Diabetes and pregancy

Question 1

What is gestational diabetes (GDM)?

Answer 1

Diabetes diagnosed in the 2nd or 3rd trimester that was not clearly overt diabetes before pregnancy

Question 2

What causes insulin resistance in pregnancy?

Answer 2

1. Placental hormones
   (progesterone, human placental lactogen)
2. Increase insulin resistance to divert nutrients to the foetus

Question 3

Why does gestational diabetes occur?

Answer 3

If the mother is already insulin resistant before pregnancy, further insulin resistance raises blood glucose too high

Question 4

What are the complications of pre-existing diabetes (T1DM/T2DM) in pregnancy?

Answer 4

1. Congenital malformations
2. Prematurity
3. Intrauterine growth restriction (IUGR)

Question 5

Why does gestational diabetes cause macrosomia?

Answer 5

Foetal hyperinsulinaemia

Question 6

What is the main complication of neonatal hyperinsulinaemia?

Answer 6

Neonatal hypoglycaemia after birth due to continued high insulin levels

Question 7

What are other foetal complications of GDM?

Answer 7

Polyhydramnios
Intrauterine death

Question 8

What neonatal complications are associated with diabetes in pregnancy?

Answer 8

(1) Respiratory distress
(2) Hypoglycaemia
(3) Hypocalcaemia
(4) CNS defects
(anencephaly, spina bifida)

(5) Skeletal abnormalities
(caudal regression syndrome)

Question 9

How is gestational diabetes diagnosed?

Answer 9

75g OGTT (Oral Glucose Tolerance Test) means the patient drinks a solution containing 75 grams of glucose and blood glucose levels are measured before (fasting) and 2 hours after to assess how well the body handles sugar

(1) Fasting glucose ≥5.6 mmol/L
= If blood sugar is 5.6 mmol/L or higher before drinking glucose, GDM is diagnosed.

(2) 2-hour glucose ≥7.8 mmol/L
= If blood sugar is 7.8 mmol/L or higher two hours after drinking glucose, GDM is diagnosed.

Question 10

What is the memory aid for

5.6 mmol/L = Fasting glucose threshold for GDM

7.8 mmol/L = 2-hour post-OGTT threshold for GDM ?

Answer 10

Diagnosis of GDM is as easy as 5678

Question 11

What is the most important pre-pregnancy intervention for women with diabetes?

Answer 11

Folic acid 5 mg (higher dose than the standard 400 µg) at least 3 months pre-conception to reduce congenital malformations

Question 12

Which antihypertensive drugs should be used in pregnancy?

Answer 12

Labetalol, nifedipine, methyldopa

Avoid ACE inhibitors!!!

Question 13

Why is aspirin 150 mg started at 12 weeks in diabetic pregnancies?

Answer 13

To reduce the risk of pregnancy-induced hypertension (pre-eclampsia)

Question 14

What are the blood glucose targets in pregnancy?

Answer 14

(1) Pre-meal: <4-5.5 mmol/L

(2) 2-hour post-meal: <6-6.5 mmol/L

Question 15

How is T1DM managed in pregnancy?

Answer 15

Insulin

Question 16

How is T2DM managed in pregnancy?

Answer 16

Metformin initially, then insulin if needed

Question 17

How is GDM managed?

Answer 17

Lifestyle changes → Metformin → Insulin if needed

Question 18

How is diabetes monitored postpartum?

Answer 18

6-week postnatal fasting glucose or OGTT to check for persistent diabetes

Question 19

What percentage of GDM patients develop Type 2 Diabetes later?

Answer 19

50% within 10-15 years

Question 20

What is HCG?

Answer 20

hCG stands forhuman chorionic gonadotropin, a hormone produced by the placenta during pregnancy

Question 21

Where does HCG come from?

Answer 21

Secreted bysyncytiotrophoblastsof the placenta

Question 22

What use is HCG in practice?

Answer 22

Diagnosing pregnancy (e.g., pregnancy tests)

Question 23

Human Placental Lactogen (HPL) is secreted from where?

Answer 23

Secreted bysyncytiotrophoblastsof the placenta

Question 24

What week of pregnancy does organogenesis start?

Answer 24

Starts aroundweek 3–8 of gestation

Question 25

What are the two most important things to do for antenatal care in people with T1/T2 diabetes?

Answer 25

1. Strict glycemic control = frequent glucose monitoring, use of insulin or adjustments 2. Folic acid supplementation  = high dose: 5 mg daily before conception and during early pregnancy to prevent neural tube defects

Question 26

Gestational diabetes usually presents in the first trimester. True or false and why if false?

Answer 26

False = Gestational diabetes typically develops later, usually in the second or third trimester

Question 27

Methyldopa in pregnancy is the preferred treatment for blood pressure. True or false and why if false?

Answer 27

True

Question 28

Folic acid 5mg should be started when a woman knows she is pregnant. True or false and why if false?

Answer 28

False = Folic acid 5mg should ideally be started before pregnancy, ideally at least one month prior, to reduce the risk of neural tube defects

Question 29

A woman in early pregnancy with known hypothyroidism should double her thyroxine dose when she finds she is pregnant. True or false and why?

Answer 29

True = In early pregnancy, the demand for thyroid hormones increases, and women with hypothyroidism may need a higher dose of thyroxine (typically increasing by 25-30%) to maintain normal thyroid levels

Question 30

A 28-year-old primigravida female of 26 weeks’ gestation presents to the Obstetric Diabetes Clinic following her oral glucose tolerance test last week. Her test results demonstrate: (1) Fasting glucose 7.8 mmol/L (normal range 3.5-5.5 mmol/L) (2) 2-hour glucose 9.4 mmol/L What is the most appropriate management?

Answer 30

Initiation of insulin

Question 31

A 28-year-old primigravida female of 26 weeks’ gestation presents to the Obstetric Diabetes Clinic following her oral glucose tolerance test last week. Her test results demonstrate: (1) Fasting glucose 7.8 mmol/L (normal range 3.5-5.5 mmol/L) (2) 2-hour glucose 9.4 mmol/L. Why wouldn't diet and lifestyle changes be the first line management?

Answer 31

Lifestyle changes is indicated if the fasting plasma glucose level is below 7 mmol/l at the time of diagnosis

Question 32

What BMI cut off defines obesity?

Answer 32

30

Question 32

A 28-year-old primigravida female of 26 weeks’ gestation presents to the Obstetric Diabetes Clinic following her oral glucose tolerance test last week. Her test results demonstrate: (1) Fasting glucose 7.8 mmol/L (normal range 3.5-5.5 mmol/L) (2) 2-hour glucose 9.4 mmol/L. Why wouldn't metformin be the first line of management?

Answer 32

Metformin is the first-line treatment provided if the fasting plasma glucose level is below 7 mmol/l following a 2-week trial of altering diet and exercise

Question 33

What is the name of a large baby in utero?

Answer 33

Macrosomia

Question 34

What is the most commonest form of congenital malformation seen in diabetic pregnancy?

Answer 34

Macrosomia

Question 35

A baby in the postnatal ward who was delivered 10 hours ago has just had a generalised seizure lasting 2 minutes. There were no complications during the vaginal delivery and the baby’s birthweight was 4.8kg. A newborn baby check carried out was unremarkable and prior to the seizure the baby appeared well with an APGAR score of 10 at 5 minutes. What condition did the mother likely suffer from during pregnancy? and why is tat your answer?

Answer 35

Gestational diabetes = Macrosomia (birthweight >4kg) and neonatal seizures are both complications of poorly controlled maternal diabetes during pregnancy

Question 36

A 30-year-old woman comes to the clinic at 24+5 weeks gestation. She has a BMI of 32kg/m^2 and a family history of diabetes mellitus. As such, you decide to test her fasting glucose and find it is 6.8mmol/L (normal range 3.5-5.5 mmol/L) What is the most appropriate initial management? and why isn't it insulin or metformin?

Answer 36

Two-week trial of diet and exercise = In those with a fasting glucose of >5.6mmol/L but <7mmol/L, NICE recommend a trial of diet and exercise for two weeks

Question 37

What are the risk factors for MODY

Answer 37

(1) Ethnic backgrounds with a high prevalence of type 2 diabetes (eg, Middle Eastern, South Asian, and Afro-Caribbean) (2) Prior history of GDM (3) Prior delivery of macrosomic babies (>4.5kg) (4) History of stillbirth or perinatal death (5) Maternal obesity (BMI>30) (6) Diabetes in first-degree relatives

Question 38

What are the Foetal Complications for MODY

Answer 38

(1) Macrosomia (birthweight >4kg) (2) Increased risk of sacral agenesis in the developing foetus (3) Pre-term delivery (4) Neonatal hypoglycaemia (5) Long-term risk

Question 39

A 19-year-old woman attends her booking appointment after recently finding out she is pregnant for the first time. She has no past medical history and no family history. Her BMI is 30.9kg/m², her blood pressure is normal, and a urine dipstick is unremarkable. She does not smoke or drink alcohol. What investigation should she be offered?

Answer 39

Oral glucose tolerance test (OGTT) at 24-28 weeks

Question 40

Gestational diabetes can be diagnosed by either?

Answer 40

1. fasting glucose is >= 5.6 mmol/L 2. 2-hour glucose level of >= 7.8 mmol/L '5678'

Question 41

In gestational diabetes, if blood glucose targets are not met with diet/metformin then what should be added?

Answer 41

insulin

Question 42

What type of insulin is used in gestational diabetes?

Answer 42

Short-acting only

Question 43

A 27-year-old nulliparous woman is diagnosed with gestational diabetes during her current pregnancy via an oral glucose tolerance test (OGTT). She asks whether her diagnosis will impact future pregnancies. What is the most appropriate approach to screening for gestational diabetes in future pregnancies?

Answer 43

Women with gestational diabetes in a previous pregnancy should be offered an OGTT as soon as possible after booking and subsequently at 24-28 weeks