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Clinical Nutrition 3 > Diabetes in Pregnancy > Flashcards

Diabetes in Pregnancy Flashcards

1
Q

What are the two categories of diabetes in pregnancy?

A
  • Pre-gestational diabetes

- Gestational diabetes

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2
Q

Pre-gestational diabetes?

A
  • Pregnancy in pre-existing diabetes

- Can be type 1 or type 2

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3
Q

Gestational diabetes?

A

Diabetes diagnosed in pregnancy

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4
Q

What are the risk factors of GDM being ____

A
  • 35 years or older

- From high risk ethnic group (African, Arab, Asian, Hispanic, Indigenous or South Asian)

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5
Q

Using what increases the risk of GDM?

A

-Corticosteroid medication

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6
Q

Having what increases the risk of GDM?

A
  • Obesity
  • Pre-diabetes
  • GDM in a previous pregnancy
  • Given birth to a baby >4kg
  • A parent, brother or sister with T2DM
  • PCOS or acanthosis nigricans
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7
Q

(T/F) GDM can always be prevented

A

F, not in all cases

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8
Q

What does current literature suggest about the prevention of GDM?

A

-Diet-based interventions, when compared to PA alone and metformin alone appear to show the most potential for preventing GDM, especially when directed towards overweight and obesity

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9
Q

What did a recent-meta analysis show about excessive gestational weight gain (GWG)?

A

-When occurring in the first and second trimester, will increase the risk of GDM

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10
Q

What does an increase in BMI during the inter-pregnancy in women with normal BMI or with a BMI >27 kg/m2 suggest?

A

Higher risk of GDM in their second pregnancy

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11
Q

What does a decrease in BMI in inter-pregnancy period in women with overweight or obesity?

A

Lower risk of developing GDM in their second pregnancy

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12
Q

What is inter-pregnancy?

A

Between pregnancy

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13
Q

What should be reinforces during the preconception period for women with overweight and obesity?

A

The importance of healthy diet and lifestyle

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14
Q

(T/F) In a normal pregnancy, insulin resistance will increase with maternal adiposity and cortisol production from the placenta

A

T

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15
Q

What causes insulin resistance in a normal pregnancy?

A
  • Increase in maternal adiposity

- Cortisol production from the placenta

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16
Q

What is the purpose of the development of insulin resistance during the second half of pregnancy?

A

Serve as a physiological adaptation of the mother to ensure adequate CHO supply for the rapidly growing fetus

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17
Q

What is the primary source of fuel for the mother?

A

Due to the insulin resistance, favour of fats than CHO for energy of mother and spares CHO for the fetus

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18
Q

Despite the intermittent maternal food intake, how does glucose and lipid metabolism change?

A

-Changes in glucose and lipid metabolism occur progressively during pregnancy to ensure a continuous supply of nutrients to the growing fetus

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19
Q

At the third trimester, insulin sensitivity may gradually decline to ___ of the normal expected value

A

50%

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20
Q

What are the 4 phases of PG-DM?

A

1) Pre-conception counseling
2) Management during pregnancy
3) Management in labour
4) Postpartum considerations

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21
Q

What are the 4 phases of GDM?

A

1) Prevention, screening & diagnosis
2) Management during pregnancy
3) Management in labour
4) Postpartum considerations

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22
Q

____ in Pregnancy can result in adverse pregnancy outcomes

A

Dysglycemia

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23
Q

What can have adverse effects on the fetus?

A

Elevated glucose levels

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24
Q

Consequences of elevated glucose first semester?

A

Fetal malformations

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25
Q

Consequences of elevated glucose in the second and third trimesters?

A

Increased risk of macrosomia and metabolic complications

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26
Q

Why is glycemic control pre-conception essential?

A

The absolute risk of a fetal anomaly increases exponentially with increased preciconceptional A1C

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27
Q

Key points for pre-conception counseling for PG-DM?

A
  • Advise reproductive age women with diabetes about reliable birth control
  • Achieve a healthy weight is essential to avoid the obesity associated with adverse pregnancy outcomes
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28
Q

What is noted about metformin in preconception counseling for women with pre-gestational diabetes?

A
  • Metformin in PCOS may improve fertility

- Metformin is safe for ovulation induction in PCOS

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29
Q

Pre-conception checklist for women with pre-existing diabetes?

A
  • Use reliable birth control until adequate glycemic control
  • Attain a preconception A1C of =7% or 6.5% if safe
  • May remain on metformin and glyburide until pregnancy, otherwise switch to insulin
  • Assess for and manage any diabetes complications
  • Folic acid 1 mg/day: 3-months pre-conception to 12 weeks post-conception
  • Discontinue potential embryopathic meds
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30
Q

Which meds are potentially embryopathic?

A
  • ACE inhibitors/ARB

- Statin therapy

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31
Q

T1DM pregnancy management for pre-existing diabetes?

A

-Basal-bolus insulin therapy at 3-4 injections per day or continuous subcutaneous insulin infusion

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32
Q

T2DM pregnancy management for pre-existing diabetes?

A

-Switch to insulin

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33
Q

Suggestions for customizing insulin therapy for close monitoring?

A
  • Bolus insulin: May use aspart or lispro instead of regular insulin
  • Basal insulin: may use detemir or glargine as alternative to NPH (NPH OK if T2DM)
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34
Q

When should SMBG be performed?

A

Both pre and post-prandially

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35
Q

Fasting and pre-prandial BG target?

A

<5.3 mmol/L

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36
Q

1hr postprandial BG?

A

<7.8 mmol/L

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37
Q

2hr postprandial BG?

A

<6.7 mmol/L

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38
Q

A1C target>

A

= 6.5% if = 6.1% if possible

–> To lower late stillbirth and infant death

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39
Q

How should targets be modified in those with severe hypoglycemia/unawareness?

A

Individualized

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40
Q

What is recommended for diabetes management in type 1 diabetes

A
  • CGM should be considered in all women

- Will decrease LGA, NICU >24hrs, neonatal hypoglycemia, infant length of stay

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41
Q

General pregnancy management for patients with pre-existing diabetes?

A
  • Encourage weight gain according to IOM recommendations

- ASA to reduce the risk of pre-eclampsia, starting at 12-16 weeks GA

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42
Q

BMI <18.5 recommended weight gain?

A

12.5-18.0 kg

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43
Q

BMI 18.5-24.9 recommended weight gain?

A

11.5-16.0

44
Q

BMI 25.0-29.9 recommended weight gain?

A

7.0-11.5 kg

45
Q

BMI >/30 recommended weight gain?

A

5.0-9.0 kg

46
Q

Why should we diagnose and treat GDM?

A

-Due to the severe risks glycemia can have on the mother and the fetus

47
Q

What are some consequences of uncontrolled glycemia during pregnancy

A
  • Macrosomia
  • Shoulder dystocia and nerve injury
  • Neonatal hypoglycemia
  • Pre-term delivery
  • Hyperbilirubinemia
  • Caesarian section
  • Offspring obesity
  • Offspring diabetes
48
Q

When is universal screening for GDM performed?

A

At 24-28 weeks Gestational age

–> Screening will be performed earlier if there are risk factors for GDM

49
Q

If a women is at high risk of T2DM, how should they first be screened?

A

-Screen with A1C or FPG if A1C unreliable in the first trimester

50
Q

If after early screening, and A1C is seen to be >/= 6.5% or FPG >/= 7.0 mmol/L, how should it be treated?

A
  • treat like T2DM

- Confirm diagnosis post-partum

51
Q

When are all women screen for GDM? High risk?

A
  • All pregnant women between 24 and 28 weeks gestations

- If there is a high-risk, screening should be offered at any stage in the pregnancy

52
Q

What is the preferred approach to GDM screening?

A

50 g glucose challenge test with PG 1 hour later

53
Q

What confirms a diagnosis of GDM with the 50 g glucose test?

A
  • If >/= 11.1 mmol/L
  • If 7.8-11.0 mmol/L with confirmation with a 75 g OGTT
  • -> If less that 7.8 mmol/L, BG is normal
54
Q

75 g OGTT results to confirm GDM? (Note this is the confirming test after the inconclusive 50 g OGTT)

A

If one of the following is met or exceeded:

  • FPG >/=5.3 mmol/L
  • 1hrPG >/= 10.6 mmol/L
  • 2hrPG >/= 9.0 mmol/L
55
Q

What is the alternative approach to screening for GDM?

A

-75 g OGTT then measure FPG 1hPG and 2hPG

56
Q

Results of the alternative 75 g OGTT which would confirm GDM?

A

If one of the following is met or exceeded:

  • FPG >/= 5.1 mmol/L
  • 1hPG >/= 10.0 mmol/L
  • 2hPG >/= 8.5 mmol/L
57
Q

If glycemic targets are not met between 1-2 weeks, what should be initiated?

A

1-2 weeks

58
Q

What is the first-line medication in GDM?

A

INSULIN (not metformin)

-May use aspart, lispro, glulisine, perinatal outcomes similar

59
Q

Metformin may be used as an alternative to insulin, what does the evidence show?

A
  • Good safety data in pregnancy
  • Evidence of less maternal weight-gain, less large-for-gestational-age, less neonatal hypoglycemia
  • Women should be informed that it crosses the placenta
  • Safety data in offspring postpartum up to 2 years
60
Q

Insulin is necessary in ___ of those on metformin

A

40%

61
Q

What may be used in women who refuse insulin and not well controlled on metformin?

A

Glyburide

-Sulfonylureas

62
Q

When should fetal surveillance increased? When should induction be offered?

A
  • In women with poorly controlled and/or with co-morbidities
  • Offer induction 38-40 weeks GA to potentially reduce still-birth and C-section
  • Earlier or later induction should be considered based on glycemic control and presence of other co-morbidities
63
Q

What is the goal of nutritional therapy within the context of diabetes and pregnancy?

A
  • To promote adequate maternal and fetal growth while avoiding ketosis
  • -> Remember that the glucose is sent to the fetus first
  • -> A moderate carbohydrate diet is recommended as a first-line therapy with increasing evidence of emphasizing low-GI CHO’s
64
Q

Nutrition intervention snack distribution?

A
  • Women should aim for 3-moderate sized meals and 2 or ,ore snacks of which one should be before bedtime
  • Small frequent meals will help women minimize nausea and ketone formation
65
Q

Breakfast recommendation?

A

15-30 g of CHO and preferably no fruits or milk

66
Q

Why should fruits and milks be limited at breakfast?

A

They are more insulin resistant in the morning, therefore we want to slightly limit carbs an limit these foods due to sensitivities in the AM of fructose and lactose
–> However, low-lactose dairy products may be tolerated such as greek yogurt

67
Q

Lunch & Dinner recommendations?

A

30-45 g of CHO, where vegetables should make up the majority of the plate
each meal should consist of CHO + PRO + FAT

68
Q

Low GI?

A

<55

69
Q

Medium GI?

A

56-69

70
Q

High GI?

A

70>

71
Q

How should snacks be administered?

A
  • Snacks will help women feel full between meals, avoid dropping blood sugars and prevent them from overeating at their next meals
  • Should consisted of 15-30 g of CHO
  • Consist of CHO and protein
72
Q

Which nutrients should be especially considered in a pregnant womenss diet? (C-FIVE)

A
  • Calcium
  • Folate
  • Iron
  • Vitamin D
  • EFAD
73
Q

Folic acid supplements 1 month before pregnancy and once they get pregnant?

A

-400 mcg
-600 mcg
Daily

74
Q

What other supplements should be considered in pregnancy?

A

-Iron, calcium, vitamin D or a MV

75
Q

What are 3 types of common prenatal MVs? Are they designed to meet the RDA for pregnant women?

A

-Pregvit
-Pregvit folate 5
-Materna
–> NO
Materna has the lowest amount of nutrients compared to others, but none meet the recommendations as the primary source should be through foods

76
Q

What is the consensus of energy intake for pregnancy?

A
  • There is no universal recommendation
  • ADA recommends 20 kcal/kg /day
  • If >120% of IBW, 23 kcal/kg of day
  • If <90% of IBW 36-40 kcal/kg/day
77
Q

What does ADA recommend about hypocaloric diets for obese women?

A

It runs a risk of high levels of blood ketones to the fetus, and risk of sacrificing maternal nutritional status
–> Require close monitoring

78
Q

Caloric intake should promote what? (3)

A
  • Fetal/neonatal and maternal health
  • Achieve glycemic goals
  • Promote appropriate gestational weight gain (GWG)
79
Q

EER pregnancy?

A

Nonpregnant EER + Pregnancy Energy Deposition (PED)

80
Q

EER 1st trimester PED?

A

0

81
Q

EER 2nd trimester PED?

A

340

82
Q

EER 3rd trimester PED?

A

452

83
Q

First trimester time?

A

0-13 weeks

84
Q

Second trimester time?

A

14-26 weeks

85
Q

Third trimester time?

A

27-40 weeks

86
Q

How to calculate energy requirements in the 2nd and 3rd trimesters?

A

180 kcals + (8 kcals x weeks gestation

87
Q

Protein requirements

A

10 to 35% of energy or 1.1 g/kg/day

88
Q

Fat requirements?

A

20-35%

89
Q

CHO requirements? CHO requirements at St. Mary’s?

A

45-65%

30-35%

90
Q

When BMI is >30, what weight should be used?

A

Adjusted body weight
Actual BW - IBW (at BMI of 25) + IBW
–> Then add the estimated requirement by trimester

91
Q

Specific DRI macronutients recommendations, including those with GDM for CHO, protein and fibre?

A
  • 175 g of CHO
  • 71 g of protein (or 1.1 g/kg/day)
  • 28 g of fibre
92
Q

What does regular exercise and a healthy diet promote?

A
  • Improved glycemic control
  • Facilitate weight control
  • Improve insulin sensitivity
93
Q

The risk of GDM is _____ to the degree of PA in the year prior to pregnancy

A

inversely proportional

94
Q

What is exercise before and during early pregnancy associated with?

A

A 51% and 48% reduction in GDM risk, respectively.

–>Exercise started before and continued throughout pregnancy may lead to GDM risk reduction of 69%

95
Q

PA recommendation in pregnancy?

A

150 minutes each week, with approximately 3-5 sessions of 30-45 minutes each.

96
Q

Important consideration about initiating exercise?

A

Important for those who were not active prior to being pregnancy to start very gradually

97
Q

What should be encouraged in post-partum management?

A

1) Breastfeeding

2) 75 g OGTT at 6 weeks and 6 months PP to check glycemic control

98
Q

Benefits of breastfeeding on GDM post-partum management?

A

-Reduce neonatal hypoglycemia, childhood obesity & diabetes AND maternal risk of diabetes & hypertension

99
Q

When should the 75 OGTT be performed? How does this change if mom was diagnoses with diabetes early in pregnancy?

A
  • Usually 6 weeks to 6 months

- If diagnosed early do FPG or OGTT at 6-8 weeks post-partum

100
Q

75 OGTT post-partum normal?

A

healthy behaviour continuation

101
Q

75 OGTT post-partum IGT?

A

-Healthy behaviour interventions +/- metformin

102
Q

75 OGTT post-partum T2DM?

A

-Healthy behaviour interventions +/= metformin and +/=-insulin

103
Q

Practical suggestions for morning sickness? (re-cal that many women are on insulin, the experience frequent N/V)

A
  • SMFQM

- Higher BG in AM, and may divide their bolus if they anticipate not eating their entire meal due to sickness

104
Q

What does G3P1A1L1 mean?

A 
G3= 3rd pregnancy
P1 = one delivery
A1= one abortion
L1 = 1 living child
105
Q

What is EFW?

A

Estimated Fetal weight

106
Q

(T/F) Even in normal, non-diabetic pregnant women may have higher levels of ketones in their blood and urine

A

T

Often after a long period of fasting, such as in the morning

Clinical Nutrition 3 (30 decks)

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