Diabetes in Pregnancy

Question 1

A woman has presented to MFAU on Monday morning for her regular bi weekly ctg’s, you see she has GDM and is not on insulin.
She informs you her levels have been high for the last few days.
She hasn’t brought her BGL book or BGL meter.
What would you consider doing?

Answer 1

Perform a random blood glucose level
•Page the dietitians for review and inform them of the situation - they will either come to review her in MFAU or make phone or email contact to thoroughly review her BGL’s.
•If she requires Insulin because her blood glucose levels are elevated then a referral will be made to the Diabetes Service for Insulin treatment

Question 2

What are the limits for Glucose Tolerance Test at fasting, 1 hour and 2 hours?

Answer 2

75g fasting Oral Glucose Tolerance Test (OGTT)
POSITIVE =
Fasting - > 5.1 mmol/L
1Hr - > 10.0 mmol/L
2 hour - > 8.5 mmol/L

Question 3

You saw a woman over the weekend in ANC and sent her for a GTT
You have checked the results Tuesday after your lunch break and they are:
FASTING: 4.4
1HR: 10.5
2 HR: 7.7
What would you do?

Answer 3

Call her and inform her of her GTT result, inform her that her 1 hour result is high, refer her to the Diabetes Service and explain she will see the Dietitian and Diabetes Educator at a Gestational Diabetes Class

Question 4

What should be recommended in postnatal education to GDM women?

Answer 4

Women diagnosed with GDM in pregnancy are
recommended to undergo a post partum
glucose tolerance test (GTT) approximately 6-12
after birth with their general practitioner

Then every 2 years thereafter to ensure they do not have T2DM out of pregnancy.

Question 5

What are the most common birth defects of uncontrolled GDM?

Answer 5

The most common diabetes related birth defects in are neural tube, cardiac and musculo-skeletal

Question 6

Hypoglycaemia causes which maternal complication?

Answer 6

increased rate systemic infection

Question 7

Hyperglycaemia causes which maternal complication?

Answer 7

shoulder dystocia

Question 8

Diabetic Ketoacidocis causes which maternal complication?

Answer 8

Pre-eclampsia

Question 9

Hypertension causes which maternal complication?

Answer 9

increased risk operative birth

Question 10

What are the Congenital abnormalities of uncontrolled blood sugar levels in pregnancy?

Answer 10

• Stillbirth & neonatal death
• Birth trauma
• Macrosomia, >90th Percentile
• Pre-term baby
• Hypoglycaemia, <2.6mmol
• Hyperbilirubaemia (Jaundice)
• Respiratory Distress

Question 11

What is the postnatal management of GDM?

Answer 11

Insulin requirements fall to normal after the delivery of the placenta
•T1DM – discuss with phsyicians and they will likely alter insulin doses back pre- pregnancy requirements or less. Continue monitor 4 point BGL’s.
•T2DM– Medication review by the physicans on the postnatal ward. Usually cease insulin. May continue with oral hypoglycaemic’s. Continue to monitor BGL’s.
•GDM – cease insulin – continue 4 point BGL over 24 hours. Postnatal OGTT 6-12 weeks weeks.

Question 12

What is the effect of GDM on lactogenesis?

Answer 12

•Excessive insulin causes hypoglycaemia, stimulating the release of adrenaline, which in turn inhibits the release of milk production
(Asselin et al 1987)
•Lactation may be more difficult as maternal diabetes and obesity can delay the onset of lactogenesis

Question 13

How is GDM managed in pregnancy?

Answer 13

• Weekly contact with the diabetes educator midwives & physicians
• We are concerned if a woman requires a lot less insulin toward the end of pregnancy
• When pregnant, we know that women require 2-3 times more insulin to do the same job to maintain BGL’s within a normal target range.

Question 14

What are the symptoms of Diabetic Ketoacidosis?

Answer 14

• Nausea
• vomiting
• Headaches
• Abdominal pain
• Leg cramps
• Acetone smelling breath
• Flushed cheeks
• If they have been unwell

Question 15

What are the High risk factors for GDM?

Answer 15

 Previous GDM
 Ethnicity: Asian (including Indian), Aboriginal, Pacific Islander, Maori, Middle Eastern, non-white African
 Maternal age > 40 yrs
 Family history DM (1st degree relative with DM including a sister with GDM)
 Obesity, especially if BMI > 35kg/m²
 Hypertension prior to 20 weeks
 Previous macrosomia (baby with birth weight more than 4000g
 History of unexplained stillbirth
 Previous baby with congenital abnormalities
 Polycystic ovarian syndrome
 Medications: corticosteroids, antipsychotics

Question 16

What is included in T2DM education for women with GDM?

Answer 16

What is diabetes? The types of diabetes
 Basic physiology - the role of food and insulin.
 Insulin requirements in each trimester
 The effects of diabetes on pregnancy
 The effects of pregnancy on diabetes
 The role of healthy eating in blood glucose control
 The role of exercise in blood glucose control
 Self -monitoring of blood glucose levels / equipment check
 Review of type 2 medications in regards to suitability in pregnancy
 Insulin self -administration and insulin adjustment / equipment check
 Lifestyle changes

Question 17

What are the ADIPS recommended goals for self blood glucose monitoring?

Answer 17

 Fasting <5.1mmol/L
 One hour post prandial <7.4 mmol/L
 Two hours post-prandial < 6.7 mmol/L

Question 18

What is Diabetic ketoacidosis?

Answer 18

 a life threatening metabolic complication of absolute insulin deficiency
 characterised by the triad of:
o Hyperglycaemia
o Ketonaemia from fatty acid metabolism
o Metabolic acidosis.
The resulting hyperglycaemia results in loss of water and electrolytes, hyperosmolality and fluid depletion.

Question 19

What is the Initial investigation for diabetic ketoacidosis?

Answer 19

1. BSL (laboratory and fingerpick): Check hourly
2. Arterial blood gases,
3. Urine and serum ketone level (blood β – ketone testing can be done using the Optium meter)
4. Urea and electrolytes

Question 20

Managment of DKA in pregnancy / birth suite?

Answer 20

1. Urinary catheter (if not producing urine after 3 hours).
2. Arterial line
3. Nasogastric tube (if drowsy / vomiting).
4. Sodium Chloride 0.9% Use for initial resuscitation
   o 1 – 2 L in the first hour
   o 500-1000mL / hour over the next 2-4 hours
5. Insulin infusion - 50 units Neutral insulin Actrapid ® in 500mL 0.9% sodium chloride 60msl/hour
6. Repeat ABG’s at 2 - 4 hours to check acidosis is being corrected,
7. Potassium <3.5, give 10mmol/L potassium chloride (KCL) per hour IV. Recheck every 1 – 2 hours.
8. Bicarbonate - In pregnancy, the normal PH is 7.4-7.45, so a PH of 7 represents severe acidosis and bicarbonate may be considered.
9. 10% DEXTROSE Commence at 40mL/hour when BGL <10 mmol/ hour to be run concurrently with 0.9% sodium chloride