Gestational Diabetes and Obesity

Question 1

When are women screened for gestational diabetes?

Answer 1

24-28 weeks

Question 2

What is gestational diabetes?

Answer 2

glucose intolerance dx in pregnancy

–> insulin resistance state d/t increased prolactin, placental lactogen, growth hormone, progesterone and cortisol

Question 3

What is White’s Classification system?

Answer 3

grades gestational diabetes

A1: controlled with diet
A2: controlled with diet and insulin

to H which is worst (heart disease)

D-H: end organ damage

Question 4

Describe prevalence of gestational DM

Answer 4

increasing d/t race and lifestyle

86% of 7% of pregnancies that are complicated by DM

Question 5

When would you screen early for gestational DM?

Answer 5

Overweight (BMI >25)
AND
FH
High risk race
Previous large 
    gestational infant
Previous Hx GDM
HTN
PCOS
Increased A1C
Hx of CVD

Question 6

What happens if you screen for GDM by risk factors alone?

Answer 6

miss 50% gestational DM cases

Question 7

What is the 2 step approach to screen DM?

Answer 7

1 hr glucose tolerance test
–> not dependent on prior oral intake

If abnormal–> 3hr glucose tolerance test

**dx if both abnormal or 1hr over 200

Question 8

What is an abnormal glucose tolerance test result?

Answer 8

130-140 mg/dL using 50g glucose

Question 9

What happens if you have over 200mg/dl after 1hg glucose tolerance test?

Answer 9

diabetes education

–>don’t need to do 3hr test

Question 10

Do you need to be fasting for a 3hr glucose tolerance test?

Answer 10

yes

Question 11

Do you need to be fasting for a 1 hr glucose tolerance test?

Answer 11

No

Question 12

What are alternative screens to the 2 step approach for GDM?

Answer 12

2hr glucose test with 75g glucose

HgA1C

Fasting glucose

Random glucose

Question 13

What are treatments via diet and exercise for GDM while pregnant?

Answer 13

Dietary: caloric intake based on weight

–> 50 carb, 25 protein and fat

Moderate exercise 3-5x week, 150min/week
**Walk after meals

Question 14

What is the testing regimen for GDM?

Answer 14

Daily monitoring

Fasting and 1-2 hrs postprandial

–>fasting should be less than 95

–>2hr less than 120

–>1hr less than 140

Question 15

When does glucose peak postprandial?

Answer 15

90 minutes

Question 16

What can help achieve euglycemia in GDM 70-80% of the time?

Answer 16

dietary changes

Question 17

What are potential oral hypoglycemic agents for DGM?

Answer 17

glyburide

metformin

Question 18

What is the gold standard to treat GDM?

Answer 18

insulin

–> may refuse d/t not comfortable, so use oral agents

Question 19

If a woman refuses to take insulin, what oral med is first line?

Answer 19

metformin

Question 20

Describe the action of metformin

Answer 20

crosses placenta, stimulates glucose uptake in peripheral tissues
–> inhibits hepatic gluconeo

Question 21

Describe glyburide

Answer 21

Sulfonylurea
–>binds pancreatic B cell K/ATP receptors

increases insulin sensitivity

2.5-20mg

Question 22

What is starting dose of insulin to treat GDM?

Answer 22

.7-1 unit/kg

mix long and short acting

**does not cross placenta

Question 23

What is the mother at risk for if she has GDM?

Answer 23

preeclampsia
large for gestational age
delivery trauma

Question 24

Describe states for increased risk for type 2 DM after birth

Answer 24

4x more likely in first 5 years
–>high in latina women

70% develop within 20 years after pregnancy

Question 25

What are fetal risks of GDM?

Answer 25

-macrosomia
large baby

• neonatal hypoglycemia
• hyperbilirubinemia

-shoulder dystocia
shoulders larger than head, get stuck in delivery

• birth trauma
• stillbirth
• increased risk of childhood and adult onset obesity and DM

Question 26

Surveillance antepartum GDM

Answer 26

• begin monitoring fetus at 32 weeks
• –>A1 lower risk, no monitoring
• US for growth
• serial amniotic fluid measurements

Question 27

When to deliver with GDM

Answer 27

A1: after 39 weeks

A2: after 39 weeks

Preexisting DM: 38-39

Poorly controlled: 37-39

Question 28

Postpartum management of GDM

Answer 28

2hr glucose tolerance test 6 weeks postpartum

repeat screening every 1-3 years after delivery

Question 29

What percent of pregnancies are complicited d/t obesity?

Answer 29

25%

–> 30% large babies d/t maternal weight gain

Question 30

What are some fetal complications d/t maternal obesity?

Answer 30

Neural tube -
Spina bifida
Cardiovascular
Cleft palate/lip
Fetal death

Question 31

What is Barker Hypothesis

Answer 31

Adipose tissue (obesity) has long term outcomes for offspring

–> changes metabolic programming in utero

Question 32

What is the MOA of adipose tissue in fetal outcomes?

Answer 32

Adipose tissue is active endocrine organ

–>effects metabolic, vascular and inflammatory pathways that can lead to insulin resistance and preeclampsia

Question 33

What are antepartum risks r/t obesity?

Answer 33

Increased risk of miscarriage (more than 1)

Increased risk Type 2 DM and GDM

HTN and preeclampsia

Preterm delivery

Question 34

What are intrapartum risks a/w obesity?

Answer 34

longer labor
dysfunctional labor
higher induction risk
failed inductions
higher c-section rates
anesthesia complication 
macrosomic infants
hemorrhage
VTE (2-4x higher) 
       embolism
Infection risk

Question 35

Risk for stillbirth increases with what?

Answer 35

weight = obesity

Question 36

What is elevated even with patients who were obese and lost weight?

Answer 36

neural tube defects

–>800mg folic acid daily

Question 37

Timing of maternal deaths

Answer 37

31% during pregnancy
17% delivery
19% first postpartum week
21% weeks 2-6
12% week 6- 1 yr

Question 38

What are the 3 delays d/t maternal mortality?

Answer 38

1: decision to come in
2: delay in arrival
3: delay in dx