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
2
Q
Percentage of pregnancies complicated by DM
A
3 - 10%
3
Q
Hyperglycaemia first detected at any time during pregnancy should be classified as either – or –
A
Diabetes mellitus in pregnancy
Gestational diabetes mellitus
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
5
Q
Hyperglycaemia in pregnancy can be – or –
A
Diabetes in pregnancy or gestational diabetes
6
Q
Diabetes in pregnancy is subdivided into – and –
A
- Diagnosed before pregnancy
- Diagnosed for the first time during pregnancy
7
Q
T/F: Diabetes in pregnancy can be type 1 or type 2 DM
A
T
8
Q
Hyperglycemia during pregnancy that is not diabetes
A
Gestational DM
9
Q
Hyperglycemia diagnosed for the first time during pregnancy
A
Gestational DM
10
Q
Gestational DM may occur at any time during pregnancy but most likely after – weeks
A
24 weeks
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
12
Q
T/F: Diabetes in pregnancy can occur at any time including first trimester
A
T
13
Q
Class A1 in White’s classification of DM
A
gestational diabetes; diet controlled
14
Q
Medication controlled gestational DM in White’s classification is class what?
A
A2
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
16
Q
Class C of White’s classification of DM
A
onset at age 10-19 or duration of 10–19 years
17
Q
Gestational diabetes in White’s classification of DM are class – and –
A
A1 and A2
18
Q
T/F: Class B and C in White’s classification of DM are for diabetes existing before pregnancy
A
T
19
Q
Class T in White’s DM classification
A
Prior kidney transplant
20
Q
Class H in Whites’s DM classification
A
Ischaemic heart disease
21
Q
Class R in White’s DM classification
A
Proliferative retinopathy
22
Q
Class F in White’s DM classification
A
Diabetic nephropathy
23
Q
Class RF in White’s DM classification
A
Retinopathy and nephropathy
24
Q
Class E in White’s DM classification
A
overt diabetes mellitus with calcified pelvic vessels
25
Class D in White's DM classification
onset before age 10 or duration greater than 20 years
26
Two forms of screening for DM
Clinical screening
Biochemical screening
27
Clinical screening for DM involves -- and --
History and examination
28
Biochemical screening involves
50g1-hour challenge (≥ 7.8)
29
Epidemiologically screening may be done in 2 ways -- and --
Universally
Selectively/opportunistic
30
2 components of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)
1. 50g 1-hour non fasted challenge on all women
2. followed by 100g 3-hour OGTT for those who are positive
31
Sensitivity of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)
approximately 100%
32
Drawback of UNIVERSAL BIOCHEMICAL SCREENING (ADA/ACOG)
Expensive
33
T/F: Selected screening involves identifying patients with risk factors for DM then screening
T
34
Risk factors for DM used in selected screening for DM
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
35
Specificity of selected screening
56%
36
Sensitivity of selected screening
63%
37
% of women with diabetes in pregnancy that may go unnoticed with selected screening
37%-50%
38
T/F: RBS is a good screening tool
F
39
T/F: RBS is useful in picking up Diabetic Emergencies
T
40
T/F: FBS is useful as part of OGTT
T
41
T/F: FBS is a useful screening tool
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)
42
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)
T
43
T/F: ANY glycosuria with ketonuria strongly suggest DM
T.
– DO RBS Immediately
44
2+ glycosuria is diagnostic of DM
F. Suggestive
45
When is glycosuria suggestive of DM
Repeated mild glycosuria (1+)
Isolated heavy glycosuria (2+ and above)
46
Diabetes in pregnancy should be diagnosed by the 2006 WHO criteria for diabetes if one or more of the following 3 criteria are met:
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
Gestational diabetes mellitus should be diagnosed at any time in pregnancy if one or more of the following criteria are met:
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
According to NICE FBG of -- is diagnostic of GDM
>/= 5.6
49
According to NICE 2HPG of -- is diagnostic of GDM
>/=7.8
50
T/F: With NICE there are no established criteria for the diagnosis of diabetes based on the 1-hour post-load value
T
51
4 Prenatal Patient categories at diagnosis
1. Known Pre-gestational DM (T2DM, T1DM)
2. Newly Diagnosed GDM
3. Newly Diagnosed DM
4. Diagnosed in an Emergency state (DKA, HONK)
52
In preconception management of GDM optimum glycaemic control includes
HbA1c ˂ 6.5 % OR ˂ 7% if on insulin,
OR
FBG ˂ 5.5 mmol/l and
PPG ˂ 8.0 mmol/l
53
In preconception management of GDM actively discourage pregnancy if HbA1c
˃ 8% (WHO/ADA/IADPSG)
˃10% (NICE 2015)
54
T/F: Offer up to monthly measurement of HbA1c levels for women with diabetes who are planning a pregnancy.
T
[NICE 2008, amended 2020]
55
4 classes of drugs to be stopped in the preconception management of DM
Review medications and stop statins, fibrates, ACE , Some oral hypoglycaemics
56
In antenatal management of DM OGTT is repeated at how many weeks GA if normal at presentation
24 - 28 weeks
57
How often is USS and CTG done in the antenatal period and from what GA
monthly USG,
CTG every 2 weeks from 34wks
58
Dawn phenomenon:
early morning hyperglycaemia due to physiological increase in GH, Cortisol and Catecholamines at night
59
Somogyi :
rebound hyperglycaemia from counter-regulatory hormone release following hypoglycaemia
60
Goals for glycaemic control in pregnancy:
Fasting -
Premeal less than -
1H Post prandial -
2H Post prandial -
Bedtime -
2- 6 am =
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
T/F: All women diagnosed with GDM should be started on diet and exercise and reviewed in 1-2 weeks
T
62
How many meals is recommended in the antenatal management of DM
3 major meals with 3 snacks
63
Pharmacological therapy should be initiated if
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
First choice medication in antenatal DM management
Insulin
65
T/F: Metformin and glibenclamide can be used in the antenatal management of DM
T
66
NICE TREATMENT TARGET (2015)
FPG 4 - 5.3 mmol/L
1HPP 7.8 mmol/L
2HPP 6.4 mmol/L
67
In the antenatal management of DM, IF FPG LESS THAN 7.0 what next?
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
When is insulin given in the antenatal management of of DM
FPG 6-6.9 + EVIDENCE OF MASCROSOMIA AND/OR POLYHYDRAMNIOS
69
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
T
70
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
T
71
Consider continuous glucose monitoring for pregnant women who are on insulin therapy but do not have type 1 diabetes, if:
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
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).
T
73
AVERAGE INSULIN REQUIREMENT PER GA
6-18 weeks
18-26 weeks
26-36 weeks
Greater than 36weeks
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
Total starting dose of insulin
Usually should not be more that 60 iu /day to start
75
Preferable types of insulin used
mainly premixed insulin ( eg Humulin®(Eli Lilly), and mixtard® (Novo Nordisk)
76
Insulin dose
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
T/F: GDM have good outcome with glibenclamide (glyburide)
T
78
T/F: Patients with T2DM who were on glibenclamide before pregnancy appear to have increased perinatal mortality with continued use
T
79
T/F: T2DM patients should be switched to insulin
T
80
T/F: Metformin is safe in pregnancy
T
81
Dose of metformin used in pregnancy
Start at 500mg daily and increase gradually to a maximum of 2500mg daily dose
82
With DM, aim at delivery at what GA
39-40weeks.
83
T/F: Steroids for lung maturity are contraindicated in DM
may be given to aid lung maturity but strict glycaemic control should be ensured as it may derail glycaemic control previously achieved.
84
NICE RECOMMENDATION ON TIMING OF DELIVERY (2015)
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
How often should glucose be monitored in labour
GKI infusion with hourly blood glucose checks
86
Target blood glucose in labour
4-7 mmol/L
87
T/F: Early morning CS for DM
T
88
T/F: Overnight fasting with no insulin prior to elective CS
F
Patient should have evening insulin dose and bed time snack
89
T/F: OGTT on the morning of elective CS
F
In well controlled patients only FBS may be done on the morning of surgery
90
Dose of GKI for elective CS
GKI (500mls 10% Dex+10 mmol KCl+10 Units Soluble Insulin) at 100mls/Hr
91
T/F: Sacral agenesis/caudal regression ( upto 400x more frequent, nearly pathognomonic of DM Fethopathy) as fetal DM complication
T
92
T/F: absent kidneys (Potter’s syndrome), polycystic kidneys, double ureter as fetal DM complications
T
93
T/F: higher- transposition of great vessels, VSD,ASD, situs inversus are fetal DM complications
T
94
T/F: anecephaly, open spina bifida, microcephaly, encephalocele, menningomyelocele
T
95
T/F: Tracheoesophageal fistula, bowel atresia, imperforate anus
T
96
T/F; IUGR is a complication of DM
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
T/F: – hyperinsulinaemia suppress production and maturation of surfactants
T
98
5 possible causes of IUFD in DM
Possibly from cord thrombosis and accelerated placenta aging
GA greater than 36weeks
IUGR
Ketoacidosis ( more dangerous than hypoglycaemia to the fetus)
Hydramnios
99
T/F: DKA may occur at lower glucose levels (11.1mmol/L) and more rapidly in pregnant women
T
100
With DKA, IUFD will occur in what percentage of fetuses
10 30%
101
% of DKA caused by medical illness/infections
50%
102
% of DKA caused by treatment non-compliance
20%
103
% of DKA caused by unknown precipitants
30%
104
T/F: Antenatal steroids for lung maturation and beta adrenergic (terbutaline) can precipitate or exacerbate DKA especially PreGDM
T
105
T/F: With DKA in pregnancy there is higher pH with ketosis
T
106
Management of DKA in pregnancy
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
List 7 maternal complications of DM
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
T/F: Severe hypoglycemia is teratogenic in the first trimester
T
ASK all PreGDMs!!
109
When is nephropathy diagnosed in pregnancy with DM
Diagnose in preg if persistent proteinuria (300mg/day or 1+) in absence of UTI prior to 20wks.)
110
T/F: Pregnancy does not change the long-term prognosis of DM retinopathy
T
111
--% of GDM PATIENT WILL NEED MEDICATION
70%
112
--% OF GDM WILL DEV T2DM IN 5 TO 10YRS
>50%
