Diabetes in Pregnancy

Question 1

Gestational DM:

Answer 1

Related to hPL, diabetogenic hormone
Shows up in late 2nd/early 3rd trimester
Not ass w/ congenital anomalies like pregestational DM

Question 2

Risk of gestational DM

Answer 2

But do have incr risk neonatal hypoglycemia, hypoCa, hyperbili, polycythemia; risk of maternal T2DM later

Question 3

When to screen for gestational DM

Answer 3

Screen between 24-28 wks as described above. 50g 1h GLT → 100g 3h OGTT.

Question 4

White Classification:

Answer 4

GDM A1 = diet controlled
GDM A2 = needs meds / insulin
Diabetes that existed before pregnancy:
B-->C-->D for duration (<10, 10-20, >20 y)
F=neFropathy
R=Retinopathy
H=Heart dz
T=prior renal Transplant

Question 5

Monitor A2 (not A1) pts

Answer 5

NST or mod BPP starting between 32-36 wks

U/S for EFW (estimated fetal weight) between 34-37 wks

Question 6

Pregestational DM puts mom at risk for:

Answer 6

PEC/eclampsia, SAB, infection, polyhydramnios, PP hemorrhage, C/S

Question 7

All types of DM puts baby at risk for:

Answer 7

Higher risk for hypoglycemia, respiratory distress, polycythemia, hyperbili, hypoCa

Question 8

DM in pregnancy management:

Answer 8

Get HbA1c at outset to see status; then follow closely; good control prior to pregnancy is key

Also should get 4mg folate daily (higher risk of NTD).

Diet/exercise → meds / insulin as needed!

If poor control (T2 or T1): Should get ECG (esp if HTN), HbA1c, optho consult, etc.

If insulin dependent, offer fetal lung maturity @ 37 wks or IOL @ 38-39wks without testing

Question 9

Type 1 DM management:

Answer 9

Prepregnancy control key. Pumps are good. Don’t mess with insulin regimen until needed.

Question 10

Type 2 DM management:

Answer 10

Made worse by pregnancy, may go from diet/exercise or oral meds → insulin needs (manage as above)

Question 11

Type 2 DM intrapartum screening of baby:

Answer 11

Fetal testing @ 32 wks, earlier if poor control. Weekly NST / modified BPP for AFI.

Get growth U/S @ 32-36 wks

Question 12

Management of gestational diabetes

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Answer 12

Treat with CHO restricted diet, exercise to enhance postprandial blood sugar control (biggest time in gDM)

Tx if > 90 FBG, > 140 1h postprandial, > 120 2h postprandial.

Insulin (NPH x 2 doses + short-acting humalog/novolog) is conventional option

Can also use gyburide / metformin (“experimental”)

Question 13

Pregestational diabetes puts baby at risk for:

Answer 13

If really high HbA1c, think congenital defects (cardiac most common; also renal / NTD / pretty much all systems.
Caudal regression syndrome / sacral agenesis classic 2/2 disproportionally high risk in poorly controlled diabetics, but not as common as others

Question 14

Delivery recommendations for gestational diabetes

Answer 14

Scheduled delivery @ 39 wks if A2 commonly done; put on dextrose / insulin if needed.

If very poor control, may offer delivery between weeks 37-39.

○ Offer C/S to pts with EFW > 4,000g (incr risk shoulder dystocia