*Diabetes Flashcards
What does insulin do?
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)
What happens in GDM?
- 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
What are the diagnostic criteria for GDM following 75g OGTT?
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
Non-fasting random PG?
> 7.8
Proceed to OGTT
Diet and exercise management for women with GDM
- 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
Describe BGL monitoring
- 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
What are the glucose levels for likely overt diabetes?
Fasting >7mmol/L
Random >11.1mmol/L
HbA1c >6.5%
What does a HbA1c measure?
The amount of glycated haemoglobin
Average blood sugar levels - past 3 months
The amount of glucose attached to hemoglobin
Maternal and fetal surveilance for women requring insulin
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
Intrapartum and insulin
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)
Postnatal - baby
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.
Risks associated with GDM
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
Aims of collaborative management …
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
High risk factors for GDM
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
Screening for GDM in pregnancy invovles:
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
If diagnosed with GDM, what does the management involve?
Multidisciplinary team
Education
Diet
Physical activity
Blood glucose monitoring
HbA1C each trimester
What education is provided to women with GDM?
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
Management for GDM woman not requiring insulin
5 areas with dot points
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
Management for GDM woman requiring insulin
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
Complications for baby of diabetic mother
Skin infections
Hyperbilirubinaemia
Bleeding from thick cord
Increased incidence of congenital malformations
Considerable weight loss occurs in first week
Lethargy
Postpartum for GDMi mother
Usually dramatic decrease in insulin needs
High risk of developing diabetes in next 10 years, need follow up
Discuss contraception
Insulin released from X?
Glucacon released from Y?
Z released glucose into the blood?
Beta cells of pancreas
Alpha cells of pancreas
Liver
