Endocrine Flashcards
Discuss Addison’s in pregnancy
-Pathophysiology
-Presentation
-Diagnosis
-Effect of pregnancy on Addison’s
-Effect of Addison’s on pregnancy
-Management in pregnancy
- Pathophysiology
-Autoimmune destruction of adrenal gland leading to deficiency in (glucocorticoid) cortisol and (mineralcorticoids) aldosterone. - Presentation
-Hypotension, salt wasting, skin pigmentation, weight loss
-Associated with other autoimmune disease - T1DM, Graves - Diagnosis
-Loss of cortisol response to ACTH (Synacthen test)
-Hyperkalemia, hyponatremia, hypocalcemia
-Low morning cortisol (can be WNL in pregnancy) - Effect of pregnancy on Addison’s
-May mask symptoms but doesn’t generally affect it
-May deteriorate PP - Effect of Addison’s on Pregnancy
-No effect
-Adrenal antibodies do cross placenta but very rare to have adrenal insufficiency - Management in pregnancy
-Need to replace glucocorticoids and mineralocorticoids (hydrocortisone and fludrocortisone)
-Need stress dosing if hyperemesis, infection, stressful events
-Need stress dosing for labour
-Watch for profound hypotension with fluid shifts and diuresis PP. Manage with IV Saline
Discuss Conns in pregnancy
-Pathophysiology
-Presentation
-Diagnosis
-Management in pregnancy
- Pathophysiology
-Caused by primary hyperaldosteronism due to adrenal hyperplasia/adenoma/carcinoma - Presentation
-Hypertension, hypokalemia - Diagnosis
-High aldosterone
-Hypernatremia, hypokalemia - Management in pregnancy
-Control BP - manage same as chronic HTN
-Replace potassium
-Avoid ACEi and spironolactone as cause feminisation of male fetus.
-Defer surgery until after pregnancy
Discuss congenital adrenal hyperplasia in pregnancy
-Pathophysiology
-Presentation
-Diagnosis
-Effect of CAH on pregnancy
-Effect of pregnancy on CAH
-Management in pregnancy
- Pathophysiology
-Autosomal recessive condition with lack of adrenal enzymes.
-90% caused by lack of 21-hydrolase enzyme. Results in low cortisol and aldosterone and high androgens - Presentation for classic
-Masculinisation of female fetus, salt wasting crisis as neonate - Diagnosis
-17 hydroxyprogesterone levels are elevated
-Synacthen test. Cortisol will not respond to ATCH - Effects of CAH on pregnancy
-Increased miscarriage rates
-IUGR
-CS due to CPD from android pelvis
-PET, GDM - Effects of pregnancy on CAH
-Increased risk of female fetus having CAH and virilisation of genitalia - Management in pregnancy
-Pre-pregnancy counselling for genetics
-Continue fludrocortisone and hydrocortisone replacement in pregnancy
-Stress dose for hyperemesis, infection, labour
-Monitor for PET
-Consider dexamethasone from early pregnancy (before 6 weeks) to avoid virilisation of female fetus genitalia. Stop once sex known to be male as don’t need or CVS/Amnio show fetus not affected. Dexamethasone is not without fetal complications. Needs careful counselling
-Growth scans
-OGTT
-MDT - MFM, endocrinologists
Discuss management of phaeochromocytoma in pregnancy
-Pathophysiology
-Presentation
-Diagnosis
-Effects of phaeo on pregnancy
-Effects of pregnancy on phaeo
-Management
- Pathophysiology
-Tumour of the adrenal medulla producing excess catecholamines - Presentation
-Paroxysms of hypertension
-Headache
-Palpitations
-Sweating
-Anxiety
-Can mimic PET - Diagnosis
-Raised 24hr urinary catecholamines
-USS or MRI (best) to localise tumour (10% extramedullary) - Effects of phaeo on pregnancy
-Increased maternal and fetal mortality (25-60% if undiagnosed)
-Increased risk of arrythmia, CVA, pulmonary oedema, cardiogenic shock
-Increased risk GDM
-IUGR, acute/ chronic hypoxia, Abruption - Effect of pregnancy on Phaeo
-Potentially fatal HTN crises stimulated by labour, delivery, or pressure of gravid uterus on tumour when supine - Management
-MDT - endocrine, obstetrics, anaesthetics, neonatologist, surgeons
-Alpha blockade with prazosin / phenoxybenzamine
-Beta blockade for arrythmia but only once alpha blockers used.
-Cautions with meds which increase BP - metocloprimide, phenothiazides
-Surgical removal either <23 weeks or PP
-Delivery by CS. Half the risk of maternal mortality
What are the mechanisms in pregnancy which increase risk of DKA (4)
-Increased insulin resistance from placental hormones (human placental lactogen, cortisol, prolactin and progesterone)
-Increased carbohydrate absorption with reduced gut motility
-Predisposition for starvation with increased metabolic demands from utero-placental unit resulting in decreased fasting glucose and predisposition to ketoacidosis
-Limited buffering in blood with reduced bicarb (Increased renal loss), Predominance of respiratory alkalosis
What are the possible causes of DKA in pregnancy (5)
- Insulin withdrawal - faulty pump, non compliance
- New T1DM
- Increased metabolic demands - sepsis, trauma
- Reduced absorption - hyperemesis, fasting
- Drugs - beta mimetics, steriods
Discuss gestational diabetes
-Definition
-Incidence
-Risk factors (7)
- Definition
Impaired glucose tolerance with onset or first recognition in pregnancy. - Incidence
-10% - Risk factors
-PCOS
-FHx of >1 first degree relative with diabetes
-Previous GDM or macrosomia
-Medications - steroids, antipsychotics
-Obesity >30 BMI
-Ethnicity - Asian, Indian, Maori, Pacific, Aboriginal
-Advanced maternal age >40
Describe antenatal screening for GDM
-RANZCOG recommendation
-Australian cut offs for GDM
-Time for testing - high risk, and average risk
- RANZCOG recommendations
-2hr 75g diagnostic test (no screening test) - Australian cut offs
-Fasting glucose >5.1
-1Hr Glucose >10
-2Hr Glucose >8.5 - Time for testing
-Women at high risk - OGTT at first opportunity after conception and if negative 24-28 weeks
-Average risk women - OGTT 26-28weeks
Describe the New Zealand diagnostic pathway for GDM
-First antenatal HbA1c
-Screening cut off
-Diagnostic cut off
- First antenatal HbA1c
-HbA1c >=50 - probable undiagnosed diabetes. Immediate referral to specialist diabetes clinic. (WHO says >=48)
-HbA1c < = 40 - GCT
-HbA1c 41-49 - OGTT - GCT
-Positive if >=7.8 - proceed to OGTT
- >11.1 = diagnostic for GDM - OGTT
-Fasting >= 5.5
-2 hr >= 9.0
- Do OGTT directly if: BMI >30, Prev GDM, 1st degree relative with DM
Discuss risks associated with GDM
-Risk to mother during pregnancy (5)
-Risk to fetus
-Risk to mother PP
- Risk during pregnancy.
-HTN, PET, CS, SD, Birth injury, PPH
-At risk of all same issues as T2DM but to a much lesser degree - Risks to fetus
-IUGR, Macrosomia, NICU admissions, neonatal hypoglycemia,
-Not associated with congenital abnormalities - Maternal risks PP
-40-60% chance of developing T2DM in 10-15yrs
-30% risk of recurrent GDM
Discuss antenatal management of GDM
-Lifestyle advice
-Aim for glucose
-Medical management
-Fetal surveillance
-Maternal surveillance
- Lifestyle advice
-Dietary - reduce fat, increase fibre, low GI foods
-Moderate exercise 30mins / day
-Weight gain - if BMI >30 aim 5-9kg - Glucose targets
-Fasting <5
-1hr post food <7.4
-2hrs post food <6.7 - Medical management
-If levels persist above target for >2weeks consider medical
-Metformin: contra-indicated in IUGR, PET, Inadequate maternal wt gain. Crosses placenta. Not teratogenic
-Short acting insulin to bring down post parandial levels
-Intermediate acting to bring down high fasting levels - Fetal surveillance
-GS at time of diagnosis and 36-37 weeks - Maternal monitoring
-PET - BP and urinalysis
-BGL
Discuss timing of delivery for GDM
- If GDM without complications - IOL at 40/40
- If GDM with co-morbidities Aim IOL 38-39/40 (Macrosomia +/- poorly controlled diabetes)
- If GDM and EFW >4.5kg offer CS
Discuss labour and postpartum management of GDM
-Labour management
-Postpartum management
- Labour management
-Stop insulin when in labour
-If high BSL consider GIK
-Hourly BSL should be 4-7 - Postpartum management
-Following delivery stop insulin and all oral agents
-Monitor BSL for 24hrs to make sure no ongoing hyperglycemia
-Monitor baby’s BSL 1-2hrs after birth
-Discuss risk of GDM recurrence and T2DM in later life (up to 90%)
-HbA1c 3 months PP
-HBA1c or OGTT two yearly
What are the parameters for diagnosis of DM
-HbA1c parameters (2)
-Glucose levels (3)
- -HbA1c 41-49 = pre diabetes
-HbA1c 50 or more = diabetes - Glucose levels
-Random glucose >11
-Fasting glucose >7
-2 hr 75mg OGTT >11
What are the effects of pregnancy on diabetes (9 effects)
- Increased insulin requirements - 2x higher in term T1DM
- Increased risk of diabetic nephropathy - 30% if HTN
-If mild pre-existing nephropathy often reversible. If severe not reversible - Increased risk of progression to retinopathy
-T1DM >T2DM
-10% increased risk of progression if mild retinopathy
-50% increased risk of progression if proliferative retinopathy - Increased risk of HTN
- Increased risk of hypoglycemia
-Better control
-Increased insulin sensitivity in first trimester
-Increased unawareness of hypoglycemia - Diabetic ketoacidosis.
-Rare in pregnancy
-Triggered by infection, steroid use, hyperemesis - Worsening of autonomic neuropathy
- Worsening of Gastric paresis
- Normocytic normochromic anaemia
What are the effects of diabetes on pregnancy for mothers (6 effects)
- Increased miscarriage
- HTN and PET 3-4 x risk
- Infections
- Mode of delivery - more IOL and CS
- Increased perineal injury
- PPH if macrosomic
What are the effects of diabetes on pregnancy for fetus (11 effects)
- Congenital abnormalities
-4% incidence. 2 fold increase. 22% chance
-Cardiac 3 times risk
-NT defects 3 x risk
-Sacral agenesis - rare but specific to DM
-Situs inverts, renal anomalies
-Increased risk with increased HBA1c - Macrosomia
-Related to blood sugar control but can still have with excellent control - Polyhydramnios
-Related to fetal polyuria
-Increased risk of PTL, PPROM, Cord prolapse - Sudden intrauterine fetal demise - 5 fold increase
-Due to chronic hypoxia from accelerated metabolism
-High O2 requirements
-Uteroplacental vasculopathy
-Highest risk at term. RR 7.2
-CTG, BPP and doppler don’t predict - PTD - 5 times more likely to be born before 37/40
- Shoulder dystocia - 8% vs 3% in general population. Increased risk at any weight
- Fetal distress in labour
- Jaundice - polycythemia
- Respiratory distress syndrome
- Erbs palsy - 10 times risk
- IUGR from impaired placental perfusion
Discuss management of women with diabetes: preconception (9 points)
- Basic advice: smoking, exercise, optimise wt, immunisations
- Optimise BSL. Aim for HbA1c <48. Advise better outcomes with better control (miscarriage, anomilies, macrosomia, IUFD)
- Stop sulphonylureas. Switch to insulin
- Retinal screening - treat if proliferative retinopathy
- Renal function - BP, Cr, Urinalysis. If Cr >125 advise against pregnancy
- Assess cardiovascular risk.
- Stop statins and ACEi / switch if required
- Commence on 5mg folic acid
- Advise against pregnancy if IHD, untreated proliferative retinopathy, severe gastroparesis, severe renal impairment
What is the risk of a child having T1DM if:
1. The mother has it
2. The father has it
3. Both parents have it
- 2-3%
- 6-9%
- 20-30%
Discuss antenatal care for women with diabetes (7)
- MDT based care with obstetrician, physician, dietician, diabetic educator
- Education on diet and physical exercise.
- BSL monitoring
-HBA1c once a trimester
-Aim 4.0-5.3 fasting BSL
-Aim <7.8 1 hr post parandial - Hypoglycemia management
-Discuss risks
-Avoid starvation
-Educate partner
-Have hypo kits available - Pre-eclampsia prevention
-Aspirin 100mg PO OD 12-36 weeks
-Calcium 1.5 g PO OD 12 weeks onwards
-BP and urinalysis each visit - Retinal screening in first trimester +/- 3rd trimester
- Renal screening - serum Cr and PCR each trimester
Discuss fetal monitoring in diabetic women (6)
- Early dating scan for accurate dating
- Nuchal translucency - can help for cardiac anomalies
- Detailed anatomy 18-20. Can consider at 16/40 in addition to 20/40 anatomy scan if high risk or obese
- Fetal echo 24/40
- Growth scans at minimum 28,32,36 weeks
- Weekly CTG from 34/40
Discuss intrapartum care of diabetic women
1. Mode of delivery
2. Timing of delivery
3. BSL control
- Mode of delivery
-Aim for vaginal birth
-If EFW >4.5kg offer CS - risk of shoulder dystocia - Timing
-By term in DM without complications
-After 37 weeks depending on situation
-If delivering before 34 weeks may need GIK infusion with steroids
-Need to consider risk and benefits of delivery/prematurity - BSL control
-Hourly BSL monitoring aiming for 4-7 BSL
-Sliding scale of short acting insulin and dextrose infusions
-Give reduced long acting (1/2 to 1/3) and stop short acting insulin in labour or pre CS
Discuss post-partum care for diabetic women
1. T1DM women
2. T2DM women
3. Other PP care
- T1DM women
-Half insulin infusion after delivery if T1DM.
-Once eating normally can recommence pre-pregnancy sub cut regimen
-If breast feeding insulin dose reduced - T2DM women
-Recommend pre-pregnancy medications
-May need insulin if breast feeding - Other care
-Check neonatal BSL at hr and pre feeds
-Contraceptive advice
-Life style advice
-Biannual diabetes FU
Describe the physiological changes in pregnancy regarding calcium metabolism
-Is pregnancy hypocalcemic or hypercalcemic state?
-How does that state occur
-How is that state counter balanced
- Pregnancy is a relatively hypocalcemic state
- Hypocalcemia is driven by:
-Increased fetal uptake of calcium
-Increased maternal renal losses
-Reduced serum albumin so reduced protein bound calcium - Hypocalcemia is counter balanced by:
-Increased PTH
-PTH reduces renal clearance from kidneys
-PTH increase intestinal absorption of vit D