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Obstetrics and Gynaecology > Diabetes in pregnancy > Flashcards

Diabetes in pregnancy Flashcards

1
Q

Definition of gestational diabetes

A

Glucose intolerance onset/first recognised in pregnancy

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2
Q

Percentage of women with GDM who develop DM in the following 20 years

A

50%

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3
Q

Risk factors for GDM

A 
Previous GDM
Previous elevated BGL
Previous macrosomic infant
Obesity (BMI >30), PCOS
Steroids
Age >25
Multiples
Family history
Asian
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4
Q

Diagnosis of GDM criteria

A

OGTT (preferred test for diagnosis) 24-28 weeks
One or more of:
• Fasting ≥ 5.1 mmol/L
• 1 hour ≥ 10 mmol/L
• 2 hour ≥ 8.5 mmol/L
If fasting >7 of 2 hour post >11.1= DM in pregnancy

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5
Q

If OGTT cannot be done, alternative

A

HbA1c (if OGTT not suitable)
• 1st trimester only
• Result ≥ 41 mmol/mol (or 5.9%)

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6
Q

Physiology of GDM

A

Pregnancy= relative insulin resistance= +production
Fasting levels lower and post prandial hgiher
HPL +lipolysis, sparing glucose for fetus

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7
Q

Hormones which reduce glucose uptake

A

Progesterone
Prolactin
Cortisol
Placental lactogen->large glucagon like effect

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8
Q

Effects of GDM on neonate

A 
Polyhydramnios
Macrosomia
\+Skin thickness, abdominal adiposity
Neonatal hypoglycemia
Preterm
Hyperbilirubinemia (polycythemia)
Poor lung maturation (polycythemia)
Polycythemia
Hypocalcemia
Jaundice
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9
Q

Maternal effects of GDM

A 
Gestational HTN
Pre-eclampsia
C-section
Risk of future GDM, DM
Birth injruy
Bacterial infections
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10
Q

Management goals of GDM

A 
MDC-> dietician, diabetes educator, endocrinologist, obstetrician
Diet, exercise, glucose monitoring
Insulin, metformin
Monitoring growth of fetus
Intrapartum glycemic control
Fetal sugars post delivery
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11
Q

Are congenital defects + in GDM

A

No, but increased in pregestational diabetes

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12
Q

When should the OGTT be done before 26-28 weeks

A

When +risk factors, done in first trimester

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13
Q

Risks of macrosomia for infant

A 
Shoulder dystocia - risk increases as fetal weight increases
Bone fracture
Nerve palsy
Caesarean section birth
Hypoxic-ischaemic encephalopathy (HIE)
Death
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14
Q

Antenatal care of GDM- initial visit

A

Review history
Diabetes educator
Dietitian w/i 1 week
Psychosocial if required
Commence self monitoring
BMI->discuss healthy weight gains
Physical activity, smoking, alcohol
Baseline USS at 28-30 weeks
Initial laboratory investigations (routine tests, creatinine)
If diabetes in pregnancy->optometrist, opthalmologist, microalbuminuria
Fetal growth monitoring–>first trimester scan, 20 week morphology, 28/34 week scan for macrosomia
Glucose monitoring 4 X daily (fasting, 2 hr post meals)
If good control can reduce
Insulin if indicated
Diet, exercise, limit pregnancy weight gain

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15
Q

Indications for insulin

A

Fasting >5.5 one+/week

Post prandial >7.5 2+/week in absence of dietary non-compliance

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16
Q

Antenatal care of GDM- each visit

A

Surveillance->review for complications (preeclampsia, features of infection)
Review weight gain, diet, exercise
Test urine for protein/ketones
Check BGL patterns
Psychosocial
Fetal well being USS 2-4 weekly as indicated
F/U for pharmacology, diabetes educator review
Review suitability of model of care
Review next contact requirements

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17
Q

Intrapartum management of GDM–>vaginal delivery

A

If on metormin->cease when labouring
Insulin–>
Cease when labour
If morning IOL: eat breakfast and give usual rapid acting insulin, omit morning long/intermediate
If afternoon IOL: Give usual meal/bedtime insulin
Monitor BGL 2/24

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18
Q

Intrapartum management of GDM C-section

A

Day before- cease metformin 24 hours before, give insulin dose at night
Day of morning procedure- fast from 2400, omit morning insulin
Monitor BGL 2/24

19
Q

BGL >7 in labor

A

Review clinical circustance–>stage of labour, intake
Option 1–>repeat BGL in 1 hour and reassess
Option 2–> Consider insulin infusion

20
Q

BGL

A

Cease insulin
If symptomatic-treat hypo and BGL in 15 m/60
If asymptomatic and receiving insulin, reassess BGL in 15/60
If asymptomatic, not receiving insulin, repeat BGL in 1 hour and reassess

21
Q

Postpartum care for all GDM when pharmacological therapy

A

Cease insulin/metformin immediately after birth
Target BGL medical review, IV fluid 12 hourly
>7–>medical review. Insulin rarely required postpartum
If BGL >4, diet tolerated, cease mainine IV fluids after borth
All routine care
Support and encourage breastfeeding
Keep newborn warm. Feed within 30-60 minutes.
Fed–>BGL before second feed
XFed->BGL at 2 hours
BGL every 4-6 hours pre-feeds until monitoring ceases

22
Q

Discahrge

A

Advise benefis of optimising diet, exercise and weight
Repeat OGTT at 6-12 weeks
Lifelong screening
Early glucose screening in future pregnancy

23
Q

Monitoring postpartum for GDM mother not on pharmacotherapy

A

Cease monitoring after birth

24
Q

Reasons cesarean section incidence in insulin dependant women is 2-3 times higher than the normal population (4)

A

Failed induction
Fetal distress in early labour
Disproportion
An abnormal lie

25
Q

Immediate care of the baby

A

Pediatrician present at delivery
Resuscitate if required
Dry, keep warm
Check BG at 30 mins, 1 hour, 4 hour, 8 hour, 12 and 24 hour
Treat CHD, NTD
Measure serum bilirubin->hyperbilirubinemia

26
Q

What should be checked for at 22-24 week scan

A

Fetal heart, check for congenital heart abnormalities.

27
Q

Are GDM at increased risk of pyelonephritis

A

Yes- 4 X risk

28
Q

Congenital abnormalities associated with pre-existing diabetes

A

NTD
Cardiac abnormalities
Skeletal abnormalities
Orofacial clefts

29
Q

Pregnancy effects on diabetic patient

A

Nephropathy->+risk of pre-eclampsia, impaired renal function
Gastroparesis
+Proliferative retinopathy
+Asymmetrical growth, SGA, pretern

30
Q

Preconception care for diabetics

A

Contraception until ready for pregnancy
Screen women with T1DM for TSH antibodies
Counsel regradingglycemic state in pregnancy, maternal/neonatal complications->risk to pregnancy, fetus,
Diet, exercise, weight, folic acid
Cease ACEi/ARB- use labetolol
Evaluation complications and comorbidities->refer to those when necessary:
nephrology, opthalmology etc

31
Q

Antenatal care of woman with pre-existing diabetes- FIRST VISIT

A 
First visit-->all normal investigations. Cease other meds-insulin only.
Education with diabetes educator
Diet, exercise, weight
Glucose monitoring
Potential to need to increase insulin
Risks of poor glycemic control
32
Q

At each subsequent antenatal visit with pre-existing DM

A 
Regular vist investigations etc
Diabetic record of home monitoring
BP
Symptoms of pre-eclampsia, UTI
Fetal growth
33
Q

When can delivery wait for spontaneous labour

A

Blood glucose control satisfactory
Normal fetal growth
No complications

34
Q

When should IOL occur

A

Poor metabolic control at 38 weeks
Polyhydramnios
Macrosomia
No spontaneous labour at term

35
Q

Management if delivery required

A

Betamethasone 11.4mg X 2 doses 24 hours apart
Admission for insulin sliding scale
Consult physician/endocrinologist

36
Q

When should C section be considered with large baby->in diabetic and non-diabetic

A

In diabetic- 4.5kg

Non-diabetic 5kg

37
Q

Do insulin requirements typically increase or decrease on delivery of placenta and with breast feeding

A

Reduction, may be able to cease insulin for several hours following delivery

38
Q

When would you consider umbilical artery blood flow measurement

A 
Fetal macrosomia
IUGR
Hypertension
Smoker
Poor glycemic control
Evidence of microvascular or macrovascular disease
39
Q

Type 1 diabetic wanting to become pregnant- important points in history

A

GynaeC, obstetric, medical/family/social, iron/folate, immunisations
Blood glucose control, monitoring
HbA1C, review->any evidence of opthalmology, vasculopathy (retinopathy, kidney, heart, feet)

40
Q

“What are the risks for me and my baby” T1DMM

A

If there is no evidence of significant diabetic vasculopathy, pregnancy will not have an adverse effect on her health.
If glucose not controlled in earl pregnancy->fetal abnormalities can occur double risk (normal risk 2-3%)
Poor control in later pregnancy->macrosomia and stillbirth->abnormal fat distribution, metabolic dysfunction and stillbirth.

41
Q

Risk to maternal health if pre-existing renal, HTN, severe retinopathy

A

Blindness
Renal failure requiring dialysis
Termination must be discussed

42
Q

“Is there any way to reduce the risk to my baby” and follow up

A

Need good sugar control before and during
See endocrinologist prior to conception->insulin regimen may need to be tweaked
FBC, rubella, varicella
Take folic acid 5mg now until end of first trimester
Important investigations:
->Early dating scan
->CFTS 10-13 weeks
->USS at 18 weeks: if severe abnormalities detected, option to terminate
->USS 22-24 weeks to detect cardiac abnormalities (50% of the abnormalities seen in diabetic pregnancies

43
Q

Fetal abnormalities associated with diabetes

A 
NTD
Cardiac
Bowel
Urinary tract
Sacral agenesis
44
Q

Advice to diabetic patient about care in later pregnancy

A
  1. Good sugar control
  2. Regular growth scans from 24 weeks->looking at disproportionate growth, polyhydramnios
  3. Increased risk of shoulder dystocia, still birth, cesaerean
  4. Following birth->hypoglycemia, neonatal respiratory distress, low calcium and magnesium, jaundice, polycythemia
  5. With good sugar control can expect a live healthy baby

Obstetrics and Gynaecology (45 decks)

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