Diabetes in Pregnancy Flashcards
1
Q
What are the two categories of diabetes in pregnancy?
A
- Pre-gestational diabetes
- Gestational diabetes
2
Q
Pre-gestational diabetes?
A
- Pregnancy in pre-existing diabetes
- Can be type 1 or type 2
3
Q
Gestational diabetes?
A
Diabetes diagnosed in pregnancy
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)
5
Q
Using what increases the risk of GDM?
A
-Corticosteroid medication
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
7
Q
(T/F) GDM can always be prevented
A
F, not in all cases
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
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
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
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
12
Q
What is inter-pregnancy?
A
Between pregnancy
13
Q
What should be reinforces during the preconception period for women with overweight and obesity?
A
The importance of healthy diet and lifestyle
14
Q
(T/F) In a normal pregnancy, insulin resistance will increase with maternal adiposity and cortisol production from the placenta
A
T
15
Q
What causes insulin resistance in a normal pregnancy?
A
- Increase in maternal adiposity
- Cortisol production from the placenta
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
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
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
19
Q
At the third trimester, insulin sensitivity may gradually decline to ___ of the normal expected value
A
50%
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
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
22
Q
____ in Pregnancy can result in adverse pregnancy outcomes
A
Dysglycemia
23
Q
What can have adverse effects on the fetus?
A
Elevated glucose levels
24
Q
Consequences of elevated glucose first semester?
A
Fetal malformations
25
Consequences of elevated glucose in the second and third trimesters?
Increased risk of macrosomia and metabolic complications
26
Why is glycemic control pre-conception essential?
The absolute risk of a fetal anomaly increases exponentially with increased preciconceptional A1C
27
Key points for pre-conception counseling for PG-DM?
- 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
28
What is noted about metformin in preconception counseling for women with pre-gestational diabetes?
- Metformin in PCOS may improve fertility
| - Metformin is safe for ovulation induction in PCOS
29
Pre-conception checklist for women with pre-existing diabetes?
- 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
30
Which meds are potentially embryopathic?
- ACE inhibitors/ARB
| - Statin therapy
31
T1DM pregnancy management for pre-existing diabetes?
-Basal-bolus insulin therapy at 3-4 injections per day or continuous subcutaneous insulin infusion
32
T2DM pregnancy management for pre-existing diabetes?
-Switch to insulin
33
Suggestions for customizing insulin therapy for close monitoring?
- 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)
34
When should SMBG be performed?
Both pre and post-prandially
35
Fasting and pre-prandial BG target?
<5.3 mmol/L
36
1hr postprandial BG?
<7.8 mmol/L
37
2hr postprandial BG?
<6.7 mmol/L
38
A1C target>
= 6.5% if = 6.1% if possible
| --> To lower late stillbirth and infant death
39
How should targets be modified in those with severe hypoglycemia/unawareness?
Individualized
40
What is recommended for diabetes management in type 1 diabetes
- CGM should be considered in all women
| - Will decrease LGA, NICU >24hrs, neonatal hypoglycemia, infant length of stay
41
General pregnancy management for patients with pre-existing diabetes?
- Encourage weight gain according to IOM recommendations
| - ASA to reduce the risk of pre-eclampsia, starting at 12-16 weeks GA
42
BMI <18.5 recommended weight gain?
12.5-18.0 kg
43
BMI 18.5-24.9 recommended weight gain?
11.5-16.0
44
BMI 25.0-29.9 recommended weight gain?
7.0-11.5 kg
45
BMI >/30 recommended weight gain?
5.0-9.0 kg
46
Why should we diagnose and treat GDM?
-Due to the severe risks glycemia can have on the mother and the fetus
47
What are some consequences of uncontrolled glycemia during pregnancy
- Macrosomia
- Shoulder dystocia and nerve injury
- Neonatal hypoglycemia
- Pre-term delivery
- Hyperbilirubinemia
- Caesarian section
- Offspring obesity
- Offspring diabetes
48
When is universal screening for GDM performed?
At 24-28 weeks Gestational age
| --> Screening will be performed earlier if there are risk factors for GDM
49
If a women is at high risk of T2DM, how should they first be screened?
-Screen with A1C or FPG if A1C unreliable in the first trimester
50
If after early screening, and A1C is seen to be >/= 6.5% or FPG >/= 7.0 mmol/L, how should it be treated?
- treat like T2DM
| - Confirm diagnosis post-partum
51
When are all women screen for GDM? High risk?
- 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
What is the preferred approach to GDM screening?
50 g glucose challenge test with PG 1 hour later
53
What confirms a diagnosis of GDM with the 50 g glucose test?
- 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
75 g OGTT results to confirm GDM? (Note this is the confirming test after the inconclusive 50 g OGTT)
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
What is the alternative approach to screening for GDM?
-75 g OGTT then measure FPG 1hPG and 2hPG
56
Results of the alternative 75 g OGTT which would confirm GDM?
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
If glycemic targets are not met between 1-2 weeks, what should be initiated?
1-2 weeks
58
What is the first-line medication in GDM?
INSULIN (not metformin)
| -May use aspart, lispro, glulisine, perinatal outcomes similar
59
Metformin may be used as an alternative to insulin, what does the evidence show?
- 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
Insulin is necessary in ___ of those on metformin
40%
61
What may be used in women who refuse insulin and not well controlled on metformin?
Glyburide
| -Sulfonylureas
62
When should fetal surveillance increased? When should induction be offered?
- 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
What is the goal of nutritional therapy within the context of diabetes and pregnancy?
- 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
Nutrition intervention snack distribution?
- 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
Breakfast recommendation?
15-30 g of CHO and preferably no fruits or milk
66
Why should fruits and milks be limited at breakfast?
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
Lunch & Dinner recommendations?
30-45 g of CHO, where vegetables should make up the majority of the plate
**each meal should consist of CHO + PRO + FAT**
68
Low GI?
<55
69
Medium GI?
56-69
70
High GI?
70>
71
How should snacks be administered?
- 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
Which nutrients should be especially considered in a pregnant womenss diet? (C-FIVE)
- Calcium
- Folate
- Iron
- Vitamin D
- EFAD
73
Folic acid supplements 1 month before pregnancy and once they get pregnant?
-400 mcg
-600 mcg
Daily
74
What other supplements should be considered in pregnancy?
-Iron, calcium, vitamin D or a MV
75
What are 3 types of common prenatal MVs? Are they designed to meet the RDA for pregnant women?
-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
What is the consensus of energy intake for pregnancy?
- 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
What does ADA recommend about hypocaloric diets for obese women?
It runs a risk of high levels of blood ketones to the fetus, and risk of sacrificing maternal nutritional status
--> Require close monitoring
78
Caloric intake should promote what? (3)
- Fetal/neonatal and maternal health
- Achieve glycemic goals
- Promote appropriate gestational weight gain (GWG)
79
EER pregnancy?
Nonpregnant EER + Pregnancy Energy Deposition (PED)
80
EER 1st trimester PED?
0
81
EER 2nd trimester PED?
340
82
EER 3rd trimester PED?
452
83
First trimester time?
0-13 weeks
84
Second trimester time?
14-26 weeks
85
Third trimester time?
27-40 weeks
86
How to calculate energy requirements in the 2nd and 3rd trimesters?
180 kcals + (8 kcals x weeks gestation
87
Protein requirements
10 to 35% of energy or 1.1 g/kg/day
88
Fat requirements?
20-35%
89
CHO requirements? CHO requirements at St. Mary's?
45-65%
| 30-35%
90
When BMI is >30, what weight should be used?
Adjusted body weight
Actual BW - IBW (at BMI of 25) + IBW
--> Then add the estimated requirement by trimester
91
Specific DRI macronutients recommendations, including those with GDM for CHO, protein and fibre?
- 175 g of CHO
- 71 g of protein (or 1.1 g/kg/day)
- 28 g of fibre
92
What does regular exercise and a healthy diet promote?
- Improved glycemic control
- Facilitate weight control
- Improve insulin sensitivity
93
The risk of GDM is _____ to the degree of PA in the year prior to pregnancy
inversely proportional
94
What is exercise before and during early pregnancy associated with?
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
PA recommendation in pregnancy?
150 minutes each week, with approximately 3-5 sessions of 30-45 minutes each.
96
Important consideration about initiating exercise?
Important for those who were not active prior to being pregnancy to start very gradually
97
What should be encouraged in post-partum management?
1) Breastfeeding
| 2) 75 g OGTT at 6 weeks and 6 months PP to check glycemic control
98
Benefits of breastfeeding on GDM post-partum management?
-Reduce neonatal hypoglycemia, childhood obesity & diabetes AND maternal risk of diabetes & hypertension
99
When should the 75 OGTT be performed? How does this change if mom was diagnoses with diabetes early in pregnancy?
- Usually 6 weeks to 6 months
| - If diagnosed early do FPG or OGTT at 6-8 weeks post-partum
100
75 OGTT post-partum normal?
healthy behaviour continuation
101
75 OGTT post-partum IGT?
-Healthy behaviour interventions +/- metformin
102
75 OGTT post-partum T2DM?
-Healthy behaviour interventions +/= metformin and +/=-insulin
103
Practical suggestions for morning sickness? (re-cal that many women are on insulin, the experience frequent N/V)
- SMFQM
| - Higher BG in AM, and may divide their bolus if they anticipate not eating their entire meal due to sickness
104
What does G3P1A1L1 mean?
```
G3= 3rd pregnancy
P1 = one delivery
A1= one abortion
L1 = 1 living child
```
105
What is EFW?
Estimated Fetal weight
106
(T/F) Even in normal, non-diabetic pregnant women may have higher levels of ketones in their blood and urine
T
Often after a long period of fasting, such as in the morning
