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OBGYN > Dibetes In Pregnancy > Flashcards

Dibetes In Pregnancy Flashcards

1
Q

What was the impact of diabetes before insulin?

A
  • maternal mortality = 30%
  • perinatal mortality = 60%
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2
Q

What is the impact of types 1&2 diabetes in pregnancy now?

A
  • perinatal mortality 3.5 times higher
  • stillbirth rate 5 times higher

(Than non-diabetic pregnancy)

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3
Q

What does the St. Vincent Declaration say?

A

The outcome of a diabetic pregnancy should approximate that of a non-diabetic pregnancy

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4
Q

What is the physiology behind diabetes in pregnancy?

A

Pregnancy is ‘diabetogenic’

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5
Q

How is pregnancy diabetogenic?

A

Glucose tolerance decreases in pregnancy

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6
Q

What causes glucose tolerance to decrease in pregnancy? (4)

A
  • altered CHO metabolism
  • human placental lactose (decreased insulin sensitivity)
  • progesterone (decreased insulin sensitivity)
  • cortisol (decreased insulin production
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7
Q

What happens in pregnancy if you already have IGT or tendency towards it?

A

Worsens it => DM

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8
Q

How does pregnancy impact those with pre-existing diabetes?

A

Insulin requirements increase

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9
Q

Why does Glycosuria ≠ Diabetes?

A

Glycosuria can occur at normal blood glucose levels in pregnancy

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10
Q

Why does glycosuria occur at normal blood glucose level in pregnancy?

A

Due to lowering of the renal threshold for glucose excretion

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11
Q

When is normal glycosuria evident in pregnancy?

A

Least evident in morning

Most evident after meals

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12
Q

What is the epidemiology of diabetes in pregnancy according to the Atlantic dip guidelines/saolta hospital group guidelines?

A
  • pre-existing diabetes = 0.4%
  • gestational diabetes = at least 10%
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13
Q

What is the definition of gestational diabetes?

A

Carbohydrate intolerance with onset or first recognition during pregnancy

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14
Q

Will gestational diabetes resolve after pregnancy?

A

May or may not

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15
Q

How common is gestational diabetes?

A

Becoming more common

10% of pregnant women

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16
Q

What are the parameters for diagnosis of GDM based on the International Association of Diabetes in Pregnancy Study Group (IADPSG) 2010?

A

Fasting, 75g load in 300 ml over 5 min

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17
Q

What is the epidemiology of pregnancies complicated by diabetes?

A

87.5% = GDM

7.5% = T2 DM

5% = T1 DM

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18
Q

What are the pre-existing risk factors for GDM? (6 high risk & 3 medium risk)

A

~70% of population fit into these risk factors

High risk:
- previous macroscomic baby (>4.5kg)
- previous GDM
- high BMI - obese BMI >30
- ethnicity (south Asian and Afro Caribbean, screen all ethnic group)
- PCOS (string of pearls appearance)
- family history (1st degree relative with dm)

Medium risk:
- previous still birth/ unexplained perinatal death
- age >30
- long term steroid use

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19
Q

What are the risk factors in this pregnancy that require GDM screening? (4)

A
  • polyhydramnios (single pocket >8cm or AFI >25)
  • > 90th centile fetal weight (macrosomia)
  • multiple pregnancy
  • glycosuria
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20
Q

What does the WHO say about screening for GDM?

A

Best practice: universal screening: offered in many European countries.
If universal screening not possible screen based on risk factors: high, medium, low.

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21
Q

When is GDM screened for based on Atlantic Dip guidelines?

A

If high risk factor as soon as feasible and if
negative repeat at 24-28 weeks. If medium risk
factor then 24-28 weeks.

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22
Q

When should patients with pre-gestational diabetes (ie T1/2) or GDM in previous pregnancy be seen?

A

In Diabetes Antenatal Clinic

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23
Q

How are newly diagnosed GDM managed?

A

Glucometer: 7 point profile (pre + post prandial and before bedtime)

Trial of Diet and Exercise
(calorie restriction/30 mins exercise each day)
(successful in about 50% of cases of GDM)

24
Q

At what point would someone being managed conservatively with GDM need to get medical management?

A

Fasting BM> 5
1 hour post-prandial > 7
on three or more occasions then metformin or
insulin

25
Q

What do the foetal complications of diabetes in pregnancy relate to?

A

GLUCOSE CONCENTRATIONS

(So type1/2 > GDM)

26
Q

What are the potential foetal complications of diabetes in pregnancy? (9)

A
  • congenital abnormalities (NTD/cardiac/sacral agenesis) increased x2 (T1 & T2 only)
  • preterm labour (10-12%: esp. T1&2)
  • poor foetal lung maturity (high glucose concn decrease surfactant)
  • Macrosomia (32% BW >4kg)
  • birth trauma (LSCS in 43%/ instrumental deliveries, shoulder dystocia)
  • foetal compromise/IUGR
  • foetal distress in labour
  • sudden foetal death
  • miscarriage (T1&T2 only)
27
Q

What are the congenital cardiac defects a/w/ diabetes in pregnancy?

A
  • double‐outlet right ventricle
  • truncus arteriosus
  • transposition of the great arteries
  • ventricular septal defect
  • hypoplastic left heart syndrome
28
Q

What are the neonatal complications of a baby born to a mother with diabetes? (5)

A
  • hypoglycaemia
  • polycythaemia (increased RBC/Hb)
  • hyperbilirubinaemia
  • hypocalcaemia/hypomagnesaemia (can = seizures)
  • neonatal cardiomyopathy
29
Q

What risk does a child have of developing T1 DM if there mother has diabetes?

A

2-3%

30
Q

What risk does a child have of developing T1 DM if their father has diabetes?

A

5-6%

31
Q

What are the maternal complications of diabetes in pregnancy related to?

A

Glucose levels

  • T1 & T2 more likely affected than GD
32
Q

What are some maternal complications of diabetes in pregnancy? (6)

A
  • Control of diabetes: Incr Insulin req/ketoacidosis/hypoglycaemia
  • Microvascular complications of Diabetes (mainly type 1/type DM)
  • Pre-eclampsia (and pregnancy induced HTN)
    (Type 1 /2 Diabetics)
  • Polyhydramnios
  • infections (UTI, wound infections and endometritis)
  • increased risk of c-sections and instrumental deliveries
33
Q

How does pregnancy impact the micro vascular complications of DM?

A
  • retinopathy may worsen & need treatment
  • nephropathy = deterioration in renal function and increase proteinuria
34
Q

How is diabetes in pregnancy managed?

A

Good glucose control and foetal monitoring

Multidisciplinary approach
6 doctors, 2 nurses, 1 ancillary
Obs, Med, GP, Paeds (neonatal), ophthalmology,
nephrology, Midwife, Diabetic Nurse specialist
Dietician

35
Q

What is the main aim of preconception care in pre-existing diabetes?

A

improve glycemic control

36
Q

How is glycemic control improved in pre-existing diabetes when giving preconception care?

A
  • Ideally combined diabetic and maternity care for 3-6 mnths prior to optimise HBA1C. Aim hbA1C< 6% (42mmol/mol). (<7% (53mmol/mol)more realistic). >10% (86mmol/L) avoid
  • In type 2: Continue metformin and start insulin: stop all other oral glucose lowering agents.
  • Dietary advice. Regular (up to 7 times daily at times) BMs
  • Consider Glucagon (for hypoglycemic episodes)
37
Q

What other considerations are needed as part of preconception care in pre-existing diabetes?

A
  • Review medications:
    -stop ACEi/ARB (tetratogenic), statins, smoking
  • Commence folic acid
    -5mg (up to 12wks gestation)
  • Creat/EGFR/ACR, retinopathy, TFTs (and other booking bloods)
38
Q

What drug is becoming more commonly used in pregnancy according to the EMeRGE study: Saolta Hospital Group?

A

Metformin

39
Q

What should be done for patients already on Metformin with PCOS in pregnancy?

A

Continue into pregnancy

40
Q

What should be done for women on Metformin due to type 2 DM in pregnancy?

A

Continue (and add insulin if required)

41
Q

What antenatal care/visits should patients with diabetes in pregnancy have?

A
  • combined obstetric and diabetic clinic: At least 2-4 weekly visits up to 34 weeks, then weekly
  • U/S Scans: dating scan, 20 wk (foetal ECHO), 28, 32, 36 wks (growth, liquor)
    +/- Umbilical artery Doppler.
    (above for Type1/Typ2 DM or Gestational Diabetes not diet controlled)
  • T1 & T2 have to have a foetal echo at 20 weeks and have to go to Dublin tertiary centre for it
42
Q

How should glycemic control be monitored during pregnancy for women with diabetes?

A

a) check HBA1C every 2-4 weeks
Target HBA1C: 6-6.5% -42-48mmol/mol (balance with hypos)

b) prepandial 4-5
    post prandial <7 1hr
    higher insulin doses in later pregnancy.

Beware failing requirements = (placental failure)

43
Q

What complications should be monitored for in pregnancy when the mother has diabetes?

A

Monitor for htn, pre-eclampsia, ketoacidosis, TFTs
Retinal screening (at least each trimester in pregestational). Monitor u+e.

44
Q

What should people at high risk of pre-eclampsia take from 12 weeks as a prevention strategy?

A

Aspirin

45
Q

Do pregnant women with diabetes need to take aspirin?

A

Type 1/2 diabetics should be on aspirin (75mg-150mg) from 12 weeks.

46
Q

Why are steroids problematic in a pregnancy with diabetes?

A

Betamethasone or Dexamethasone can dramatically increase BM levels in women with diabetes

47
Q

When are steroids indicated in pregnancy with diabetes?

A

Indicated up to 36+6 weeks (can get RDS later in pregnancy

48
Q

How does the steroid admin differ between pregnant women with diabetes?

A
  • If on insulin: Start IV sliding scale insulin within 2 hrs of first injection and continue for 12 hrs after second injection. Aim BMs 4-7 mmols/L
  • If not on insulin: 2 hrly BMs and start SS if > 7
49
Q

What are there concerns about when giving steroids to pregnant women with diabetes?

A
  • tocolytics = threatened pre-term labour you can give tocolytics to try reduce pre-term contractions (eg salbutamol which worsens glucose control = hyperglycemia)
50
Q

When and how should babies of mothers with diabetes in pregnancy be delivered?

A
  • NICE argue for routine Delivery (IOL or C-section) in Type 2/1 <39 weeks and GDM by <41 weeks
  • Atlantic dip argues should balance risk of still birth-v-glycaemic control, macrosomia, foetal well being, maternal wishes.
51
Q

Why may mothers with diabetes in pregnancy need a c-section?

A

If weight >4kg

(Needed in 50%)

52
Q

How are T1 & T2 diabetis handled during labour?

A
  • IV sliding scale insulin (actrapid or novarapid)
  • 2 cannulas
  • 1 litre 5% dextrose (100ml/hr)
  • aim BSL- 4-7. check hrly BSLs and adjust.
53
Q

How are gestational diabetics handled during labour?

A
  • If on diet alone – no need for SS unless BSL raised on hrly BM check (> 7 x 2)
  • if on insulin/metformin as above.
54
Q

What do all mothers with diabetes in pregnancy need during labour?

A

Continuous CTG

55
Q

What postpartum care does a mother with pre-existing diabetes need?

A

½ infusion when placenta delivers, stop when ready to eat (stop infusion 30-60mins after s/c insulin/medication)

56
Q

What postpartum care does a mother who had gestational diabetes need?

A

stop insulin infusion when placenta delivers.
Monitor BM x24hrs.

should have GTT at 6-12wks (in hospital)

annual fasting glucose and hba1c – with GP (>50% diabetic within 10 yrs)

57
Q

What postpartum care does a baby born to a mother with diabetes need?

A

1) remain with mother (if possible)

2) feed as soon as possible. (within 1hr -breast best).

3) BM approx 4-6 hours (before 2nd feed) (hypo<2.6)
BM falls then rises in first 2-3 hrs so avoid early test unless indicated
additional tests only if clinical signs.

OBGYN (25 decks)

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