Diabetes in Pregnancy - Harlev

Question 1

What is the White Classification in Pregnancy

Answer 1

Type A1: No effect on end organs
-No treatment other than diet

A2: No effect on end organs
Tx with insulin or other intervention required

B, C, D: rarely used (indicate age of onset)

Organ damage:

F: Nephropathy

R: Proliferative retinopathy

H: Heart

Question 2

How is overt diabetes not diagnosed pregestation differentiated from gestational diabetes?

How is treatment different?

What portion of women continue from GDM to DMII?

Answer 2

Fasting plasma glucose ≥126 mg/dL in FIRST TRIMESTER only

A1C ≥6.5 percent using a standardized assay (anytime during pregnancy, if >12 discuss TOP)

Random plasma glucose ≥200 mg/dL + classic signs and symptoms

Ketoacidosis (doesn’t happen in GDM and in DMII in pregnancy can happen as low as 200)

Treatment and management same as gestational diabetes

50% of women become overt diabetics after GDM

Question 3

What differences did the 2005 and 2009 trials show in diabetic women between intervention and routine care?

Answer 3

Decreased serious perinatal complications (perinatal death, shoulder dystocia, bone fracture, and nerve palsy), stillbirth or perinatal death and neonatal complications: hyperbilirubinemia, hypoglycemia, hyperinsulinemia, birth trauma all significantly reduced

Half the microsomia rate

Decreased shoulder dystocia

Concluded that proper treatment of (even mild) gestational diabetes reduces serious perinatal morbidity and may also improve the woman’s health-related quality of life and reduces the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders

In contrast: GDM does not cause fetal anomalies and fetal death is the same as the general pop if it is appropriately treated.

Question 4

How is GDM generally screened now?

Answer 4

No consensus on recommendations

In Israel there is Universal testing

In US and Canada, low risk women who are young and healthy get no screening
High risk (obesity and family history) get a glucose tolerance test (GTT)
Average risk: screen with a glucose challenge test (GCT) at 24-28 weeks and if positive give GTT

Glucose challenge test:
-No fast, drink 50g oral glucose
-Check insulin after one hour
>140 mg/dL do GTT (gives 20% false negative)

Glucose tolerance test:

• Gold standard, but no international agreement
• Overnight fast, at t0 give 100g glucose in US, 75g in Europe, fasting glucose should be 95 mg/dL
• Test insulin each hour for 3 hours (2 in Europe)
• Normal values are 180, 155 (and 140 in 3rd hour in US) respectively
• 2 or more abnormal values mean GDM

Question 5

What are the hypoglycemic agents use to treat GDM?

Answer 5

Glyburide:

• sulfanylurea
• Stimulates insulin release, also acts on the liver
• First line with reasonablly elevated glucose levels
• some women don’t respond (if the FGL >110)
• Only for GDM not for DMII

Metformin: not currently used in GDM (in DMII works on multiple stages)

Insulin:

• studies are ambiguous about long term effects but no prenatal effects
• First line in obese women
• Needs to be logged, today used by pump and sensor

Question 6

What are the fetal effects in GDM?

Answer 6

Elevating fasting glucose levels do increase the rates of unexplained stillbirths.

Insulin resistance increases risk of preeclampsia.

Polyhydramnios

Hypoglycemia

Hyperbilirubinemia

ypocalcemia

Erythremia

Respiratory distress syndrome

Caused by HPL (human placental lactogen), increased hormones and stress

Question 7

What are the fetal and maternal effects of pregestational diabetes?

Answer 7

Miscarriage
Preterm Delivery
Malformations - incidence women with type 1 diabetes is 5 percent
Altered Fetal Growth (macrosomia or growth restriction)
Unexplained Fetal Demise
Hydramnios

Caudal regression
Situs inversus
Duplex ureter
Spina bifida, hydrocephaly or other CNS defect
Cardiac defects (transposition of vessels/septal defects)
PKCD
Organ damage

Mother:
Diabetic Nephropathy
Diabetic Retinopathy
Diabetic Neuropathy
Preeclampsia (can lead to growth restiction)
Diabetic Ketoacidosis

Question 8

How is delivery managed in diabetic women?

Answer 8

Labor induction may be attempted when the fetus is not excessively large and the cervix is considered favorable

Cesarean delivery rates range from 50 to 80 percent

Reduce or delete the dose of long-acting insulin given on the day of delivery

Continuous insulin infusion by calibrated pump is most satisfactory

Capillary or plasma glucose levels should be checked frequently, and regular insulin should be administered accordingly