Diabetes in pregnancy Flashcards
Definition of gestational diabetes
Glucose intolerance onset/first recognised in pregnancy
Percentage of women with GDM who develop DM in the following 20 years
50%
Risk factors for GDM
Previous GDM Previous elevated BGL Previous macrosomic infant Obesity (BMI >30), PCOS Steroids Age >25 Multiples Family history Asian
Diagnosis of GDM criteria
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
If OGTT cannot be done, alternative
HbA1c (if OGTT not suitable)
• 1st trimester only
• Result ≥ 41 mmol/mol (or 5.9%)
Physiology of GDM
Pregnancy= relative insulin resistance= +production
Fasting levels lower and post prandial hgiher
HPL +lipolysis, sparing glucose for fetus
Hormones which reduce glucose uptake
Progesterone
Prolactin
Cortisol
Placental lactogen->large glucagon like effect
Effects of GDM on neonate
Polyhydramnios Macrosomia \+Skin thickness, abdominal adiposity Neonatal hypoglycemia Preterm Hyperbilirubinemia (polycythemia) Poor lung maturation (polycythemia) Polycythemia Hypocalcemia Jaundice
Maternal effects of GDM
Gestational HTN Pre-eclampsia C-section Risk of future GDM, DM Birth injruy Bacterial infections
Management goals of GDM
MDC-> dietician, diabetes educator, endocrinologist, obstetrician Diet, exercise, glucose monitoring Insulin, metformin Monitoring growth of fetus Intrapartum glycemic control Fetal sugars post delivery
Are congenital defects + in GDM
No, but increased in pregestational diabetes
When should the OGTT be done before 26-28 weeks
When +risk factors, done in first trimester
Risks of macrosomia for infant
Shoulder dystocia - risk increases as fetal weight increases Bone fracture Nerve palsy Caesarean section birth Hypoxic-ischaemic encephalopathy (HIE) Death
Antenatal care of GDM- initial visit
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
Indications for insulin
Fasting >5.5 one+/week
Post prandial >7.5 2+/week in absence of dietary non-compliance
Antenatal care of GDM- each visit
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
Intrapartum management of GDM–>vaginal delivery
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
Intrapartum management of GDM C-section
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
BGL >7 in labor
Review clinical circustance–>stage of labour, intake
Option 1–>repeat BGL in 1 hour and reassess
Option 2–> Consider insulin infusion
BGL
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
Postpartum care for all GDM when pharmacological therapy
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
Discahrge
Advise benefis of optimising diet, exercise and weight
Repeat OGTT at 6-12 weeks
Lifelong screening
Early glucose screening in future pregnancy
Monitoring postpartum for GDM mother not on pharmacotherapy
Cease monitoring after birth
Reasons cesarean section incidence in insulin dependant women is 2-3 times higher than the normal population (4)
Failed induction
Fetal distress in early labour
Disproportion
An abnormal lie
Immediate care of the baby
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
What should be checked for at 22-24 week scan
Fetal heart, check for congenital heart abnormalities.
Are GDM at increased risk of pyelonephritis
Yes- 4 X risk
Congenital abnormalities associated with pre-existing diabetes
NTD
Cardiac abnormalities
Skeletal abnormalities
Orofacial clefts
Pregnancy effects on diabetic patient
Nephropathy->+risk of pre-eclampsia, impaired renal function
Gastroparesis
+Proliferative retinopathy
+Asymmetrical growth, SGA, pretern
Preconception care for diabetics
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
Antenatal care of woman with pre-existing diabetes- FIRST VISIT
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
At each subsequent antenatal visit with pre-existing DM
Regular vist investigations etc Diabetic record of home monitoring BP Symptoms of pre-eclampsia, UTI Fetal growth
When can delivery wait for spontaneous labour
Blood glucose control satisfactory
Normal fetal growth
No complications
When should IOL occur
Poor metabolic control at 38 weeks
Polyhydramnios
Macrosomia
No spontaneous labour at term
Management if delivery required
Betamethasone 11.4mg X 2 doses 24 hours apart
Admission for insulin sliding scale
Consult physician/endocrinologist
When should C section be considered with large baby->in diabetic and non-diabetic
In diabetic- 4.5kg
Non-diabetic 5kg
Do insulin requirements typically increase or decrease on delivery of placenta and with breast feeding
Reduction, may be able to cease insulin for several hours following delivery
When would you consider umbilical artery blood flow measurement
Fetal macrosomia IUGR Hypertension Smoker Poor glycemic control Evidence of microvascular or macrovascular disease
Type 1 diabetic wanting to become pregnant- important points in history
GynaeC, obstetric, medical/family/social, iron/folate, immunisations
Blood glucose control, monitoring
HbA1C, review->any evidence of opthalmology, vasculopathy (retinopathy, kidney, heart, feet)
“What are the risks for me and my baby” T1DMM
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.
Risk to maternal health if pre-existing renal, HTN, severe retinopathy
Blindness
Renal failure requiring dialysis
Termination must be discussed
“Is there any way to reduce the risk to my baby” and follow up
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
Fetal abnormalities associated with diabetes
NTD Cardiac Bowel Urinary tract Sacral agenesis
Advice to diabetic patient about care in later pregnancy
- Good sugar control
- Regular growth scans from 24 weeks->looking at disproportionate growth, polyhydramnios
- Increased risk of shoulder dystocia, still birth, cesaerean
- Following birth->hypoglycemia, neonatal respiratory distress, low calcium and magnesium, jaundice, polycythemia
- With good sugar control can expect a live healthy baby
