screen
 Anatomy scan
 Twice weekly CTG from 28 - 32 weeks
 Ultrasound in 3rd trimester
(Type 1 commence at 26 weeks and then 4 weekly)

Maternal Surveillance
 Ophthalmalogic and vasculopathy baseline
 Spot urine albumin:creatinine ratio each trimester
 TFT
 During insulin adjustments 1 - 2 weekly contacts

Question 20

Complications for baby of diabetic mother

Answer 20

 Skin infections
 Hyperbilirubinaemia
 Bleeding from thick cord
 Increased incidence of congenital malformations
 Considerable weight loss occurs in first week
 Lethargy

Question 21

Postpartum for GDMi mother

Answer 21

Usually dramatic decrease in insulin needs
High risk of developing diabetes in next 10 years, need follow up
Discuss contraception

Question 22

Insulin released from X?
Glucacon released from Y?
Z released glucose into the blood?

Answer 22

Beta cells of pancreas
Alpha cells of pancreas
Liver