gestational diabetes Flashcards
gestational diabetes mellitus (GDM)
any degree of glucose intolerance w/ onset or 1st recognition during pregnancy. This does not exclude the possibility that unrecognized glucose intolerance has antedated or begun concomitantly w/ the pregnancy.
what is the MC medical complication & metabolic d/o of pregnancy?
GDM
occurs in 2-14% of population
ethnic groups w/ higher incidence of Type 2 diabetes, therefore GDM
Hispanic Americans
African Americans
Native Americans
Pacific Islanders
increased insulin release
maternal estrogens & progesterone
metabolic changes during pregnancy are essential for what to be delivered to the developing fetus
adequate nutrients
what results in lower fasting glucose levels
increase in peripheral glucose utilization & glycogen storage w/ reduction in hepatic glucose production
what rises linearly throughout the 2nd & 3rd trimesters?
placental steroids & peptide hormones
i.e. human chorionic sommatomammotropin
cortisol, prolactin, progesterone, estrogen
placental steroids & peptide hormones increase what
tissue insulin resistance which means the demand for insulin increases
the bodies demand for insulin increases between what weeks of pregnancy?
24th-28th
the pancreas releases 1.5-2.5 times more insulin to respond to the increase in insulin resistance. pts w/ nml pancreatic function are able to meet these demands, but people w/______________________leads to inadequate insulin secretion in the presence of increasing insulin resistance.
borderline pancreatic function
during a healthy pregnancy, mean fasting blood glucose levels decline to an avg. of what
74 mg/dL
peak postprandial values rarely exceed
120 mg/dL
meticulous glucose ctrl during pregnancy has been shown to reduce what
risk of macrosomia
<120 mg/dL 20% develop
up to 160 mg/dzl 35% develop
risk assessment for GDM should be done when
1st prenatal visit
clinical characteristics consistent with high risk
advanced maternal age morbid obesity hx of GDM glycosuria strong FH of DM
high risk pts should undergo testing for GDM as soon as feasible. If initial screening is negative repeat screening should be done at
24-28 wks
avg risk pts should have testing done?
24-28 wks
low risk pts must meet what requirements in order to avoid glucose testing?
age<25 yo wt nml pre-pregnancy member of ethnic group w/ low GDM prev. no known DM in 1st degree relative no hx of abnormal glucose tolerance no hx of poor OB outcome/ macrosomic infant
one-step approach to GDM screening
perform a diagnostic 3 hr oral glucose tolerance test (OGTT) w/o prior plasma/ serum glucose screening
pt must be on unrestricted diet x3 days
the one-step approach for GDM screening is cost effective in what population
high-risk pts/ populations
two-step approach to GDM detection for avg. risk at 24-28 wks
Step 1: plasma glucose concentration 1 hr after a 50g oral glucose load
If results:
>140 mg/dL= schedule pt for 3 hr OGTT
>130 mg/dL=ID’s 90% of pts w/ GDM
When does the 3 hr OGTT not need to be performed?
1 hr 50g glucose screen >185 mg/dL or a fasting >126 mg/dL
the 100g 3 hr OGTT
must be done after 3 days of unrestricted carbohydrate diet & while pt is fasting
venous plasma glucose measured at 1, 2, & 3 hrs after
+ test requires 2 values be met or exceeded. 1 abnormal value should be followed w/ repeat test one month later
Criteria of positive 100gm OGTT
fasting glucose: 95mg/dL
1 hr glucose: 180mg/dL
2 hr glucose: 155mg/dL
3 hr glucose: 140mg/dL
what are the immediate risks to the mother w/ GDM?
increased incidence of c-section
preeclampsia
polyhydraminos
what are the long term risks to the mother w/ GDM?
recurrent GDM & high risk for developing diabetes
immediate risk to the infant from GDM
macrosomia (d/t excessive fetal insulin d/t increased delivery of glucose & amino acids to the fetus via maternal circulation) shoulder dystocia (d/t macrosomia)
Macrosomia definition
birth wt above 90th percentile for gestation age or > than 4000g (8.8lbs)
shoulder dystocia can result in what?
brachial plexus injury
clavicular fracture
fetal distress
low APGAR scores
with extremely poor glucose control there is an increase in what?
fetal mortality d/t fetal acidemia & hypoxia
neonatal hypoglycemia
Long term risks to infant from GDM
increased risk of adolescent obesity & type 2 diabetes
What is the foundation for the tx of GDM?
dietary therapy
what is the ADA recommended dietary therapy?
2000-2500 kcal/d (35 kcal/kg present pregnancy wt) w/ 50-60% carbs (35-40%), 10-20% protein & 25-30% fat (<10% saturated fat)
other recommendations of dietary therapy
30 kcal/kg if nml wt
24 kcal/kg if overwt
12 kcal/kg if morbidly obese
in at least 1/2 of the cases, diet alone will maintain what?
fasting & postprandial blood glucose values w/in target range
post prandial values have been more strongly associated w/ what?
risk of macrosomia
modest carbohydrate restriction 45% of total calories may blunt what?
postprandial glucose
how often should glucose monitoring be done w/ GDM
@ least weekly w/ a fasting glucose & a 1 hr postprandial
increase/ decrease frequency PRN
T/F- there are oral diabetes meds currently approved for use in pregnancy
FALSE
study using insulin & glyburide showed no difference
what drug is not FDA approved but is being utilized by diabetes centers
Glyburide- it doesn’t cross the placenta
recommendations for initiating insulin therapy are
fasting plasma glucose is >105 mg/dL
1 hr postprandial glucose levels >140 mg/dL
2 hr postprandial >120 mg/dL
macrosomia may be further reduced if insulin is initiated when FPG >95 mg/dL
target glucose levels
fasting values 50-90 mg/dl
preprandial 60-105 mg/dl
2 hr postprandial <130 mg/dl
2-6 am value 60-90 mg/dl
NPH, regular, aspart, lispro are category what?
B
insulin glargine is pregnancy cat. ?
C
lantus insulin has a high affinity to what type of receptors?
IGF-1 receptors
not recommended in pregnancy
insulin detemir is a cagegory?
C
has low affininity for IGF-1
not currently used in pregnancy, but may be best bet at some point
exercise as an adjuvant therapy in GDM
fetal safety has been estab. if maternal heart rate is maintained <1 hr & the mother stays hydrated & does not get over heated
imaging studies/ procedures
growth ULS for fetal size- do bet. 36-37 wks
amniocentesis is used to check___________________if delivery is contemplated prior to 39 wks gestation
fetal lung profile
fetal mvnt counting
every night @ 28 wks in <60 min
10 mvnts is good
all pts should do
non stress test
twice weekly
2 heart rate accels in 20 min
begin at 28-30 wks w/ insulin at 36 wks w/ diet
contraction stress test
weekly
no HR decels in response to 3 contractions in 10 min
begin in all pts at 28-30 wks?
ULS biophysical profile
weekly score of 8 in 30 min 3 mvnts=2 1 flexion=2 30 secs of birthing=2 2cm amniotic fluid=2
Pts can progress to term if
GDM is uncomplicated & controlled w/ diet, unless other complications arise
estimating fetal wt is done how
serial ULS’s
plays a major role in decision making process for route of delivery
postpartum follow up
counsel on high risk for recurrent GDM
screen for DM 6 wks post partum- if nml reassess at min of 3 yr intervals
monitor annually women w/ impaired fasting glucose or impaired glucose tolerance
in order to improve insulin sensitivity & attempt to prevent developing type II DM, what should be started postpartum?
wt loss program consisting of diet & exercise
what helps to decrease the chance of developing type II DM as well as decreases the risk of iinfant obesity & impaired glucose tolerance?
breastfeeding, unless difficulties in glycemic control
