Diabetes in pregnancy

Question 1

Investigations for gestational diabetes

Answer 1

Initial

• Urinanalysis–> shows glycosuria, increased risk
• Urine ketones–> Type 1 diabetic, investigates insulin dependency

75g Oral glucose intolerance test
- 2 hours post >7.8

Fetal ultrasound

• Congenital abnormalities
• Fetal growth
• Liquor volume (risk of polyhydramnios)

Others:

Fasting plasma glucose
- >5.6

Random blood plasma glucose
- >11.1

HbA1c

• > 48mmol/mol or 6.5%
• Very high can indicate pre-existing diabetes

Question 2

Glycosuria of pregnancy

Answer 2

Normal plasma glucose with glycosuria due to reduced renal threshold for glucose
- Not due to diabetes (hyperglycaemia)

Question 3

Maternal complications of gestation diabetes (7)

Answer 3

Delivery complications

• Shoulder dystocia/ other traumas
• Induced labour/ C-section

Pre-eclampisa/ eclampsia

Infections

• UTIs
• Wound infections

Retinal/ renal disease

Question 4

Gestational DM risk factors (7)

Answer 4

Previous Gestation DM

Family history

High BMI

Previous macrosomic baby (>4.5kg)

Ethnicity (non-white)

Older age

PCOS

Question 5

Fetal complications of gestational DM

Answer 5

Prematurity

Macrosomia
- Shoulder dystocia

Polyhydramnios
- Cord prolapse

Congenital abnormalities

Neonatal hypoglycaemia
- Due to hyperinsulinaemia arising from hyperglycaemia

Neonatal deatg

Miscarriage/ neonatal death

Question 5

Management of gestational DM

Answer 5

1. Lifestyle
   - Good diet and exercise
   - Daily monitoring of blood glucose
   - Screen/control other risk factors for CVD disease: smoking, hypertension, cholesterol
2. Medication
   - Metformin if diet and exercise do not control glucose within 1-2 weeks
   - Insulin if fasting glucose >7

Question 6

Management of gestational DM

during birth

Answer 6

Slide scale insulin

- Maintain glucose between 4 and 7 mmol/L

Question 7

When should labour be induced in gestational DM

Answer 7

Between weeks 37-39

Question 8

Management of existing diabetes in pregnancy

Answer 8

Good glycaemic control via normal measures

Folic acid 5mg/OD

Aspirin 150mg OD

Question 9

Annual risk of type 2 dm in those with gestational DM

Answer 9

4% per annum

Question 10

Monitoring in gestational DM

Answer 10

Retinal assessment
- Digital imaging

Renal assessment

Question 11

Fasting glucose of ______ is diagnostic of GDM

Answer 11

5.6

Question 12

2-hours post plasma glucose of ______ in GTT is diagnostic of GDM

Answer 12

7.8

Question 13

What medications should be stopped in pregnant women with pre-exisiting diabetes

Answer 13

Statins + ACEi

Question 14

________ should be taken 3 months in advance of conceiving for diabetic women

Answer 14

Folic acid 5mg

Question 15

What things should be taken/ under control for women with existing diabetes

Answer 15

Folic acid 5mg (pre and 1st trimester)

Aspirin 150mg

Optimise glucose control

Review of medication

Question 16

What women have to have GTT between weeks 24 and 28 weeks

Answer 16

BMI >30

Previous macrosomic baby

FHx of high diabetes prevalence

Glycosuria >2 once or >1 twice (one week apart)

Question 17

_____ % of women with GDM have DM in 10 years

Answer 17

50

Question 18

Post-natal screen in women with GDM

Answer 18

HbA1c checked 6-12 weeks post-partum

Question 19

What women should be advised to not conceive

Answer 19

Type 1 DM with HbA1c >10.2

T1 DM with Cr >245

Question 20

When is GTT used to screen for gestational DM in women with risk factors

Answer 20

After booking

24-28 weeks (if first is normal)

Question 21

Monitoring of blood glucose in GDM

Answer 21

Check glucose daily (T1 DM/ multiple insulin a day)

• Fasting (when waking)
• Pre‑meal
• 1‑hour post‑meal
• Bedtime

(T2 DM, single drug)

• fasting
• 1‑hour post‑meal

Question 22

Glucose targets for GDM

Answer 22

Fasting = 5.3

1-hour post= 7.8

2-hour post= 6.4

Question 23

Glucose targets for GDM

Answer 23

Fasting = 5.3

1-hour post= 7.8

2-hour post= 6.4