Gestational Diabetes and Obesity Flashcards
What are predisposing factors for gestational diabetes?
overweight (BMI >25)
FHx of DM
certain race/ethnicity
H/o LGA infant
Previous GDM
HTN
PCOS
A1C >5.7%
H/o CVD
How do you screen for gestational DM?
- All patients between 24-28wks get the 1hr glucose tolerance test “Glucola” 50g sugar load
- Abnormal is a glucose level between 130-140 after one hour
- If abnormal, get a three hour GTT.
- If 1hr is >200, patient has gestational DM, don’t need 3hr.
What is a three hour GTT?
Three hour glucose tolerance test
done fasting
Blood measured fasting and then once each hour for three hours after drinking Glucola.
2 abnormal values = gestational diabetes
Alternative screenings for gestational DM include
2hr GTT with a 75g load (varied evidence, not standard of care)
HgA1C (if pre-existing dm, or suspect underlying/undiagonsed)
Fasting glucose
random glucose monitoring
Keep in mind, 1hr GTT between 24-28wks is standard of care for every patient
How is GDM managed?
- Diet changes
Calories-30kcal/kg
50% Carbs, 25% proteins, 25% fat
B:20%, L:30%, D:30%, S:20%
- Exercise
Moderate exercise 3-5x per week, 150min/wk total
walking after meals (increase insulin independent glucose uptake)
GDM patients should check levels how often?
daily
fasting and 1-2 hrs postprandial
fasting should be less than 95
1hr <140
2hr < 120
peak postprandial glucose is at 90min
can modify throughout pregnancy based on pt
How effective is lifestyle modification for treating GDM?
70-80% effective
What are the Pros and Cons of Metformin for GDM management?
Pros: stimulates glucose uptake in peripheral tissue, good for hx of PCOS and preexisting DM, cost effective, high compliance rates
Cons: not as effective as insulin, crosses placenta (no data on neonatal effects), can cause abdominal pain, diarrhea; quarter to half of patients will still need insulin
What are the Pros and Cons of Glyburide on GDM management?
(sulfonurea drug that binds to ATP/K receptors)
PRos: increases insulin sensitivity in peripherla tissues, fewer pts require insulin
Cons: mixed data on placental crossing, has been assx with fetal hypoglycemia, not as effective as insulin, no data on long term effects
What is the gold standard medication for treating GDM?
What are the pros and cons of this drug?
Insulin! (said like 3x so know it plz)
Pros: Does not cross placenta, mix of long-acting and short-acting
Cons: dosing can change based on trimester, needles, ouch.
What are the maternal risks of GDM during pregnancy/delivery?
in pregnancy, increased risk of preeclampsia, LGA, delivery trauma
FYI, LGA=Large for Gestational Age AKA big ole baby. This can cause delivery trauma because babies of moms with GDM tend to grow bigger torsos/shoulders, whereas normal babies will grow their head bigger than their torso. When torso is bigger than head, head can come out and shoulders get stuck, causing a shoulder dystocia which can be fixed by breaking baby’s clavicle which heal well, but can cause neuro issues/trauma or there can be head trauma from forceps/vaccuum assisted deliveries…AKA just don’t have a giant baby.
What are future maternal risks from having GDM while pregnant?
Increased risk of developing T2DM (4x in next 5 yrs, 10x in next 10 years)
70% of women develop T2DM within 20-28yrs
60% of Latina women will develop T2DM within 5yrs
What are the fetal risks associated with GDM?
Macrosomia (big ole baby)
neonatal hypoglycemia
hyper-bilirubinemia
shoulder dystocia
birth trauma
stillbirth
increased risk of childhood and adult onset obesity and DM
What are monitoring and delivery protocols for GDM?
NSTs and BPPs at 32wks
for well controlled GDM pts, deliver after 39wks
pre-existing DM, deliver between 38-39wks
poorly controlled, delivery between 37-39wks
What is post-partum management for GDM?
2hr GTT at 6wk post partum visit
PCP follow up
preventative therapy
repeat screening every 1-3yrs after delivery
How much of the general population is overweight and obese?
How many pregnancy complications are due to obesity?
How many infants are considered LGA due to maternal weight gain?
about 50% (half overweight, half obese)
25%
30%
What are the maternal antepartum risks associated with obesity?
- Increased risk of >1 miscarriage
- Increased risk of T2DM and GDM
- Pregnancy assx HTN and preeclampsia (risk doubles with each 5kg/m2 of increased BMI)
Preterm delivery
- Post-term pregnancy, multifetal pregnancy and OSA
What are the intrapartum risks associated with maternal obesity?
- longer, dysfunctional labor
- higher induction risks
- failed inductions
- higher c/s rates
- lower successful VBAC rates
- anestheisa complicaitons
- macrosomic infants (>4000g)
- hemorrhage
What are post-partum risks associated with maternal obesity?
- 2-4x higher risk of VTE
- infection rates higher
- post-partum depression
- congenital anomalies
- fetal death rate, perinatal death, and infant death increased
What are the infant risks assx with maternal obesity?
- LGA
- Childhood obesity
- neurodevelopment (cognitive impairment, autiusm, ADHD, schizophrenia)
- asthma
What would pre-pregnancy manangement look like for an obese patient?
counsel on risks
evaluate and manage any comorbidities
counsel on diet/exercise
consider bariatric surgery
10% BMI reduction = 10% risk reduction for preeclampsia, GDM, macrosomia and still birth
20-30% decrease in BMI=decrease in c/s and shoulder dystocia
Pregnancy management of obese patients includes
baseline assessment
early 1hr GTT
counseling with high risk OB (Maternal Fetal Medicine-MFM), nutrition and anesthesia
weight loss
exercise
low dose ASA in 2nd trimester (avoid HTN and blood clots)
US for fetal anatomy
What labor and delivery precautions are taken for obese patients?
ensure proper size equipment
close fetal monitoring
anesthesia consult
deliver by due date to avoid C/S
C-s if needed (for giant baby, other maternal complications)
What does post-partum care look like for an obese patient?
Diabetes screening 6-12 months after
weight-loss/diet/exercise
depression monitoring
co-morbidity monitoring
What are maternal causes of death in the US
hemorrhage
infection
fluid embolism
thrombotic emboliusm
HTN
CVA
cardiomyopathy
anesthesia-related
unknown
How many women die annulaly related to pregnancy?
700 (in the US)
60% of which are preventable
factors include: increasing age, BMI, comorbidities, racial disparities
Why? coding, reporting, errors, health status (obesity, DM, etc.)
50% of maternal deaths occur during what stage of pregnancy/delivery/post-partum?
During post-partum stages
