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Year 4 Obstetrics & Gynaecology > Diabetes in Pregnancy > Flashcards

Diabetes in Pregnancy Flashcards

1
Q

What are the antepartum risks associated with pre-existing diabetes in 1st trimester

A 
Miscarriage 
Congenital malformations (e.g. sacral agenesis)
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2
Q

What are the antepartum risks associated with diabetes in pregnancy later on in gestation?

A

Pre-eclampsia
Macrosomia (large for gestational age)
Polyhydramnios (foetal polyuria)
Intrauterine death

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3
Q

What are the intrapartum risks associated with diabetes in pregnancy?

A

Stillbirth

Shoulder dystocia

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4
Q

What are the postpartum risks associated with diabetes in pregnancy?

A

Neonatal hypoglycaemia - because used to high glucose levels from mother

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5
Q

Diabetes risks: mnemonic

A 
SMASH
Shoulder dystocia 
Macrosomia
Amniotic fluid excess 
Stillbirth 
Hypertension (pre-eclampsia) and neonatal hypoglycaemia
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6
Q

What are the mechanisms of late complications?

A

Maternal hyperglycaemia –> Foetal hyperglycaemia –>

Foetal hyperglycaemia results in:

  • Foetal macrosomia b/c insulin = growth factor + sugar –> increased fat
  • Foetal hyperinsulinaemia = because the foetal hyperglycaemia causes pancreas to be turned up higher than normal leading to hyperinsulinaemia

Foetal macrosomia –> leads to shoulder dystocia
Foetal hyperinsulinaemia –> Neonatal hypoglycaemia - b/c too much insulin for levels present once maternal glucose removed at birth

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7
Q

How can the risks of diabetes in pregnancy be significantly reduced?

A

By optimising control

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8
Q

How should pregnancies in patients with diabetes be treated?

A

As high risk and monitored closely

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9
Q

What are the NICE 2015 guidelines regarding pre-existing diabetes in pregnancy?

A

Impact on pregnancy starts from pre-conception
So need to start high dose folic acid (5mg daily) from 6 weeks pre-conception
Don’t stop contraception until good control achieved - HbA1c < 48mmol/mol
Monitor eyes and renal function carefully during pregnancy

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10
Q

What is the risk if poor control (HbA1c >86mmol/mol)?

A

Very high risk of congenital malformations (avoid pregnancy)

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11
Q

Diagnosis of pre-existing diabetes

A

Already likely to have a diagnosis / but not always

Confirmed with oral glucose tolerance test (OGTT)

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12
Q

When should you suspect diabetes?

A

If there is persistent glycosuria in first trimester and high random blood sugars on testing

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13
Q

Does a first trimester presentation suggest pre-existing or gestational diabetes?

A

Pre-existing

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14
Q

What are the effects of pre-existing diabetes on pregnancy?

A

Increased insulin requirement (insulin resistance increases in all pregnancies)
Acceleration of retinopathy
Deterioration of renal function if pre-existing nephropathy - can manifest as hypertension
Maternal hypoglycaemia in early pregnancy - can lose awareness to this, especially if morning sickness etc

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15
Q

What are the principles of management in pre-existing diabetes?

A

Pre-conceptual counselling - improved control reduces risk
Manage with diabetes team - alter medications to optimise control
Stop ACE inhibitors and statins - these are teratogenic
Screen for and monitor vascular complications
Early viability scan (because increased risk of miscarriage)
Detailed anomaly scan - increased risk of sacral agenesis where the bottom part of the neural tube does not form properly

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16
Q

What is gestational diabetes?

A

Diabetes with its initial onset/ first recognised in pregnancy

17
Q

When is gestational diabetes most likely to impact the pregnancy?

A

In the second trimester

18
Q

Are macro- or micro- vascular complications present?

A

No

19
Q

What is the pathophysiology behind gestational diabetes?

A

Increased insulin requirement plus increased insulin resistance pushes the body into a temporary diabetic state

20
Q

What factors result in Insulin resistance?

A 
Increased calorie intake
Reduced exercise 
Increased fat deposition 
Placental lactogen & placental progesterone rise in 2nd trimester
Increased cortisol and GH in pregnancy
21
Q

What is used to screen selected women for gestational diabetes at 28 weeks

A

Oral glucose tolerance test

22
Q

What comprises an oral glucose tolerance test?

A

Fasting venous plasma glucose measured
75g oral glucose load administered
Venous plasma glucose is measured at 2hrs

23
Q

HbA1c is used for diagnosis of diabetes in pregnancy - true or false?

A

False - it is not used

24
Q

What are the NICE guidelines for glucose levels in the diagnosis of gestational diabetes?

A

Fasting glucose >5.6mmol/mol

Two hour glucose >7.8mmol/mol

25
Q

Do impaired fasting glycaemia and impaired glucose tolerance exist in gestational diabetes?

A

No - anything above normal values are diagnosed as gestational diabetes

26
Q

Why are there screening criteria for gestational diabetes and what are they?

A

Because according to BMJ 2014 - non-selective screening results in over-diagnosis

Screening criteria:
BMI>30
Previous gestational diabetes
Previous large baby >4.5kg 
First degree relative with diabetes 
Population with high prevalence of diabetes (South Asia, black Caribbean, Middle Eastern)
27
Q

What are other reasons for screening?

A

Previous unexplained stillbirth
Excess amniotic fluid (polyhydramnios)
Large for dates in this pregnancy
PCOS

28
Q

In gestational diabetes there is no increased risk of …. & …… Why?

A

No increased risk of:
Miscarriage & Congenital malformations
because gestational diabetes is short term and has its effects from 2nd trimester

29
Q

What is the management for gestational diabetes?

A

Dietary advice - may need metformin or insulin (can be discontinued after delivery)
Fasting glucose at 6 weeks post partum to exclude underlying diabetes mellitus

30
Q

What are the principles of management for pre-existing and gestational diabetes?

A

Serial growth scans
If large for gestational age - consider elective caesarean section
Induction at 38-40 weeks –> because higher risk of stillbirth
Be alert to possible shoulder dystocia
Close neonatal monitoring of blood sugars

Year 4 Obstetrics & Gynaecology (8 decks)

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