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OBGYN 4MB > Diabetes in Pregnancy > Flashcards

Diabetes in Pregnancy Flashcards

1
Q

Define diabetes mellitus

A

A metabolic disorder of multiple aetiologies characterised by chronic hyperglycaemia resulting from defects in insulin secretion, insulin action or both.

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2
Q

Define gestation diabetes mellitus (GDM)

A

Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. Includes women with impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). Affects at least 1/10 pregnancies.

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3
Q

Why do patients with T1DM and T2DM need preconceptual care?

A
  • High risk patients with poorer fetal outcome
  • Needed to optimise glycaemic control
  • Review medical and obstetric hx
  • Advise on glycaemic control
  • Screen for and manage complications
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4
Q

List the risks of a diabetic pregnancy

A
  • Risks to the mother:
    1. Hypo/Hyperglycaemia
    2. Ketoacidosis
    3. C-section
    4. Retinopathy
    5. HTN/Pre-eclampsia
    6. Nephropathy
  • Risks to the fetus:
    1. Miscarriage
    2. Still birth/neonatal death
    3. Congenital malformations
    4. Premature delivery
    5. Birth trauma secondary to macrosomia
    6. Neonatal hypoglycaemia
    7. Neonatal polycythemia
    8. Neonatal hypocalcaemia
    9. Neonatal hyperbilirubinaemia
    10. Neonatal cardiomyopathy
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5
Q

What is the risk of the offspring of a diabetic parent developing diabetes?

A
  • T1DM = 2-3% if mother affected; 5-6% if father affected
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6
Q

Discuss counselling and contraceptive advice for pre-existing diabetics

A
  • Stress need for preparation for pregnancy and counselling
  • Intensive preparation should ideally begin 3-6mths before desired time of conception
  • Contraceptives should be continued until HbA1c optimised
  • Avoid COCP in women with vascular complications and HTN
  • Woman should meet team looking after her
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7
Q

How is glucose monitoring addressed in preconceptual care and counselling?

A
  • Review technique and frequency
  • Record measurements 7 times/day (fasting, pre-meals, 1hr post-meals and before bed)
  • Targets:
  • Fasting and pre-meal = 3.5-5.5mmol/L
  • 1hr post-meal = <7mmol/L
  • Discuss management of hypoglycaemia
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8
Q

What should be discussed in relation to nutritional management in preconceptual care and counselling?

A
  • Diet:
  • Low GI foods
  • Not excessive in fat
  • Encouraged to achieve normal BMI prior to pregnancy
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9
Q

What advice should be given in relation to gestational weight gain?

A
  • Excessive weight gain is a risk factor for adverse outcome
  • Advise on expected weight gain according to BMI
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10
Q

How and why do we screen for pre-existing nephropathy and HTN in diabetics?

A
  • Association between pre-existing nephropathy and poorer pregnancy outcome
  • Measure urine PCR to identify renal status prior to pregnancy
  • Do baseline serum creatinine and eGFR
  • eGFR <40 at beginning of pregnancy may experience irreversible decline in renal function
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11
Q

What is the protocol for retinopathy screening for diabetics in pregnancy?

A
  • Fundal exam advised prior to conception and once in each trimester for those without retinopathy
  • If have established retinopathy = every 6wks
  • Advise ophthalmologist
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12
Q

What additional blood tests need to be done in diabetic patients?

A
  1. TFTs

2. Rubella antibodies (where status unknown)

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13
Q

What is the criteria for diagnosis of GDM?

A
  • Diagnosis done with 75g OGTT
  • Fasting = >5.1mmol/L
  • 1hr = >10.0mmol/L
  • 2hr = >8.5mmol/L
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14
Q

Who is screened for GDM?

A
  • Best practice is to recommend universal screening with OGTT at 24-28wks
  • Can do selective screening on basis of risk
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15
Q

List the high risk factors for GDM

A
  1. Severe obesity (BMI > 30)
  2. Hx GDM or macrosomic baby
  3. Presence of glycosuria
  4. Dx of PCOS
  5. Strong family hx of T2DM
  6. Ethnicity (all ethinic subgroups)
  • OGTT ASAP if any of these present
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16
Q

List the medium risk factors for GDM

A
  1. BMI 25-30
  2. Maternal age >30
  3. Long term steroids
  4. Previous unexplained perinatal death
  5. Polyhydramnios and/or macrosomia in existing pregnancy
  • Screen at 24-28wks if any of these present
17
Q

List the factors that make a patient low risk for GDM

A
  1. Age <25
  2. Weight normal before pregnancy
  3. Caucasian
  4. No known DM in first degree relatives
  5. No hx of abnormal glucose tolerance
  6. No hx of poor obstetric outcome
  • If have all of above do not require GDM screening
18
Q

How is diabetes managed in pregnancy?

A
  • Blood glucose checked 7 times a day
  • Nocturnal hypoglycaemia or variable fasting glucose - 3am glucose level
  • Multi-dose injection regime recommended for most
  • Adjust own insulin doses based on intake
  • HbA1c checked at booking and every 2-4wks thereafter; target <6%
  • Continuous subcut insulin infusion considered for those unable to meet targets
  • Decrease in insulin requirements during pregnancy may indicate decrease in placental function
  • Pre-pregnancy insulin regime and insulin regime after delivery recorded in notes along with need for sliding scale during delivery
19
Q

What are the doses of insulin used in pregnancy?

A
  • If started in first trimester = 0.7U/kg/day
  • 2nd trimester = 0.8U/kg/day
  • 3rd trimester = 0.9U/kg/day
  • 36-40wks = 1U/kg/day
20
Q

How can we prevent and manage DKA in pregnancy?

A
  • Patient education about sick day management, frequent BG testing, increased insulin doses and the significance of vomiting and dehydration
  • Nausea, vomiting, abdo pain, fever and poor oral intake = high index of suspicion
  • Test urinary and plasma ketones if unwell
  • Low threshold for admission
21
Q

How can we manage nutrition in a diabetic pregnancy?

A
  • Dietician involvement
  • 40% carbohydrate, 30% fat, 30% protein per day
  • T2DM focus on portion size
  • Advise on appropriate gestational weight gain
  • Vit D supplementation if of Asian origin
22
Q

How is vomiting managed in a diabetic pregnancy?

A
  • Severe nausea of pregnancy = antiemetics
  • Severe vomiting = hospitalise
  • Check TFTs if hyperemesis gravidarum
23
Q

How can we manage hypoglycaemia in pregnant diabetics?

A
  • Partners of all women with pregestational diabetes given a glucagon kit and taught how to use it
24
Q

How do we screen for nephropathy and HTN during pregnancy?

A
  • Screened for albumin secretion at booking and/or in first or second trimester
  • Close monitoring prior to and during pregnancy
25
Q

Describe the obstetric management of the diabetic patient?

A
  • Dating scan at 11-14wks
  • Routine review every 2-4wks up to 34wks and weekly thereafter
  • Anomaly scan at 20wks
  • Growth scans at 28 and 34 wks
  • During labour and delivery continuous CTG and FBS available on request
  • Woman instructed on importance of fetal movements and contact obstetric unit if decreased
26
Q

What is important about the timing and mode of delivery?

A
  • Risk of stillbirth balanced against the risks of IOL at 38-39wks and success rate of vaginal delivery following IOL
  • Consider risk factors:
  • Prepregnancy and within pregnancy glycaemic control
  • Evidence of fetal macrosomia
  • Compliance with glucose and fetal monitoring
  • Previous pregnancy outcomes
27
Q

What is the first intervention used in GDM?

A
  • Trial of diet and exercise

- If fasting glucose still high = insulin

28
Q

How are T1DM and T2DM patients managed during labour?

A
  • Once labour established insulin sliding scale commenced
  • Allowed light diet
  • Chart hourly BG
  • Keep glucose conc of 4-7mmol/L (prevent neonatal hypoglycaemia)
  • If fasting for C-section - background basal dose continues without bolus doses
29
Q

Describe the insulin sliding scale

A
  • Glucose infusion 5% glucose at 100ml/hr
  • Insulin infusion:
  • 50U in 50ml of 0.9% NaCl
  • Start infusion as directed by blood glucose estimation
  • Rate of glucose infusion maintained at 100ml/hr
  • Rate of insulin infusion adjusted according to BG level
  • Use saline if additional fluids needed (DO NOT USE HARTMANNS)
30
Q

What is the protocol for C-section in diabetic patients?

A
  • Set up glucose and insulin infusion at 8am
  • Elective C-section = omit breakfast or SC insulin in morning
  • IV antibiotics given prophylactically
31
Q

What is the protocol for IOL in diabetic patients?

A
  • Admit evening prior to allow for timely commencement of insulin infusion
  • All assessed vaginally on admission
32
Q

How are T1DM and T2DM patients managed post-delivery?

A
  • Half insulin infusion after placenta delivered
  • Monitor BG every 2hrs
  • Adjust insulin infusion rate according to BG, keeping glucose infusion constant
  • Continue IV fluids and insulin infusion until ready to eat
  • Start SC insulin at pre-pregnancy dose or planned regime with food
  • Discontinue insulin infusion 30-60mins after SC insulin to ensure overlap
33
Q

How are GDM patients managed post-delivery?

A
  • Insulin infusion stopped as soon as placenta delivered
  • BG monitoring continued prior to each meal and 1-2hrs postprandially for 24hrs post delivery
  • If all values <7 preprandially and <11 postprandially women may discontinue monitoring
34
Q

What is the postnatal follow up for T1DM and T2DM patients?

A
  • Postnatal examination 6-12wks after birth
  • If planning further pregnancy - back to prepregnancy care
  • If not - back to general diabetes services
35
Q

What is the postnatal follow up for GDM patients?

A
  • Postnatal examination 6-12wks after birth
  • Postnatal glucose tolerance test at 6-12wks
  • Return to GP care after receiving appropriate dietary and lifestyle advice
  • Annual screening recommended
  • Planning another pregnancy within 1yr - rebooked for prepregnancy clinic and repeat prepregnancy OGTT rescheduled

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