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Year 2 Clinical > Diabetes and Endocrinology in Pregnancy > Flashcards

Diabetes and Endocrinology in Pregnancy Flashcards

1
Q

Key events in the ovarian cycle?

A

Day 1 is when menstruation begins

  1. Follicular growth occurs at day 10 and oestradiol is produced
  2. Ovulation occurs at day 14 and LH secretion peaks
  3. Luteal function begins and the follicle develops the corpus luteum; progesterone and oestradiol are produced
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2
Q

Hormone produced during progression from follicle to progesterone?

A

Follicle - oestradiol

Implanted fertilised ovum - HCG (pregnancy test basis)

Corpus luteum - progesterone

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3
Q

Hormones produced by the placenta?

A

Human Placental Lactogen (hPL)

Placental progesterone

Placental oestrogens

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4
Q

Hormones produced by the pituitary, in relation to pregnancy?

A

Prolactin (lactogen)

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5
Q

Development of gestational diabetes?

A

Progesterone and hPL produced during pregnancy cause insulin resistance in the mother

In a predisposed individual, the BG rises and gestational diabetes occurs

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6
Q

3 types of diabetes in pregnancy?

A
  1. T1DM
  2. T2DM
  3. Gestational diabetes mellitus (tends to occur in the 3rd trimester)
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7
Q

When does foetal organogenesis begin?

A

5 weeks and possibly earlier

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8
Q

Complications of diabetes in pregnancy?

A

Congenital malformation

Prematurity

Intra-uterine growth retardation (IUGR) - small baby

Macrosomia - large baby

Polyhydramnios (excessive amniotic fluid)

Intrauterine death

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9
Q

Complications of diabetes in pregnancy for the neonate?

A

Respiratory distress due to immature lungs

Hypoglycaemia causes fits, which may cause brain damage

Hypocalcaemia causes fits, which may cause brain damage

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10
Q

CNS defects that can occur due to diabetes in pregnancy?

A

Anencephaly (absence of a major portion of the brain, skull, and scalp that occurs during embryonic development)

Spina bifida

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11
Q

Skeletal abnormalities that can occur due to diabetes in pregnancy?

A

Caudal regression syndrome

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12
Q

Genital and GI abnormalities that can occur due to diabetes in pregnancy?

A

Ureteric duplication

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13
Q

How does macrosomia occur?

A

Maternal hyperglycaemia causes foetal hyperglycaemic and hyperinsulinaemia

In the 3rd trimester, the foetus produced its own insulin (a major growth factor) but, in addition to the extra insulin, this causes macrosomia and neonatal hypoglycaemia

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14
Q

Pre-pregnancy counselling for T1DM or T2DM patients?

A

Good BG control pre-conception limits the risk of congenital malformation

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15
Q

Management of a pregnancy in T1DM and T2DM?

A

Folic acid (5mg); in a non-diabetic patient, the dose is only 400mcg

Consider a change from oral medication to insulin

Regular eye checks are required (3 monthly) due to accelerated retinopathy

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16
Q

How should BP be managed in pregnancy?

A

Avoid ACEIs and statins

For BP control, use:
• Labetalol
• Nifedipine
• Methyldopa

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17
Q

Management of pregnancy for all (T1DM, T2DM and GDM)?

A

Follow a diabetic diet and aim for BG control:
• Pre-meal: <4 - 5.5 mmol/L
• 2 hours post-meal: <7 mmol/L

Monitor HbA1c and BP

Maintain BG during labour with IV insulin and IV dextrose

18
Q

Pharmacological treatment of GDM?

A
  1. Lifestyle Mx

2. Metformin; they may need insulin

19
Q

Follow-up of GDM?

A

A glucose tolerance test is done 6 weeks post-natal to ensure resolution of DM

If it has not resolved, they have T2DM

20
Q

Implications of GDM?

A

A marker of insulin resistance

With GDM, 50% go on to develop T2DM within 10-15 years; this is even higher for obese patients

Some patients, e.g: if they are thin, may actually have T1DM

21
Q

Methods of preventing diabetes following GDM?

A 
Keeping weight as low as possible with aerobic exercise and a healthy diet:
• Low refined sugar
• Predominant sugar
• Low saturated fat
• Low energy foods

Metformin, acarbose, etc, can be considered

Annual fasting glucose must be checked

22
Q

Thyroid demand during pregnancy?

A

Increased demand during pregnancy and maternal thyroxine is important for neonatal development in early pregnancy, esp. of the brain

Thyroid gland increases in size and there is increased T4 production, to maintain normal conc.

23
Q

What is anovulatory cycle?

A

Menstrual cycle during which the ovaries do not release an oocyte; thus, ovulation does not occur

Hype and hyperthyroidism can cause this

24
Q

Effect of pregnancy on thyroid hormones?

A

Plasma protein binding increases

25
Q

Effect of hCG in pregnancy?

A

Free T4 (fT4) increases in some pregnancies

Low TSH in some pregnancies

Hyperemesis gravidarum can occur

26
Q

What is hyperemesis gravidarum?

A

Severe nausea and vomiting during pregnancy, such that weight loss and dehydration occur

27
Q

Biochemistry in hyperemesis gravidarum?

A

hCG high

Majority have abnormal TSH/fT4

28
Q

Action of TSH and hCG?

A

TSH and hCG both increase thyroxine, which suppresses TSH

29
Q

Structural similarities and differences between TSH and hCG?

A

Both are 2 chain peptides in which the:
• α-chain is identical
• β-chain is different

30
Q

How to manage pre-existing hypothyroidism in pregnancy?

A

INCREASE thyroxine dose by 25mcg AS SOON AS pregnancy is suspected (do not wait for blood tests)

Check TFTs monthly for the 1st 20 weeks and then every 2 months until term

31
Q

TSH aim in pregnancy?

A

<3 mU/L

32
Q

Risk of untreated hypothyroisidm in pregnancy?

A

Foetal neuropsychological development, e.g: lower IQ

Increased risk of:
• Abortion
• Pre-eclampsia
• Abruption
• Post-partum haemorrhage
• Pre-term labour
33
Q

Risk of hyperthyroidism?

A

Infertility

Spontaneous miscarriage

Stillbirth

Thyroid crisis (AKA storm) in labour

Transient neonatal thyrotoxicosis (a jittery baby that does not feed properly or put on weight)

34
Q

Causes of thyrotoxicosis in pregnancy?

A
  • Grave’s disease
  • Toxic multi-nodular goitre (TMNG), toxic adenoma
  • Thyroiditis
35
Q

How to distinguish hyperemesis from hyperthyroidism?

A

Hyperemesis has:
• Increased hCG and decreased TSH
• Not TRab antibody +ve
• IMPROVES/resolved by 20 weeks gestation (on the other hand, hyperthyroidism worsen as time progresses)

36
Q

Treatment of thyrotoxicosis in pregnancy?

A

ONLY treat if it persists >20 weeks (supportive Mx in this time); if it settles, it was hyperemesis. Also, Grave’s may settle as pregnancy suppresses autoimmunity

β-blockers, if required

LOW DOSE anti-thyroid drugs:
• 1st trimester - propylthiouracil
• 2/3rd trimester - Carbimazole
….WAIT AS LATE AS POSSIBLE BEFORE STARTING THESE

37
Q

Problems with carbimazole in pregnancy?

A 
Can cause:
• Embryopathy in 1st trimeter
• Scalp abnormalities
• GI abnormalities
• Choanal &amp; oesophageal atresia
38
Q

Problems with propylthiouracil in pregnancy?

A

Risk of liver toxicity

Best to avoid, except possibly in the 1st trimester and then switch to carbimazole

39
Q

TRAb antibodies in pregnancy?

A

Check these in the 3rd trimester and, if present, suspect thyroid dysfunction in the fetus

These antibodies can cross the placenta and cause NEONATAL TRANSIENT HYPERTHYROIDISM

40
Q

Describe post-partum thyroiditis

A

Tends to occur ~6-8 weeks following labour

At 4-6 months, female develops hypothyroidism, so she is not treated before this

Should recover ~12 months post-partum, although some develop persistent hypothyroidism, i.e: beyond 1 year

41
Q

Presentation of post-partum thyroiditis?

A

Small, diffuse, non-tender goitre

42
Q 
What is the thyroid status of the pregnancy woman at 10 weeks gestation:
• fT4 15 (10-20)
• TT3 3.4 (up to 2.6)
• TSH 0.3 (0.4-4)
?
A

hCG-mediated suppression of TSH is most likely (this is normal)

However, it could also be early Grave’s disease

Year 2 Clinical (119 decks)

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