Diabetes in pregnancy

Question 1

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?

Answer 1

C refer

Question 2

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?

Answer 2

A discuss

Question 3

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?

Answer 3

if diet controlled - B consult

if requiring insulin - C refer

Question 4

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?

Answer 4

B consult

Question 5

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?

Answer 5

C refer

Question 6

What is gestational diabetes?

Answer 6

any degree of glucose intolerance with onset or first recognition in pregnancy

Question 7

What is the incidence of gestational diabetes?

Answer 7

GDM affects 8-10% of pregnancies in australia

Question 8

When is GDM usually tested for?

Answer 8

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

Question 9

What are the risk factors for GDM?

Answer 9

• 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)

Question 10

What 4 tests may be used in screening for GDM?

Answer 10

• oral glucose tolerance test (diagnostic)
• non fasting plasma glucose
• HbA1c (not reimbursed by medicare)

Question 11

Criteria for diagnosis of GDM with a GTT

Answer 11

Fasting glucose >5.1 mmol/L
and/or
2h glucose >8 mmol/L
values vary according to local protocols

Question 12

What is the procedure for a GTT?

Answer 12

• 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

Question 13

What blood glucose levels should be targeted (fasting, 1 hour and 2 hour post meal) in diet controlled GDM?

Answer 13

• fasting

Question 14

What strategies are common in managing GDM antenatally?

Answer 14

• modification of diet
• regular exercise
• home blood glucose monitoring
• increased frequency of antenatal visits
• interdisciplinary team (midwife, obstetrician, diabetes educator, dietition, other specialists)
• insulin

Question 15

What are the associated risks of gestational diabetes?

Answer 15

• polyhydramnios
• preeclampsia
• C/S
• PPH
• perinatal death
• macrosomia (shoulder dystocia, perineal trauma)
• birth trauma
• neonatal hypoglycaemia, hypocalcaemia, magnesaemia
• respiratory distress syndrome
• hyperbilirubinaemia
• neonatal polycythaemia

Question 16

What long term risks exist for women that have had gestational diabetes?

Answer 16

50% risk of developing type 2 DM within 20 years

Question 17

What drugs may be used to treat women with gestational diabetes that isn’t controlled sufficiently with diet?

Answer 17

• insulin
• metformin
• glibenclamide (caution)

Question 18

What are the postnatal recommendations for women with gestational diabetes?

Answer 18

GTT at 6-12 weeks postpartum
diabetes testing 1-2 yearly

Question 19

List 5 important considerations providing labour care for women with GDM?

Answer 19

• 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

Question 20

List 4 means of assessing fetal wellbeing where mum has GDM?

Answer 20

• fetal movements
• fundal height
• ultrasound
• regular CTG if IUGR or macrosomia

Question 21

What are the three different types of diabetes?

Answer 21

• type 1 insulin deficient
• type 2 insulin resistant
• gestational

Question 22

How do the normal physiological changes of pregnancy usually change insulin requirements?

Answer 22

• usually fall in first trimester
• rise in second and third trimesters
• return quickly to prepregnancy after birth

Question 23

What is the mode of action for metformin?

Answer 23

• reduces insulin resistance
• reduces hepatic glucose production, decreased absorption of glucose and increased peripheral uptake of glucose

Question 24

How safe is use of metformin in pregnancy?

Answer 24

• 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

Question 25

What other medicines interact with insulin?

Answer 25

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