Diabetes in pregnancy

Question 1

risks associated with diabetes in pregnancy?

Answer 1

• pre-eclampsia
• worsening of diabetic retinopathy
• miscarriage
• stillbirth
• prematurity
• congenital malformations especially congenital heart disease and NTDs
• macrosomia
• shoulder dystocia-obstructed labour where after delivery of head, anterior shoulder cannot pass below the pubic symphysis, brachial plexus injury
• impaired lung maturation
• cardiac problems
• neonatal hypoglycaemia

Question 2

risks associated with having a large for gestational age baby (a risk of diabetes in pregnancy)?

Answer 2

• ?premature labour, PPH
• birth trauma, shoulder dystocia
• induction of labour
• C section

Question 3

complications for baby in later life after being born to a mother with diabetes?

Answer 3

increased risk of diabetes and obesity

Question 4

advice to women with diabetes planning to become pregnant on reducing the risk of baby having neural tube defects?

Answer 4

to take folic acid 5mg/day when planning to become pregnant, up until 12 weeks of gestation.

this higher dose is also recommended if patient has had a previous baby with a NTD or if pt on anti-epileptic medication or if pt obese.

Question 5

monitoring of women with diabetes before they become pregnant?

Answer 5

monthly HbA1c
meter for self-monitoring of glucose
if type 1 DM, blood ketone testing strips and meter to test if become hyperglycaemic or unwell

Question 6

which hormones in particular cause women to become resistant to insulin in pregnancy?

Answer 6

cortisol

human placental lactogen

Question 7

pathophysiology of gestational diabetes?

Answer 7

during the 2nd half of pregnancy, there is a further increase in insulin resistance and slight deterioration in glucose tolerance
those unable to meet this with a compensatory rise in insulin production develop gestational diabetes-carbohydrate intolerance that develops during pregnancy and disappears after delivery.

however, around 15% of those who develop diabetes in pregnancy continue to be diabetic post-delivery

Question 8

importance of keeping HbA1c below 48mmol in those with established diabetes in pregnancy?

Answer 8

reduces the risk of congenital malformations in the baby

Question 9

association between diabetes in pregnancy and shoulder dystocia?

Answer 9

diabetes is an independent RF for shoulder dystocia
macrosomia also makes shoulder dystocia more likely

induction may be used to reduce the risk

Question 10

medicines safe for control of diabetes in pregnancy?

Answer 10

metformin and insulin

all other medicines should be discontinued

ensure ACEIs, AIIRBs and statins are also stopped.

Question 11

1st choice long acting insulin during pregnancy?

Answer 11

isophane (NPH insulin)

Question 12

when should r/f to a nephrologist be considered in a patient with diabetes who is receiving pre-conception care?

Answer 12

if serum creatinine 120micromol/l or more, urinary ACR greater than 30mg/mmol or eGFR less than 45.

ensure pt r/f to nephrologist in the above cases before she considers discontinuing contraception.

Question 13

antenatal testing for gestational diabetes in a pt who has had gestational diabetes in a previous pregnancy?

Answer 13

should have OGTT as soon as possible after booking, and if normal then repeat at 24-28weeks
or offer early self monitoring of blood glucose

Question 14

criteria to be met to make a diagnosis of gestational diabetes?

Answer 14

fasting plasma glucose of 5.6mmol/L or more, or 2hr plasma glucose level in an OGTT of 7.8mmol/L or more.
should be offered a r/v in the joint diabetes and antenatal clinic within 1 week.

*ensure all women with diabetes in preg have contact with the joint diabetes and antenatal clinic every 1-2wks for assessment of blood glucose control.

Question 15

recommended health and lifestyle advice for woman with gestational diabetes in pregnancy?

Answer 15

-eat a healthy diet, encourage foods with a low glycaemic index to replace those with a high index.
-r/f to dietician
-regular exercise e.g. walking for 30mins after a meal
-offer trial of diet and exercise to those with fasting glucose level less than 7 at diagnosis.
if changes not met within 1-2 wks, offer metformin
insulin can be used as alternative, or in addition if targets not met

glibenclamide can be considered if insulin declined or metformin not tolerated.

Question 16

management of women with gestational diabetes with fasting plasma glucose of 7 or greater at diagnosis?

Answer 16

treatment with insulin straight away, with or without metformin, plus changes in diet and exercise

consider if between 6 and 6.9 and complications e.g. macrosomia, polyhydramnios

Question 17

target blood glucose levels in pregnancy?

Answer 17

fasting below 5.3
1 hr post meals below 7.8
2 hr post meals below 6.4

Question 18

monitoring of fetal growth and wellbeing in pregnant women with diabetes?

Answer 18

US monitoring of fetal growth and AF every 4 weeks from 28 weeks to 36 weeks
umbilical artery Doppler monitoring only if risk of fetal growth restriction

Question 19

recommended time for labour for women with diabetes in pregnancy?

Answer 19

offer induction from 37+0 to 38+6 weeks to reduce risk of stillbirth in women with type 1 or type 2 DM (or C section if indicated)

if gestational DM, advise to give birth no later than 40+6

Question 20

CBG monitoring during labour?

Answer 20

hourly

ensure maintained between 4 and 7mmol/L

Question 21

blood glucose lowering therapy management after birth for those with gestational diabetes?

Answer 21

discontinue immediately after birth

Question 22

f/u of patient with gestational diabetes after the birth?

Answer 22

ensure following diet and lifestyle advice
if blood glucose returns to normal after birth ensure fasting plasma glucose check at 6-13 weeks-if less than 6 then moderate risk of developing type 2 DM, if 7 or more then likely to have type 2 DM and offer diagnostic test to confirm.