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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
What do the foetal complications of diabetes in pregnancy relate to?
GLUCOSE CONCENTRATIONS (So type1/2 > GDM)
26
What are the potential foetal complications of diabetes in pregnancy? (9)
* 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
What are the congenital cardiac defects a/w/ diabetes in pregnancy?
* double‐outlet right ventricle * truncus arteriosus * transposition of the great arteries * ventricular septal defect * hypoplastic left heart syndrome
28
What are the neonatal complications of a baby born to a mother with diabetes? (5)
* hypoglycaemia * polycythaemia (increased RBC/Hb) * hyperbilirubinaemia * hypocalcaemia/hypomagnesaemia (can = seizures) * neonatal cardiomyopathy
29
What risk does a child have of developing T1 DM if there mother has diabetes?
2-3%
30
What risk does a child have of developing T1 DM if their father has diabetes?
5-6%
31
What are the maternal complications of diabetes in pregnancy related to?
Glucose levels - T1 & T2 more likely affected than GD
32
What are some maternal complications of diabetes in pregnancy? (6)
* 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
How does pregnancy impact the micro vascular complications of DM?
* retinopathy may worsen & need treatment * nephropathy = deterioration in renal function and increase proteinuria
34
How is diabetes in pregnancy managed?
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
What is the main aim of preconception care in pre-existing diabetes?
**improve glycemic control**
36
How is glycemic control improved in pre-existing diabetes when giving preconception care?
* 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
What other considerations are needed as part of preconception care in pre-existing diabetes?
* 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
What drug is becoming more commonly used in pregnancy according to the EMeRGE study: Saolta Hospital Group?
Metformin
39
What should be done for patients already on Metformin with PCOS in pregnancy?
Continue into pregnancy
40
What should be done for women on Metformin due to type 2 DM in pregnancy?
Continue (and add insulin if required)
41
What antenatal care/visits should patients with diabetes in pregnancy have?
* 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
How should glycemic control be monitored during pregnancy for women with diabetes?
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
What complications should be monitored for in pregnancy when the mother has diabetes?
Monitor for htn, pre-eclampsia, ketoacidosis, TFTs Retinal screening (at least each trimester in pregestational). Monitor u+e.
44
What should people at high risk of pre-eclampsia take from 12 weeks as a prevention strategy?
Aspirin
45
Do pregnant women with diabetes need to take aspirin?
Type 1/2 diabetics should be on aspirin (75mg-150mg) from 12 weeks.
46
Why are steroids problematic in a pregnancy with diabetes?
Betamethasone or Dexamethasone can dramatically increase BM levels in women with diabetes
47
When are steroids indicated in pregnancy with diabetes?
Indicated up to 36+6 weeks (can get RDS later in pregnancy
48
How does the steroid admin differ between pregnant women with diabetes?
* 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
What are there concerns about when giving steroids to pregnant women with diabetes?
* tocolytics = threatened pre-term labour you can give tocolytics to try reduce pre-term contractions (eg salbutamol which worsens glucose control = hyperglycemia)
50
When and how should babies of mothers with diabetes in pregnancy be delivered?
* 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
Why may mothers with diabetes in pregnancy need a c-section?
If weight >4kg (Needed in 50%)
52
How are T1 & T2 diabetis handled during labour?
* 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
How are gestational diabetics handled during labour?
* 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
What do all mothers with diabetes in pregnancy need during labour?
Continuous CTG
55
What postpartum care does a mother with pre-existing diabetes need?
½ infusion when placenta delivers, stop when ready to eat (stop infusion 30-60mins after s/c insulin/medication)
56
What postpartum care does a mother who had gestational diabetes need?
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
What postpartum care does a baby born to a mother with diabetes need?
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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