Diabetes in Pregnancy Flashcards
Outline the changes in insulin requirements in pregnancy
insulin is needed less in the first trimester because you are barfing a lot and not eating much (less glucose), but as baby’s needs are increased metabolically, you eat more food, and you need more insulin
which glucose receptors are prsent on the placenta?
GLUT1- similar to in certain brain cells (astrocytes and endothelial cells in the brain)
3 key counter regulatory hormones that lead to insulin resistance
- human placental grwoth hormone
- TNFalpha
- progresterone
Why is hyperglycermia a teratogen of pregnancy?
Modulates expression of apoptosis regulatory gene
even prior to implantation
outline adverse pregnancy outcomes related to glucose control in 1st, 2nd and 3rd trimesters>
- increased fetal malformations
2 and 3rd trimester: increse risk of big baby and metabolic complications
fetal abnormalities in poorly controlled type 1 and 2 diabetic pregnancies
Cardiac • Multiple organs • CNS – spina bifida, ancephaly • Situs inversus • Renal agenesis • Duplex ureter • Caudal regression • Miscarriage
why does diabetes (uncontrolled) lead to larger babies/
- high maternal and fetal glucose causes fetal hyperinsulinemia
- promotes excess nutrient storage, resulting in a big fetus
- Energy assoc. with conversion of excess glucose into fat
- *causes depletion in fetal O2 levels** Relative fetal hypoxia –
- *increase EPO**
How does high maternal and fetal glucose levels cause hyperbilirubinemia?
Energy assoc. with conversion of excess glucose into fat
causes depletion in fetal O2 levels Relative fetal hypoxia –
increase EPO
- fetal hypoxia results in surges in CATECHOLAMINE, causing: 1. hypertension 2. cardiac hypertrophy 3. stimualtion of EPO, red cell hyperplasia, polycythemia
- high HCT leads to vascular sludging, poor circulation and post natal hyperbilirubinemia
4 management steps of diabetes in pregnanyc
- preconsception counseling
- management during pregnancy
- management in labour
- post partum considerations
5 conditions that are preventing if you have a lower A1c PRECONCEPTION
- spontaneous abortion
2 .congenital anomalies
- pre-eclampsia
- progression of retinopahty in pregnancy
- intrauterine fetal death
preconception A1C goal, and during pregnancy A1c goal?
preconception A1c <7. During preganncy A1c <6.5
- fasting PG <5.3, 2h post prandial PG <6.7
- need to be monitoring blood sugars at least 4-7 times a day
women with diabetes and pregnant should be screened for nephropathy. how?
assess creatinine and urin microalbulin/creatinine ratio (ACR)
- women with micro albuminuir a or overt nephropathy are at increased risk for hypertension and preeclampsia and preterm delivery
Preconception Checklist for Women with Type 1 or 2 Diabetes
1. Attain a preconception A1C of ≤__% (≤ __% if
safe)
2. Assess for and manage any complications
3. Switch to __ if on __ agents
4. __ __ 1 mg/d: 3 months pre-conception to 12
weeks post-conception
5. Discontinue potential embryopathic meds:
__-inhibitors/__ (prior to or upon detection of
pregnancy)
__ therapy
1. Attain a preconception A1C of ≤7.0% (≤ 6.5% if
safe)
2. Assess for and manage any complications
3. Switch to insulin if on oral agents
4. Folic Acid 1 mg/d: 3 months pre-conception to 12
weeks post-conception
5. Discontinue potential embryopathic meds:
Ace-inhibitors/ARB (prior to or upon detection of
pregnancy) Statin therapy
why should women with diabetes have a reliable form of BC?
becuase Metformin may improve fertility.
Outline teh IOM Guidelines for Gestational Weight Gain
generally, the heavier you are pre-pregnancy, the less weight you should gain
More evidence for poor
glycemic control & __
stillbirth
a greater than 15% insulin requirement drop leasd to:
more pre-eclampsia, more SGA in 1 study, likelihoog to be delivered earlier y 1.2 weel, and more frequent NICU admission
a large drop in insulin requirementes can lead to more pre-eclampsia, more SGA in 1 study, likelihoog to be delivered earlier y 1.2 weel, and more frequent NICU admission.
what should you do in the setting of a large drop in insulin requirements?
- consider possible explanations
- review risks for stillbirth: look at glycemic control, previous still birth, gestational age, late materal age, smoking history etc.
- don’t be overly reassured by normal fetla monitoring
- check ketones even if euglycemic, and for SOB and nausea vomiting and abdominal pain
risks for still birth
Glycemic control - retinopathy - previous stillbirth - Gestational age - obesity - late maternal age - smoking history - SGA
Delivery Timing in Pre-existing Diabetes. When should you deliver before?
- uncomplicated delivery between 38-39 weeks to reduce risk of still birth.
- deliver BEFORE THAT if there are fetal indications, or poor glycemic control
why should you switch to inuslin instead of oral agents in pregnancy? What is the exception?
oral agents are more likely to cross the placental barrier and also be in breasmilkd, and is associated with 2 fold increased risk of neonatal hypoglycemia.
One excpetion is metformin– metformin use in type 2 DM has shown positive results because there is reduced maternal weight gain and improved glycemic control. there is lower infant adisposity and fewer cases of macrosomic infants.
3 aspects of fetal surveillance
- ultrasounds
- NSTs
- After 32-34 weeks, weekly assessments of fetal health and growth to help plan delivery
Delivery Glycemic Control
Goal: ___ mmol/l
- Monitor glucose 1-2 hours
- If glucose rises above__ mmol/l then give I.V. __
Goal: 4-7 mmol/l
- Monitor glucose 1-2 hours
- If glucose rises above 7.0 mmol/l then I.V. insulin
Post partum, should you increase or decrease insulin compared to third trimester?
adjust theinsulin lower. you are at risk for hypoglycemia. Use less than pre-pregnancy doses.
post partum, you should Screen for postpartum __ in T1DM
Screen for postpartum thyroiditis in T1DM. check TSH 2 to 6 months post partum
gestational diabetes predisposes a high risk of ____ diabetes later in life
high risk of TType II diabetes
8 gestational diabetes risk factors
outline the 2 step testing process for GDM. When should you test?
around 24 weeks, you should do a glucose challenge test, with PG 1 hour later. If glucose level is 7.8-11, gotta do a fasting gluocse (noramlly should be below 5.3)
fasting glucose and 2h post prandial glucose glycemic targets during pregnancy
eat healthy: don’t starve yourself. Avoid hypocaloric diet cause that can lead to weight loss + ketosis
Postpartum GDM Management Checklist
- Encourage ___
- ___ ___ test between 6 weeks - 6 months
postpartum to detect diabetes - Discuss increased long-term risk of
diabetes – Importance of returning to pre-
pregnancy weight
- Screen for __ before next conception
- Encourage Breastfeeding
2. 75g OGTT between 6 weeks - 6 months
postpartum to detect diabetes - Discuss increased long-term risk of
diabetes – Importance of returning to pre-
pregnancy weight
- Screen for diabetes before next conception
T/F: breasfeeding Reduces or at least delay mother’s risk of diabetes and
metabolic syndrome
true. breastfeeding also is a reduced risk to offspring of diabetes, obesity and impaired glucose tolerance
T/F maternal DMI is a strong predictor of child obesity
true
