Diabetes in Pregnancy & Obstetric cholestasis Flashcards
What is gestational diabetes?
Diabetes which is 1st diagnosed in pregnancy.
May be that symptoms were present before conception however if diagnosed in pregnancy still classed as gestational.
What are the maternal complications of pre gestational diabetes? (6)
Increased risk of:
- C-section delivery
- Polyhydraminos
- Pre-Eclampsia (12%)
- Chronic HTN (10%)
- Diabetic Ketoacidosis
- Preterm labour
Pneumonic
Chronic Diabetes Can Precipitate Pre Eclampsia & labour
What are the fetal complications of pre-gestational diabetes? (5)
Hyperglycaemia is teratogenic therefore increases congenital abnormalities (2-3x more likely)
Spontaneous miscarriage and increased risk of still birth
Late intrauterine fetal death (high fetal mortality associated with DKA)
Fetal macrosomia associated with shoulder dystocia
Pre term labour and prolonged premature rupture of membranes.
What is the recommended HbA1c level for a women with diabetes to try conceiving?
Less than 6.1 %
What normally happens to mother’s blood glucose levels during pregnancy?
Fasting blood glucose levels become lower in pregnancy
What are the recommendations for antepartum management of pre gestational diabetes?
Insulin (needs to be slightly increased as pregnancy goes on) + diet control.
Aim for fasting blood glucose of less than 95mg/dL
Ophthalmic screening each trimester.
Monitor renal function closely (24hr urinary protein and creatinine clearance) .
Low dose aspirin from 12 weeks (reduce incidence of pre-eclampsia)
Consider thyroid function testing.
What are the risks of gestational diabetes to the mother?
Increased risk of:
- Pre-eclampisa
- Polyhydraminos
- C-section
- Pre term labour
But more likely to develop gestational diabetes again (50%).
Increased risk of developing diabetes (40-60%).
What are the risks to the foetus of gestational diabetic mothers?
Increased risk of macrosomia associated with:
-Increased risk of shoulder dystocia
Pre-term labour
Increased still birth risk
Post part hypoglycaemia
What is the screening programme for gestational diabetes?
At risk groups are offered screening with a GTT at 28 weeks.
If previously had gestational diabetes screened at 18 weeks.
What are the risk factors for developing gestational diabetes?
Previous pregnancy:
- Previous gestational diabetes
- Previous macrocosmic baby
PMH:
- 1st degree relative with diabetes
- South asian/afro-carribean
- PCOS
Current:
- Obesity
- Persistent glycosuria
- Polyhdraminos
What is classed as a positive GTT test in gestational diabetes?
Fasting plasma glucose level of 5.6 mmol/L or above
OR
2-hour plasma glucose level of 7.8 mmol/L or above.
How is gestational diabetes treated?
Stepwise approach + monitoring
BM monitoring 7 times a day before and after each meal + once before bed.
- Diet only (1-2 week trial)
- Metformin
- Insulin +/- metformin
If fasting blood glucose is greater than 7 on diagnosis start at step 3.
What should a pregnant women aim for her BM readings to be?
Before meals should be below 5.2mmol/L
After meals should be below 7.8mmol/L
What is the routine management of delivery with a gestational diabetic mother?
C-section if macrocosmic baby greater than 4kg
May also induce early (stop baby getting too big)
Usually done by 39 weeks
How does obstetric cholestasis present?
Pruritus without rash + abnormal liver function + complete remission after delivery
Typically worse at night & involves palms and soles
Look for dark stools/pale urine/jaundice