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m4 obgyn > Diabetes in pregnancy > Flashcards

Diabetes in pregnancy Flashcards

1
Q

Types of diabetes in pregnancy

A
  1. Pre-existing DM
    - type 1 vs 2
    - presents prior to onset of pregnancy
  2. Gestational DM
    - pre-existing DM vs true GDM
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2
Q

Gestational DM

A

Any degree of glucose intolerance with onset in pregnancy (2nd & 3rd trimester) and resolution within 6 weeks after delivery
- Pregnancy-induced insulin resistance mediated by pregnancy hormones
- NOT a/w fetal abnormalstes
- NOT a/w maternal end organ damage

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3
Q

Carbohydrate metabolism in pregnancy

A

Diabetogenic properties of pregnancy hormones: human placental lactogen, cortisol, estrogen, progesterone
-> affect pancreatic beta-cell function & peripheral tissue
sensitivity to insulin
-> Insulin sensitivity ↓ by 50-70%
-> state of insulin
resistance
-> ↑ insulin demand to maintain glucose homeostasis

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4
Q

Specific complications of pre-existing DM in pregnant moms

A

Fetal: Fetal Abnormalities
- Neural tube defect
- CVS abnormalities
- Sacral agenesis
- Caudal regression syndrome

Maternal: End organ diabetic complications

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5
Q

Effects of maternal hyperglycaemia on the fetus

A

Due to facilitated diffusion, maternal hyperglycaemia leads to fetal hyperglycaemia
-> Stimulates fetal pancreatic beta-cell hyperplasia
-> Fetal hyperinsulinaemia

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6
Q

Fetal complications a/w Pre-Existing DM and GDM

A
  1. Macrosomia (Result of fetal hyperinsulinemia)
    - Birth trauma
    - Shoulder dystocia
    - Caesarean delivery
    - Prolonged labour
  2. IUGR
    - Atherosclerosis of uterine vessels in pre-existing DM
    - Co-existing preeclampsia
    - Placental insufficiency
  3. Polyhydramnios (Fetal polyuria)
  4. Premature birth
  5. Sudden intrauterine death
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7
Q

Pathophysio of fetal macrosomia

A

Fetal hyperinsulinemia
-> Promotes the growth of insulin-sensitive
tissue: adipose tissue, muscle, liver
-> disproportionate ↑ in size of trunk & shoulders (↑AC, ↓H/A ratio)
-> macrosomia

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8
Q

Neonatal complications a/w Pre-Existing DM and GDM

A
  1. Neonatal hypoglycemia
  2. Neonatal hypocalcemia/ hypomagnesemia
  3. Jaundice/ Polycythemia
  4. Respiratory distress syndrome/ Tachypnea of newborn
  5. NICU admission

(Future)
6. Metabolic syndrome
7. Obesity

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9
Q

Respiratory distress syndrome in neonate

A

Hyperinsulinaemia affects pulmonary surfactant
production → delay pulmonary maturation

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10
Q

Maternal complications a/w Pre-Existing DM and GDM

A
  1. Preeclampsia/ Pregnancy-induced HTN
  2. Prolonged labour/ Traumatic delivery/ Operative delivery/ PPH
  3. Increased risk of T2DM (30%) and CVS disease
  4. In pre-existing DM:
    - Worsening of retinopathy
    - Nephropathy
    - DKA (Esp in T1DM with hyperemesis in pregnancy)
    - Frequent UTI/ thrush
  5. Post natal complications
    - Extended vaginal tears
    - Wound complications
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11
Q

Screening of DM in pregnancy

A

Universal screening
- done at 26-28 weeks
- perform 75g 3-point OGTT
- do in 1st trimester if RFs present

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12
Q

Diagnostic criteria of 75g OGTT for DM in pregnancy

A

Fasting ≥ 5.1 mmol/L
1-hour ≥ 10 mmol/L
2-hour ≥ 8.5 mmol/L
Any 1/3 met = GDM

If fasting ≥7.0 or 2-h ≥11.1: suspect possible pre-existing DM

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13
Q

Risk factors of GDM

A
  • Maternal age >35
  • BMI >25
  • FHx of DM
  • Previous big baby >4 kg
  • Previous still birth/ fetal anomaly
  • Glycosuria
    Can also be physiological (Blood volume increases during pregnancy → renal perfusion increases but kidney reabsorptive capacity remains the same → urine has glucose)
  • Previous GDM
  • PCOS
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14
Q

Management of GDM

A
  1. Multidisciplinary team management
    - Diabetic nurse, Dietician, Obstetrician
  2. Nutritional therapy
  3. Regular exercise as tolerated in pregnancy
  4. Patient education
  5. Monitor blood sugar profile more regularly
    - 7 point blood sugar profile
    - Before and after meals x3
    + before sleeping
    (at least 2 days a week, weekday and weekend)
  6. If dietary management cannot consistently maintain BSL within normal range -> Start insulin
  7. Monitor fetal growth closely
    - Detailed fetal anomaly scan at 20-22 weeks as per normal pregnancies
    - Serial growth scans at 28 weeks
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15
Q

Glycemic targets in GDM

A

7 point blood sugar profile
- Before and after meals x3
+ before sleeping
*at least 2 days a week, weekday and weekend

Targets:
Pre-meal: 4.4 – 5.5 mmol/L
Post meal: 5.5 – 6.6 mmol/L

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16
Q

Serial growth scan at 28 weeks to assess for

A
  • Abdominal circumference (AC)
  • Head circumference (HC)
  • H/A ratio
  • Liquor volume
  • Estimate fetal weight
17
Q

Management of pre-existing DM in pregnancy

A
  1. MDT Mx
    - Diabetic nurse, Dietician, Obstetrician, Endocrinologist
  2. Assess for complications of DM
    - Referral to ophthalmologist TRO diabetic retinopathy
    - Check kidney function (UECr), consider referral to nephrologist if needed
  3. 5mg folic acid p
    - reduce congenital abnormalities
  4. HbA1c target 6.0-6.5%
    - reduce congenital abnormalities
  5. Monitor blood sugar profile more regularly
    - 7 point blood sugar profile
    - Before and after meals x3
    + before sleeping
    (at least 2 days a week, weekday and weekend)
  6. Early FA scan at 17-18 weeks and repeat at 21-22 weeks
  7. If T1DM, test for ketonuria if unwell or hyperglycemic
  8. Switch OHGA to insulin but metformin can continue
    - insulin regime
  9. Aspirin 100mg od (Due to risk of pregnancy-induced HTN)
  10. Monitor fetal growth closely
    - Early fetal anomaly scan (17-18 weeks)
    - Detailed fetal anomaly scan at 20-22 weeks as per normal pregnancies
    - Serial growth scans after 28 weeks
  11. Monitor for maternal Cx (Renal, cardio, eye)
18
Q

Antenatal management - Insulin regime for pre-existing DM pregnancy

A

Combination of short/ intermediate acting insulin
- Up to 4 injections daily (pre-meal + bedtime)
- High sugar readings BEFORE meals: Intermediate acting insulin
- High sugar readings AFTER meals: Short-acting insulin prior to each meal to cover sharp rise due to meals

*Insulin does not cross placenta

19
Q

Timing of delivery for pregnant woman with DM

A
  • Good diet control: Deliver by 40 weeks + 6 days
  • Good control with insulin: Delivery at 38 weeks
  • Poor control with diet towards end of pregnancy: Delivery at 38 weeks
  • Poor control with insulin: Aim as close at 37 weeks
20
Q

Intrapartum care for mom and fetus

A
  1. Tight glucose control in labour ~4-7 mmol/L  
  2. Dextrose drip with separate insulin infusion adjusted according to sliding scale with hourly assessment of blood glucose level to guide titration
    - <4mmol/L –> Stop insulin infusion
    - 4-7mmol/L –> Continue 1u/h
    - >7mmol/L –> Increase to 2u/h
  3. Aim vaginal delivery
  4. Continuous CTG monitoring
21
Q

Postpartum for GDM

A
  • If on insulin, usually can go off insulin immediately
  • Monitor sugars and check with 2-point 75g OGTT 6 weeks after delivery
    -> Normal: Repeat every 1-3 years
    -> Abnormal: Refer to specialist
  • Contraception counselling
    *Estrogen-containing contraceptives not recommended for women with DM + vascular disease
22
Q

Postpartum for pre-existing DM

A
  • Use pre-pregnancy insulin regime if previously on insulin
  • Consider reducing dose if breastfeeding due to risk of hypoglycemia
  • If on OHGA pre-preg, then continue low dose insulin or metformin
  • For next pregnancy, book early
  • Contraception counselling
    *Estrogen-containing contraceptives not recommended for women with DM + vascular disease
23
Q

Normal 3-point OGTT

A

Fasting: 3.0-5.0 mmol/L
1h </= 9.9
2h </= 8.4

m4 obgyn (37 decks)

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