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2-Diabetes Mellitus In Pregnancy > Diabetes Mellitus /Nice Guideline > Flashcards

Diabetes Mellitus /Nice Guideline Flashcards

1
Q

What are the classical features that diabetic patients may present with?

A

Candida infection ( pruritus valvae)
Staphylococcul skin infections
Macreovascular arterial disease: ( coronary- cerebral- peripheral)
Microvascular arterial disease: ( retinopathy- nephropathy- neuropathy).

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2
Q

What is the risk of developing disease in the children of a parent with: diabetes type 1/ type 2?

A

Type 1 : 5%
Type 2 : 10- 15 %

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3
Q

Children of a mother with gestational diabetes are at increased risk of what?

A

Obesity
Diabetes

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4
Q

What are the maternal complications of diabetes in pregnancy?

A

1- miscarriage
2- gestational HTN / PEC
3- periodontal disease
4- CS
5 - UTI / other infections.
6- obstetric trauma

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5
Q

What are the fetal anomalies most seen in diabetic mothers?

A

Cardiac/ renal anomalies
Neural tube defects
Microcephaly
Sacral agenesis

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6
Q

What are the fetal complications of diabetes in pregnancy

A

1- congenial abnormalities
2- hypoglycemia
3- stillbirth / perinatal mortality
4- polyhydramnios
5- birth injuries
6- macrosomia/ FGR
7- postnatal adaptation problems

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7
Q

What is the pathophysiology of fetal effects in diabetic mothers

A

Maternal hyperglycemia 👉 fetal hyperglycemia 👉 fetal pancreatic B - cell hyperplasia 👉 fetal hyperinsulinaemia 👉 :
1 macrosomia
2 organomegaly
3 polycythaemia 👉 jaundice
4 hypoglycemia
5 RDS

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8
Q

Preconception counseling for diabetic women?

A

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

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9
Q

How to monitor blood glucose/ ketone before pregnancy in diabetic women?

A

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)

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10
Q

What are the target glucose / HbAc1 ranges before pregnancy?

A

*Fasting glucose: 5-7 mmol/L
*Plasma glucose premeals: 4-7 mmol/L
*HbAc1 < 48 mmol/mol : < 6.5 %

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11
Q

Above what level of HbAc1 pregnancy should be delayed until lower levels?

A

> 85mmol/mol = 10%

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12
Q

What medications could be used before and during pregnancy to control blood glucose?

A
  • metformin
  • Insulin : - rapid acting: aspart
    Lispro
    - intermediate acting isophane insulin: NPH insulin
    - long acting insulin:
    *detemir
    * glargine
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13
Q

What kind of insulin is considered as first choice for long acting insulin during pregnancy?

A

Isophane insulin = NPH insulin

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14
Q

When diabetic women should be referred to a nephrologist before stopping contraceptions?

A

1- Cr > 120 mcmol / L(1.35mg)
2- urinary
albumin/ Cr ratio > 30 mg/mmol
3-estimated glomerular filtration
rate eGFR < 45

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15
Q

What are the risk factors to offer a pregnant woman testing for gestational diabetes?

A

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

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16
Q

In a pregnant woman with risk factors for diabetes what test should be offered?when?

A

Oral glucose tolerance test OGTT
75 g / 2 hours
24-28 weeks of pregnancy

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17
Q

What to offer to a pregnant woman with previous GDM?

A
  • 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
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18
Q

What criteria to diagnose gestational diabetes?

A

fasting plasma glucose level of 5.4 mmol/ L or more

# OGTT 2- hour level of 7.8 mmol/L or more

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19
Q

What is the management of GDM?

A

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

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20
Q

When do you treat GDM with insulin directly and diet/ exercise - with or without metformin?

A
  • GDM & FBS - level of 7 or above at diagnosis
    *GDM & FBS between 6 and 6.9 with complications such as macrosomia or hydramnios
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21
Q

What is the frequency of blood sugar test in type 1 pregnant woman?

A

Fasting
Pre-meal
1- hour post meal
Bed time

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22
Q

What is the frequency of blood sugar test in type 2 & GDM on multiple insulin doses ?

A

Fasting
Pre-meal
1- hour post meal
Bed time

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23
Q

What is the frequency of blood sugar test in type 2& GDM on a single insulin dose?

A

Fasting
Pre-meal
1- hour post meal

24
Q

What is the frequency of blood sugar test in type 2 & GDM on diet and exercise only ?

A

Fasting
Premeal
1- hour post meal

25
Q

What are the target levels of blood Glucose in pregnancy?

A

Below:
Fasting < 5.3 mmol/L
1- hour post meal < 7.8 mmol/L
2- hours post meal < 6.4 mmol/L

26
Q

Diabetes who are taking insulin should maintain their blood glucose above what level?

A

4 mmol/L

27
Q

What is the frequency to offer HbA1c test to women with preexisting diabetes?

A

At booking
2nd & 3rd trimester

28
Q

Why do we offer HbA1c test to women with GMD?

A

To identify possibility of preexisting type 2 diabetes

29
Q

When to offer subcutaneous insulin infusion SCII ( insulin pump therapy)
To pregnant women with insulin- treated diabetes?

A

1- if taking multiple daily injections
2- if don’t achieve blood glucose control without significant disabling hypoglycemia.

30
Q

What are the 2 types of continuous glucose monitoring (CGM)?

A

Real time CGM ( rtCGM)
Intermittently scanned CGM( isCGM)

31
Q

When to offer rtCGM for glucose monitoring in diabetic pregnant women?

A

Type 1 diabetes

32
Q

When to consider offering rtCGM for glucose monitoring in diabetic pregnant women?

A

Women who are taking insulin:
* if problematic severe hypoglycemia
* unstable glucose levels despite efforts to optimize glycemic control

33
Q

Where to admit pregnant women with suspected diabetic ketoacidosis ?

A

Level 2 critical care

34
Q

How to make retinal assessment during pregnancy?

A

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

35
Q

Retinopathy IS NOT contraindication for ……

A

*Vaginal birth
* rapid optimization of blood glucose control

36
Q

When to make renal assessment for diabetic pregnant women?

A

At first contact during pregnancy for women with preexisting diabetes
IF; they haven’t had in the last 3 months

37
Q

When to refer a diabetic pregnant woman to a nephrologist?

A

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

38
Q

When to consider thromboprophylaxis for diabetic pregnant women ?

A

Proteinuria > 5 g/ day
= albumin: cr ratio > 220 mg/ mmol

39
Q

How often to monitor fetal growth and wellbeing in diabetic pregnant women ?

A

Every 4 weeks from 28 - 36 weeks

40
Q

When to offer Labour induction or CS to diabetic pregnant women?

A

(37_38+6d )weeks to women with type 1&type 2

41
Q

What to advice a woman with uncomplicated gestational diabetes about the time to give birth?

A

No later than 40 weeks+6 days

42
Q

What to consider about preterm Labour in diabetic pregnant women?

A

*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 🏥

43
Q

When to offer induction of labour or CS to diabetic pregnant women before 37 weeks?

A

In the presence of maternal or fetal complications

44
Q

How often to monitor blood glucose in diabetic pregnant women who went through general anesthesia for birth?

A

EVERY 30 MINUTES until the woman is fully conscious.

45
Q

How often to monitor blood glucose during labour in diabetic pregnant women? What is the targets?

A

EVERY 1 HOUR
Targets: 4- 7 mmol/L

46
Q

During the labour of diabetic pregnant women when to offer IV dextrose and Insulin infusion from the onset of the labour?

A
  • type 1 diabetes
  • women with diabetes whose plasma glucose IS Not maintained between 4-7 mmol/L
47
Q

How to manage glucose lowering therapy in the post natal period in diabetic women?

A

GDM 👉 stop therapy immediately
after birth
Type1 👉reduce insulin immediately
After birth and monitor BG
Type2👉 continue metformin

48
Q

If blood glucose levels returned to normal after birth in GDM women how to monitor her in post natal period?

A
  • offer lifestyle advice
  • offer FBG test 6-13 weeks after birth to exclude diabetes
  • after 13 weeks offer FBG test
    Or HbA1c
49
Q

What is the prognosis of FBG test in post natal period in diabetic women?

A

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

50
Q

What is the prognosis of HbA1c test in post natal period in diabetic women?

A

*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

51
Q

When to check blood glucose in the babies of women with diabetes?

A

2-4 hours after birth routinely

52
Q

What signs may develop in the babies of women with diabetes that require blood tests?

A

Clinical signs of
Polycythaemia
Hyperbilirubinemia
Hypocalcaemia
Hypomagnesaemia

53
Q

When to offer echocardiogram for babies of women with diabetes?

A

1- Clinical signs of : congenital heart disease or / cardiomyopathy
2- heart murmur

54
Q

When diabetic women should feed their babies after birth?

A

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

55
Q

When to offer additional measures such as tube feeding or IV dextrose for babies of diabetic mothers after birth?

A

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

2-Diabetes Mellitus In Pregnancy (2 decks)

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