Diabetes

Question 1

What is the oral glucose test

Answer 1

Blood test before eating breakfast followed by glucose drink and another blood sample two hours later

Question 2

When are women screened for GDM?

Answer 2

16-18/40 if previous hx of GDM (retest at 28/40 if normal)

24-28/40 for those at risk

Question 3

What is the GDM diagnosis

Answer 3

Fasting glucose level of 5.6 or above

2 hour plasma glucose level of 7.8 or above

Question 4

Characteristics of GDM (x4)

Answer 4

Carbohydrate intolerance of variable severity with onset of first recognition during present pregnancy.
Usually no symptoms
Develops in 2nd/3rd trimester
Related to changes in carbohydrate metabolism and increased insulin resistance

Question 5

Ways GDM can be diagnosed (x4)

Answer 5

Routine screening
Large for dates baby
Polyhedral nips
Glycosuria

Question 6

How is GDM managed? (X7)

Answer 6

Modification of normal diet
Home monitoring of blood glucose levels
Insulin if dietary compliance poor/hyperglycaemia persists
Avoid starting hypoglycaemic drugs (risk of teratonics)
Full hospital care
Regular growth scans
Consider timing and mode of delivery

Question 7

GDM management intrapartum x3

Answer 7

May not need insulin during labour
Sliding scale insulin
Stop sliding scale when placenta delivered
Insulin requirements return rapidly to pre pregnancy levels

Question 8

GDM management postpartum x3

Answer 8

Oral gtt at 6 weeks p/n
Counselling about diabetes risk in the future
If on insulin stop sliding scale when placenta is delivered and stop dextrose within 1-2 hours

Question 9

Classification of type 1 diabetes (x4)

Answer 9

No insulin production
Auto immune beta cell destruction causing antibodies to islet cells to be detectable
Age

Question 10

What type of diabetes is ketoacidosis related to?

Answer 10

Type 1

Question 11

What is ketoacidosis?

Answer 11

Blood sugar over 11, ph7.3

Question 12

Symptoms of ketoacidosis x7

Answer 12

Thirst
Polyuria 
Fatigue 
Dramatic weight loss 
Cramps
Abdominal pain 
Blurred vision

Question 13

Severe symptoms of ketoacidosis x6

Answer 13

Nausea 
Vomiting 
Abdominal pain 
Shortness of breath 
Drowsiness 
DeAth

Question 14

Who is screening for GDM recommended to? (X5)

Answer 14

Previous GDM, family hx, previous large for dates baby, high BMI, ethnicity

Question 15

Presenation of type 2 diabetes (x6)

Answer 15

Insulin resistance 
Obesity 
Increased risk by inactivity and high fat diet
Strong genetic factor 
>35 
Often slow onset

Question 16

Aim of pre existing diabetes pre conception care

Answer 16

To reduce risks of congenital abnormalities and improve obstetric outcomes

Question 17

Pre existing pre conception care includes (x6)

Answer 17

Education
Good control of blood glucose levels 
Avoid unplanned pregnancies 
Lower hba1c levels 
Frolic acid 5mg/day until 12/40
Assess extent of retinopathy, nephropathy and hypertension

Question 18

Diabetes target blood glucose level during pregnancy

Answer 18

3.5-5.9 (fasting)

Question 19

Key medical antenatal points (x3)

Answer 19

Monitor hba1c
Frequent monitoring of blood glucose levels
Increased insulin requirements as pregnancy advances may mean a need for continuous insulin infusion

Question 20

Care if women presents with ketoacidosis? X2

Answer 20

Urgent hospital admission

Treatment with iv fluids and insulin

Question 21

How is type 2 usually controlled in pregnancy?

Answer 21

Usually need for them to be on insulin even if their diabetes is usually well controlled

Question 22

What hypoglycaemic drug can be taken during pregnancy?

Answer 22

Meteor in

Question 23

Why do hypoglycaemic agents have to be discontinued during pregnancy?

Answer 23

They cross the placenta

Question 24

Who should be involved in antenatal care for those with diabetes?

Answer 24

Multidisciplinary team 
Nutritionist 
Obstetrician 
Midwife 
Diabetic dr/nurse

Question 25

What is the insulin schedule during pregnancy?

Answer 25

4x daily 3 pre meal doses - rapid acting (with meals)/ fast acting (before meals) 1 night time intermediate acting dose

Question 26

Why do you continue insulin if patient is ill?

Answer 26

When Ill infections mean you need a higher insulin dose

Question 27

What should happen if a patient is on steroids or beta sympathy mimetic drugs

Answer 27

Increase insulin as likely to cause hyperglycaemia

Question 28

Other things that should be monitored through pregnancy (x2)

Answer 28

Retinal - eye text in early pregnancy and every 6 months | Renal function

Question 29

Scans that should be carried out? X6

Answer 29

``` Early scan (dating/viability) Nuchal translucency at 11-13+6 with risk assessment Foetal cardiology scan 18-20 Detailed anomaly scN Doppler blood flow studies Regular growth scans ```

Question 30

When should an anaesthetic assessment take place?

Answer 30

3rd trimester

Question 31

Target glucose level in the intrapartum period?

Answer 31

4-7mmol/l

Question 32

What is hypoglycaemia?

Answer 32

When blood glucose falls below 4

Question 33

Causes of hypoglycaemia (x8)

Answer 33

``` Intensive insulin therapy Imbalance of food activity and insulin Exercise Alcohol and drugs Low carbohydrate diets Vomiting Breast feeding Infection site problems ```

Question 34

Describe the patients state in a mild hypo

Answer 34

Conscious and able to swallow

Question 35

Mild hypo treatment x5

Answer 35

15-20g quick acting carbohydrate Recheck 10 mins later if still less than 4 repeats cycle When blood glucose >4 give complex carbohydrate If blood glucose remains 45 mins contact doctor urgently Consider 1mg of glucagon im or iv 10% glucose infusion at 100ml/hr

Question 36

Describe patients state in a moderate hypo

Answer 36

Patient in uncooperative but is able to swallow

Question 37

Moderate hypo treatment

Answer 37

1.5-2 tubes of glucogel/dextrogel squeezed into mouth between teeth and gums or 2 teaspoons of honey/jam May need to give glucagon 1mg IM (May not be effective if prolonged hypo)

Question 38

Describe he patients state during a severe hypo

Answer 38

Requires assistance to recover | Low level of consciousness/unable to swallow

Question 39

Treatment of severe hypo x3

Answer 39

Glucagon 1 mg IM 75-80ml of 20% glucose (over 10-15 mins) 150-160ml of 10% glucose (over 10-15 mins)

Question 40

Conditions for discharge of the newborn x3

Answer 40

Must be at least 24 hours old, feeding well and maintaining blood glucose levels

Question 41

How can we prevent hyperglycaemia in newborns? X3

Answer 41

Early and regular feeds Keep warm Skin to skin

Question 42

How often should blood glucose levels be checked on the newborn

Answer 42

Routine every 2-4hrs after birth then 4hrly for first 24 hours

Question 43

What blood glucose level are we aiming for in newborns

Answer 43

> 2.5

Question 44

What blood glucose level in newborns would result in admission to special care unit?

Question 45

Signs of hypoglycaemia in newborns

Answer 45

``` Jittery Hypothermia Poor muscle tone Poor feeding Reduced responsiveness ```

Question 46

Actions if neonate has hypoglycaemia (x5)

Answer 46

``` Well clothed and kept warm Frequent regular feeds Skin to skin Breast feeding Stable room temperature ```

Question 47

What is fetal macrosomia?

Answer 47

Birthweight >4.5 or >90th centile

Question 48

Effect of diabetes on pregnancy (x5)

Answer 48

``` Increased risk of miscarriage Increased risk of pet Increased risk of infection Increased risk of c/s rate Increased poor outcome related to quality of blood glucose control and presence of existing complications ```