Diabetes in Pregnancy (Gestational + pregestational) Flashcards
Between what weeks should screening take place?
24-28 weeks (insulin requirements sharply rise)
What risk factors would prompt you to screen earlier? Ie. an A1C at first prenatal visit!
What if early screen is negative?
Previous diagnosis of GDM Prediabetes Member of a high-risk population (Aboriginal, Hispanic, South Asian, Asian, African) Age ≥35 years BMI ≥30 kg/m 2 PCOS, acanthosis nigricans Corticosteroid use History of macrosomic infant Current pregnancy showing macroscomic infant or polyhydramnios
If positive: ie: A1C >= 6.5 or FBG > 7, consider that she had pre-existing type 2
If negative, screen again at 24-28 weeks.
What are some dietary guidelines for a woman with GDM?
Should see a registered dietician
Individualized plan
Replace high GI foods with low GI.
FROM ESSENTIALS If obese, reduce energy intake by 30% Distribute CHO throughout meals. Low GI can help. Include destined snack to reduce risk of starvation ketosis Low glycemic index Minimum 175g CHO per day Hypo caloric diets NOT recommended CHO up to 50% Fat up to 40 % (higher than non GDM)
What are the risk factors for GD?
Family Hx of D Obesity Ethnicity (4As and H) Previous macrosomal infant Previous GDM
Why is it so important for women to have good glycemic control prior to
Conception?
Hyperglycemia at conception and in first tri is associated with increased fetal malformations.
Poorly controlled D can result in:
Macrosomia Higher perinatal mortality Congenital malformations Neonatal morbidities HTN/ preeclampsia Pre term delivery Increased C section rate
Retinopathy in pregnancy is a major concern. How should it be screened?
Eye exam PRIOR to conception
In first trimester
Then prn in pregnancy
AND within first year post partum
**bigger risk in those who have a greater A1C reduction to achieve
What percent of pregnant women experience HTN?
40-45%
T1 has more pre eclampsia. Ie: increased BP and proteinuria.
What meds can be used to treat HTN in pregnancy?
Quick guide lists only labetolol and Adalat.
Guidelines state:
CCBs
Labetolol
Methyl dopa
What drugs must be stopped when pregnant?
ACE ARB
Statins PRIOR TO ideally
Nephropathy or microalbuminuria is associated with increased maternal and fetal complications in those with diabetes prior to conception. How should screening take place?
Prior to conception! SCr and ACr and eGFR.
During P use SCr as eGFR underestimates.
ACr and SCr do in EVERY trimester!
List the pregnancy targets. FBG 1 HR PP 2 HR PP A1C
Less thAn: 5.3 7.8 6.7 <= 6.5 but 6.1 better if possible to lower risk of late stillbirth
Can raise targets of hypo.
Does maternal hypoglycemia cause increased risk of malformations or adverse outcomes?
No
How long should metformin be given in PCOS?
Until pregnant. No evidence of harm in conception or first tri but no evidence to continue past conception.
What is the most serious danger with pregnancy and CSII?
Pump failure causing DKA. Can result in fetal fatality
What two po drugs can be used during breastfeeding?
-Metformin and glyburide. No studies in other.
Once diagnosed with gestational, how long can you give a woman to bring BG under control before initiating insulin?
2 WEEKS
Why is POst partum monitoring for GDM moms so
Important and when should it take place?
20% of GDM will have type 2 PP
Monitor with FBG AND. OGTT between 6 weeks and 6 months
What’s the percent probability that GDM will re occur with a second pregnancy
30-84%
What if a woman cannot or will not take insulin for GSM?
Metformin can be used but women should know that it does cross placenta and longer term studies are not yet available. AND about 40% women on metf will still need insulin.
Glyburide is an alternate if metf not tolerated but both are OFF LABEL
- up to 80% will be controlled on glyburide (doesnt cross placenta)
- 43% of those on metformin will req supplemental insulin (crosses placenta)
Children of mothers with GD are at higher risk of:
IGT
Obesity
How can women manage the frequent changes in BG needs during pregnancy?
BG can range lower and higher at different times during pregnancy. Eg. Initially BG may go up then At 8-12 weeks often lower.
Women have to become skilled at frequent monitoring and adjustment!
Are artificial sweetness considered safe in pregnancy?
Yes
Excessive folic acid supplementation can mask a deficiency in what vitamin?
B12
😕 don’t remember that from pharmacy school!!
Why do GD women post partum need an OGTT and not just a FBG?
FBG can miss up to 40% of dysglycemias post partum.
Test OGTT 6 weeks to 6 months post partum
ALSO before another pregnancy or every three years.
Both type one and type two females are more susceptible to hypo in which two trimesters?
First and second!
A rise in what hormones in the second trimester causes insulin resistance?
human placental lactogen (HPL)
cortisol
prolactin
Prevalence in canada of GDM
3.7% in non -aboriginal pop
8-18% in aboriginals
How is GDM dx?
2 step (preferred) 1) 50 g oral glucose (regardless of last meal or time of day) BG at 1hr less than 7.8= normal BG at 1 hr greater than or equal to 7.8 to 11= need to do OGTT BG at 1 hr greater than or equal to 11.1 = GDM dx
2) 75g OGTT done on another day (8hrs of fasting but no more than 14hrs of fasting. at lest 3 days w/o restriction of diet (greater than 150g CHO/day) or exercise. remain seated and no smoking during test
FBG >=5.3
1hr PP >= 10.6
2hr PP >= 9
**if ONE value is met it’s GD
What is the alternative screening method?
1 step 75g OGTT - GDM if one of the following:
FBG greater than or equal to 5.1mmol/L
1hr PP greater than or equal 10.0
2hr PP greater than or equal to 8.5
What proportion of GDM will require insulin treatment?
20% will require insulin
1) diet modification + 2) physical activity (light walk for 30-60mins post meal can reduce PPBG)
does insulin cross the placenta?
no
which insulin is NOT recommended in pregnancy?
premix is NOT recommended Detemir is approved in preg Glargine is safe in preg rapid is okay NPH is opk
What is macrosomia?
birth weight >4000-4500g or large for gestational age baby
occurs due to increased transfer of maternal glucose to fetus = fetus develops hyperinsulin to store excess glucose as fat.
Incidence of macrosomia?
14-21%
in non-DM rate ~14%
What are the benefits of breastfeeding?
1) reduced incidence of hypoglycemia in new born
2) reduces rates of dvlping t2dm in mom
3) reduces obesity and diabetes development in child (continue for 3 months post partum)
Why do babies of mom’s with GDM have higher rates of resp distress syndrome?
fetal hyper insulin inhibits lecithin production which is needed for surfactant protection which stabilizes the alveoli.
What is the risk for a woman with GDM to develop t2dm?
3-6months post partum risk of glucose abnormality is 16-20%
When and how much folic acid should be taken?
1mg daily starting 3 months prior to and continuing for 12 weeks post conception. Can switch to multi containing 0.4 to 1mg for rest of pregnancy and post partum period
Should type two patients who want to get pregnant switch from oral meds to insulin prior to conception or wait until Pregnant?
Metf and gkyburudr can stay on until pregnant. Other meds should switch to insulin prior to conception
What’s the BG goal during labor?
4-7 –>this reduced neonatal hypoglycemia
-may need glucose during labour for high needs
When a woman is diagnosed with GDM what two things are at the core of the treatment plan?
Diet modification
Daily physical activity.
*plan should be individualized to supply adequate energy and based on Canada’s food guide.
what sweeteners are not recommended in pregnancy?
Cyclamate
What minimum
Amount of CHO is needed?
175g.
Up To 50% calories. Because this is lower than non pregnant D, more fat is needed. Fat is 40% rather than 20-35.
How does walking for 30-60 minutes post prandial help?
Reduces postprandial BG and potentially helps delay or avoid insulin therapy.
What factors in a GDM mother increases her risk of developing type two? 4
- High pre-pregnancy BMI
- How severe her GDM was
- How early GDM was detected
- Elevated plasma homocysteine levels at 6 weeks postpartum.
Does glyburide cross the placenta?
Does metformin?
Glyburide no
Metformin yes but doesn’t appear to cause harm
**both are off label uses in Canada!!
Why is shoulder dystocia common in GDM?
0.2-3% in general population verses 3-9% in GDM
Babies above 4000g are likely to carry increased weight on the trunk leading to larger shoulder circumference.
Infants born of GDM mothers can have an incidence of neonatal hypo of 30-50%. What’s the BG range that’s considered hypo in a neonate?
Less than 1.9.
Mean BG in neonate is without a GDM mother is 2.6.
Some women with GDM who are lean and young may develop type 1 diabetes. How can you differentiate?
Test autoantibodies. If positive, they’re at increased risk of developing type 1 in next 6 months.
does metformin improve fertility in women with PCOS?
yes - advise reliable birth control as ovulation improves
one of the slides said tdz can also be used in PCOS ??
attain a preconception A1C of ≤7.0% (or A1C as close to normal as can safely be achieved) to decrease the risk of? 4.
- Spontaneous abortion
- Congenital anomalies
- Pre-eclampsia
- Progression of retinopathy in pregnancy
When should screening for postparttum thyroditis occur?
in what kind of diabetes? 1 or 2?
check TSH at 2-4 months postpartum
t1dm
Women with Pre-existing diabetes (prior to pregnancy) should start what drug and when to prevent pre eclampsia?
81 ASA at 12-16 weeks
Which long acting insulin can be used instead of NPH though there are similar perinatal outcomes
Detemir most evidence. Glargine ok too
If a women is given steroids to improve fetal lung maturation what should be done proactively and why?
Increase insulin proactively to prevent hyperglycaemia and DKA
How is insulin dosing handled post Partum?
Should decrease insulin immediately after delivery and titration as needed
Are BG targets for GDM and pre-existing diabetes the same or different!??
Same
Can monogenic diabetes be diagnosed first in pregnancy?
Yes. Suspect in women with GDM but no risk factors and have no auto antibodies so cannot be type one
