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
Post partum management of gestational diabetes
2 hour GTT after 6 weeks postpartum
primary care physician follow up
Preventative therapu
- impaired fasting
- impaired Glucose tolerance
- diabetes
repeat screening every 1-3 years after delivery
percentage of obesity in pregnancies and the classes of BMI needed to be obese?
2015 of people are 26 % obese and 26% overweight
BMI over 30kg/m2
Class I BMI = 30-34.9
Class II BMI = 35-39.9
Class III BMI = above 40
25% of pregnancy complications are due to obesity
30 percent of LGA infants due to maternal weight gain
what is the mechanism of action obesity has on pregnancies
Adipose tissue is active endocrine organ
- effects are metabolic, vascular, and inflammatory pathways
- insulin resistance has a negative effect on placenta growth and function leading to preeclampsia
Barker hypothesis:
- long term outcomes for offspring
- changes in metabolic programming in uterus
- fetal origins of adult disease theory
- difficult to study
what can severe morbidity lead to?
- hemorrhage
- cardiac, respiratory, cerebrovasculature, hematologic complications
- venous thromboembolism
- sepsis
- hepatic or renal failure
- anesthesia related complications
- uterine rupture
antepartum risks of obesity in pregnancy
increased risk of miscarriage
increased risk of occult type 2 DM and GDM
Pregnancy associated hypertension and preeclampsia
-bariatric surgery decreased their risk
preterm delivery
- medical complications
- extreme premature risk
Post term pregnancy; multi fetal pregnancy; obstructive sleep apnea
Intrapartum risks of obesity pregnancies
- longer abor and more dysfunctional labor
- higher induction risks
- more failed inductions
- higher c-section rates
- lower sucessful VBAC rates
- anesthesia complications
- macrosomic infants >4000 g
- hemorrhage
postpartum risks of obesity pregnancies
- 2-4x higher risk of venous thromboembolism
- higher infection rates of endometritis,wound and episitomy
- postpartum depression
- congenital anomalies
- fetal death, infant death is increased
Infant risks of a maternal obese pregnancies
LGA
- shoulder dytocia
- predisposition to obesity later in life
Childhood obesity
- 1 parent 2x
- 2 parents 15x
Neurodevelopment
- cognitive impairment like autism, ADHD, anxiety
- increased risk of cerebral palsy via RR class III
Asthma
Pre-pregnancy management for obese pregnancies
Ideal world = preconceptual planning counsel on risks evaluate and management comorbid conditions weight loss counseling bariatric surgery
10 percent reduction in BMI
-10 percent risk reduction in preeclampsia, GDM, macrosomia, still birth
20-30% reduction in BMI
-decrease in C-section and shoulder dystocia risks
Recommended range of total weight gain via BMI
less than 18 = 28-40
18.5 to 24.9 = 25-35lbs
25-29.9 = 15-25 lbs
30 and greater = 11-20 lbs
Pregnancy management for obese pregnancies
Baseline assessements (BMI, BP, US, meds) ealy Gestational diabetic screen -counseling on nutrition and weight gain -Exercise -genetic screening -low does of asprin in second trimester -fetal anatomic survey
labor and delivery of obese pregnancies
Appropriate equipment
-larger chairs and birthing beds
fetal monitoring
Anesthesia consultation
delivery by due date
Cesarean delivery
- thromboprophylaxis
- antibiotic prophylaxis
Postpartum monitoring for obese pregnancies
Post Cesarean monitoring
breastfeeding support
contraception
diabetes screening 6-12 weeks after delivery
weight loss/diet/excercise
depression monitoring
co-morbidities
Bariatric surgery and pregnancy
benefits of surgery:
- pregnancy complications are less
- less congenital anomalies
- neural tube defects increased with or without surgery
Recomend to wait 12-18 months before conceiving
-rapid weight loss phase has passed
risks in pregnancy:
- bowel obstruction
- glucola screening
- increased cholelithiasis
Characteristics of Maternal mortality Ratio
has been going up due to the increased obesity
-60 percent of these deaths are preventable
there are racial disparities among mortality rates
main cause is hemorrhage, or cardiovascular conditions
and mainly occur during pregnancy or post partum due to the delays for the decision to come in, delay in arrival, or delay in diagnosis
where do we go from here?
Access to care
open dialogue to issues and biases
eductatuon and clinical bundles to outlying areas
telemedicine access for rural health
outreach to rural areas and high risk areas
relationships
community partners
better reporting
access points for better education and communication
