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O&G > Diabetes in Pregnancy > Flashcards

Diabetes in Pregnancy Flashcards

1
Q

Pre-existing disorders in pregnancy: KEY questions (2)

A
  1. Effect on mother

2. Effect on baby

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2
Q

Aims of preconception review (4)

A
  • Optimise disease control
  • Ensure medication is safe for pregnancy
  • Enable counselling about risks + management of pregnancy
  • Women able to make informed choice
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3
Q

Pregnancy + Diabetes: Target BMs (NICE guidelines)

A
  • Fasting glucose: <5.3
  • Post meal: <7.8
  • HbA1c: <48
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4
Q

Risk factors for c-section in patients with high BMI (5)

A
  • Anaesthetic difficulties
  • Surgical access
  • PPH
  • Infection risk is increased
  • VTE risk
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5
Q

Diabetes in pregnancy + c-sections

A
  • NICE: recommends delivery of diabetic patients on insulin by 38/40.
  • Optimal timing for LCSC (Lower segment caesarean section) is non-diabetic patients is >39/40.
  • LCSC prior to 39/40 is associated with increased risk of acute respiratory arrest syndrome (ARDS) in neonate + higher rates of admission to NICU.
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6
Q

Medications + pregnancy: NSAIDS

A

CONTRAINDICATED:Increased risk Oligohydramnios and Premature closure fetal ductus arteriosus. Sometimes used in pregnancy for severe inflammatory conditions

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7
Q

Medications + pregnancy: PROPYLTHIOURACIL

A

Description: Used to treat hyperthyroidism.

CAUTION:Associated with severe liver disease/failure in some pregnancies.

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8
Q

Medications + pregnancy: LAMOTRIGINE

A

Description: Anticonvulsant - used to treat epilepsy + bipolar disorder.

CAUTION:Is considered the safest anti-epileptic drug (AED) when compared with the others. There is still however some concerns regarding an increased risk of congenital malformations compared with women not on AED. Most women of childbearing age who can be controlled on lamotrigine are so, due to its lower risk profile.

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9
Q

Medications + pregnancy: SODIUM VALPROATE

A

Description: used to treat epilepsy + bipolar

CAUTION:Sodium valproate​ has a much higher association of congenital malformations and should therefore be avoided.

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10
Q

Medications + pregnancy: ISOTRETINOIN

A

Description: used to treat acne

CONTRAINDICATED:Used in treatment of severe acne.

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11
Q

Medications + pregnancy: CARBIMAZOLE

A

Description: used to treat hyperthyroidism

CAUTION:Associated with rare skin disorder if taken in 1sttrimester – aplasia cutis.

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12
Q

Medications + pregnancy: TRIMETHOPRIM

A

Description: antibiotics, used to treat UTIs.

CAUTION: CAUTION:Interferes with folic acid pathway and is therefore considered teratogenic when taken in the 1sttrimester. It is considered generally safe after the 1sttrimester.

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13
Q

Medications + pregnancy: NITROFURATOIN

A

Description: antibiotics, used to treat UTIs.

CAUTION:Should be avoided in Pregnancy at term >36/40 due to association with haemolytic anaemia.

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14
Q

Medications + pregnancy: RAMIPRIL

A

Description: ACE-I

CONTRAINDICATED:ACE inhibitor should be avoided in second and third trimester due to increased risk of fetal renal damage.

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15
Q

Medications + pregnancy: CITALOPRAM

A

Description: SSRI antidepressant

CAUTION:SSRI can be associated with increased congenital heart disease when taken in 1sttrimester BUT if required for maternal mental health well-being it is generally not advisable to stop. This should be discussed with the women though

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16
Q

Fetal scalp electrode (FSE): Definition

A

FSE: Internal fetal heart rate monitoring uses an electric transducer connected directly to the fetal skin.

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17
Q

OBESITY in prenancy increase risk of:

  • Antenatal complications (6)
  • Intrapartum complications (2)
  • Postpartum complications (3)
A

Antenatal complications:

  • Miscarriage
  • Congenital malformation
  • PET
  • GDM
  • Macrosomia
  • VTE

Intrapartum complications:

  • Monitoring of baby during labour (may need FSE)
  • Anaesthetic difficulties

Postpartum complications:

  • PPH
  • Wound infection
  • VTE
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18
Q

Pre-conception review of medication: DIABETES

  • Most commonly used in pregnancy (2)
  • Avoided in pregnancy (3)
A

Most commonly used in pregnancy:

  • Metformin
  • Insulin

Avoided in pregnancy:

  • Glibenclamide
  • Statins
  • ACE-i
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19
Q

Pre-conception review of medication: HYPERTENSION

  • Most commonly used in pregnancy (3)
  • Avoided in pregnancy (3)
A

Most commonly used in pregnancy:

  • Labetalol
  • Nifedipine
  • Doxazosin

Avoided in pregnancy:

  • ACE-i
  • Angiotensin II blockers
  • Diuretics
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20
Q

Pre-conception review of medication: HAEMATOLOGY

  • Most commonly used in pregnancy (1)
  • Avoided in pregnancy (1)
A

Most commonly used in pregnancy:
- LMWH

Avoided in pregnancy:
- Warfarin

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21
Q

Pre-conception review of medication: EPILEPSY

  • Most commonly used in pregnancy (1)
  • Avoided in pregnancy (3)
A

Most commonly used in pregnancy:
- Lamotrigine (safest, although still associated with slightly higher congenital abnormalities)

Avoided in pregnancy:

  • Phenobarbitone
  • Phenytoin
  • Sodium valproate
22
Q

Pre-conception review of medication: ENDOCRINE

  • Most commonly used in pregnancy (2)
  • Avoided in pregnancy (2)
A

Most commonly used in pregnancy:

  • Carbimazole (although can cause aplasia cutis)
  • Propylthiouracil (PTU) - (does have some association with liver failure)

Avoided in pregnancy:

  • Radioactive iodine
  • Sex hormones
23
Q

Pre-conception review of medication: INFLAMMATORY CONDITIONS

  • Most commonly used in pregnancy (3)
  • Avoided in pregnancy (3)
A

Most commonly used in pregnancy:

  • Sulfazalazine
  • Mesalazine
  • Prednisolone

Avoided in pregnancy:

  • Methotrexate
  • Cyclophosphamide
  • NSAIDS
24
Q

Diabetes in pregnancy: Epidemiology

A

Definition: most common pre-existing disease in pregnancy.

  • 87.5% is gestational diabetes
  • 7.5% is T1DM
  • 5% T2DM
25
Q

Diabetes + pregnancy: OVERVIEW

A

Without good glycaemic control, there is increased fetal + neonatal morbidity + mortality.

Management should be by the MDT, including:

  • Obstetrician
  • Physician/diabetologist
  • Diabetic nurse
  • Dietician

Glucose metabolism is altered by pregnancy.

Many pregnancy hormones are diabetogenic (produce diabetes) - (human placental lactogen, cortisol, glucagon, oestrogen and progesterone).

Insulin requirements ↑ throughout and are maximum at term.

26
Q

Pathophysiology of diabetes in pregnancy (3)

A
  • Increased insulin resistance
  • Reduced glucose tolerance
  • Reduced renal tubular threshold for glucose
27
Q

Effect of PREGNANCY on DIABETES (6)

A
  • Increased insulin dose required
  • Increased hypoglycaemia attacks
  • Ischaemic heart disease
  • Retinopathy
  • Nephropathy
  • Ketoacidosis
28
Q

Effect of DIABETES on PREGNANCY:

  • Maternal (6)
  • Fetal (5)
A

Maternal:

  • Maternal hyperglycaemia (leads to fetal hyperglycaemia)
  • Increased miscarriage
  • Increased risk PET
  • Worsening renal disease
  • Infections
  • Increased induction + LCSC rate

Fetal:

  • Increased congenital malformation
  • Unexplained stillbirth
  • Fetal hyperglycaemia
  • Neonatal hypoglycaemia
  • Respiratory distress syndrome
29
Q

Why is Respiratory Distress Syndrome more common in babies with diabetic mothers?

A

Due to surfactant deficiency occurring through reduced production of pulmonary phospholipids

30
Q

Effect of DIABETES on PREGNANCY: Explained

A
  • Maternal hyperglycaemia leads to fetal hyperglycaemia.
  • This results in increased production of insulin in the fetal pancreas.
  • Insulin = growth factor.
  • This can result in MACROSOMIA.
  • This is turns leads polyhydraminos.
  • Which may lead to pre-term labour or cord collapse.
  • Macrosomia is also associated with ↑ incidence of induction, dysfunctional labour, shoulder dystocia and PPH.
  • Fetal hyperinsulinemia also leads to chronic fetal hypoxia stimulating haemopoesis and resulting in polycythaemia and jaundice.
  • This can lead to splenomegaly.
  • Following delivery the high circulating levels of insulin can result in neonatal hypoglycaemia.
  • This is caused by the removal of maternal glucose supply at birth.
31
Q

Pre-exisiting diabetes: Pregnancy counselling (4)

A
  • General advice: weight loss, smoking, alcohol
  • Blood glucose targets
  • Aspirin 75 mg once daily ↓ risk of pre-eclampsia
  • Measure BM: fasting, pre-meal, post-meal + bedtime
32
Q

Risk factors for GDM (5)

A
  • BMI > 30
  • Previous GDM
  • Previous baby >4.5kg
  • Family hx (1st degree relative)
  • Ethnic origin with high relevance
33
Q

GDM: Diagnosis (2)

A
  • Fasting glucose: >5.6 mmol/litre

- 2 hour plasma glucose: >7.8 mmol/litre

34
Q 
Antenatal care: All Diabetes - 
USS appointment (5)
A
  • Routine dating at 11-13/40
  • Routine anomaly at 〜20/40
  • Serial growth scans: every 4/52 from 28/40
  • (To assess fetal size + monitor for macrosomia)
  • Women with other co-morbidities should be considered for anaesthetic assessment by the 3rd trimester.
35
Q

Diabetes: Timing + mode of delivery (4)

A
  • Uncomplicated T1DM + T2DM: offer all women elective delivery between 37-38+6/40 (either by LCSC or IOL)
  • Women with maternal/fetal complications: offer prior to 37/40
  • Women with GDM: offer delivery before 40+6
  • Diabetic pregnancies with evidence of macrosomia + EFW > 4.5kg: offer elective LCSC (as alternative to VG) due to concerns regarding shoulder dystocia.
36
Q

Diabetes: Intra- partum care (4)

A
  • Intrapartum targets for BM: 4-7
  • Women with T1DM who cannot maintain BM: start of insulin dextrose sliding scale.
  • Breastfeeding should be encouraged, ideally 1st feed should occur within 30 minutes.
  • Fetal BM should be checked every 2-4 hours (maintain above 2 mmol/litre)
37
Q

Pre-existing diabetes: Post-partum care (3)

A
  • Post-delivery insulin requirements rapidly fall.
  • Women with pre-existing diabetes: should re-start pre-pregnancy dose (reduced if breast feeding).
  • Women with GDM: usually stop all glucose reducing agents immediately after delivery.
38
Q

Complications of diabetes in pregnancy: MATERNAL (9)

A
  • UTI
  • Recurrent vulvovaginal candidiasis
  • Pregnancy-induced hypertension
  • Preeclampsia
  • Obstructed labour
  • Operative deliveries
  • ↑ retinopathy
  • ↑ nephropathy
  • Cardiac disease
39
Q

Complications of diabetes in pregnancy: FETAL (7)

A
  • Miscarriage
  • Congenital abnormalities
  • Preterm labour
  • Polyhydramnios (25%)
  • Macrosomia (25-40%)
  • IUGR
  • Unexplained IUD
40
Q

Complications of diabetes in pregnancy: NEONATAL (9)

A
  • Polycythaemia
  • Jaundice
  • Hypoglycaemia
  • Hypocalcaemia
  • Hypomagnesaemia
  • Hypothermia
  • Cardiomegaly
  • Birth trauma: shoulder dystocia, fractures, Erb’s palsy, asphyxia
  • Respiratory distress syndrome
41
Q

Diabetes: Pre-pregnancy counselling

A

Offer to all diabetic women of reproductive age, include:

  • Achievement of optimal control
  • Assessment of severity of diabetes
  • Education
  • General health
  • Folic acid
  • Rubella status
  • Contraception
42
Q

Diabetes: Antenatal care (9)

A

Managed by MDT (with diabetologist);

  • Control
  • HbA1c every month
  • Dietician review
  • Dating ultrasound
  • Downs syndrome screening
  • Anomaly scan
  • Fetal echocaridography (for congenital abnormalities)
  • Antenatal surveillance (USS, umbilical artery doppler)
  • Hypoglycaemia awareness
43
Q

Diabetes: Labour + post-partum care

A

Think about:

  • Timing of delivery
  • Mode of delivery (Vaginal delivery = preferred)
  • Glycaemic control
  • Post-partum care
  • Contraception
44
Q

GDM: Definition

A

Definition: A type of diabetes that affects pregnant women usually during the 2nd/3rd trimester. Women with gestational diabetes don’t have diabetes before their pregnancy and after giving birth it usually goes away.

Diagnosis is based on an Oral Glucose Tolerance Test (OGTT), usually undertaken at 26-28 weeks gestation.

N.B. A normal result in early pregnancy does not mean that gestational diabetes will not develop.

45
Q

GDM: Management

A
  • Management by MDT
  • Measure BM 4-6 times/day
  • Diet should be first line treatment
  • Start insulin if ↓ glycaemic control
  • No increased risk of miscarriage or congenital abnormalities
  • Antenatal + post-partum care same as established diabetes
  • Post-partum:
    (1) Stop insulin/glucose infusions
    (2) Check glucose prior to discharge
    (3) Arrange OGTT
    (4) Education - T2DM prevention
46
Q

Shoulder Dystocia: Definition

A

Definition: Any delivery that requires additional obstetric manoeuvres after gentle downward traction on the head has failed to deliver shoulders

47
Q

Complications of shoulder dystocia: FETAL (6)

A
  • Hypoxia and neurological injury
  • Brachial plexus palsy
  • Fracture of clavicle or humerus
  • Intracranial haemorrhage
  • Cervical spine injury
  • Fetal death (rare)
48
Q

Complications of shoulder dystocia: MATERNAL (2)

A
  • PPH

- Genital tract trauma (3rd/4th degree tears)

49
Q

Shoulder Dystocia: Mechanism

A
  • Common: anterior shoulder impacts on symphysis pubis
  • Due to failure of internal rotation of shoulders
  • Rare: posterior shoulder impacted on sacral promontary (resulting in bilateral impaction)
  • Fetal deterioration = rapid
  • Often without cord acidosis
  • Due to cord compression + trauma
50
Q

Shoulder Dystocia: Risk factors

  • Antenatal (5)
  • Intrapartum (2)
A

Prediction of shoulder dystocia by use of risk factors has poor predictive value. Only 50% of shoulder dystocia is associated with a birth weight >4kg.

Antenatal:

  • Previous hx of shoulder dystocia
  • Fetal macrosomia
  • BMI > 30 (+ excessive weight gain in pregnancy)
  • Diabetes mellitus
  • Post-term pregnancy

Intrapartum:

  • Lack of progress in 1st/2nd stage of labour
  • Instrumental vaginal delivery
51
Q

Shoulder dystocia: Management

A

Prompt, skillful, and well-rehearsed manoeuvres may improve outcome.

mnemonic: HELPERR
- H: Call for help
- E: Episiotomy
- L: Legs into McRoberts
- P: Suprapubic pressure applied to posterior aspect of anterior shoulder
- E: Enter pelvis for internal manoeuvres
- R: Release of posterior arm by flexing elbow
- R: Roll over on to ‘all fours’

Other manoeuvres:

  • Zanvanelli
  • Symphysiotomy

O&G (13 decks)

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