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WACS > DM IN PREGNANCY > Flashcards

DM IN PREGNANCY Flashcards

1
Q

Define DM

A

Diabetes mellitus (DM) is a metabolic disorder of multiple aetiology characterized by, chronic hyperglycaemia with disturbance of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both

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2
Q

Percentage of pregnancies complicated by DM

A

3 - 10%

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3
Q

Hyperglycaemia first detected at any time during pregnancy should be classified as either – or –

A

Diabetes mellitus in pregnancy
Gestational diabetes mellitus

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4
Q

Current definition of GDM include – and –
.

A

women with diabetes and
women with intermediate hyperglycaemia – impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) as defined in non-pregnant adults

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5
Q

Hyperglycaemia in pregnancy can be – or –

A

Diabetes in pregnancy or gestational diabetes

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6
Q

Diabetes in pregnancy is subdivided into – and –

A
  1. Diagnosed before pregnancy
  2. Diagnosed for the first time during pregnancy
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7
Q

T/F: Diabetes in pregnancy can be type 1 or type 2 DM

A

T

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8
Q

Hyperglycemia during pregnancy that is not diabetes

A

Gestational DM

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9
Q

Hyperglycemia diagnosed for the first time during pregnancy

A

Gestational DM

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10
Q

Gestational DM may occur at any time during pregnancy but most likely after – weeks

A

24 weeks

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11
Q

Hyperglycemia diagnosed for the first time during pregnancy is regarded as diabetes in pregnancy if

A

It meets criteria for diabetes mellitus in the nonpregnant state

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12
Q

T/F: Diabetes in pregnancy can occur at any time including first trimester

A

T

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13
Q

Class A1 in White’s classification of DM

A

gestational diabetes; diet controlled

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14
Q

Medication controlled gestational DM in White’s classification is class what?

A

A2

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15
Q

Class B in White’s classification of DM

A

onset at age 20 or older or with duration of less than 10 years

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16
Q

Class C of White’s classification of DM

A

onset at age 10-19 or duration of 10–19 years

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17
Q

Gestational diabetes in White’s classification of DM are class – and –

A

A1 and A2

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18
Q

T/F: Class B and C in White’s classification of DM are for diabetes existing before pregnancy

A

T

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19
Q

Class T in White’s DM classification

A

Prior kidney transplant

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20
Q

Class H in Whites’s DM classification

A

Ischaemic heart disease

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21
Q

Class R in White’s DM classification

A

Proliferative retinopathy

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22
Q

Class F in White’s DM classification

A

Diabetic nephropathy

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23
Q

Class RF in White’s DM classification

A

Retinopathy and nephropathy

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24
Q

Class E in White’s DM classification

A

overt diabetes mellitus with calcified pelvic vessels

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25
Q

Class D in White’s DM classification

A

onset before age 10 or duration greater than 20 years

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26
Q

Two forms of screening for DM

A

Clinical screening
Biochemical screening

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27
Q

Clinical screening for DM involves – and –

A

History and examination

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28
Q

Biochemical screening involves

A

50g1-hour challenge (≥ 7.8)

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29
Q

Epidemiologically screening may be done in 2 ways – and –

A

Universally
Selectively/opportunistic

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30
Q

2 components of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)

A
  1. 50g 1-hour non fasted challenge on all women
  2. followed by 100g 3-hour OGTT for those who are positive
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31
Q

Sensitivity of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)

A

approximately 100%

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32
Q

Drawback of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)

A

Expensive

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33
Q

T/F: Selected screening involves identifying patients with risk factors for DM then screening

A

T

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34
Q

Risk factors for DM used in selected screening for DM

A

Family history of diabetes

Previous history of GDM or IGT, previous macrosomia, previous unexplained SB,

Index preg Hx - advanced maternal age, obesity, repeated glycosuria in pregnancy, polyhydramnios and suspected macrosomia

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35
Q

Specificity of selected screening

A

56%

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36
Q

Sensitivity of selected screening

A

63%

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37
Q

% of women with diabetes in pregnancy that may go unnoticed with selected screening

A

37%-50%

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38
Q

T/F: RBS is a good screening tool

A

F

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39
Q

T/F: RBS is useful in picking up Diabetic Emergencies

A

T

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40
Q

T/F: FBS is useful as part of OGTT

A

T

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41
Q

T/F: FBS is a useful screening tool

A

F.
As the ONLY tool may not be of much value, because in the physiology of pregnancy, FBS is usually low. (Post prandial hyperglycaemia is usually the common issue)

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42
Q

T/F: Most GDM patients have high post prandial blood glucose because of deficiency of insulin to respond to the high load (post receptor resistance)

A

T

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43
Q

T/F: ANY glycosuria with ketonuria strongly suggest DM

A

T.
– DO RBS Immediately

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44
Q

2+ glycosuria is diagnostic of DM

A

F. Suggestive

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45
Q

When is glycosuria suggestive of DM

A

Repeated mild glycosuria (1+)

Isolated heavy glycosuria (2+ and above)

46
Q

Diabetes in pregnancy should be diagnosed by the 2006 WHO criteria for diabetes if one or more of the following 3 criteria are met:

A

Fasting plasma glucose ≥ 7.0 mmol/l (126 mg/ dl)

2-hour plasma glucose ≥ 11.1 mmol/l (200 mg/dl) following a 75g oral glucose load

Random plasma glucose ≥ 11.1 mmol/l (200 mg/ dl) in the presence of diabetes symptoms.

47
Q

Gestational diabetes mellitus should be diagnosed at any time in pregnancy if one or more of the following criteria are met:

A

Fasting plasma glucose 5.1-6.9 mmol/l (92 -125 mg/dl)

1-hour plasma glucose ≥ 10.0 mmol/l (180 mg/dl) following a 75g oral glucose load*

2-hour plasma glucose 8.5-11.0 mmol/l (153 -199 mg/dl) following a 75g oral glucose load

48
Q

According to NICE FBG of – is diagnostic of GDM

A

> /= 5.6

49
Q

According to NICE 2HPG of – is diagnostic of GDM

A

> /=7.8

50
Q

T/F: With NICE there are no established criteria for the diagnosis of diabetes based on the 1-hour post-load value

A

T

51
Q

4 Prenatal Patient categories at diagnosis

A
  1. Known Pre-gestational DM (T2DM, T1DM)
  2. Newly Diagnosed GDM
  3. Newly Diagnosed DM
  4. Diagnosed in an Emergency state (DKA, HONK)
52
Q

In preconception management of GDM optimum glycaemic control includes

A

HbA1c ˂ 6.5 % OR ˂ 7% if on insulin,
OR
FBG ˂ 5.5 mmol/l and
PPG ˂ 8.0 mmol/l

53
Q

In preconception management of GDM actively discourage pregnancy if HbA1c

A

˃ 8% (WHO/ADA/IADPSG)
˃10% (NICE 2015)

54
Q

T/F: Offer up to monthly measurement ofHbA1c levelsfor women with diabetes who are planning a pregnancy.

A

T
[NICE 2008, amended 2020]

55
Q

4 classes of drugs to be stopped in the preconception management of DM

A

Review medications and stop statins, fibrates, ACE , Some oral hypoglycaemics

56
Q

In antenatal management of DM OGTT is repeated at how many weeks GA if normal at presentation

A

24 - 28 weeks

57
Q

How often is USS and CTG done in the antenatal period and from what GA

A

monthly USG,
CTG every 2 weeks from 34wks

58
Q

Dawn phenomenon:

A

early morning hyperglycaemia due to physiological increase in GH, Cortisol and Catecholamines at night

59
Q

Somogyi :

A

rebound hyperglycaemia from counter-regulatory hormone release following hypoglycaemia

60
Q

Goals for glycaemic control in pregnancy:
Fasting -
Premeal less than -
1H Post prandial -
2H Post prandial -
Bedtime -
2- 6 am =

A

Fasting - 3.3-5.0
Premeal less than - 5.5
1H Post prandial - less than 7.8
2H Post prandial - less than 6.7
Bedtime - less than 6.7
2- 6 am = 3.3-5.0

61
Q

T/F: All women diagnosed with GDM should be started on diet and exercise and reviewed in 1-2 weeks

A

T

62
Q

How many meals is recommended in the antenatal management of DM

A

3 major meals with 3 snacks

63
Q

Pharmacological therapy should be initiated if

A

Glycaemic control is poor after 1-2 weeks of diet/ exercise (GDM if FBG ˃ 6.9 mmol/l or 2h ˃ 11.0mmol/l )

Diagnosis is DM in pregnancy (FBG ˃ 6.9 mmol/l or 2h ˃ 11.1mmol/l or RBS ˃ 11.1mmol/l in the presence of symptoms)

Patients are diagnosed in hyperglycaemic emergencies, eg DKA

64
Q

First choice medication in antenatal DM management

A

Insulin

65
Q

T/F: Metformin and glibenclamide can be used in the antenatal management of DM

A

T

66
Q

NICE TREATMENT TARGET (2015)

A

FPG 4 - 5.3 mmol/L
1HPP 7.8 mmol/L
2HPP 6.4 mmol/L

67
Q

In the antenatal management of DM, IF FPG LESS THAN 7.0 what next?

A

TRIAL ON LIFESTYLE AND DIET SHOULD BE OFFERED

ADD METFORMIN IF ABOVE TARGETS ARE NOT MET IN 2 WEEKS

METFORMIN + INSULIN IF FPG ≥ 7.0mmol/L AFTER 2 WEEKS ON LIFESTYLE (WORSENING)

68
Q

When is insulin given in the antenatal management of of DM

A

FPG 6-6.9 + EVIDENCE OF MASCROSOMIA AND/OR POLYHYDRAMNIOS

69
Q

T/F: Offer continuous glucose monitoring (CGM) to all pregnant women with type 1 diabetes to help them meet their pregnancy blood glucose targets and improve neonatal outcomes

A

T

70
Q

T/F: Offer intermittently scanned CGM (isCGM, commonly referred to as flash) to pregnant women with type 1 diabetes who are unable to use continuous glucose monitoring or express a clear preference for it

A

T

71
Q

Consider continuous glucose monitoring for pregnant women who are on insulin therapy but do not have type 1 diabetes, if:

A

they have problematic severe hypoglycaemia (with or without impaired awareness of hypoglycaemia)or
they have unstable blood glucose levels that are causing concern despite efforts to optimise glycaemic control.[2015, amended 2020]

72
Q

T/F: For pregnant women who are using isCGM or continuous glucose monitoring, a member of the joint diabetes and antenatal care team with expertise in these systems should provide education and support (including advising women about sources of out-of-hours support).

A

T

73
Q

AVERAGE INSULIN REQUIREMENT PER GA

6-18 weeks

18-26 weeks

26-36 weeks

Greater than 36weeks

A

6-18 weeks 0.7 units/kg

18-26 weeks 0.8 units/kg

26-36 weeks 0.9 units/kg

> 36weeks 1.0 units/kg

74
Q

Total starting dose of insulin

A

Usually should not be more that 60 iu /day to start

75
Q

Preferable types of insulin used

A

mainly premixed insulin ( eg Humulin®(Eli Lilly), and mixtard® (Novo Nordisk)

76
Q

Insulin dose

A

initiation dose 0.3-1.0 iu/kg (START low generally 0.3-0.7 iu/kg to avoid periods of hypoglycaemia; then titrate up.

77
Q

T/F: GDM have good outcome with glibenclamide (glyburide)

A

T

78
Q

T/F: Patients with T2DM who were on glibenclamide before pregnancy appear to have increased perinatal mortality with continued use

A

T

79
Q

T/F: T2DM patients should be switched to insulin

A

T

80
Q

T/F: Metformin is safe in pregnancy

A

T

81
Q

Dose of metformin used in pregnancy

A

Start at 500mg daily and increase gradually to a maximum of 2500mg daily dose

82
Q

With DM, aim at delivery at what GA

A

39-40weeks.

83
Q

T/F: Steroids for lung maturity are contraindicated in DM

A

may be given to aid lung maturity but strict glycaemic control should be ensured as it may derail glycaemic control previously achieved.

84
Q

NICE RECOMMENDATION ON TIMING OF DELIVERY (2015)

A

Pre-gestational DM (TYPE 1 AND 2)
Elective delivery between 37-38 weeks

consider delivery before 37 weeks if metabolic or fetal/maternal complications occur

GDM
Advise delivery no later than 40w+6d
Elective delivery can be done prior to this. ( silent on minimum GA if all is well)

85
Q

How often should glucose be monitored in labour

A

GKI infusion with hourly blood glucose checks

86
Q

Target blood glucose in labour

A

4-7 mmol/L

87
Q

T/F: Early morning CS for DM

A

T

88
Q

T/F: Overnight fasting with no insulin prior to elective CS

A

F
Patient should have evening insulin dose and bed time snack

89
Q

T/F: OGTT on the morning of elective CS

A

F
In well controlled patients only FBS may be done on the morning of surgery

90
Q

Dose of GKI for elective CS

A

GKI (500mls 10% Dex+10 mmol KCl+10 Units Soluble Insulin) at 100mls/Hr

91
Q

T/F: Sacral agenesis/caudal regression ( upto 400x more frequent, nearly pathognomonic of DM Fethopathy) as fetal DM complication

A

T

92
Q

T/F: absent kidneys (Potter’s syndrome), polycystic kidneys, double ureter as fetal DM complications

A

T

93
Q

T/F: higher- transposition of great vessels, VSD,ASD, situs inversus are fetal DM complications

A

T

94
Q

T/F: anecephaly, open spina bifida, microcephaly, encephalocele, menningomyelocele

A

T

95
Q

T/F: Tracheoesophageal fistula, bowel atresia, imperforate anus

A

T

96
Q

T/F; IUGR is a complication of DM

A

T. IUGR –Microvascular disease.
Placenta compromise include fibrinoid necrosis, abnormal villus maturation, proliferative endarteritis of fetal stem arteries. They are irreversible when they occur early in pregnancy despite good glycaemic control later

97
Q

T/F: – hyperinsulinaemia suppress production and maturation of surfactants

A

T

98
Q

5 possible causes of IUFD in DM

A

Possibly from cord thrombosis and accelerated placenta aging

GA greater than 36weeks

IUGR

Ketoacidosis ( more dangerous than hypoglycaemia to the fetus)

Hydramnios

99
Q

T/F: DKA may occur at lower glucose levels (11.1mmol/L) and more rapidly in pregnant women

A

T

100
Q

With DKA, IUFD will occur in what percentage of fetuses

A

10 30%

101
Q

% of DKA caused by medical illness/infections

A

50%

102
Q

% of DKA caused by treatment non-compliance

A

20%

103
Q

% of DKA caused by unknown precipitants

A

30%

104
Q

T/F: Antenatal steroids for lung maturation and beta adrenergic (terbutaline) can precipitate or exacerbate DKA especially PreGDM

A

T

105
Q

T/F: With DKA in pregnancy there is higher pH with ketosis

A

T

106
Q

Management of DKA in pregnancy

A
  1. Rapid fluid replacement: 1L NS in 1st Hr. 2L in next 2-4 Hrs. (change to DNS if glucose ≤13mmol/L)
  2. IV soluble insulin 0.2-0.4 IU/Kg as loading dose then
  3. check electrolyte every 4 Hrs and correct potassium as needed
107
Q

List 7 maternal complications of DM

A
  1. Hypoglycaemia
  2. Rapid progression MICROVASCULAR and ATHEROSCLEROTIC disease
  3. Nephropathy
  4. Retinopathy
  5. Hypertensive disorders
  6. Preterm labour and delivery
  7. Perineal tears
108
Q

T/F: Severe hypoglycemia is teratogenic in the first trimester

A

T
ASK all PreGDMs!!

109
Q

When is nephropathy diagnosed in pregnancy with DM

A

Diagnose in preg if persistent proteinuria (300mg/day or 1+) in absence of UTI prior to 20wks.)

110
Q

T/F: Pregnancy does not change the long-term prognosis of DM retinopathy

A

T

111
Q

–% of GDM PATIENT WILL NEED MEDICATION

A

70%

112
Q

–% OF GDM WILL DEV T2DM IN 5 TO 10YRS

A

> 50%

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