GDM

Question 1

definition of GDM

Answer 1

Any degree of glucose intolerance with onset or first recognition during pregnancy.

If diagnosed during pregnancy, it is gestational diabetes

Question 2

how common is GDM

Answer 2

i. Most common medical complication and metabolic disorder of pregnancy

Question 3

Who manages GDM

Answer 3

1. OBs don’t manage these patients. These patients are managed by the endocrinologist

Question 4

what do we normally see in first trimester with regards to hormones

Answer 4

Early in pregnancy maternal estrogens and progesterone increase and promote beta cell hyperplasia and increased insulin release.
Increase in peripheral glucose utilization and glycogen storage with reduction in hepatic glucose production results in lower fasting glucose levels.

Normally glucose levels drop
pts that already have DM need to be told about first trimester lows

Question 5

who is at greater risk for GDM

Answer 5

iii. This is highest in ethnic groups that have higher incidence of Type 2 diabetes (Hispanic Americans, African Americans, Native Americans and Pacific Islanders).

Question 6

what do we see in pregnancy with regards to placental streoids

Answer 6

Placental steroids and peptide hormones (ie. human chorionic sommatomammotropin, cortisol, prolactin, progesterone and estrogen) rise linearly throughout second and third trimesters.

increased tissue insulin resistance in addition to this

steroids dramatically increase demand for insulin and the sensitivity is down
this becomes a problem only if the body can’t produce enough insulin

Question 7

what are the effects of insulin sensitivity and increase glucose demands on the fetus

Answer 7

insulin does not cross the placenta but glucose does

baby gets a bunch of extra glucose and makes insulin

stores extra glucose

baby has normal blood sugar

this puts babies at risk for low blood sugar when the cord gets cut

Question 8

Ideal time to start screening for gestational diabetes

Answer 8

This becomes apparent between 24th-28th week. = TEST QUESTION

Question 9

in mothers without GDM

Answer 9

The pancreas releases 1 ½ - 2 ½ times more insulin to respond to the increase in insulin resistance.
Patients with normal pancreatic function are able to meet these demands.

Question 10

FBG in pts without GDM and pre-existing DM pts goal

Answer 10

In healthy pregnancies, mean FBG levels decline to an average of 74mg/dl with peak postprandial values (1 hour after meal) rarely exceeding 120mg/dl.

Preexisting diabetes goal is around 90

Meticulous glucose control during pregnancy has been shown to reduce the risk of macrosomia.

Question 11

RF for GDM

Answer 11

1. Advanced maternal age
2. Morbid obesity
3. History of GDM** – screen first
4. Glycosuria
5. Strong family history of DM

Question 12

Approaches to testing for GDM

Answer 12

One-step approach: use in high risk population

Two-step approach for women at average risk at 24-28wks: (standard approach)

Question 13

when would you use the ones step method for testing for GDM

Answer 13

Perform a diagnostic 3hr oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening. Cost effective in high-risk patients or populations. (Patient needs to be on an unrestricted diet for three days)

Question 14

what’s the first step for two step approach

Answer 14

1. Screen by measuring the plasma glucose concentration 1 hr after a 50g oral glucose load.
   a. Pt’s go in and they have 50g glucose load and their glucose is tested 1 hour later. If above 140 then they schedule a 3 hour) GTT. If you use 140 as the cut off, you are able to identify 80% of pt’s with GDM

Question 15

when would you do a 3 hour OGTT

Answer 15

2. If >140mg/dl then schedule a 3 hour OGTT – oral glucose tolerance test (this identifies 80% of patients with GDM)

Question 16

immediate risk of GDM

Answer 16

1. Increased incidence of cesarean section (30%)
2. Preeclampsia (20-30%)
3. Polyhydraminos (20%) – increased amniotic fluid

Question 17

The 100g, 3 hour OGTT

Answer 17

Must be done after 3 days of an unrestricted carbohydrate diet and while the patient is fasting. Venous plasma glucose is measured at 1, 2 and 3 hours after a 100g-glucose load. A positive test requires that 2 values be met or exceeded.

Question 18

what should you do with a abnormal value on the 3hr OGTT

Answer 18

One abnormal value should be followed with a repeat test one month later.

Question 19

Criteria of positive 100gm OGTT

Answer 19

1. Fasting glucose: 95mg/dl
2. 1 hour glucose: 180mg/dl
3. 2 hour glucose: 155mg/dl
4. 3 hour glucose: 140mg/dl

Question 20

long term risks of GDM

Answer 20

1. Recurrent GDM and high risk for developing diabetes (8%/yr)

Question 21

Shoulder dystocia due to macrosomia resulting in:

Answer 21

1. Brachial plexus injury
2. Clavicular fracture
3. Fetal distress
4. Low APGAR scores

Question 22

extreme concern for babies b/c with extremely poor glucose control

Answer 22

1. With extremely poor glucose control increase risk of fetal mortality due to fetal acidemia and hypoxia

Question 23

foundation for the treatment of GDM.

BG goals of ____-and post prandial around ____

Answer 23

Dietary therapy is the foundation for the treatment of GDM.
-diet alone will maintain fasting and postprandial blood glucose values within target range.

Measure their blood sugar, FBG goals of < than 95 and post prandial around 130

Question 24

Glucose monitoring should be done at least

Answer 24

Glucose monitoring should be done at least weekly with a fasting glucose and a 1 hour post prandial

Question 25

Recommendations for initiating insulin therapy are:

Answer 25

1. FBG >105mg/dl
2. 1 hour PPG >140mg/dl
3. Macrosomia maybe further reduced if insulin is initiated when FBG >95mg/dl.

Question 26

oral DM medications

Answer 26

No oral diabetes medications are currently approved for use in pregnancy.

iii. Glyburide is not FDA approved for use in pregnancy but growing number of diabetes centers are using this.

does not cross the placenta

Question 27

what are the fasting targets

preprandial values and 1 hr PPG

Answer 27

1. fasting 60-90mg/dl
2. Preprandial values 60-105mg/dl
3. 1 hr PPG < 130mg/dl

Question 28

insulin tx

Answer 28

Start with bed time levemir (detemir) 6 units and then titrate up if needed

1. Start basal insulin first
2. Rapid acting insulin is started PRN. If your after meal goes up more than 130, then just take 1 unit. If they go up to 160s, then take 2 units. If they have to do it for more than 1 time for the same meal, then take 1 unit prior to the meal

Question 29

which insulins are category B

Answer 29

NPH, Regular, aspart, Lispro and detemir are category B

Question 30

adjunctive therapy for GDM

Answer 30

iExercise is an adjuvant therapy in GDM. Fetal safety has been established if the

maternal heart rate is maintained <140 beats/minute at durations <1 hour and the mother stays hydrated and does not get over heated.

Question 31

Growth ultrasound for fetal sized should be done once at

Answer 31

36-37wks gestation.

Question 32

if delivery is contemplated prior to 39wks gestation.

Answer 32

ii. Amniocentesis for fetal lung profile if delivery is contemplated prior to 39wks gestation.

if blood sugar not well controlled, then lung development seems to be delayed

Question 33

The goal of management of third trimester pregnancies in women with diabetes are to

Answer 33

The goal of management of third trimester pregnancies in women with diabetes are to prevent still birth and asphyxia.

Question 34

Fetal Movement counting

-how frequent

and what is a reassuring result

Answer 34

Every night at 28 wks in <60 min

10 movements

Question 35

Non stress test
how frequent

and what is a reassuring result

Answer 35

Twice weekly

2 heart rate accels in 20 minutes Begin at 28-30 wks w/ insulin at 36 wks

Question 36

contraction stress test

Answer 36

Weekly

No HR decels in reponse to 3 contractions in 10 min

Question 37

when would you take a pt off metformin

Answer 37

do not recommend to start taking but if already taking it

between 12th-17th week

Question 38

Ultrasound Biophysical Profile*****

Answer 38

Weekly Score of 8 in 30 min 3 movements = 2
1 flexion = 2
30 secs of brthing = 2
2cm amniotic fluid = 2