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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

A

Fetal:
1. Fetal Abnormalities
- Neural tube defect
- CVS abnormalities
- Sacral agenesis
- Caudal regression syndrome
2. IUGR (more common in women in T1DM compared to T2DM)
3. Prematurity

Maternal: Worsening of end organ diabetic complications
- Worsening of retinopathy
- Nephropathy
- DKA (Esp in T1DM with hyperemesis in pregnancy)
- Frequent UTI/ thrush
- HTN

+ ALL the complications due to GDM

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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. Polyhydramnios (Fetal polyuria)
  3. Stillbirth/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

*Pedersen hypothesis

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8
Q

Neonatal complications a/w Pre-Existing DM and GDM

A
  1. Macrosomia
    - excess fat deposits: chest, abdomen and scapula
  2. SGA/IUGR
    - mothers with chronic vascular cx of DM
  3. Neonatal hypoglycemia (<2.6mmol/L in D1 of life)
    - highest risk: first 3h of life
    - resolves by 48h
    - Sx: jitteriness, sweating, respiratory distress, apnoea, seizures, agitation
  4. Neonatal hypocalcemia/ hypomagnesemia
    - delayed maturation of parathyroid axis
    - usually transient: 1st 24-72h of life
  5. Hyperbilirubinemia (jaundice)
  6. Polycythemia
    - venous hematocrit > ‘70%
    - increased RBC mass
    - increased viscosity: tissue hypo-perfusion, thrombosis, stroke
    - Sx: plethoric, sluggish, lethargy
  7. Respiratory distress syndrome
    - insulin blunts maturational effects of cortisol towards surfactant production
  8. Transient tachypnea of newborn
  9. CNS dysfunction (multifactorial)
    - Perinatal asphyxia
    - Glucose, electrolyte abnormalities
    - Polycythemia
    - Birth trauma
  10. Spinal cord and brachial plexus injury during birth
  11. NICU admission

Long-term complications
12. Metabolic syndrome
13. Obesity
14. CVS disease

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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. Post natal complications
    - Extended vaginal tears
    - Wound complications
    - Increased risk of T2DM (60%) and CVS disease
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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
  • Previous GDM
  • PCOS
  • Glycosuria
    Can also be physiological (Blood volume increases during pregnancy → renal perfusion increases but kidney reabsorptive capacity remains the same → urine has glucose)
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14
Q

Management of GDM

A
  1. Multidisciplinary team management
    - Diabetic nurse, Dietician, Obstetrician
  2. Nutritional therapy FIRST
  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, consecutive days)
  6. If dietary management cannot consistently maintain BSL within normal range -> Start insulin/metformin
  7. Start Aspirin prophylaxis 150mg (Due to risk of pregnancy-induced HTN)
  8. 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, consecutive

Targets:
Pre-meal (5mins before): 4.4 – 5.5 mmol/L
Post meal (2h from start of food intake): 5.5 – 6.6 mmol/L
Bedtime: 4.4 – 5.5 mmol/L (min 3h from dinner time)

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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, consecutive)
  6. Early FA scan at 17-18 weeks and repeat at 20 weeks
  7. If T1DM, test for ketonuria if unwell or hyperglycemic
  8. Switch OHGA to insulin but metformin can continue
    - insulin regime
  9. Aspirin 150mg 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
  • Encourage breastfeeding (improves glucose metabolism in the short-term)
  • 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
  • Encourage breastfeeding (improves glucose metabolism in the short-term)
  • 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: Do 2 point OGTT in first trimester
  • 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

24
Q

How to prepare woman with pre-existing DM for future pregnancy?

A

Multidisciplinary team
Sugar control
- diet, exercise, control bmi
- HbA1c aim below 6
Screen for macro and micro xm
- Retinopathy, nephropathy, neuropathy
- HTN
If HTN, change ace inhibitors
Contraception if HbA1c high to prevent pregnancy
Folic acid in case of pregnancy

25
Q

Subsequent risk of development of DM in GDM patients

A
  • Approximately 60% of women with a past history of GDM develop T2DM later in life
  • Each additional pregnancy also confers a threefold increase in the risk of T2DM in women with a history of GDM

m4 obgyn (41 decks)

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