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Obstetrics > Gestation Diabetes > Flashcards

Gestation Diabetes Flashcards

1
Q

Describe risk factors for GDM? (11)

A

BMI > 30
ethnicity
Previous GDM
Previous elevated BGl
Maternal age >= 40
Family history of DM (1st degree relative or sister with GDM)
Previous macrosomia (BW > 4500g or> 90th)
Previous perinatal loss
PCOS
Medications (e.g. corticosteroids, antipsychotics)
Multiple pregnancy

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2
Q

If no RF on admission, when do you assess for GDM and outline the protocol.

A

At 24-28 weeks gestation.

2 hour 75g OGTT

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3
Q

Describe diagnosis of GDM based on OGTT or HbA1C

A

HbA1C >= 41mmol/mol (or 5.9%)

OGTT one or more:

  • Fasting >= 5.1
  • 1 hour >= 10
  • 2 hour&raquo_space;= 8.5
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4
Q

Describe protocol for ceasing Metformin or insulin around timing and mode of birth for vaginal birth

A

Metformin: cease when in labour established.
Insulin:
- cease when labour established
- if for morning IOL (and labour not established) eat breakfast and give usual rapid acting insulin. Omit morning long or intermediate acting insulin
- if afternoon IOL (and labour not established) give usual mealtime and bedtime insulin.

When in labour monitor BGLs Q2 hourly aiming between 4-7.

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5
Q

Describe timing of cessation of insulin or Metformin around an elective CS?

A

Day before procedure:
Cease Metformin after evening dose prior to procedure.
Give usual insulin night before procedure

Day of morning procedure:
Fast for 6 hours
When fasting omit s/C insulin
If insulin infusion consult with anaesthetist

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6
Q

How is GDM diagnosed using the OGTT?

A

One or more of:

  • Fasting >/= 5.1 mmol/L
  • 1 hour >/=10mmol/L
  • 2 hours >/= 8.5mmol/L
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7
Q

Describe BSL monitoring in the postpartum period for a women who has/had GDM?

A

If previously on pharmacotherapy:
Monitor BGLs preprandial and before bed (QID)
If all preprandial BGL between 4-7mmol/L case monitoring 24 hours after birth.
If not previously on pharmacotherapy: case BGL monitoring after birth.

Advised women to get repeat OGTT at 6-12 weeks postpartum to screen for persistent diabetes. Recommend lifelong screening for diabetes at least every 3 years.
Early glucose testing in future pregnnacy.

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8
Q

What kind of referral and follow-up is required postpartum for women who had GDM during pregnancy?

A

Advise women to see their GP to be screened for persistent diabetes at 6-12 weeks postpartum using the OGTT and non-pregnancy diagnostic criteira.
Women with a history of GDM require life-long screening for the development of diabetes or pre-diabetes at least every 3 years.
Perform early glucose testing in a future pregnancy.

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9
Q

What information would you give to women with GDM and breastfeeding?

A

Women with GDM are less likely to breastfeed (75% vs 86%) and to continue for a shorter duration (9 vs 17 weeks) compared to women without GDM. This values are even lower in owmen who require insulin therapy or who are obese.
Growing evidence that breastfeeding has short and long term benefits for moths with GDM.
One study found BF duration of 3 or more months reduced the risk of type 2 diabetes and delayed development of T2DM. afurther 10 years c/w BF < 3 months.
MFM and insulin safe in BF.

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10
Q

In the postpartum period, for women with GDM, what is the preprandial target BGL for women?

A

Less htan or equal to 7.0mmol/L (preprandial)

NB: if all preprandial BGL are between 4.0 and 7.0mmol/L discontinue monitoring 24 hours after birth.

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11
Q

Describe protocol for intrapartum BGL monitoring for women without pharmacotherapy and for with pharmacotherapy?

A

For non-pharmacological therapy: BGL on arrival then Q4H.

For women on pharmacotherapy: BGL on arrival then Q2H.

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12
Q

Describe protocol for ceasing pharmacotherapy (MFM and insulin) prior to elective CS?

A

Cease MFM 24 hours prior to elective procedure.
For women taking insulin:
- Administer urual rapid and intermediate/long acting insulin the night before. Fast from midnight.
- Omit all insulin on morning of CS.

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13
Q

For women taking MFM, when do you medication:

  • At onset of spontaneous labour
  • For IOL
A
  • Cease MFM when in established labour for both spont onset and IOL.
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14
Q

For women on insulin and undergoing a morning IOL, when do they cease insulin?

A

Advise women:

  • eat early morning breakfast.
  • administer usual dose of rapid acting insulin with breakfast.
  • omit long or intermediate acting insulin in the morning.
  • cease insulin when in established labour
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15
Q

For pm IOL, when would you cease insulin?

A

Administer usual dose of rapid acting insulin with evening meal.
If not in established labour, administer long or intermediate acting insulin before bedtime.
Cease insulin when in established labour.

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16
Q

How would you discuss mode of birth, taking into account estimated fetal weight, for a woman with GDM?

A

If fetal weight is estimated at:

  • Less than 4000g, vaginal birth is usually appropriate.
  • 4500g or more, recommend a CS
  • 4000-4500g, consider other individual factors (e.g. maternal stature, obs hx, prvious birth hx, previous macrosomia +/- shoulder dystocia
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17
Q

Discuss timing of birth in relation to GDM

A

Well managed with MNT and no fetal macrosomia or other complications, wait for spont labour.
With suspected fetal macrosomia or other complications, consider birth from 38-39 weeks gestation.
Pharmacotherapy alone is not an indication for birth before term.
In most cases, women with optimal BGLs who are receiving pharmacotherapy therapy do not require expedited birth before 38 weeks gestation.

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18
Q

Macrosomia increases the risk of which fetal birth injuries? (2)

A

shoulder dystocia

brachial plexus injuries

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19
Q

What are the symptoms of hypoglycaemia?

A 
Hunger
Light headedness/headache
Sweating/shaking/weakness
Tingling around the lips
Irritability
Blurred vision
Severe hypoglycaemia (when unable to treat) can lead to confusion and loss of consciousness and requires urgent medical treatment
20
Q

Describe insulin regime:

- Elevated fasting glucose

A

Single bedtime injection of intermediate-acting insulin (will often suffice)

21
Q

Describe insulin regime:

- Postprandial hyperglycaemia.

A

Meal time rapid acting

22
Q

Describe the insulin regime:

- Fasting and postpradial hyperglycaemia

A

Basal-bolus insulin regimen

  • meal-time rapid-acting insulin and bedtime intermediate acting OR
  • twice daily mixed insulin (if woman is reluctant to inject QID)
23
Q

Describe potential side effects of insulin therapy

A

Hypoglycaemia
Local (injection site) allergic reactions
Systemic reaction (skin eruptions, oedema)

24
Q

Insulin requirements tend to rise throughout the 3rd trimester. When does insulin requirement tend to plateau?

A

K36-38

25
Q

Describe potential side effects of metformin (5)

A

Nausea, loss of appetite
Diarrhoea
Vomtiing
Lowering of serum vit B12 levels (generally if longer term therapy)
May be associated with preterm birth prior to 37 weeks.

26
Q

C/I to metformin

A

conditions that may alter renal function

Severe hepatic impairment.

27
Q

What education would you give women surrounding taking metformin

A

Take MFM after a meal.
Cease if significant gastro intestinal side effects occur and are persistent.
Add insulin if glycaemic targets not achieved or metformin not tolerated.

28
Q

What are the indications for MFM?

A

If average BGL over 1 week is elevated (BGL at the saem monitoring time each day) after consideration of dietary and physical activity factors.
USS shows incipient fetal macrosomia (AC above the 75% ) at dx.
Mild overall elevated BGL or elevated fasting BGL

29
Q

Does MFM cross the placenta?

A

Yes but there appear to have been no teratogenic problems

30
Q

Contraindications for physical activity include the following.

A

Haemodynamic significant heart conditions.
Restrictive lung conditiosn.
Incompetent Cx/cerclage
multiple gestation at risk for premature labour
persistent 2nd or 3rd trimester bleeding.
Placenta praevia after 26 weeks of gestation.
Premature labour during the current pregnnacy
ruptured membranes
PET
Intrauterine growth restriction

31
Q

How would you counsel a women on moderate intensity exercise.
Which types of activities should pregnant women avoid.

A

Physical activity of moderate intensity enables the woman to talk but not sign whilst exercising.
Recommend 30 mins of physical activity on most days of the week. (may be broken into 10min periods of mod effort)
Avoid activities that:
- involve lying flat on the back.
- Increase the risk of falling or abdo trauma (e.g. contact sporst, most racquet sports, horseback riding, water skiing)
- Are at extreme altitutes (e.g. scuba or mountain climbing)

32
Q

How often should a GDM woman monitor her BGLs?

AND

What are the suggested BGL targets for fasting, 1 and 2 hours postprandial.

A

Initially recommend BG self-monitoring QID either:
Before breakfast and 1 hour postprandial OR
Before breakfast and 2 hours postprandial

Fasting: = 5.0
1 hour after meal: = 7.4
2 hours after meal: = 6.7

33
Q

How often should you monitor fetal growth and wellbeing?

A

Assess the fetal response to maternal GDM by USS measurement of fetal AC commencing at 28-30 weeks.
Consider 2-4 weekly USS for women with unstable diabetes or who require pharmacological therapy.
If excesssive fetal growth or AC (above 75%() is detected consider more intensive management which may include
- lower targets for glycaemic mng
- Addition of pharmacological therapy

NB: Fetal AC >/= 75% for gestational age, measured at 29 to 33 weeks gestation, correlates with an increased risk for birth of an LGA infant.

34
Q

What is the recommended weight gain range according to pre-pregnancy BMI

A

< 18.5 -> 12.5 to 18kg
18.5-24.9 - >11.5 to 16kg
25.0 -29.9 -> 7 to 11.5kg
>/= 30 - > 5 to kg

35
Q

Rapid gestational weight gain, especially in a diabetic, may indicate what fetal complication?

A

Polyhydramnios

36
Q

What additional antenatal care would you recommend for a woman with diabetes in pregnnacy?

A

Recommend morph USS as there may be an increased risk of fetal congenital anomaly.
Test for retinopathy and/or nephropathy as these substantially increase the risk of developing PET.
- Recommend optometrist or ophthalmologist review
- Test for microalbuminuria

37
Q

What is diabetes in pregnancy? and what is the diagnostic criteria (how do these compare to GDM).

A

Women with elevated values that would be diagnostic of diabetes outside of pregnancy.
Fasting >/= 7.0 (c.f. 5.1- 6.9)
1 hour level NOT used (c.f. >/=
2 hour >/= 11.1mmol (c.f. 8.5 - 11.0)
Random BGL >/= 11.1
Or HbA1c >/= 48mmol/mol or 6.5% in early pregnancy

38
Q

What BGL targets are diagnostic of GDM?

A

Fasting: >/= 5.1 - 6.9
1 hour: >/= 10..0
2 hour: 8.5 -11.0

39
Q

Describe the process for the OGTT?

In what situations would you delay the OGTT?

A

routinely recommended at 24-28 weeks.
Advise women to maintain a normal diet and then to fast for 8 to 14 hours before the OGTT.
During fasting, to drink water to prevent dehdyration and to continue any usual medications.

Do not perform OGTT within one week of maternal steroids
If taking MFT for PCOS, OGTT results may be misleading.

40
Q

What are maternal short term risks of GDM? (6)

A 
PET
Induced labour
Operative birth
Hdyramnios
PPH
Infection
41
Q

What are maternal long term risks of GDM (3)?

A

Recurrent GDM in subsequent pregnancies
Progression to T2DM
- about 5% develop T2DM within 6 months of birth
- ABout 60% develop T2DM within 10 years.
Development of CVD.

42
Q

What are newborn/fetal short term risks of GDM? (8)

A 
Resp distress syndrome
Jaundice 
Hypoglycaemia
Premature birth
Hypocalcaemia
Polycythaemia
Increased newborn weight and adiposity
Macrosomia
  - Shoulder dystocia - risk increases as fetal weight increases.
  - Bone #
  - Nerve palsy
  - CS birth
  - HIE
  - Death
43
Q

What are the newborn long term risks of GDM?

A

Impaired glucose tolerance
Development of T2DM
Obesity
There is no evidence that current treatment reduces long terms risks in the newborn

44
Q

Define LGA baby?

A

Fetal weight greater than 90th percentile for gestational age

45
Q

Define macrosomia?

A

Excessive fetal growth variously described as more than 4000g or more than 45000g.

Obstetrics (14 decks)

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