Diabetes in the perinatal period

Question 1

what is diabetes

Answer 1

clinical syndrome characterised by hyperglycaemia due to deficiency or diminished effectiveness of insulin. affects normal metabolism of carbs, fat and proteins

Question 2

pregestational

Answer 2

type 1 - 0.4%
type 2 - 1%

Question 3

gestational

Answer 3

diagnosed of glucose intolerance of variable degree with onset or first recognition during pregnancy - 5%

Question 4

carb metabolism in pregnancy

Answer 4

fetus receives glucose via the placenta by facilitated diffusion
Resistance to insulin also an issue caused by human placental lactogen, oestrogen, progesterone and cortisol
3rd trimester maternal use of fat for energy causes an increase in free fatty acids and glycerol, increase risk of ketosis

Question 5

fetal metabolism

Answer 5

fetus produces insulin from 9 weeks
increased maternal blood glucose levels lead to hyperinsulinemia and macrosomia

Question 6

type 1 management

Answer 6

team approach - endo, OB, midwives, diabetes educator, dietician
insulin therapy
education

Question 7

type 1 is

Answer 7

cellular mediated autoimmune destruction of the islet cells
pancreas stops making insulin because of beta cell destruction
without insulin, the body’s cells cant turn glucose into energy
body uses its own fat to substitute for glucose

Due to the destruction of β-cells, patients with T1DM require insulin replacement to achieve euglycaemia

Question 8

ketoacidosis

Answer 8

chemical substances accumulate in the blood because of utilising fat for energy when treated with exogenous insulin

Question 9

monitoring diabetes

Answer 9

maintain BGL
reduce long term complications

Question 10

HbA1c

Answer 10

long term glucose control is measured by a blood test to measure glycosylated haemoglobin
measures % of Hb that is glycoslyated - reflecrs avg. BG during preceding 1-2 months
higher result reflects poorer BGL control should be <7%

Question 11

insulin requirements during pregnancy

Answer 11

in 1st tri = often need reduction of insulin due to transfer of glucose to fetus and reduction in dietary intake

2nd half = increase in diabetogenic effects of hormones causes an increase in insulin requirements
ketogenesis is risk
last 3-4 weeks = insulin needs plateau or decrease = this increases risk of hypoglycaemia and stillbirth

Question 12

complications

Answer 12

ketoacidosis
hypoglycaemia
microvascular (neuropathy, nephropathy, retinopathy)
macrovascular
atherosclerotic heart and vascular changes
urinary and vaginal infections

Question 13

maternal complications

Answer 13

miscarriage
pre-eclampsia
polyhydramnios
infection
pre-term labour
c-section

Question 14

perinatal and neonatal outcomes

Answer 14

intrauterine death
neonatal mortality
congenital abnormalities
RDS
LGA or IUGR
hypoglycaemia
Hyperbilirubinaemia

Question 15

type 2

Answer 15

insulin resistance at the tissue level
makes too little insulin or unable to use insulin made
pregnant women with type 2 diabetes risk giving birth to stillborn or major birth defects

A relative lack of endogenous insulin plus pancreatic β-cell dysfunction reduces glucose uptake by cells, resulting in hyperglycaemia. Hyperglycaemia is caused by a lack of endogenous insulin. Insulin deficiency usually occurs because of resistance to the actions of insulin in muscle, fat and the liver, and an inadequate response by the pancreatic β-cells.

Question 16

GDM

Answer 16

carb intolerance of variable severity with onset at first recognition during the present pregnancy
24-28 weeks
the body is unable to produce enough insulin for its own needs, because of either impaired insulin secretion, impaired insulin action, or both.

Question 17

GDM pathophysiology

Answer 17

Beta cell production of insulin is limited. If the body is unable to produce enough insulin, gestational diabetes develops.
Generally normal blood glucose level in first half of pregnancy

Question 18

risk factors GDM

Answer 18

obesity
previous macrosomic baby weighing >4.5kg
previous GM, fam history
maternal age >25
ATSI, maori, middle eastern, asian
poor obstetric history

Question 19

GDM diagnosis

Answer 19

fasting = plasma glucose of >5.1mmol/L
1 hr = >10mmol/L
2 hrs = 8.5mmol/L

diet management and control
insulin therapy
self monitoring
short acting (actrapid, novarapid, lispro)
long acting protophane
oral (metformin, gilbenclamide)
diet
exercise
prevention of infection

Question 20

diabetes management in labour and birth

Answer 20

BGLs hourly
dextrose infusion commenced to maintain BGL between 4-7mmol/L and CTG
macrosomic fetus = informed of risks and benefits of vaginal birth, IOL and LSCS

Question 21

postnatal care

Answer 21

Insulin requirements fall rapidly after birth, so BGLs done frequently.
Insulin doses are reduced if type 1, or ceased if GDM.
Breastfeeding encouraged.
Family planning discussion and that oral contraceptives may affect carbohydrate metabolism and therefore insulin requirements.
A follow up glucose tolerance test (GTT) is recommended at 6-8 weeks and/or HbA1c at 3 months. If impaired glucose tolerance, arrange endocrinologist review.
Other women should be advised about a healthy lifestyle and to have a GTT every 2 years.

Question 22

management to prevent hypoglycaemia

Answer 22

BGLs fall to 2.6 post birth
commence feeding around 1 hr and assess BGL 2 hr post birth
feed at least 3rd hourly to maintain BGL
checked 4-6 hrs for the first 24-48 hrs

Question 23

signs of neonatal hypoglycaemia

Answer 23

• Hypothermia
• High pitched cry
• Poor temperature control
• Sweating
• Poor suck or refusal to feed
• Tremors
• Exaggerated Moro reflex
• Irritability
• Lethargy
• Hypotonia (decreased muscle tone)
• Seizures
• Cyanosis
• Pallor (pale)
• Tachypnoea/apnoea
• Tachycardia
• Congestive heart failure
• Respiratory distress

Question 24

management neonatal hypogylcaemia

Answer 24

*Clinical definition varies according to the age and hours old an infant is, however a safe definition of a low BGL is below 2.6mmol/L, whether the neonate is symptomatic or not.
 If asymptomatic feed immediately.
 Repeat BGL in 1 hour
 If >2.6 mmol/L feed as usual
 If <2.6mmol/L repeat feed
*If symptomatic, or if the BGL remains below 2.6mmol/L after second feed, or is below hospital policy threshold for oral feeds then the neonate is given IV dextrose 10% 10mL as a bolus dose
*Bolus dose followed with 10% dextrose infusion in a nursery

Question 25

role of insulin

Answer 25

facilitates the uptake of glucose by facilitating its movement from the blood into target cells (liver, skeletal and muscle)
* stimulates formation and storage of lipids and glycogen
* lowers circulating blood glucose.

It does this by:
* increasing glucose transport by target cells
* accelerating glucose utilisation (target cells) and enhanced ATP production
* stimulating glycogen synthesis (skeletal, muscle and liver cells)
* decreasing glucogenesis.