GDM/ PREGNANCY DM Flashcards
Define preexisting or pregestational diabetes.
It refers to type 1 or 2 diabetes diagnosed before conception.
Describe gestational diabetes.
It is diabetes diagnosed in the second or third trimester of pregnancy that was not clearly present prior to gestation.
Define overt diabetes in the context of pregnancy.
It refers to a patient diagnosed in the first trimester who likely has previously undiagnosed type 2 diabetes.
Describe the insulin requirements during pregnancy.
Insulin requirements during pregnancy can be three times normal levels, especially as pregnancy progresses.
How does insulin production change during pregnancy?
Usual insulin production during pregnancy increases,
but there can be a shortage in cases of gestational diabetes.
Define gestational diabetes in relation to insulin production.
Gestational diabetes is characterized by a shortage of insulin production during pregnancy, leading to elevated blood sugar levels.
What happens to insulin levels at 24 weeks of pregnancy? HOW MANY FOLDS
insulin levels can be approximately
two times the normal levels.
How do insulin requirements change by 28 weeks of pregnancy?
By 28 weeks of pregnancy, insulin requirements continue to increase, reflecting the body’s changing needs.
Describe the changes in insulin requirements during early pregnancy for women with type 1 diabetes.
During early pregnancy, women with type 1 diabetes experience enhanced insulin sensitivity and lower glucose levels, leading to lower insulin requirements.
How does insulin resistance change during pregnancy?
Starting from?
% per week?
Insulin resistance begins to increase around 16 weeks of pregnancy, with total daily insulin doses increasing linearly by 5% per week through week 36.
Define the typical change in daily insulin dose by the end of pregnancy compared to pre-pregnancy requirements.
كم تدبيله؟
By the end of pregnancy, daily insulin doses typically double compared to pre-pregnancy requirements.
What happens to insulin requirements toward the end of the third trimester?
Last weeks?
Why?
Insulin requirements level off toward the end of the third trimester due to placental aging.
How does the delivery of the placenta affect insulin sensitivity?
Insulin sensitivity increases dramatically with the delivery of the placenta.
What is the change in insulin requirements in the immediate postpartum period?
%?
In the immediate postpartum period, insulin requirements are roughly 34% lower than pre-pregnancy insulin requirements.
How long does it take for insulin sensitivity to return to pre-pregnancy levels after delivery?
Insulin sensitivity returns to pre-pregnancy levels over the following 1-2 weeks after delivery.
What precautions should women taking insulin consider during breastfeeding?
3 items
Women taking insulin should pay particular attention to hypoglycemia prevention during breastfeeding and due to erratic sleep and eating schedules.
Explain the significance of a rapid reduction in insulin requirements during pregnancy.
إيش السبب؟
A rapid reduction in insulin requirements can indicate the development of placental insufficiency.
Describe the significance of a personal history of impaired glucose tolerance in pregnancy.
A personal history of impaired glucose tolerance or gestational diabetes mellitus (GDM) in a previous pregnancy is a significant risk factor for developing GDM in subsequent pregnancies.
How does family history influence the risk of developing GDM?
Family history of diabetes, particularly in first-degree relatives, increases the risk of developing gestational diabetes mellitus (GDM).
Define the impact of prepregnancy BMI on gestational diabetes risk.
BMI FROM __ and above?
A prepregnancy BMI greater than 30 kg/m² is associated with an increased risk of developing gestational diabetes mellitus (GDM).
What role does maternal age play in the risk of GDM?
Older maternal age is considered a risk factor for the development of gestational diabetes mellitus (GDM).
Identify the ethnic groups that have a higher prevalence of type 2 diabetes and GDM.
Hispanic American, African American, Native American, South or East Asian, and Pacific Islander groups have a higher prevalence of type 2 diabetes and are at increased risk for gestational diabetes mellitus (GDM).
How does significant weight gain relate to GDM risk?
Significant weight gain in early adulthood, between pregnancies, or excessive gestational weight gain during the first 18 to 24 weeks of pregnancy is a risk factor for developing gestational diabetes mellitus (GDM).
Explain the association between medical conditions like PCOS and GDM.
Medical conditions such as polycystic ovary syndrome (PCOS) are associated with an increased risk of developing gestational diabetes mellitus (GDM).
What is the significance of a previous birth of a macrosomic baby in relation to GDM?
Having previously given birth to an infant weighing 4000 grams or more is a risk factor for developing gestational diabetes mellitus (GDM) in future pregnancies.
How do NICE guidelines define independent risk factors for GDM?
According to NICE guidelines, independent risk factors for developing gestational diabetes mellitus (GDM) include family history of type 2 diabetes, previous GDM, previous macrosomic baby, and certain ethnic origins.
Describe the short-term risks associated with hypertensive disorders of pregnancy.
Short-term risks include preeclampsia, gestational hypertension, large for gestational age (LGA) newborns, birth trauma to mother or newborn, operative delivery, perinatal mortality, neonatal respiratory problems, and metabolic complications.
How do hypertensive disorders of pregnancy affect newborns in the short term?
They can lead to IUGR newborns, birth trauma, and neonatal respiratory problems.
Define the long-term risks for mothers after experiencing hypertensive disorders during pregnancy.
Long-term risks for mothers include the future development of type 2 diabetes and cardiovascular disease.
What are the potential long-term risks for offspring of mothers with hypertensive disorders during pregnancy?
Offspring may face obesity, abnormal glucose tolerance, hypertension, metabolic syndrome, and an increased risk of autism and other adverse neurodevelopmental outcomes.
How does polyhydramnios relate to pregnancy complications?
Polyhydramnios is a short-term risk associated with hypertensive disorders of pregnancy, which can lead to various complications.
Describe the relationship between hypertensive disorders of pregnancy and perinatal mortality.
Hypertensive disorders of pregnancy are associated with an increased risk of perinatal mortality.
What are some metabolic complications that can arise in neonates due to DM disorders in pregnancy?
Metabolic complications can include hypoglycemia, hyperbilirubinemia, hypocalcemia, and polycythemia.
How does the risk of birth trauma manifest in mothers and newborns due to DMD disorders?
DM disorders can lead to birth trauma for both the mother and the newborn, increasing the likelihood of complications during delivery.
Define macrosomia in the context of pregnancy complications.
Macrosomia refers to a newborn that is larger than average for gestational age, often associated with hypertensive disorders during pregnancy.
What is the significance of shoulder dystocia in relation to pregnancy outcomes?
Shoulder dystocia is a common adverse outcome during delivery, occurring in about 16.20% of cases, and can lead to birth trauma.
How can hypertensive disorders of pregnancy influence future health outcomes for mothers?
They can increase the risk of developing type 2 diabetes and cardiovascular disease later in life.
Describe the potential neurodevelopmental outcomes for children born to mothers with hypertensive disorders during pregnancy.
Children may face an increased risk of autism and other adverse neurodevelopmental outcomes, potentially linked to shared environmental and genetic factors.
Describe the timing for screening for gestational diabetes mellitus (GDM).
Screening for GDM is performed early if the patient is at high risk. If early testing is negative or not performed, universal screening occurs at 24 to 28 weeks of gestation.
Define the one-step strategy for diagnosing GDM.
The one-step strategy involves performing a 75-g oral glucose tolerance test (OGTT) at 24-28 weeks of gestation, measuring plasma glucose when the patient is fasting and at 1 and 2 hours.
How is the diagnosis of GDM made using the one-step strategy?
The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded: Fasting: 92 mg/dL, 1 h: 180 mg/dL, 2 h: 153 mg/dL.
Explain the two-step strategy for diagnosing GDM.
The two-step strategy includes Step 1: a 50-g glucose load test (GLT) at 24-28 weeks, and if the 1-hour plasma glucose is 130, 135, or 140 mg/dL, proceed to Step 2: a 100-g OGTT when fasting.
What plasma glucose levels indicate a diagnosis of GDM in the two-step strategy?
In the two-step strategy, GDM is diagnosed if at least two of the following plasma glucose levels are met or exceeded: Fasting: 95 mg/dL, 1 h: 180 mg/dL, 2 h: 155 mg/dL, 3 h: 140 mg/dL.
How should the OGTT be performed for accurate results?
The OGTT should be performed in the morning after an overnight fast of at least 8 hours.
What is the significance of the glucose load test (GLT) in the two-step strategy?
The GLT is a preliminary test that helps determine if a patient should proceed to the more comprehensive 100-g OGTT for diagnosing GDM.
Describe the criteria for diagnosing GDM according to the American College of Obstetricians and Gynecologists.
The ACOG notes that one elevated value from the OGTT can be used for diagnosis of GDM, rather than requiring two elevated values.
Describe the initial step in screening for diabetes in pregnant patients.
Assess if the patient has risk factors for unrecognized diabetes at the first prenatal visit.
How should a positive diabetes test result be managed during pregnancy?
Begin standard management of diabetes in pregnancy.
What is the recommended action for a negative diabetes test result during pregnancy?
Continue with routine pregnancy and postpartum care.
Define the follow-up for patients with a positive test for gestational diabetes.
Begin standard management of gestational diabetes and perform a glucose tolerance test (GTT) 4 to 12 weeks postpartum.
What additional care should be provided for patients with a positive diabetes test postpartum?
Refer for ongoing management of type 2 diabetes and discuss risks in planning for future pregnancies.
How often should testing for diabetes be repeated in postpartum patients with a negative test?
Repeat testing at a minimum of every 3 years.
What lifestyle interventions should be discussed with postpartum patients at risk for type 2 diabetes?
Counsel regarding diet and exercise to reduce risk.
What should be included in routine postpartum care for patients with a negative diabetes test?
Counsel regarding future risk for type 2 diabetes and cardiovascular disease.
What is the significance of identifying risk factors for unrecognized diabetes during the first prenatal visit?
It helps determine the need for testing and early management to prevent complications.
How does the management of gestational diabetes differ from standard diabetes management during pregnancy?
Gestational diabetes management includes specific protocols and monitoring, including a GTT.
Describe the relationship between high maternal plasma glucose and fetal growth outcomes.
High maternal plasma glucose is associated with an increased frequency of adverse perinatal outcomes, including excessive fetal growth and fetal hyperinsulinism.
Define fetal hyperinsulinism and its association with maternal glycemia.
Fetal hyperinsulinism refers to elevated insulin levels in the fetus, which is associated with high maternal glycemia and can lead to birth weights greater than the 90th percentile.
How does maternal glycemia affect fetal adipose tissue growth?
Maternal glycemia values are linked to excessive fetal growth, particularly in the development of fetal adipose tissue.
What was the focus of the HAPO study regarding fetal growth?
The HAPO study focused on the effects of maternal hyperglycemia on fetal growth outcomes, particularly the association with fetal hyperinsulinism and increased birth weight.
Explain the significance of the findings from the HAPO study published in 2009.
The findings from the HAPO study highlight the critical relationship between maternal glycemia and adverse pregnancy outcomes, emphasizing the need for monitoring and managing maternal blood glucose levels.
Describe the role of medication in managing glycemic control.
Medication can help regulate blood sugar levels in individuals with diabetes, ensuring that glycemic targets are met.
How does lifestyle management contribute to overall health?
Lifestyle management includes dietary changes, physical activity, and stress reduction, which can improve overall health and prevent complications.
Define the importance of folic acid in medication management.
Folic acid is crucial for preventing neural tube defects in pregnancy and is often recommended as part of prenatal care.
What is the significance of monitoring lab results like the Alc ratio?
The Alc ratio helps assess long-term blood sugar control, guiding treatment decisions for diabetes management.
Explain the concept of referral to ophthalmology in diabetes care.
Referral to ophthalmology is important for monitoring and managing potential eye complications related to diabetes.
How can education impact diabetes management?
Education empowers patients with knowledge about their condition, enabling them to make informed decisions about their health and treatment.
Describe the potential risks associated with stillbirth and diabetes.
Diabetes can increase the risk of stillbirth, making it essential for pregnant individuals with diabetes to manage their condition closely.
What is the purpose of mentoring in healthcare settings?
Mentoring in healthcare provides guidance and support to less experienced professionals, enhancing their skills and knowledge.
How can advice about target glycemic levels benefit patients?
Providing advice on target glycemic levels helps patients understand their goals and the importance of maintaining optimal blood sugar control.
Define the role of lifestyle changes in preventing complications of diabetes.
Lifestyle changes, such as diet and exercise, can significantly reduce the risk of complications associated with diabetes.
Describe the trend of absolute risk for women over their lifetime.
Absolute risk increases linearly, being approximately 20% at 10 years, 30% at 20 years, 40% at 30 years, 50% at 40 years, and 60% at 50 years.
How does lactation affect women with diabetes?
Lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted.
Define the immediate benefits of breastfeeding for infants.
Breastfeeding provides immediate nutritional and immunological benefits for the baby.
What should be discussed with women with diabetes of reproductive potential?
A contraceptive plan should be discussed and implemented.
How should women with a history of gestational diabetes be screened postpartum?
They should be screened at 4-12 weeks postpartum using the 75-g oral glucose tolerance test.
What interventions should women with a history of gestational diabetes and prediabetes receive?
They should receive intensive lifestyle interventions and/or metformin to prevent diabetes.
How often should women with a history of gestational diabetes be screened for type 2 diabetes?
They should have lifelong screening every 1-3 years.
What is the recommendation for postpartum care regarding psychosocial support?
Postpartum care should include psychosocial assessment and support for self-care.
How does insulin resistance change immediately postpartum?
Insulin resistance decreases dramatically, and insulin requirements are often roughly half of the prepregnancy requirements for the initial few days postpartum.
What are the long-term benefits of breastfeeding for mothers and offspring?
Breastfeeding may confer longer-term metabolic benefits to both mother and offspring.
Describe the relationship between pancreatitis and PPDM.
Pancreatitis can lead to PPDM, with the highest risk associated with recurrent bouts.
Define a distinguishing feature of PPDM.
A distinguishing feature of PPDM is concurrent pancreatic exocrine insufficiency, which can be assessed through the monoclonal fecal elastase 1 test or direct function tests.
How can pathological pancreatic imaging assist in diagnosing PPDM?
Pathological pancreatic imaging, such as endoscopic ultrasound, MRI, or computed tomography, can help in diagnosing PPDM.
Explain the significance of the absence of type 1 diabetes-associated autoimmunity in PPDM.
The absence of type 1 diabetes-associated autoimmunity is significant in diagnosing PPDM, as it differentiates it from type 1 diabetes.
What is the impact of pancreatitis on insulin and glucagon secretion?
In pancreatitis, there is a loss of both insulin and glucagon secretion, often leading to higher-than-expected insulin requirements.
Discuss the risk of microvascular complications in PPDM.
The risk for microvascular complications in PPDM appears to be similar to that of other forms of diabetes.
How can transplantation affect insulin secretion in PPDM patients?
Transplantation can be performed to retain insulin secretion in patients with PPDM.
What is the potential outcome of auto-transplantation in some PPDM cases?
In some cases, auto-transplantation can lead to insulin independence or decrease insulin requirements.
Describe the recommendations for screening women planning pregnancy for diabetes.
Women planning pregnancy should be screened for risk factors and consider testing all women for undiagnosed diabetes.
What is the recommended timing for testing women with risk factors for diabetes during pregnancy?
Women with risk factors should be tested for diabetes before 15 weeks of gestation.
How should women identified with diabetes during pregnancy be treated?
Women identified as having diabetes during pregnancy should be treated as such.
What screening is recommended for abnormal glucose metabolism before 15 weeks of gestation?
Screening for abnormal glucose metabolism is recommended to identify women at higher risk of adverse pregnancy and neonatal outcomes.
When should gestational diabetes mellitus be screened in pregnant women?
Gestational diabetes mellitus should be screened at 24-28 weeks of gestation in pregnant women not previously found to have diabetes.
What diagnostic test is used for screening gestational diabetes mellitus?
The 75-g oral glucose tolerance test is used for screening gestational diabetes mellitus.
What is the recommendation for women with a history of gestational diabetes regarding diabetes screening?
Women with a history of gestational diabetes should have lifelong screening for diabetes or prediabetes at least every 3 years.
What interventions are recommended for women with a history of gestational diabetes?
Women with a history of gestational diabetes should receive intensive lifestyle interventions and/or metformin.
Define gestational diabetes mellitus (GDM).
GDM is defined as any degree of glucose intolerance that is first recognized during pregnancy.
Describe the effectiveness of lifestyle modification in managing GDM.
Studies suggest that 70–85% of women diagnosed with GDM can control it with lifestyle modification alone.
Define the caloric intake recommendations for managing GDM.
Caloric intake is based on ideal body weight, recommending 25 to 35 kcal/kg of ideal weight.
How should macronutrients be distributed in the diet for GDM management?
The diet should consist of 40% to 55% carbohydrates, 20% protein, and 25% to 40% fat.
Do women with GDM need to spread their caloric intake throughout the day?
Yes, calories should be distributed over 3 meals and 3 snacks.
Describe the basis for a food plan for pregnant women.
A food plan for pregnant women should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI).
Define the minimum carbohydrate recommendation for pregnant women according to the DRI.
The DRI for all pregnant women recommends a minimum of 175 g of carbohydrate.
How much protein is recommended for pregnant women according to the DRI?
The DRI recommends a minimum of 71 g of protein for pregnant women.
What is the recommended fiber intake for pregnant women?
The recommended fiber intake for pregnant women is 28 g.
Explain the types of fats that should be emphasized in a pregnant woman’s diet.
The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats.
How does carbohydrate intake affect glucose levels in patients with diabetes?
The amount and type of carbohydrate will impact glucose levels in patients with diabetes.
What percentage of a 2,000-calorie diet does the recommended carbohydrate intake represent for pregnant women?
The recommended carbohydrate intake of 175 g represents 35% of a 2,000-calorie diet.
Summarize the key components of a food plan for pregnant women.
A food plan for pregnant women should include at least 175 g of carbohydrates, 71 g of protein, and 28 g of fiber, with an emphasis on healthy fats.
Describe the recommended total weight gain for underweight individuals during singleton pregnancies.
The recommended total weight gain for underweight individuals (BMI < 18.5) during singleton pregnancies is between 12.5 to 28 kg.
Define the rate of weight gain for normal weight individuals in the second and third trimester.
The rate of weight gain for normal weight individuals (BMI 18.5 to 24.9) in the second and third trimester is a mean of 0.42 kg/week, with a range of 0.35 to 1 kg/week.
How does the recommended weight gain differ for individuals with multiple gestations compared to singleton pregnancies?
Recommended weight gain is higher for individuals with multiple gestations compared to those with singleton pregnancies.
Explain the weight gain recommendations for overweight individuals during singleton pregnancies.
For overweight individuals (BMI 25.0 to 29.9), the total weight gain recommendation is between 5 to 9 kg, with a rate of weight gain of 0.22 kg/week, ranging from 0.17 to 0.5 kg/week in the second and third trimester.
What is the total weight gain recommendation for obese individuals during singleton pregnancies?
The total weight gain recommendation for obese individuals (BMI ≥ 30.0) during singleton pregnancies is between 5 to 9 kg.
Describe the weight gain rate for underweight individuals in the second and third trimester.
The rate of weight gain for underweight individuals (BMI < 18.5) in the second and third trimester is a mean of 0.51 kg/week, with a range of 0.44 to 0.6 kg/week.
What is the significance of the weight gain calculations provided in the recommendations?
The weight gain calculations assume a weight gain of 0.5 to 2 kg (1.1 to 4.4 lbs) in the first trimester, which is factored into the overall recommendations for total weight gain.
How does the rate of weight gain for obese individuals compare to that of normal weight individuals?
The rate of weight gain for obese individuals (BMI ≥ 30.0) is lower at 0.27 kg/week, compared to 0.42 kg/week for normal weight individuals.
Describe the recommended duration and frequency of moderate aerobic exercise for patients.
Patients should participate in moderate aerobic exercise for at least 15 to 30 minutes, three or more times a week.
Define the impact of exercise interventions on glucose control in patients.
Exercise interventions have been shown to improve glucose control and reduce the need to start insulin or decrease insulin dose requirements.
How does smoking cessation relate to patient management?
Smoking cessation should be encouraged in all patients as part of their management.
What types of exercise are considered effective for improving glucose control?
Effective exercise types include aerobic, resistance, or a combination of both.
Explain the variability in exercise recommendations based on a systematic review.
There was heterogeneity in the types of effective exercise and the duration, with recommendations ranging from 20 to 50 minutes per day, 2 to 7 days a week of moderate intensity.
Do patients need to engage in both aerobic and resistance exercises for optimal benefits?
While both types of exercise can be effective, the systematic review indicates that either aerobic, resistance, or both can improve glucose control.
Describe the first-line pharmacological treatment for hyperglycemia in pregnancy.
Insulin is the first-line agent for management of hyperglycemia in pregnancy.
Define the range of total insulin doses for pregnant women with GDM.
The total insulin dose varies from 0.7 to 2 U/kg.
List the types of insulin approved by the FDA for use in pregnancy.
Insulin types approved by the FDA for use in pregnancy include NPH, insulin detemir, regular insulin, regular U-500, lispro, and aspart.
How does insulin detemir differ in its distribution and absorption compared to other insulins?
Insulin detemir is highly protein-bound (99% binds to albumin), which reflects its slow tissue distribution and prevents it from crossing the placenta.
Explain the pregnancy category classifications for different types of insulin.
Insulin types NPH, insulin detemir, regular insulin, regular U-500, lispro, and aspart are classified as pregnancy category B, while glargine and glulisine insulin are classified as pregnancy category C.
What is the significance of insulin detemir’s protein binding in pregnancy management?
The high protein binding of insulin detemir results in slow tissue distribution and prevents it from crossing the placenta, making it safer for use during pregnancy.
How should pharmacologic therapy be initiated for women with GDM who do not meet glycemic targets?
Pharmacologic therapy should be initiated if women with GDM do not achieve glycemic targets within 1-2 weeks with nutritional therapy and physical activity.
Describe the main objective of the EXPECT trial.
The main objective of the EXPECT trial was to evaluate the safety profile and efficacy of insulin degludec in pregnant women with type 1 diabetes, particularly focusing on HbA1c levels during pregnancy.
How long was the pregnancy period for participants in the EXPECT trial?
The pregnancy period for participants in the EXPECT trial was 28 days.
Define the key inclusion criteria for the EXPECT trial.
The key inclusion criteria for the EXPECT trial included women planning to become pregnant or those with type 1 diabetes for at least 21 years and having an insulin treatment duration of 90 days prior to screening.
What were the findings regarding the non-inferiority of insulin degludec compared to insulin detemir?
Insulin degludec was found to be non-inferior to insulin detemir with respect to HbA1c levels prior to delivery in pregnant women with type 1 diabetes.
How did the safety profiles of insulin degludec and insulin detemir compare in the EXPECT trial?
The safety profiles for both insulin degludec and insulin detemir were comparable for women with type 1 diabetes and their foetuses/infants.
What was the rate of serious adverse events (AEs) in the insulin degludec treatment group?
In the insulin degludec treatment group, the rate of serious adverse events was 12 out of 86 participants, which is approximately 14.0%.
Describe the pregnancy outcomes related to newborns in the EXPECT trial.
Pregnancy outcomes related to newborns included rates of pre-term delivery, infants born large for gestational age, and other neonatal metrics, with specific percentages reported for each outcome.
How many participants experienced early foetal loss in the EXPECT trial?
The rate of early foetal loss (<20 weeks’ gestation) was reported as 8.7% in the EXPECT trial.
What was the significance of the HbA1c levels during pregnancy in the EXPECT trial?
The HbA1c levels during pregnancy were significant as they indicated the glycemic control of the participants, with a mean level of 6.34% reported.
How did the rates of neonatal hypoglycaemia compare between insulin degludec and insulin detemir?
The rates of neonatal hypoglycaemia were reported for both insulin degludec and insulin detemir, with specific percentages indicating the incidence in each group.
Describe the FDA classification of Glyburide and Metformin for use during pregnancy.
Glyburide is classified as category B and Metformin is classified as category B/C.
How do Glyburide and Metformin transfer across the placenta during pregnancy?
Glyburide crosses the placenta with minimal transfer, while Metformin also crosses the placenta.
Define the long-term safety of Glyburide and Metformin during pregnancy.
The long-term safety of Glyburide and Metformin during pregnancy is unknown.
What is the effectiveness of Glyburide and Metformin in maintaining normoglycemia during pregnancy?
Both Glyburide and Metformin are insufficient to maintain normoglycemia at all times, particularly during pregnancy.
List the classifications of oral antihyperglycemic agents mentioned in the content.
Glyburide is category B, Metformin is category B/C, and some formulations of Metformin are category C.
Do Glyburide and Metformin have any known noninsulin antihyperglycemic alternatives during pregnancy?
No other noninsulin antihyperglycemic agents are mentioned as alternatives during pregnancy.
Explain the approval status of Glyburide and Metformin for use in pregnancy.
Both Glyburide and Metformin are approved by the FDA for use during pregnancy.
What is the significance of the classification categories B and B/C for medications during pregnancy?
Category B indicates that the medication is considered safe during pregnancy, while category B/C suggests that safety is not fully established.
Describe the placental transfer of metformin.
Metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin that are as high or higher than simultaneous maternal levels.
Define the risks associated with metformin use in pregnancy.
Metformin should not be used in women with hypertension, preeclampsia, or those at risk for intrauterine growth restriction due to the potential for growth restriction or acidosis in the setting of placental insufficiency.
How does metformin exposure affect neonatal outcomes?
Metformin exposure is associated with a lower risk of neonatal hypoglycemia and results in smaller neonates, but with an acceleration of postnatal growth leading to higher BMI in childhood.
What are the benefits of metformin compared to insulin during pregnancy?
Metformin is associated with less maternal weight gain and a lower risk of neonatal hypoglycemia compared to insulin.
Explain the teratogenic effects of metformin during pregnancy.
Metformin crosses the placenta but has not been associated with teratogenesis.
When should metformin be avoided in pregnant women?
Metformin should be avoided in pregnant women with hypertension, preeclampsia, or those at risk for intrauterine growth restriction.
Describe the transfer of glyburide across the placenta.
Glyburide crosses the placenta, with fetal glyburide levels being approximately 70% of maternal plasma levels.
How does glyburide affect neonatal health compared to insulin or metformin?
Glyburide is associated with a higher rate of neonatal hypoglycemia, macrosomia, and increased neonatal abdominal circumference than insulin or metformin.
Define the long-term safety data available for glyburide exposure in offspring.
Long-term safety data for offspring exposed to glyburide are not available.
What are the concentrations of glyburide in umbilical cord plasma compared to maternal levels?
Concentrations of glyburide in umbilical cord plasma are approximately 50-70% of maternal levels.
Explain the association of sulfonylureas with neonatal health.
Sulfonylureas, including glyburide, are known to cross the placenta and have been associated with increased neonatal hypoglycemia.
How does glyburide exposure relate to macrosomia in newborns?
Glyburide exposure has been linked to a higher rate of macrosomia in newborns compared to other treatments.
What is the significance of increased neonatal abdominal circumference in relation to glyburide?
Increased neonatal abdominal circumference has been observed in infants exposed to glyburide, indicating potential growth concerns.
Describe the role of lifestyle behavior change in managing gestational diabetes mellitus.
Lifestyle behavior change is an essential component of managing gestational diabetes mellitus and may suffice for the treatment of many women.
How is insulin used in the treatment of gestational diabetes mellitus?
Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus and should be added if needed to achieve glycemic targets.
Define the first-line agents for treating hyperglycemia in gestational diabetes mellitus.
Insulin is the preferred first-line agent for treating hyperglycemia in gestational diabetes mellitus; metformin and glyburide should not be used as first-line agents.
Explain why metformin and glyburide are not recommended as first-line agents in gestational diabetes.
Metformin and glyburide are not recommended as first-line agents because both cross the placenta to the fetus.
What should be done with metformin when treating polycystic ovary syndrome during pregnancy?
Metformin should be discontinued by the end of the first trimester when used to treat polycystic ovary syndrome and induce ovulation.
How do other oral and noninsulin injectable glucose-lowering medications compare in terms of safety for gestational diabetes?
Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data.
Describe the recommended use of metformin for women with diabetes during the preconception period and pregnancy.
Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin when the benefits of improved blood glucose control outweigh potential harm.
What should women with diabetes do with their oral blood glucose-lowering agents before pregnancy?
Women with diabetes should stop all other oral blood glucose-lowering agents before pregnancy and use insulin instead.
Define the term ‘off-label use’ in the context of metformin and long-acting insulin analogues.
Off-label use refers to the use of a medication for a purpose not specified in the official labeling; in this case, metformin and long-acting insulin analogues are used in pregnancy despite not being officially approved for that purpose.
How does the evidence regarding rapid-acting insulin analogues affect their use during pregnancy?
The available evidence on rapid-acting insulin analogues, such as aspart and lispro, does not show any adverse effects on pregnancy or the health of the baby.
What is the first choice for long-acting insulin during pregnancy for women with diabetes?
Isophane insulin, also known as NPH insulin, is recommended as the first choice for long-acting insulin during pregnancy.
When should women with diabetes consider continuing long-acting insulin analogues during pregnancy?
Women with diabetes who have established good blood glucose control before pregnancy may consider continuing treatment with long-acting insulin analogues, such as insulin detemir or insulin glargine.
What is the significance of NICE gridlive in the context of diabetes management during pregnancy?
NICE gridlive provides guidelines and recommendations, indicating that even in British practice, metformin is used off-label as a first choice for managing diabetes in pregnancy.
Describe the method used to monitor glycemic control during pregnancy.
Glycemic control during pregnancy is typically monitored by self-monitoring of blood glucose (SMBG).
How often should SMBG be performed during pregnancy?
SMBG should be performed eight or more times a day.
Define the key times when blood glucose levels should be checked by pregnant patients with diabetes.
Pregnant patients with diabetes should check blood glucose levels daily at fasting, before and one or two hours after the first bite of each meal, and at bedtime.
is the purpose of SMBG in pregnant patients with diabetes?
The purpose of SMBG is to assess glycemic control during pregnancy.
Describe the fasting glucose target recommended for gestational diabetes mellitus.
The fasting glucose target recommended is 95 mg/dL (5.3 mmol/L).
Define the one-hour postprandial glucose target for gestational diabetes.
The one-hour postprandial glucose target is 140 mg/dL (7.8 mmol/L).
How is the two-hour postprandial glucose level defined for gestational diabetes management?
The two-hour postprandial glucose level is defined as 120 mg/dL (6.7 mmol/L).
What are the recommended glucose targets for managing gestational diabetes according to the Fifth International Workshop-Conference?
The recommended glucose targets are: Fasting glucose 95 mg/dL, One-hour postprandial glucose 140 mg/dL, and Two-hour postprandial glucose 120 mg/dL.
Describe the frequency of urine collection for monitoring during pregnancy.
Every 1 to 2 weeks.
How is baseline proteinuria and creatinine clearance established during pregnancy?
A 24-hour urine collection may be performed.
Define the purpose of a 24-hour urine collection in pregnant patients.
To establish baseline levels of proteinuria and creatinine clearance due to the higher likelihood of preeclampsia.
Is it necessary to perform routine ophthalmic examinations during pregnancy?
No, it is not necessary to routinely perform ophthalmic examinations.
What is the significance of monitoring proteinuria in pregnant patients?
It helps assess the risk of preeclampsia.
Describe the risk of progression to type 2 diabetes for women with a history of gestational diabetes mellitus (GDM).
Progression to type 2 diabetes later in life occurs in 5% to 50% of women with a history of GDM.
How does a history of gestational diabetes mellitus (GDM) affect the risk of developing type 2 diabetes?
A history of GDM results in a 10-fold increase in the risk of developing type 2 diabetes.
Define the recommended timing for testing women with a history of GDM for persistent diabetes or prediabetes postpartum.
Women with GDM should be tested for persistent diabetes or prediabetes at 4–12 weeks postpartum.
What test is recommended for postpartum diabetes screening in women with a history of GDM?
The 75-g oral glucose tolerance test (OGTT) is recommended for postpartum diabetes screening.
Explain why the OGTT is preferred over A1C for testing women with a history of GDM.
The OGTT is preferred over A1C because A1C may be persistently impacted by increased red blood cell turnover related to pregnancy, blood loss at delivery, or the preceding 3-month glucose profile.
How should women with a history of GDM be monitored after delivery?
Women with a history of GDM should have follow-up testing for diabetes or prediabetes after delivery.
Describe the benefits of breastfeeding for women with gestational diabetes mellitus (GDM) and overt diabetes.
Breastfeeding is encouraged for women with GDM and overt diabetes for more than 3 months, as it lowers fasting plasma glucose and insulin levels, and is associated with a reduced prevalence of subsequent diabetes.
How does breastfeeding impact postpartum diabetes risk in women with diabetes?
Breastfeeding is associated with a reduced prevalence of subsequent diabetes both at postpartum screening and after a decade.
Define the recommended duration of breastfeeding for women with GDM and overt diabetes.
Women with GDM and overt diabetes are encouraged to breastfeed for more than 3 months whenever possible.
What effect does breastfeeding have on fasting plasma glucose and insulin levels?
Breastfeeding lowers fasting plasma glucose and insulin levels in women with diabetes.
Describe the screening process for women with a history of gestational diabetes mellitus postpartum.
Women should be screened at 4 and 12 weeks postpartum using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria.
Define the recommended intervention for women with a history of gestational diabetes mellitus who are found to have prediabetes.
Intensive lifestyle interventions and/or metformin should be provided to prevent diabetes.
How soon after childbirth should women with a history of gestational diabetes mellitus be screened for diabetes?
Screening should occur at 4 and 12 weeks postpartum.
What is the purpose of screening women postpartum who had gestational diabetes mellitus?
The purpose is to identify those who may have developed prediabetes or diabetes.
What is the significance of using the 75-g oral glucose tolerance test in postpartum care?
It is a clinically appropriate method to assess glucose metabolism in women with a history of gestational diabetes.
What lifestyle changes are recommended for women with prediabetes after gestational diabetes?
Intensive lifestyle interventions are recommended to help prevent the progression to diabetes.
What medication may be considered for women with a history of gestational diabetes who are diagnosed with prediabetes?
Metformin may be considered as part of the intervention.
Describe the lifelong screening recommendations for women with a history of gestational diabetes mellitus.
Women with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes at least every 1-3 years.
Define the importance of preconception screening for women with a history of gestational diabetes.
Preconception screening for diabetes and preconception care is important to identify and treat hyperglycemia and prevent congenital malformations.
How should postpartum mental care be approached for women with a history of gestational diabetes?
Postpartum care should include psychosocial assessment and support for self-care.
What is the recommended frequency for diabetes screening in women with a history of gestational diabetes?
The recommended frequency for diabetes screening is at least every 1-3 years.
What type of support is recommended in postpartum care for women with gestational diabetes?
Psychosocial assessment and support for self-care are recommended in postpartum care.
Describe the importance of family planning in healthcare.
Family planning is crucial in healthcare as it allows individuals and couples to make informed decisions about reproduction, ensuring that pregnancies are planned and desired, which can lead to better health outcomes for both parents and children.
How does glycemic control impact overall health?
Glycemic control is essential for managing blood sugar levels, particularly in individuals with diabetes. Proper control can prevent complications such as cardiovascular disease, nerve damage, and kidney issues.
Define lifestyle modification and its components.
Lifestyle modification refers to changes in daily habits to improve health, including diet, weight management, and exercise. These changes can significantly impact overall well-being and chronic disease management.
Explain the role of folic acid supplementation in preconception care.
Folic acid supplementation is vital in preconception care as it helps prevent neural tube defects in the developing fetus and supports overall maternal health.
What medications are commonly involved in managing diabetes and related conditions?
Common medications include diabetic medications to control blood sugar, statins to manage cholesterol levels, and blood pressure medications to reduce cardiovascular risk.
Describe the purpose of medical risk counseling in healthcare.
Medical risk counseling aims to inform patients about potential health risks and guide them in making informed decisions regarding their health and lifestyle choices.
How does preconception counseling benefit prospective parents?
Preconception counseling provides prospective parents with information and resources to optimize their health before conception, reducing risks for both the mother and the baby.
Explain the significance of retina screening in diabetic patients.
Retina screening is significant for diabetic patients as it helps detect diabetic retinopathy early, preventing vision loss and ensuring timely intervention.
Describe the importance of preconception counseling for women with diabetes.
Preconception counseling is crucial for women with diabetes and reproductive potential as it helps to manage their condition effectively before pregnancy, ensuring better health outcomes for both the mother and the baby.
How should women with preexisting diabetes planning a pregnancy be managed?
Women with preexisting diabetes planning a pregnancy should ideally be managed in a multidisciplinary clinic that includes an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist.
Define the role of a multidisciplinary clinic in managing diabetes for women planning pregnancy.
A multidisciplinary clinic provides comprehensive care by integrating various specialists to address the complex needs of women with diabetes who are planning a pregnancy, ensuring optimal health management.
What is the ADA recommendation regarding diabetes care for women of reproductive potential?
The ADA recommends that preconception counseling should be incorporated into routine diabetes care for all women starting at puberty and continuing throughout their reproductive years.
Explain the timing for initiating diabetes management for women planning a pregnancy.
Diabetes management for women planning a pregnancy should ideally begin in the preconception phase to optimize health and reduce risks during pregnancy.
Describe the importance of contraception use in women with diabetes.
Contraception use is crucial for women with diabetes until good glycemic control is achieved to prevent unplanned pregnancies and associated risks.
Define the risks associated with unplanned pregnancies in women with diabetes.
Unplanned pregnancies in women with diabetes can lead to malformations, even with mild hyperglycemia, highlighting the need for effective family planning.
How should education about family planning be approached for girls and women with diabetes?
Education should focus on the risks of unplanned pregnancies and the importance of using effective contraception to prevent pregnancy.
What is the role of preconception counseling for women with diabetes?
Preconception counseling helps women with diabetes understand the risks of pregnancy and the importance of achieving good glycemic control before conception.
Do women with diabetes of childbearing potential need specific education regarding pregnancy?
Yes, they should receive education about the risks of malformations and the necessity of effective contraception to prevent unplanned pregnancies.
Describe the importance of family planning in relation to pregnancy.
Family planning should be discussed, and effective contraception should be prescribed and used until a woman’s treatment regimen and A1C are optimized for pregnancy.
Define tight glycemic control and its significance for pregnant women.
Tight glycemic control refers to maintaining an A1C level of less than 6.5%. It is significant because hyperglycemia increases the risk of congenital malformations, miscarriage, preterm delivery, preeclampsia, macrosomia, and perinatal mortality.
How can lifestyle modifications impact pregnancy outcomes for overweight or obese women?
Lifestyle modifications such as diet, weight management, and exercise can help overweight or obese women reach a normal BMI before pregnancy, which can improve pregnancy outcomes.
What are the risks associated with hyperglycemia during pregnancy?
Hyperglycemia increases the risk of congenital malformations, miscarriage, preterm delivery, preeclampsia, macrosomia, and perinatal mortality.
Do women planning to become pregnant need preconception counseling?
Yes, preconception counseling is important for women to optimize their health and treatment before becoming pregnant.
Explain the role of long-acting reversible contraception in family planning.
Long-acting reversible contraception is an effective method that should be considered and prescribed to prevent unintended pregnancies until a woman’s health is optimized for pregnancy.
Describe the importance of achieving glucose levels before conception.
Achieving glucose levels as close to normal as safely possible, ideally an A1C of 6.5% (48 mmol/mol), is crucial to reduce the risk of congenital anomalies, preeclampsia, macrosomia, and other complications.
Define the role of preconception counseling in diabetes management.
Preconception counseling should focus on achieving glycemic targets and include additional emphasis on nutrition, diabetes education, and screening for diabetes comorbidities and complications.
How can preconception care be enhanced for individuals with diabetes?
Standard preconception care can be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications.
What are the potential risks associated with uncontrolled glucose levels during preconception?
Uncontrolled glucose levels can lead to congenital anomalies, preeclampsia, macrosomia, and other complications.
Explain the recommended A1C level for women with diabetes planning to conceive.
The recommended A1C level for women with diabetes planning to conceive is ideally 6.5% (48 mmol/mol) to minimize risks.
Describe the recommendation for folic acid supplementation before conception.
The Endocrine Society suggests a supplementation of 5 mg/day beginning 3 months before discontinuing contraception, while the ADA recommends at least 400 mcg of folic acid.
How should diabetic medication be managed prior to conception?
Switching to insulin therapy prior to conception is recommended for better glucose control and to avoid transplacental passage of the drug to the fetus.
Define the role of metformin and glyburide in pregnancy.
Metformin and glyburide are considered effective and safe for managing diabetes, particularly during the third trimester when organogenesis is mostly complete.
What should be done with statin medication before conception?
Statin medication should be discontinued prior to conception.
Explain the importance of preconception counseling in diabetes management.
Preconception counseling is crucial for optimizing health and medication management before conception, ensuring better outcomes for both the mother and fetus.
Describe the blood pressure goal during pregnancy.
The blood pressure goal during pregnancy is less than 130/80 mmHg.
Define the contraindications for ACE inhibitors and angiotensin receptor blockers during pregnancy.
ACE inhibitors and angiotensin receptor blockers are contraindicated during pregnancy because they may cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction.
List antihypertensive drugs that are considered safe and effective during pregnancy.
Safe and effective antihypertensive drugs during pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin.
Explain why chronic diuretic use is not recommended during pregnancy.
Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume.
How does blood pressure in normal pregnancy compare to the non-pregnant state?
In normal pregnancy, blood pressure is lower than in the non-pregnant state.
What are the potential risks associated with the use of ACE inhibitors during pregnancy?
The potential risks associated with the use of ACE inhibitors during pregnancy include fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction.
Identify the effects of antihypertensive medications on pregnancy.
Antihypertensive medications that are safe during pregnancy help manage blood pressure without causing harm to the fetus.
Discuss the importance of preconception counseling regarding blood pressure management.
Preconception counseling is important for managing blood pressure effectively and safely during pregnancy, ensuring the health of both the mother and the fetus.
Describe the recommended blood pressure target for pregnant patients with diabetes and chronic hypertension.
A blood pressure target of 110–135/85 mmHg is suggested to reduce the risk of accelerated maternal hypertension and minimize impaired fetal growth.
Define the medications that should be avoided during pregnancy.
Potentially harmful medications include ACE inhibitors, angiotensin receptor blockers, and statins.
How should potentially harmful medications be managed in sexually active women of childbearing age?
These medications should be stopped at conception and avoided in sexually active women who are not using reliable contraception.
What is the goal of maintaining a specific blood pressure target in pregnant patients with diabetes and chronic hypertension?
The goal is to reduce the risk for accelerated maternal hypertension and minimize impaired fetal growth.
Describe the components of preconception education for women with diabetes.
Preconception education should include comprehensive nutrition assessment, meal planning, correction of dietary deficiencies, caffeine intake management, safe food preparation techniques, lifestyle recommendations such as regular moderate exercise, avoidance of hyperthermia, adequate sleep, comprehensive diabetes self-management education, counseling on diabetes in pregnancy, and supplementation with folic acid.
How should lifestyle recommendations be tailored for women with diabetes during preconception care?
Lifestyle recommendations should include regular moderate exercise, avoidance of hyperthermia (such as hot tubs), and ensuring adequate sleep.
What medical assessments are necessary for women with diabetes during preconception care?
Medical assessments should include a general evaluation of overall health, evaluation of diabetes and its complications, obstetric/gynecologic history, and a review of current medications for appropriateness during pregnancy.
Define the importance of comprehensive diabetes self-management education in preconception care.
Comprehensive diabetes self-management education is crucial as it covers the natural history of insulin resistance in pregnancy, preconception glycemic targets, avoidance of DKA and severe hyperglycemia, and understanding the risks associated with diabetes in pregnancy.
How can dietary nutritional deficiencies be addressed in preconception care for women with diabetes?
Dietary nutritional deficiencies can be addressed through comprehensive nutrition assessment and tailored recommendations to correct these deficiencies.
Describe the risks associated with diabetes in pregnancy that should be discussed during preconception counseling.
Risks include miscarriage, stillbirth, congenital malformations, macrosomia, preterm labor and delivery, and hypertensive disorders in pregnancy.
What role does folic acid supplementation play in preconception care for women with diabetes?
Folic acid supplementation (400 mcg routine) is important to reduce the risk of neural tube defects and support overall fetal health.
How should current medications be reviewed during preconception care for women with diabetes?
Current medications should be reviewed for their appropriateness during pregnancy, considering potential risks and benefits for both the mother and the fetus.
Define the significance of evaluating obstetric/gynecologic history in women with diabetes during preconception care.
Evaluating obstetric/gynecologic history is significant as it helps identify previous complications such as cesarean sections, congenital malformations, fetal loss, and other factors that may impact pregnancy management.
What are the lifestyle modifications recommended for women with diabetes to avoid hyperthermia during preconception?
Women with diabetes are advised to avoid hyperthermia by steering clear of hot tubs and other activities that may raise body temperature excessively.
Describe the screening components for managing diabetes in pregnancy.
Screening should include diabetes complications and comorbidities such as a comprehensive foot exam, comprehensive ophthalmologic exam, ECG for women starting at age 35 with cardiac signs/symptoms or risk factors, lipid panel, serum creatinine, TSH, and urine protein-to-creatinine ratio.
Define the immunizations recommended for pregnant women with diabetes.
Recommended immunizations include Varicella, Influenza, and others if indicated.
How should a preconception plan be structured for women with diabetes?
The preconception plan should include a nutrition and medication plan to achieve glycemic targets, a contraceptive plan to prevent pregnancy until targets are met, and a management plan for general health and any comorbid conditions.
What genetic carrier statuses should be considered in the management of diabetes in pregnancy?
Genetic carrier statuses to consider include cystic fibrosis and others if indicated based on history.
Do women with diabetes need to undergo specific tests for infectious diseases during pregnancy?
Yes, screening for infectious diseases should include a Pap smear and tests for syphilis.
How can continuous glucose monitoring assist in managing diabetes during pregnancy?
Continuous glucose monitoring helps in achieving glycemic targets prior to conception and throughout pregnancy.
What are some comorbid conditions that should be managed in pregnant women with diabetes?
Comorbid conditions include hypertension, nephropathy, retinopathy, Rh incompatibility, and thyroid dysfunction.
Describe the importance of a contraceptive plan in the management of diabetes in pregnancy.
A contraceptive plan is important to prevent pregnancy until glycemic targets are achieved, ensuring better health outcomes for both mother and child.
What is the role of a lipid panel in the screening process for pregnant women with diabetes?
A lipid panel is part of the screening to assess cardiovascular risk and manage potential complications associated with diabetes.
How does the management of diabetes in pregnancy address potential complications?
Management includes screening for complications such as DKA, DVT/PE, and monitoring for conditions like anemia and infectious diseases.
Describe the risks associated with poorly controlled diabetes in the early weeks of pregnancy.
Poorly controlled diabetes in the early weeks of pregnancy increases the risks of spontaneous abortion and congenital malformations in the infant.
How does poor glycemic control later in pregnancy affect outcomes for the infant?
Poor glycemic control later in pregnancy is associated with stillbirths, fatal macrosomia, polyhydramnios, and neonatal hypoglycemia.
Define the complications that preexisting diabetes can lead to during pregnancy.
Preexisting diabetes increases the risk for diabetes-related complications such as gastroenteropathy, retinopathy, and nephropathy.
What are the potential consequences of diabetes on pregnancy outcomes?
Diabetes can lead to spontaneous abortion, congenital malformations, stillbirths, fatal macrosomia, polyhydramnios, and neonatal hypoglycemia.
Explain the importance of glycemic control in pregnancy for women with diabetes.
Maintaining good glycemic control in pregnancy is crucial to reduce the risks of adverse outcomes for both the mother and the infant.
Describe the risks associated with poorly controlled diabetes in early pregnancy.
Poorly controlled diabetes in the first weeks of pregnancy raises the risk of spontaneous abortion and congenital anomalies in the infant.
Define the common congenital anomalies associated with poorly controlled diabetes during pregnancy.
The commonest congenital anomalies are cardiac defects, neural tube defects, and genitourinary abnormalities.
How can diabetic retinopathy be affected during pregnancy?
Diabetic retinopathy may develop or progress during pregnancy, influenced by the duration of diabetes, severity of existing retinopathy, and glycemic control.
What factors are associated with the progression of diabetic retinopathy during pregnancy?
Factors associated with the progression of diabetic retinopathy during pregnancy include maternal duration of diabetes, severity of existing retinopathy, degree of glycemic control, hypertension, smoking, hyperlipidemia, and hypoglycemia.
Explain the relationship between glycemic control and diabetic retinopathy in pregnant women.
The likelihood of diabetic retinopathy progression is related to the degree of glycemic control before and during pregnancy.
Describe the counseling recommendations for women with diabetes who are planning pregnancy.
Women with preexisting type 1 or type 2 diabetes should be counseled on the risk of development and/or progression of diabetic retinopathy.
How often should dilated eye examinations be conducted for pregnant women with diabetes?
Dilated eye examinations should ideally occur before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum.
Define the monitoring schedule for diabetic retinopathy in pregnant women with diabetes.
Monitoring should occur every trimester during pregnancy and for 1 year postpartum, as indicated by the degree of retinopathy and recommendations from the eye care provider.
What is the significance of dilated eye examinations for women with diabetes during pregnancy?
Dilated eye examinations are significant for assessing the risk and progression of diabetic retinopathy, which can affect the health of both the mother and the baby.
Explain the importance of monitoring diabetic retinopathy postpartum.
Monitoring diabetic retinopathy postpartum is important to ensure any progression of the condition is identified and managed appropriately, reducing the risk of vision loss.
Describe the relationship between baseline renal function and the risk of worsening diabetic nephropathy during pregnancy.
The risk of worsening diabetic nephropathy during pregnancy is influenced by the baseline renal function and the degree of hypertension.
How does impaired initial renal function affect pregnant women with diabetic nephropathy?
If initial renal function is impaired (serum creatinine > 1.2 mg/dl, eGFR < 80 ml/min), 35% to 40% are expected to show further decline during pregnancy.
Define the expected outcomes for women with impaired renal function during pregnancy.
Women with impaired renal function during pregnancy can expect that 45% to 50% may experience renal failure at follow-up several years later.
What is the significance of serum creatinine levels in assessing renal function during pregnancy?
Serum creatinine levels greater than 1.2 mg/dl indicate impaired renal function, which is a critical factor in assessing the risk of worsening diabetic nephropathy during pregnancy.
How does eGFR relate to the risk of renal decline in pregnant women with diabetic nephropathy?
An eGFR of less than 80 ml/min indicates impaired renal function, which correlates with a higher risk of renal decline during pregnancy.
What is the purpose of SMBG in pregnant patients with diabetes?
The purpose of SMBG is to assess glycemic control during pregnancy.
List the specific times for blood glucose monitoring recommended for pregnant patients with diabetes.
The specific times for blood glucose monitoring are fasting, before and one or two hours after each meal, and at bedtime.
Describe the fasting glucose target recommended by the ADA for women with diabetes.
The fasting glucose target recommended by the ADA for women with diabetes is 70–95 mg/dL (3.9–5.3 mmol/L).
Define the one-hour postprandial glucose target for women with type 1 or type 2 diabetes according to ADA guidelines.
The one-hour postprandial glucose target for women with type 1 or type 2 diabetes according to ADA guidelines is 110–140 mg/dL (6.1–7.8 mmol/L).
How does the two-hour postprandial glucose target differ from the one-hour target for women with diabetes?
The two-hour postprandial glucose target for women with diabetes is 100–120 mg/dL (5.6–6.7 mmol/L), which is lower than the one-hour target of 110–140 mg/dL.
What are the recommended glucose targets for women with diabetes according to the ADA?
The recommended glucose targets for women with diabetes according to the ADA are: Fasting glucose 70–95 mg/dL, one-hour postprandial glucose 110–140 mg/dL, and two-hour postprandial glucose 100–120 mg/dL.
Describe the glycemic target for fasting blood glucose according to the American Diabetes Association.
The glycemic target for fasting blood glucose is less than 95 mg/dL.
Define the postprandial glycemic target for 1 hour after eating.
The postprandial glycemic target for 1 hour after eating is less than or equal to 140 mg/dL.
How does the glycemic target differ for 2 hours postprandial compared to 1 hour postprandial?
The glycemic target for 2 hours postprandial is less than or equal to 120 mg/dL, which is stricter than the 1 hour target of less than or equal to 140 mg/dL.
What is the glycemic target for overnight and preprandial blood glucose levels?
The glycemic target for overnight and preprandial blood glucose levels is less than 100 mg/dL.
Describe the glycemic goals for postpartum periods according to the American Diabetes Association.
The glycemic goal for postpartum periods is less than 150-170 mg/dL postprandial.
Define the glycemic target range for antepartum blood glucose levels.
The glycemic target range for antepartum blood glucose levels is 100-129 mg/dL postprandial.
How are glycemic targets categorized for inpatient settings during different periods of pregnancy?
Glycemic targets for inpatient settings are categorized for antepartum, peripartum, and postpartum periods, with specific targets for fasting and postprandial levels.
What is the recommended glycemic target for inpatient fasting blood glucose?
The recommended glycemic target for inpatient fasting blood glucose is less than 95 mg/dL.
Describe the glycemic target for blood glucose levels during the peripartum period.
The glycemic target for blood glucose levels during the peripartum period is similar to the antepartum and postpartum targets, focusing on maintaining levels within specified ranges.
Describe the role of Continuous Glucose Monitoring (CGM) in pregnancy.
CGM may be used as an adjunct to Self-Monitoring of Blood Glucose (SMBG), but there is no data supporting the use of CGM alone for glucose assessment in pregnancy.
Define the target blood glucose range for pregnant patients using CGM.
The target blood glucose range for pregnant patients using CGM is 63 to 140 mg/dL (3.5 to 7.8 mmol/L).
How is the goal for time in range defined for pregnant patients using CGM?
The goal for time in range for pregnant patients using CGM is greater than 70 percent.
What is the goal for time below range for blood glucose levels less than 63 mg/dL in pregnancy?
The goal for time below range for blood glucose levels less than 63 mg/dL (3.5 mmol/L) is less than 4 percent.
What is the goal for time below range for blood glucose levels less than 54 mg/dL in pregnancy?
The goal for time below range for blood glucose levels less than 54 mg/dL (3.0 mmol/L) is less than 1 percent.
What is the goal for time above range for blood glucose levels greater than 140 mg/dL in pregnancy?
The goal for time above range for blood glucose levels greater than 140 mg/dL (7.8 mmol/L) is less than 25 percent.
How are the target ranges and goals for CGM displayed for pregnant patients?
The target ranges and goals for CGM are displayed on the Ambulatory Glucose Profile.
Describe the CONCEPTT trial.
The CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial that evaluated the effectiveness of continuous glucose monitoring (CGM) in addition to standard care for pregnant women with type 1 diabetes.
How did the CONCEPTT trial impact A1C levels in pregnant women with type 1 diabetes?
The CONCEPTT trial demonstrated a mild improvement in A1C levels among pregnant women with type 1 diabetes who used continuous glucose monitoring.
Define the primary focus of the CONCEPTT trial.
The primary focus of the CONCEPTT trial was to assess the value of continuous glucose monitoring in managing blood glucose levels during pregnancy in women with type 1 diabetes.
What were the outcomes measured in the CONCEPTT trial?
The outcomes measured in the CONCEPTT trial included A1C levels, incidence of hypoglycemia, rates of large-for-gestational-age births, length of hospital stay, and neonatal hypoglycemia.
How did continuous glucose monitoring affect hypoglycemia rates in the CONCEPTT trial?
The CONCEPTT trial showed that the use of continuous glucose monitoring did not increase the rates of hypoglycemia in pregnant women with type 1 diabetes.
Describe the significance of the findings from the CONCEPTT trial.
The findings from the CONCEPTT trial are significant as they indicate that continuous glucose monitoring can improve glycemic control in pregnancy without increasing the risk of hypoglycemia, while also reducing adverse birth outcomes.
What standard care was compared to continuous glucose monitoring in the CONCEPTT trial?
The standard care compared to continuous glucose monitoring in the CONCEPTT trial included optimization of pre- and postprandial glucose targets.
Describe the changes in A1C levels during normal pregnancy.
A1C levels fall during normal pregnancy due to physiological increases in red blood cell turnover.
How should A1C be used in managing glycemic control during pregnancy?
A1C should be used as a secondary measure of glycemic control in pregnancy, after self-monitoring of blood glucose.
Define the optimal A1C target during pregnancy.
The optimal A1C target during pregnancy is 6% (42 mmol/mol) if it can be achieved without significant hypoglycemia.
What are the recommended A1C targets during different trimesters of pregnancy?
In early pregnancy, the target is 6-6.5%. In the 2nd and 3rd trimesters, the target is < 6%, but it may be relaxed to < 7% (53 mmol/mol) if necessary to prevent hypoglycemia.
How does A1C relate to postprandial hyperglycemia in pregnancy?
A1C may not fully capture postprandial hyperglycemia, which can drive macrosomia.
What fasting and postprandial glucose targets are recommended during pregnancy?
Fasting should be < 95 mg/dL, 1 hour postprandial < 140 mg/dL, and 2 hours postprandial < 120 mg/dL.
Explain the limitations of A1C in pregnancy.
A1C may not accurately reflect glycemic control due to physiological changes in red blood cell turnover during pregnancy.
Describe the recommended self-monitoring practices for blood glucose in pregnancy.
Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve optimal glucose levels.
Define the glucose targets for fasting and postprandial measurements in pregnancy.
The glucose targets are fasting plasma glucose ≤ 95 mg/dL (5.3 mmol/L), 1-h postprandial glucose ≤ 140 mg/dL (7.8 mmol/L), and 2-h postprandial glucose ≤ 120 mg/dL (6.7 mmol/L).
How does A1C levels in normal pregnancy compare to nonpregnant women?
Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women.
What is the ideal A1C target in pregnancy?
The ideal A1C target in pregnancy is ≤ 6% (42 mmol/mol) if this can be achieved without significant hypoglycemia.
When might the A1C target be relaxed during pregnancy?
The A1C target may be relaxed to ≤ 7% (53 mmol/mol) if necessary to prevent hypoglycemia.
Do some women with preexisting diabetes need to test blood glucose preprandially?
Yes, some women with preexisting diabetes should also test blood glucose preprandially.
Describe the role of continuous glucose monitoring in diabetes management during pregnancy.
Continuous glucose monitoring, when used alongside pre and postprandial self-monitoring of blood glucose, can help achieve A1C targets in diabetes and pregnancy.
How does continuous glucose monitoring impact pregnancy outcomes in women with type 1 diabetes?
Continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia when used in addition to self-monitoring of blood glucose targeting traditional pre- and postprandial targets.
Define the relationship between continuous glucose monitoring and self-monitoring of blood glucose.
Continuous glucose monitoring metrics may be used as an adjunct to self-monitoring of blood glucose but should not replace it for achieving optimal pre- and postprandial glycemic targets.
What should not be used as estimates of A1C in pregnancy?
Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C.
Describe the insulin therapy options for women with type 1 diabetes during pregnancy.
Women with type 1 diabetes require either continuous subcutaneous insulin infusion (CSII) with an insulin pump or multiple daily injections (MDI) during pregnancy.
How is CSII typically administered for women with type 1 diabetes?
CSII is administered using either lispro or aspart insulin.
Define the conditions under which CSII can be initiated during pregnancy.
CSII is generally not initiated during pregnancy, but women who effectively used a pump prepregnancy can continue this therapy.
What types of insulin are used in MDI for women with type 1 diabetes?
In MDI, lispro or aspart is used as bolus insulin in combination with either neutral protamine Hagedorn (NPH) insulin or insulin detemir for basal requirements.
Do women using an insulin pump before pregnancy need to change their therapy during pregnancy?
Women using an insulin pump effectively prepregnancy can continue this therapy during pregnancy.
How does MDI differ from CSII in the management of type 1 diabetes?
MDI involves multiple daily injections of insulin, while CSII involves continuous delivery of insulin via an insulin pump.
Describe the recommended treatment for women with type 2 diabetes who cannot achieve target glycemic levels with medical nutritional therapy alone.
Insulin therapy is suggested rather than oral antihyperglycemic agents.
How should women with type 2 diabetes on metformin or glyburide before pregnancy be managed if they have good glycemic control?
They should be transitioned to insulin therapy as early as feasible in the first trimester.
Define the approach to managing oral antihyperglycemic agents in pregnant women with type 2 diabetes.
Other oral antihyperglycemic or non-insulin injectable agents are discontinued, and insulin therapy is initiated as needed to achieve adequate metabolic control.
What is the goal of transitioning women with type 2 diabetes to insulin therapy during pregnancy?
The goal is to achieve and maintain adequate metabolic control.
Explain the timing for initiating insulin therapy in pregnant women with type 2 diabetes.
Insulin therapy should be initiated as early as feasible in the first trimester.
Describe the ADA recommendation for managing type 1 diabetes in pregnancy.
Insulin should be used for the management of type 1 diabetes in pregnancy.
Define the preferred agent for managing type 2 diabetes in pregnancy according to ADA recommendations.
Insulin is the preferred agent for the management of type 2 diabetes in pregnancy.
How can type 1 diabetes be managed during pregnancy according to the ADA recommendations?
Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes.
What is the recommendation level for using insulin in type 1 diabetes during pregnancy?
The recommendation level is A for using insulin in the management of type 1 diabetes in pregnancy.
What is the recommendation level for using insulin in type 2 diabetes during pregnancy?
The recommendation level is E for using insulin as the preferred agent in the management of type 2 diabetes in pregnancy.
Do multiple daily injections or insulin pump technology have a role in managing type 1 diabetes during pregnancy?
Yes, either multiple daily injections or insulin pump technology can be used.
Describe the recommendation for women with diabetes regarding aspirin use during pregnancy.
Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin (100–150 mg/day) starting at 12 to 16 weeks of gestation to lower the risk of preeclampsia.
How much low-dose aspirin is recommended for pregnant women with diabetes?
The recommended dosage of low-dose aspirin for pregnant women with diabetes is 100–150 mg/day.
Define the timing for starting low-dose aspirin in pregnant women with diabetes.
Low-dose aspirin should be started at 12 to 16 weeks of gestation for pregnant women with type 1 or type 2 diabetes.
What is an alternative dosage of aspirin that may be acceptable for pregnant women with diabetes?
A dosage of 162 mg/day may be acceptable for pregnant women with diabetes.
How is low-dose aspirin commonly available in the U.S.?
In the U.S., low-dose aspirin is commonly available in 81-mg tablets.
Describe the frequency of follow-up appointments during the first and second trimester of pregnancy.
Follow-up appointments should occur every 2 to 4 weeks during the first and second trimester.
How often should follow-up appointments be scheduled from 28 weeks until 36 weeks of pregnancy?
Appointments should be scheduled every 1 to 2 weeks from 28 weeks until 36 weeks of pregnancy.
What is the recommended timing for delivery in diabetic women?
The goal for delivery in diabetic women should be between 38 to 41 weeks unless complications arise.
Under what circumstances might an obstetrician induce labor before 39 weeks?
An obstetrician may induce labor before 39 weeks if there is concern about increased fetal weight.
Define the follow-up schedule for pregnancy after 36 weeks.
After 36 weeks, follow-up appointments should be scheduled weekly until term.
How does the presence of maternal or fetal complications affect the delivery timing in diabetic women?
If maternal or fetal complications arise, the timing of delivery may be adjusted from the recommended 38 to 41 weeks.
Describe the timeline of hyperglycemia after receiving betamethasone.
Hyperglycemia typically ensues by the third day after receiving betamethasone and lasts for up to 5 days following administration.
How does insulin dosage change during betamethasone treatment?
Insulin doses typically need to be increased by the first day after the first betamethasone dose (day 2) by 10%, 40%, 40%, 20%, and 20% respectively.
Define the duration of hyperglycemia following betamethasone administration.
Hyperglycemia lasts for up to 5 days following the administration of betamethasone.
What is the significance of monitoring insulin doses during betamethasone therapy?
Insulin doses need to be adjusted due to the increase in blood sugar levels caused by betamethasone.
Describe the target blood glucose level for pregnant women with pregestational diabetes.
The target blood glucose level is between 70 to 110 mg/dl.
How is glycemic management approached at the induction of labor for pregnant women with pregestational diabetes?
Glycemic management includes an IV infusion of regular insulin carefully titrated with a low-dose dextrose infusion.
Define the management approach for women with well-controlled Type 2 Diabetes during labor.
Women with well-controlled Type 2 Diabetes on subcutaneous insulin may remain on this regimen during labor, unless glycemic targets are not met.
What is the role of dextrose infusion in the management of glycemic levels during labor?
Dextrose infusion is used in conjunction with regular insulin to help maintain appropriate blood glucose levels.
How should insulin be administered to manage blood glucose levels during labor for pregnant women with pregestational diabetes?
Insulin should be administered via an IV infusion and carefully titrated.
Describe the change in insulin sensitivity after delivery of the placenta.
Insulin sensitivity increases dramatically with the delivery of the placenta.
How do insulin requirements change in the immediate postpartum period compared to prepregnancy levels?
In the immediate postpartum period, insulin requirements are roughly 34% lower than prepregnancy insulin requirements.
Define the timeline for the return of insulin sensitivity to prepregnancy levels after delivery.
Insulin sensitivity returns to prepregnancy levels over the following 1–2 weeks after delivery.
Describe the change in insulin resistance immediately postpartum.
Insulin resistance decreases dramatically immediately postpartum.
How should insulin requirements be adjusted in the initial days postpartum?
Insulin requirements often need to be evaluated and adjusted as they are roughly half the prepregnancy requirements for the initial few days postpartum.
Define the ADA recommendation for women with diabetes regarding breastfeeding.
All women, including those with diabetes, should be supported in attempts to breastfeed.
What risk does lactation pose for women with diabetes?
Lactation can increase the risk of overnight hypoglycemia.
How might insulin dosing need to change during lactation?
Insulin dosing may need to be adjusted due to the increased risk of hypoglycemia during lactation.
What medications are considered safe to use while breastfeeding?
Metformin, glyburide, and most insulins are considered safe to use when breastfeeding.
Describe the importance of family planning for women with diabetes of childbearing potential.
Regular review of family planning options ensures effective contraception is implemented and maintained, which is crucial for managing diabetes during the childbearing years.
How often should family planning options be reviewed for women with diabetes?
Family planning options should be reviewed at regular intervals, including during the immediate postpartum period.
Define the contraception options available to women with diabetes.
Women with diabetes have the same contraception options and recommendations as those without diabetes.
What type of contraception should be prescribed to women with diabetes until they are ready to become pregnant?
Long-acting, reversible contraception and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant.
Do women with diabetes have different contraception recommendations compared to those without diabetes?
No, women with diabetes have the same contraception options and recommendations as those without diabetes.
Describe the contraceptive plan for women with diabetes of reproductive potential.
A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential.
How should gestational diabetes mellitus (GDM) be managed when euglycemic with nutritional therapy and exercise?
Expectant management should be applied when the pregnancy reaches 39+0 weeks of gestation, with scheduling an induction when 41+0 weeks of gestation is reached.
What is the recommended timing for induction of labor in women with medically managed GDM?
Induction of labor is recommended at 39 weeks for women with medically managed GDM.
Define the criteria for scheduled cesarean delivery in women with GDM.
Scheduled cesarean delivery is offered to women with GDM and an estimated fetal weight of 4500 grams or more.
How does the management of GDM differ based on glucose levels?
For euglycemic women, expectant management is used, while medically managed women should have induction at 39 weeks.
What is the significance of gestational age in the management of GDM?
Gestational age is crucial for determining the timing of induction and delivery methods for women with GDM.
Define polyhydramnios.
Polyhydramnios is an excess volume of amniotic fluid, typically greater than 1000 ml, and often exceeding 3000 ml.
Describe a common complication associated with poorly controlled diabetes during late pregnancy.
Polyhydramnios is a common complication in women with poorly controlled diabetes during late pregnancy.
How can polyhydramnios affect delivery outcomes?
Polyhydramnios may lead to preterm delivery.
What risks are associated with polyhydramnios?
Polyhydramnios increases the risk for placenta abruptio and postpartum uterine atony.
What condition is most often associated with polyhydramnios?
Polyhydramnios is most often associated with fetal macrosomia.
Describe the causal chain leading to fetal macrosomia.
Maternal hyperglycemia leads to fetal hyperglycemia, which causes fetal hyperinsulinemia, ultimately resulting in fetal macrosomia.
Define fetal macrosomia and its complications.
Fetal macrosomia is a condition where a fetus is significantly larger than average, and complications include fetopelvic disproportion, which can lead to shoulder dystocia.
How can difficult vaginal delivery affect maternal health?
Difficult vaginal delivery can result in severe perineal laceration and may lead to urinary and/or fecal incontinence.
What are the clinical implications of fetal macrosomia?
Fetal macrosomia can lead to complications such as shoulder dystocia and adverse maternal outcomes during delivery.
Do clinical studies support the hypothesis regarding fetal macrosomia?
Yes, clinical and experimental studies have confirmed the hypothesis that maternal hyperglycemia leads to fetal macrosomia.
