Diabetes in pregnancy Flashcards
If a woman has preexisting type 1 or type 2 diabetes at the commencement of care, what is the responsibility of the midwife with regard to consultation and referral?
C refer
If a woman at the commencement of care presents with a history of gestational diabetes in a previous pregnancy, what is the responsibility of the midwife with regard to consultation and referral?
A discuss
If a woman develops gestational diabetes during pregnancy what is the responsibility of the midwife with regard to consultation and referral: if it is diet controlled? if she requires insulin?
if diet controlled - B consult
if requiring insulin - C refer
If a woman has a BMI 35 at the commencement of care, what is the responsibility of the midwife with regard to consultation and referral?
B consult
If a woman has a BMI >40 at the commencement of care, what is the responsibility of the midwife with regard to consultation and referral?
C refer
What is gestational diabetes?
any degree of glucose intolerance with onset or first recognition in pregnancy
What is the incidence of gestational diabetes?
GDM affects 8-10% of pregnancies in australia
When is GDM usually tested for?
routinely at 24-28 weeks gestation
early for high risk women at 12-16 weeks
at 6-8 weeks postpartum in women diagnosed with gestational diabetes
What are the risk factors for GDM?
- previous GDM
- previous stillbirth/FDIU
- ethnicity (indigenous australian, pacific islander, indian, SE Asian, middle eastern, maori, afro-carribean
- age > 40
- first degree relative with insulin dependent diabetes
- BMI>35
- previous macrosomia (>4500g)
- polycystic ovarian syndrome
- medications (corticosteroids, antipsychotics)
What 4 tests may be used in screening for GDM?
- oral glucose tolerance test (diagnostic)
- non fasting plasma glucose
- HbA1c (not reimbursed by medicare)
Criteria for diagnosis of GDM with a GTT
Fasting glucose >5.1 mmol/L
and/or
2h glucose >8 mmol/L
values vary according to local protocols
What is the procedure for a GTT?
- fasting for 10-12 hours
- baseline plasma glucose measured
- 75g glucose drunk within 5 mins
- plasma glucose measured at 1 hour and 2h
- no food, smoking, drinks other than water or exercise during test
What blood glucose levels should be targeted (fasting, 1 hour and 2 hour post meal) in diet controlled GDM?
- fasting
What strategies are common in managing GDM antenatally?
- modification of diet
- regular exercise
- home blood glucose monitoring
- increased frequency of antenatal visits
- interdisciplinary team (midwife, obstetrician, diabetes educator, dietition, other specialists)
- insulin
What are the associated risks of gestational diabetes?
- polyhydramnios
- preeclampsia
- C/S
- PPH
- perinatal death
- macrosomia (shoulder dystocia, perineal trauma)
- birth trauma
- neonatal hypoglycaemia, hypocalcaemia, magnesaemia
- respiratory distress syndrome
- hyperbilirubinaemia
- neonatal polycythaemia
What long term risks exist for women that have had gestational diabetes?
50% risk of developing type 2 DM within 20 years
What drugs may be used to treat women with gestational diabetes that isn’t controlled sufficiently with diet?
- insulin
- metformin
- glibenclamide (caution)
What are the postnatal recommendations for women with gestational diabetes?
GTT at 6-12 weeks postpartum
diabetes testing 1-2 yearly
List 5 important considerations providing labour care for women with GDM?
- timing of birth (some facilities induce, c/s at 38-39/40, particularly if macrosomic, persistant hyperglycaemic or other complications)
- glucose levels in labour
- fetal monitoring (? continuous CTG in labour for GDM on insulin, blood glucose outside optimal range or ? macrosomic)
- ? shoulder dystocia
- active management of third stage
List 4 means of assessing fetal wellbeing where mum has GDM?
- fetal movements
- fundal height
- ultrasound
- regular CTG if IUGR or macrosomia
What are the three different types of diabetes?
- type 1 insulin deficient
- type 2 insulin resistant
- gestational
How do the normal physiological changes of pregnancy usually change insulin requirements?
- usually fall in first trimester
- rise in second and third trimesters
- return quickly to prepregnancy after birth
What is the mode of action for metformin?
- reduces insulin resistance
- reduces hepatic glucose production, decreased absorption of glucose and increased peripheral uptake of glucose
How safe is use of metformin in pregnancy?
- important to talk to doctor before considering stopping treatment
- evidence suggests that metformin may increase the chances of conception for women with PCOS, women who continue taking metformin in the first trimester may also have a lower risk of miscarriage, may reduce risk of developing gestational diabetes
- category C - insufficient evidence, no evidence of adverse effects on baby or increased risk of congenital abnormalities
- appears to be safe in breastfeeding women
What other medicines interact with insulin?
decrease insulin requirements
- oral hypoglycaemic agents
- monoamine oxidase inhibitors
- non selective beta adrenergic blockers
- ACE inhibitors
- salicylates
- anabolic steroids
- quinine
- sulphonamides
increase insulin requirements
- oral contraceptives
- glucocorticoids
- thyroid hormones
- sympathomimetics
- nicotinic acid
other
- betablockers
- alcohol
