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PHARM 343 > Diabetes and Pregnancy > Flashcards

Diabetes and Pregnancy Flashcards

1
Q

Prevalence of Hyperglycemia in Pregnancy

A

Was 16.7% in 2021
- Increases with maternal age
- More common in low and middle income countries

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2
Q

Gestational Pregnancy Prevalence

A

Percentage of diabetes in pregnancy is 75-90% Gestational Diabetes

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3
Q

Effects of Dysglycemia on fetus development

A

1st Trimester (Pre-existing diabetes)
- Increase risk of fetal malformations

2nd and 3rd Trimester (Gestational diabetes)
- Increase risk of macrosomia and metabolic complications

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4
Q

Diabetes in Pregnancy
- Categories

A

Presentational Diabetes
- Preexisting diabetes (Type 1 or 2)

Gestational Diabetes
- Diabetes diagnosed in pregnancy

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5
Q

Why does Gestational Diabetes occur?
- When does it typically occur?

A
  • Occurs because of hormone changes which cause insulin to be less effective
    –> Does no affect insulin production
  • Most likely to occur in 2nd/3rd trimester
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6
Q

Gestational Diabetes
- Screening

A
  • Women should be screened between 24 and 28 weeks gestation
  • Screening should involve an oral glucose tolerance test (OGTT)
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7
Q

Gestational Diabetes
- Diagnosis

A

Women are diagnosed at varying levels of maternal hyperglycemia and maternal/fetal risk
- Hard to set thresholds
–> Set it too low and then people who may not need pharmacological therapy suddenly require medications according to the threshold)

Lots of debate on which strategy is best

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8
Q

Gestational Diabetes
- Prevention

A

For women with high risk of GDM based on pre-existing risk factors
- Screen A1c (or FBG if A1c is unreliable) in the first trimester
- Nutritional Counseling
–> Healthy eating
–> Prevention of excess weight gain

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9
Q

Risk Factors of Gestational Diabetes

A
  • High Risk Population
  • Previous GDM
  • History of macrosomic infant
  • Current fetal macrosomia
  • Current Polyhydramnios
  • Prediabetes
  • BMI greater than 30mg/m2
  • Older than 35 years old
  • Corticosteroid use
  • Polycystic Ovarian Syndrome
  • Acanthosis nigricans
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10
Q

Acanthosis Nigricans

A

Risk factor for GDM
- Discoloration of body folds and creases
- Sign of insulin resistance

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11
Q

Gestational Diabetes
- Pathophysiology

A

Normal Pregnancy:
- Insulin resistance starts in 2nd trimester
- Supplies glucose to the baby

  • Hormones interfere with insulin binding
  • Insulin resistance in mother

Insulin Resistance + Pre-existing insulin resistance and/or beta cell deficit can lead to GDM

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12
Q

Hormones that contribute to Insulin Resistance during Pregnancy

A
  • Placental Lactogen
  • Placental Growth Hormone
  • Human Chorionic Gonadotropin (hCG)
  • Cortisol
  • Prolactin
  • Estrogen
  • Progesterone
  • Leptin
  • TNFalpha
  • Resistin
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13
Q

What can pass the placenta

A

Insulin does not pass the placenta

Glucose passes through the placenta
- Fetus produces its own insulin allowing it to use the glucose for growth
–> Leads to Macrosomia

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14
Q

Implications of Gestational Diabetes
- Mother

A

Trauma from LGA infant
C-section
Pre-eclampsia
Pregnancy Induced Hypertension

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15
Q

Implications of Gestational Diabetes
- Mother (Long-Term)

A

Type 2 Diabetes
Hypertension
Heart Disease

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16
Q

Implications of Gestational Diabetes
- Baby

A

LGA and trauma from getting stuck in birth canal
- Shoulder dystocia
- Erb’s palsy/nerve injury
- Brain injury
Prematurity
Neonatal Hypoglycemia
Immature Lung function
Jaundice
Neonatal ICU Admission

17
Q

Implications of Gestational Diabetes
- Baby (Long-Term)

A

Obesity and Dysglycemia
Premature puberty in girls

18
Q

Gestational Diabetes Initial Management

A
  • Nutrition Counseling
  • Healthy diet replacing high-glycemic index foods with low-glycemic index foods
  • Weight gain and healthy lifestyle interventions during pregnancy
  • Recommended weight gain based on pre-pregnancy BMI to reduce LGA and C-section

(Diet, Exercise, Weight Management)

19
Q

Gestational Weight Gain Guideline
- According to Pre-Pregnancy BMI

A

BMI < 18.5: 28-40
BMI 18.5-24.9: 25-35
BMI 25.0-29.9: 15-23
BMI > 30: 11-20

20
Q

Gestational Diabetes Management
- Glycemic Target

A

SMBG Fasting and Post Prandially
- Fasting and Preprandial < 5.3
- 1h postprandial < 7.8
- 2h postprandial < 6.7

If targets not reached within 1-2 weeks initiate pharmacology therapy

21
Q

Gestational Diabetes Management
- Pharmacological

A

Insulin First Line (Short acting)
- Aspart, Lispro, Glulisine

Metformin as alternative

Glyburide
- Refuse insulin
- Can’t tolerate metformin

22
Q

Does metformin cross the placenta

A

Yes it does. good safety data however

23
Q

Gestational Diabetes Management
- Postpartum Management

A

Encourage breastfeeding for 3-4 months after delivery
- Reduces neonatal hypoglycemia, Childhood obesity, Diabetes
- Reduces maternal diabetes and hypertension

75 g OGTT between 6 weeks to 6 months postparatum
- To detect prediabetes or diabetes

Stop insulin after delivery
- Insulin sensitivity will return

24
Q

Pre-existing Diabetes increases risk of:
- Mother

A

Worsening of pre-existing complications:
- Nephropathy, retinopathy

25
Q

Pre-existing Diabetes increases risk of:
- Baby

A

Malformations if glucose is high in first trimester

26
Q

Most common fetal anomalies periconceptional

A

Renal Agenesis (Development of one kidney)
Anencephaly (Underdevelopment of brain)
Cardiac Abnormalities

27
Q

Pregestational Diabetes
- Preconception Counseling

A

Counsel women at reproductive age with diabetes
- Birth Control
- Metformin in PCOS can increase fertility (can induce ovulation in PCOS)
- Achieve a healthy weight before conception (obesity associated with adverse pregnancy outcomes)

28
Q

Pre-Pregnancy and Intrapartum

A

Retinopathy
- Ophthalmological evaluation

Nephropathy
- Assess creatinine + urine albumin to creatinine ratio (Women with albuminuria or overt nephropathy are at increased risk of hypertension and preeclampsia)

29
Q

Preconception Checklist for Women with Pre-existing Diabetes
- Birth Control

A

Use reliable birth control

Folic Acid 1mg/day for 3 months preconception to 12 months post-ceonception

30
Q

Preconception Checklist for Women with Pre-existing Diabetes
- A1c

A

Attain A1c below 7.0% (Try <6.5% if safe)

31
Q

Preconception Checklist for Women with Pre-existing Diabetes
- Antihyperglycemic Therapy

A

May remain on metformin + glyburide
- If on other antihyperglycemic therapies switch to insulin

32
Q

Preconception Checklist for Women with Pre-existing Diabetes
- Diabetic Complications

A

Assess for and manage any diabetes complications

33
Q

Preconception Checklist for Women with Pre-existing Diabetes
- Folic Acid

A

1 mg / daily
- 3 months preconception to 12 months post conception

34
Q

Preconception Checklist for Women with Pre-existing Diabetes
- Embryopathic Medications

A

Discontinue ACEi/ARB after detecting pregnancy

Discontinue Statin Therapy

35
Q

Pre-existing Diabetes (Type 1 Diabetes)
- Pharmacological

A

Basal-bolus insulin therapy (3-4 injections per day) or continuous subcutaneous insulin infusion

36
Q

Pre-existing Diabetes (Type 2 Diabetes)
- Pharmacological

A

Switch to insulin, monitor and determine if metformin is needed

37
Q

Pre-existing Diabetes (Which Insulin to use)
- Pharmacological

A

Bolus
- Can use aspart or lispro instead of regular

Basal
- Can use detemir or glargine instead of NPH (NPH is acceptable for type 2)

38
Q

Pre-existing Diabetes
- ASA

A

Can start at 12-16 weeks to reduce risk of pre-eclampsia

39
Q

Pre-existing Diabetes
- Postpartum care

A
  • Adjust insulin (prevent hypoglycemia)
  • Encourage breastfeeding
  • Metformin and Glyburide appear to be safe
  • Screen for postpartum thyroiditis in type 1 diabetes (Check TSH at 2-4 months postpartum)

PHARM 343 (35 decks)

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