GD Flashcards
WHat are the 2 categories of diabetes in pregnancy?
- Pregestational diabetes: Pregnancy in pre-existing diabetes
• Type 1 diabetes • Type 2 diabetes - Diabetes in Pregnancy: Diabetes diagnosed in pregnancy
what is gestational diabetes?
type of diabetes that is diagnosed during the second or third semester of pregnancy
how common is GDM?
between 3 and 20% of women develop it, depending on the risk factors
Does GDM stay after birth?
usually goes away
When and how should women be tested for GDM?
do oral glucose tolerance test 24-26 weeks gestation
doctor may decide to do an earlier test if other risk are present: obesity, family history, history of gestational diabetes
6 weeks – 6 months postpartum it is important that women have another oral glucose tolerance test to make sure.
GDM risk factors
- Previous dx of GDM
- Hx of prediabetes- predisposes to be insulin resistant
- Age ≥ 35 years
- Obesity (a body mass index greater than or equal to 30 kg/m2)
- Family hx of type 2 diabetes
- Polycystic Ovary Disease (PCOS)
- Acanthosis nigricans (darkened patches on skin)
- Corticosteroid use
- Hx of macrosomic infant (large for gestational age(LGA);>4kg)
- Member of high risk population (e.g.African,Arab,Asian,Hispanic,IndigenousorSouthAsian)
Risks of persistent hyperglycemia during pregnancy for the mother
- Increased need for C-Section
- Higher rates of pre-eclampsia
- Development of metabolic syndrome and T2DM later on in life
Risks of persistent hyperglycemia during pregnancy for the fetus
- Fetal macrosomia and increased risk for infant shoulder dystocia during childbirth
- Neonatal metabolic instabilities including hypoglycemia and hyperbilirubinemia
- Stillbirth (increased risk for untreated GDM)
Why is there hypoGL in the fetus? How is it managed?
hypoGL can happen because during pregnancy when BG is high, the baby adapts (produces more insulin)
when baby gets born, his/her insulin levels still remains high-> low BG
babies have to put on IV with D5 and their BG is tested during first few hours after birth
which fetal risk factors can be decreased via GDM treatment?
treating GD can decrease the risk of macrosomia and shoulder dystocia
GDM prevention reccs
In women at high risk for GDM based on pre-existing risk factors, nutrition counseling should be provided on healthy eating and prevention of excessive gestational weight gain in early pregnancy, ideally before 15 weeks of gestation, to reduce the risk of GDM
when should dietary changes be introduced to prevent GDM?
thus women should focus on the diet PRIOR to getting pregnant to decrease the risk of gestational diabetes
Incidence of GDM is higher in women that
- consume 5 or more regular soft drinks per week (regular soft drink intake was found to be an independent risk factor for GDM)
- Have a higher intake of red meat, processed meat, animal fat and cholesterol prior to pregnancy
- Have a pre-pregnancy BMI greater than25
- Have a higher ferritin level as well as a higher heme iron intake
- Follow a typical western dietary pattern
- Have an excessive rate of weight gain in the first trimester of pregnancy (weight gain of 0.41Kg per week or more have a 40-74% higher risk)
Gestational Diabetes (GDM) Screening in Quebec
Universal screening for GDM @ 24-28 weeks gestational age
Screen earlier if risk factors for GDM (Rescreen at 24-28 weeks if earlier screen was negative)
Early Screening for Women at High Risk for Type 2 Diabetes
Women at high risk of type 2 diabetes:
- Screen with A1C (or FPG if A1C unreliable) in first trimester
- A1C ≥6.5% or FPG ≥7.0 mmol/L-> treat like type 2 diabetes
- Confirm diagnosis post-partum
2018 GDM Diagnosis: Two Approaches
2-step approach- preferred
1-step (alternative)
describe 2 step GDM diagnosis approach
women 24-28w ->50g glucose challenge test with 1h PG value
(If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy)
Results:
1. Uf 1h PG value is <7.8 we consider it as normal and re-access at 24-28w if the test was done earlier
2. If 1h PG is 7.8-11-> 75g oral glucose test is done and fasting, 1h and 2h plasma glucose values are measure
Cut-offs for diagnosis:
FBG≥ 5.3
1h BG≥ 10.6
2h BG≥ 9
only one value has to be met and exceeded to diagnose GDM
3. if 1h PG is ≥11.-> diagnose right away
describe 1 step GDM diagnosis approach
All pregnant women 24-28 weeks(If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy)
75g glucose are given fasting, 1hPG, and 2h PG are tested GDM is diagnosed if FPG≥5.1mmol 1hPG≥10mmol 2hPG≥8.5 mmol if 1 value is met or exceeded-> GDM
Blood glucose targets in pregnancy
Fasting Blood Glucose: <5.3 mmol/L
Blood glucose 1-hour after meals: < 7.8 mmol/L
Blood glucose 2-hours after meals: < 6.7 mmol/L
When is pharmacologic therapy initiated if glycemic targets not achieved? What is the starting treatment?
If glycemic targets not achieved within 1-2 weeks, initiate pharmacologic therapy. We would start with 4 units of long acting insulin in the evening and adjust daily based on fasting blood glucose levels)
Blood Glucose Targets (If on HS or meal-time insulin insulin)
Fasting Blood If on HS insulin: 4.2-4.7 mmol/L
Blood glucose 1-hour after meals (if on meal-time insulin): 5.5-7.2 mmol/L
What dictates which type of insulin is administered?
Normaly we start with bed-time
if BG is high at 1 particular meal- insulin will be prescribed for that meal, or 3 meals if 3 meals are affected
if the client is having trouble controlling the diet- sliding target insulin is give, so the amount is adjusted according to the amount of food consumed
What can ketones in the urine indicate?
- When found in the urine, they can indicate insufficient intake, too much time between meals/snacks, dehydration or blood glucose levels are too high
- Small amounts of ketones in the morning urine can result from not eating enough the previous day.
what is the cut-off for hypoglycemia in pregnancy?
different cut-off value for hypoGL: BG <3.8mmol
What are the potential causes of hypoGL
- Ate less than usual or delayed your meal
- were more active than usual
- took more medication than planned
- had alcohol with the food
What is the 1st line med for GDM management?
Insulin first-line
• May use aspart, lispro, glulisine: perinatal outcomes similar
insulin is safe for mom and fetus
What is the alternative med for GDM management?
- Metformin may be used as an alternative to insulin
• Good safety data in pregnancy
• Evidence of less maternal weight gain, less large-for-gestational-age, less neonatal hypoglycemia
• Women should be informed that it crosses the placenta
• Safety data in offspring postpartum up to 2 years
• Insulin necessary in 40% on metformin - Glyburide may be used in women who refuse insulin and not well controlled on metformin
when do women with GDM usually give birth?
women with GDM are usually made give birth before 40 weeks
cannot do earlier that 37 or 38 weeks because babies lungs are not fully developed and f they did deliver before that, they would have to give betamethasone which can increase BG
betamethasone is primarily used to speed up lung development in preterm fetuses.
can we do anything if we only have 1 week before labour?
even if we only have 1 week, we can work on blood glucose control which will help reduce the risk of neonatal hypoglycaemia during the first few hours of birth
when is there a change in hormones that leads to an increased insulin resistance?
24-28 weeks
