Diabetes Mellitus /Nice Guideline Flashcards
What are the classical features that diabetic patients may present with?
Candida infection ( pruritus valvae)
Staphylococcul skin infections
Macreovascular arterial disease: ( coronary- cerebral- peripheral)
Microvascular arterial disease: ( retinopathy- nephropathy- neuropathy).
What is the risk of developing disease in the children of a parent with: diabetes type 1/ type 2?
Type 1 : 5%
Type 2 : 10- 15 %
Children of a mother with gestational diabetes are at increased risk of what?
Obesity
Diabetes
What are the maternal complications of diabetes in pregnancy?
1- miscarriage
2- gestational HTN / PEC
3- periodontal disease
4- CS
5 - UTI / other infections.
6- obstetric trauma
What are the fetal anomalies most seen in diabetic mothers?
Cardiac/ renal anomalies
Neural tube defects
Microcephaly
Sacral agenesis
What are the fetal complications of diabetes in pregnancy
1- congenial abnormalities
2- hypoglycemia
3- stillbirth / perinatal mortality
4- polyhydramnios
5- birth injuries
6- macrosomia/ FGR
7- postnatal adaptation problems
What is the pathophysiology of fetal effects in diabetic mothers
Maternal hyperglycemia 👉 fetal hyperglycemia 👉 fetal pancreatic B - cell hyperplasia 👉 fetal hyperinsulinaemia 👉 :
1 macrosomia
2 organomegaly
3 polycythaemia 👉 jaundice
4 hypoglycemia
5 RDS
Preconception counseling for diabetic women?
1- BMI > 27 kg/m² ( advice to loss weight)
2- folic acid (5mg / d ) until 12 weeks
3- monitor blood glucose/ ketones before pregnancy
4- use safe drugs to control Blood glucose
5- use safe drugs to control HTN / stop statin
6- retinal assessment ( if it isn’t done in the last 6 months)
7- renal assessment
How to monitor blood glucose/ ketone before pregnancy in diabetic women?
1- monthly measurement of HbAc1
2- offer blood glucose meters
3- offer ketone testing stripes to women with type 1 ( if she feels unwell or hypoglycemia)
What are the target glucose / HbAc1 ranges before pregnancy?
*Fasting glucose: 5-7 mmol/L
*Plasma glucose premeals: 4-7 mmol/L
*HbAc1 < 48 mmol/mol : < 6.5 %
Above what level of HbAc1 pregnancy should be delayed until lower levels?
> 85mmol/mol = 10%
What medications could be used before and during pregnancy to control blood glucose?
- metformin
- Insulin : - rapid acting: aspart
Lispro
- intermediate acting isophane insulin: NPH insulin
- long acting insulin:
*detemir
* glargine
What kind of insulin is considered as first choice for long acting insulin during pregnancy?
Isophane insulin = NPH insulin
When diabetic women should be referred to a nephrologist before stopping contraceptions?
1- Cr > 120 mcmol / L(1.35mg)
2- urinary
albumin/ Cr ratio > 30 mg/mmol
3-estimated glomerular filtration
rate eGFR < 45
What are the risk factors to offer a pregnant woman testing for gestational diabetes?
1- BMI> 30
2- previous macrosomia > 4.5 kg
3- previous gestational diabetes
4- family history of diabetes
( first degree relative with diabetes)
5- an ethnicity with high prevalence
of diabetes
In a pregnant woman with risk factors for diabetes what test should be offered?when?
Oral glucose tolerance test OGTT
75 g / 2 hours
24-28 weeks of pregnancy
What to offer to a pregnant woman with previous GDM?
- early self monitoring of blood
glucose
OR ; * 75g/ 2 hours OGTT as early as possible ( in 1st or 2nd trimester) - And further 75g / 2 hours OGTT
In 24-28 weeks if the result of the first OGTT is normal
What criteria to diagnose gestational diabetes?
fasting plasma glucose level of 5.4 mmol/ L or more
# OGTT 2- hour level of 7.8 mmol/L or more
What is the management of GDM?
1- Diet an exercise ( walking for 30 minutes after meals)
If Glucose targets are not met within 1- 2 Weeks
* offer metformin
If Glucose targets are not met
** offer insulin
When do you treat GDM with insulin directly and diet/ exercise - with or without metformin?
- GDM & FBS - level of 7 or above at diagnosis
*GDM & FBS between 6 and 6.9 with complications such as macrosomia or hydramnios
What is the frequency of blood sugar test in type 1 pregnant woman?
Fasting
Pre-meal
1- hour post meal
Bed time
What is the frequency of blood sugar test in type 2 & GDM on multiple insulin doses ?
Fasting
Pre-meal
1- hour post meal
Bed time
What is the frequency of blood sugar test in type 2& GDM on a single insulin dose?
Fasting
Pre-meal
1- hour post meal
What is the frequency of blood sugar test in type 2 & GDM on diet and exercise only ?
Fasting
Premeal
1- hour post meal
What are the target levels of blood Glucose in pregnancy?
Below:
Fasting < 5.3 mmol/L
1- hour post meal < 7.8 mmol/L
2- hours post meal < 6.4 mmol/L
Diabetes who are taking insulin should maintain their blood glucose above what level?
4 mmol/L
What is the frequency to offer HbA1c test to women with preexisting diabetes?
At booking
2nd & 3rd trimester
Why do we offer HbA1c test to women with GMD?
To identify possibility of preexisting type 2 diabetes
When to offer subcutaneous insulin infusion SCII ( insulin pump therapy)
To pregnant women with insulin- treated diabetes?
1- if taking multiple daily injections
2- if don’t achieve blood glucose control without significant disabling hypoglycemia.
What are the 2 types of continuous glucose monitoring (CGM)?
Real time CGM ( rtCGM)
Intermittently scanned CGM( isCGM)
When to offer rtCGM for glucose monitoring in diabetic pregnant women?
Type 1 diabetes
When to consider offering rtCGM for glucose monitoring in diabetic pregnant women?
Women who are taking insulin:
* if problematic severe hypoglycemia
* unstable glucose levels despite efforts to optimize glycemic control
Where to admit pregnant women with suspected diabetic ketoacidosis ?
Level 2 critical care
How to make retinal assessment during pregnancy?
Offer retinal assessment ( unless it’s done in the last 3 months)
*If retinopathy is diagnosed: additional assessment at16-20weeks
* if no retinopathy diagnosed:
Retinal assessment at 28 weeks
Retinopathy IS NOT contraindication for ……
*Vaginal birth
* rapid optimization of blood glucose control
When to make renal assessment for diabetic pregnant women?
At first contact during pregnancy for women with preexisting diabetes
IF; they haven’t had in the last 3 months
When to refer a diabetic pregnant woman to a nephrologist?
Cr > 120 micromol/L
Urinary albumin/cr ratio > 30 mg/mmol
Total protein excretion > 0.5 g/day
● eGFR Not measured to assess kidney function in pregnant women
When to consider thromboprophylaxis for diabetic pregnant women ?
Proteinuria > 5 g/ day
= albumin: cr ratio > 220 mg/ mmol
How often to monitor fetal growth and wellbeing in diabetic pregnant women ?
Every 4 weeks from 28 - 36 weeks
When to offer Labour induction or CS to diabetic pregnant women?
(37_38+6d )weeks to women with type 1&type 2
What to advice a woman with uncomplicated gestational diabetes about the time to give birth?
No later than 40 weeks+6 days
What to consider about preterm Labour in diabetic pregnant women?
*DON’T give betamimetic ( isoxupyrin \ Dovai or salbutamol )👉 hepato glycogenolysis
* For insulin treated patients who are taking steroids for fetal lung maturation: give additional insulin and monitor the woman closely IN The Hospital 🏥
When to offer induction of labour or CS to diabetic pregnant women before 37 weeks?
In the presence of maternal or fetal complications
How often to monitor blood glucose in diabetic pregnant women who went through general anesthesia for birth?
EVERY 30 MINUTES until the woman is fully conscious.
How often to monitor blood glucose during labour in diabetic pregnant women? What is the targets?
EVERY 1 HOUR
Targets: 4- 7 mmol/L
During the labour of diabetic pregnant women when to offer IV dextrose and Insulin infusion from the onset of the labour?
- type 1 diabetes
- women with diabetes whose plasma glucose IS Not maintained between 4-7 mmol/L
How to manage glucose lowering therapy in the post natal period in diabetic women?
GDM 👉 stop therapy immediately
after birth
Type1 👉reduce insulin immediately
After birth and monitor BG
Type2👉 continue metformin
If blood glucose levels returned to normal after birth in GDM women how to monitor her in post natal period?
- offer lifestyle advice
- offer FBG test 6-13 weeks after birth to exclude diabetes
- after 13 weeks offer FBG test
Or HbA1c
What is the prognosis of FBG test in post natal period in diabetic women?
FBG < 6 mmol/L 👉 low probability of having diabetes
ANNUAL Test
FBG 6.0-6.9 mmol/L 👉 high risk of developing type 2 diabetes
Offer advice on preventing
FBG 7 mmol/L or more 👉 diabetes
Offer a test to confirm
What is the prognosis of HbA1c test in post natal period in diabetic women?
*HbA1c < 39 (5.7%) 👉low probability of having diabetes
ANNUAL test for blood glucose
* HbA1c 39- 47 ( 5.7- 6.4%)👉 high risk of developing type 2 DM
Offer advice on preventing
* HbA1c 48 (6.5 %) or more 👉 DM type 2 ..offer a test to confirm
When to check blood glucose in the babies of women with diabetes?
2-4 hours after birth routinely
What signs may develop in the babies of women with diabetes that require blood tests?
Clinical signs of
Polycythaemia
Hyperbilirubinemia
Hypocalcaemia
Hypomagnesaemia
When to offer echocardiogram for babies of women with diabetes?
1- Clinical signs of : congenital heart disease or / cardiomyopathy
2- heart murmur
When diabetic women should feed their babies after birth?
As soon as possible within 30 minutes and every 2-3 hours
Until feeding maintains their BG levels at a minimum of 2 mmol/L
When to offer additional measures such as tube feeding or IV dextrose for babies of diabetic mothers after birth?
1-Capillary plasma glucose below 2 mmol/L on 2 consecutive readings
2- there are abnormal clinical signs
( hypoglycemia)
3- the baby will not effectively feed orally
