Diabetes in pregnancy Flashcards
risks associated with diabetes in pregnancy?
- 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
risks associated with having a large for gestational age baby (a risk of diabetes in pregnancy)?
- ?premature labour, PPH
- birth trauma, shoulder dystocia
- induction of labour
- C section
complications for baby in later life after being born to a mother with diabetes?
increased risk of diabetes and obesity
advice to women with diabetes planning to become pregnant on reducing the risk of baby having neural tube defects?
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.
monitoring of women with diabetes before they become pregnant?
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
which hormones in particular cause women to become resistant to insulin in pregnancy?
cortisol
human placental lactogen
pathophysiology of gestational diabetes?
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
importance of keeping HbA1c below 48mmol in those with established diabetes in pregnancy?
reduces the risk of congenital malformations in the baby
association between diabetes in pregnancy and shoulder dystocia?
diabetes is an independent RF for shoulder dystocia
macrosomia also makes shoulder dystocia more likely
induction may be used to reduce the risk
medicines safe for control of diabetes in pregnancy?
metformin and insulin
all other medicines should be discontinued
ensure ACEIs, AIIRBs and statins are also stopped.
1st choice long acting insulin during pregnancy?
isophane (NPH insulin)
when should r/f to a nephrologist be considered in a patient with diabetes who is receiving pre-conception care?
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.
antenatal testing for gestational diabetes in a pt who has had gestational diabetes in a previous pregnancy?
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
criteria to be met to make a diagnosis of gestational diabetes?
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.
recommended health and lifestyle advice for woman with gestational diabetes in pregnancy?
-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.
management of women with gestational diabetes with fasting plasma glucose of 7 or greater at diagnosis?
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
target blood glucose levels in pregnancy?
fasting below 5.3
1 hr post meals below 7.8
2 hr post meals below 6.4
monitoring of fetal growth and wellbeing in pregnant women with diabetes?
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
recommended time for labour for women with diabetes in pregnancy?
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
CBG monitoring during labour?
hourly
ensure maintained between 4 and 7mmol/L
blood glucose lowering therapy management after birth for those with gestational diabetes?
discontinue immediately after birth
f/u of patient with gestational diabetes after the birth?
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.
