DM in pg'y

Question 1

why does GDM dvp?

Answer 1

placental hrms and HPL are anti-insulin hrms => increased IR

Question 2

when does GDM usually manifest itself?

Answer 2

3rd tri

Question 3

who is at increased risk of congenital anomalies, GDM or pregestational DM?

Answer 3

pregestational DM

Question 4

GDM pts are at increased risk of what in fetus? in mom?

Answer 4

of fetal macrosomia, birth injuries, neonatal hypoG, hypoCa2+, hyperBr, polycythemia

moms are at increased risk of dvp’ing DMII during lifetime

Question 5

who is at risk of GDM?

Answer 5

hispanics, Asians, NAm, ob women, fhx of DM, previous infant weighing +4000g, previous stillbirth

Question 6

when to screen for GDM?

Answer 6

if 1 or more RFs present, screen at first prenatal visit and at each trimester. Otherwise, at 24-28weeks (end of 2nd tri)

Question 7

methods of screening for GDM?

Answer 7

O’sullivan test (50-g G load then measure plasma G 1 hr later. If plasma G is > 140, its +. Need to follow up with 3-hr GTT.

Question 8

what is the GTT?

Answer 8

3-d special CHO diet, then overnight fast, then measure fasting G levels in a.m., then 100mg oral G, then measure G levels at 1, 2, and 3 hours. GDM is dx’d if 2 or more of following are +:

Fasting > 95
1h > 180
2h > 155
3h > 140

Question 9

tx of GDM:

Answer 9

start on DM’c diet - 2200 cal/d, limit CHO intake to 200-220g/d, check blood G QID, and do mild exercise (walking)

Question 10

what is the White classification of GDM?

Answer 10

class A1 = diet-controlled (brings fasting G < 90, 1-hr post-prandial < 140, 2-hr postprandial < 120)
class A2 = medication-controlled

Question 11

which is usually elevated in GDM, fasting, postprandial or both?

Answer 11

postprandial, b/c its an impairment in metab of large CHO boluses.

Question 12

what kind of IN is used if needed?

Answer 12

long-acting in morning (NPH)
short-acting at dinner (Lispro or humalog)

glyburide is also qqf used

Question 13

what kind of fetal monitoring is necessary in GDMs?

Answer 13

If A2 GDM, need NST or BPP weekly or biweekly starting b/w 32 and 36w until delivery. Also do an u/s b/w 34 and 37w to eval for macrosomia.

if A1, no monitoring necessary.

Question 14

delivery mgt in pts w/GDM?

Answer 14

do an adm random G to r/o severe hyperG. Needs t/b corrected to avoid neonatal hypoG.
Can schedule induction at 39w to prevent hypoG as pg’y progresses and placental fct decreases. Prepare for shoulder dystocia.
can do elective c/s for pts w/estimated fetal weight > 4500g.

Question 15

postpartum f/u?

Answer 15

screen for DMII at postpartum visit, and annually with fasting blood G

Question 16

what is caudal regression syndrome?

Answer 16

impaired dvp of sacrum, vertebrae, pelvis. C/=> flaccid paralysis, incontinence. See increased risk of this in fetuses w/DM’c moms.

Question 17

ideally, a DM pt who wishes to become pg should be counseled on what?

Answer 17

the importance of tight G control before and during pg’y, risk of worsening renal dis if its already present, risk of congenital anomalies, increased risks of NTDs.

Question 18

what kind of diet should a DM pt be on before and during pg’y?

Answer 18

2200 cal diet, restricting CHO’s. Maintain during pg’y but with increased caloric needs up by 300.

Question 19

how to screen T1DM pts before pg’y or at initial visit?

Answer 19

ECG
24-hr urine collection for protein & creatinine clearance
HbA1c
TSH
ophtho referral

Question 20

how will IN requirements change during pg’y in a pt w/T1DM?

Answer 20

IN dose slightly increased during first half, then may increase a lot during 2nd half 2/2 increasing IR.
IN pump can be placed prepregnancy or after 1st tri if having difficulty managing w/IN injections

Question 21

guidelines for adjusting IN doses:

Answer 21

1) establish a fasting G level b/w 70-90 mg/dL
2) only adjust one dosing level at a time
3) Do not change any dosage by more than 20% per day.
4) wait 24h b/w dosage changes to evaluate the response

remember to account for physical activity, and weekday-weekend differences

Question 22

how will mgt of pre-gestational DMII change during pg’y?

Answer 22

most will require IN. Usually maintain hypoG meds that they were on before, but most still need IN. Start w/bedtime NPH and humalog or Lispro at mealtimes.

Question 23

how is delivery managed in a well-controlled pregestational IN-dependent diabetic w/no complications?

Answer 23

fetal lung maturity testing at 37w, deliver if mature. Or, can induce at 38-39 weeks without fetal lung maturity testing. Need to deliver earlier though if nonreassuring fetal status, poor G control, worsening or unctl’d HTN, worsening renal dis, poor fetal growth

During delivery, need dextrose and IN drips to maintain adequate increased G needs during labor. Maintain blood G b/w 100 and 120.

After delivery, a T1DM mom may not need any IN b/c of removal of placental hrms. T1DM will need at least a small amt of IN.

Question 24

what f/u is needed post-partum?

Answer 24

do not resume oral hypoglycemic agents if breastfeeding
if pregestational, resume prepregnancy regimens.
24-h urine collectiojn at 6 weeks postpartum
ophtho f/u