Gestational Diabetes Flashcards
What is gestational diabetes? and some underlying factors
glucose intolerance diagnosed in pregnancy
pregnancy is an insulin resistant state
- mediated by GH, CRH, and placental lactogen
- increase in prolactin, progesterone, and cortisol
Gestational diabetes
->24 weeks
Pre-exisitng diabetes: Type 1 or 2
Undiagnosed pre exisitng diabetes
Whites classification system
What is whites classification system and what are all the classes
Class A1:
-gestational diabetes diagnosed in pregnancy and controlled with just diet
Class A2:
-gestational diabetes diagnosed in pregnancy, and controlled with diet and glyburide or insulin
Class B:
-pregestational diabetes developing after age 20 yr and duration less than 10 years, controlled with diet and insulin
Class C:
-pregestational diabetes developing ages 10 and 19 years old or duration 10-19 years and controlled with diet and insulin
Class D:
-Pregestational diabetes developing before age 10 yer or duration 20 yr or more or background retiopathy; controlled with diet and insulin
class F: -pregestational diabetes at any age or duration with nephropathy; controlled with diet and insulin
class R: -pregestational diabetes at any age or duration with proliferative retinopathy; controlled with diet and insulin
class H: -pregestational diabetes at any age or duration with arteriosclerotic heart disease; controlled with diet and insulin
what are risk factors of early screening for gestational diabetes
Overweight (BMI >25)
and
- FH diabetes
- high risk race/ethnicity
- previous LGA infant
- previous GDM
- HTN
- PCOS
- A1c>5.7%
- h/o CVD
what are the screening recommendations for gestational diabetes
All patients between 24-28 weeks 2 step approach -1hr guccola, glucose tolerance test -not dependant no prior oral intake -abnormal result: 130-140mg/d:L -80-90% sensitivity -if abnormal perform a 3hr gtt
if greater than 200 then diabetic education
what is a 3 hour glucose tolerance test
Fasting
blood testing every hour for 3 hours
2 abnormal hours means it is diagnostic
Alternative screening regimes for gestational diabetes
2 hour glucose tolerance test
HgA1C
Fasting glucose
random glucose monitoring
what are some antepartum guidlines to improve gestational diabetes?
Dietary changes
- caloric intake based on weight
- 50/25/25 C/P/F
Exercise
- 150 minutes a week
- walking after meals
Testing regimen for gestational diabetes
Daily monitoring
Fasting and 1 or 2 hour postprandial
fasting is less than 95 mg/dL
1 hr< 140mg/dL
2hr<120mg/dL
peak postprandial at 90 minutes
modification of testing in well controlled patients
medication treatment for Gestational diabetes: Metformin
Biguanide
-inhibits hepatic gluconeogenesis and glucose absorption
stimulates glucose uptake in peripheral tissues
PCOS and preexisiting diabetes
lack of superiority to insulin
crosses the placenta
no long term data on neonatal effects
26-46 percent will need insulin
good option for cost, administration and compliance
medication treatment for gestational diabetes: glyburide
Sulfonylurea
binds to pancreatic beta cell ATP/K receptors
-increases insulin sensitivity in peripheral tissues
studies are mixed on amount that crossed placenta but minimal
fetal hypoglycemia
4-16 percent require insulin
- not superior to insulin
- not recomended as first line of defense
- long term effects are unknown
medication treatment for gestational diabetes: Insulin
DOes not cross the placenta
divided dosing
trimester dependent
mix of long acting and short acting insulin
What are other disease states moms are at risk for if they have gestational diabetes
Increased risk of:
- preclampsia
- LGA
- delivery trauma
future risk for type 2 DM
- 4x more likely in 5 years
- 10x more likely in 10 years
what are diseases that the fetus are at risk for if the mom has gestational diabetes
- Macrosomia
- Neonatal hypoglycemia
- hyperbilirubinemia
- shoulder dystocia
- still birth
- increased risk of childhood obesity and diabetes
when and how to monitor fetus and when to deliver fetus depending on class of gestational diabetes
Monitoring of fetus begins at 32 weeks
- fetal Non stress test
- biophysical profiles
- serial amniotic fluid measurements
when to deliver:
Class A1 DM:
-deliver after 39weeks
Class A2 DM:
-deliver after 39 weeks
Prexisting diabetes
-38-39 weeks
poorly controlled:
-37-39 weeks
Intrapartum management of diabetes in gestational diabetes
Goal of identification and management
- reduce risks of preeclampsia
- LGA
- shoulder dystocia
optimal glycemic control during labor
allow effective contractions/labor progression
optimal environment for infant at delivery
