Gestational Diabetes CIS

Question 1

Metabolic Changes in Pregnancy

Answer 1

1st trimester
Increased insulin sensitivity → increases adipose tissue deposition

2nd and 3rd trimester
Insulin resistance → adequate glucose must be available to the fetus
50% decrease in insulin-mediated glucose uptake (tissue-specific decrease in insulin receptor phosphorylation and a decrease in IRS-1)
Insulin production increases 2-3 fold (β-cell hyperplasia)
Increased lipolysis- fat stores are a source of fuel for fetus and for lactation

Question 2

Factors that Contribute to Insulin Resistance during Pregnancy

Answer 2

Human placental growth hormone (hPGH or hGH-V)
Similar to pituitary GH and PRL
More prominent than pituitary GH in maternal circulation and not regulated by GHRH
85% of GH activity due to hPGH, 12% to hPL, 3% pituitary GH

hPL- also may stimulate insulin production

Progesterone

Placental TNF-α

Question 3

Gestational Diabetes Mellitus (GDM)

Answer 3

Definition: glucose intolerance of variable severity with onset or first recognition during pregnancy
does not exclude women with glucose intolerance or diabetes prior to pregnancy

Question 4

risk factors for GDM

Answer 4

age
ethnicity
family history
obesity
GDM before
current glycosuria
diabetes in first degree relative
history of glucose intolerance
previous infant with macro something-- giant baby

Question 5

3 abnormalities that may exist in GDM

Answer 5

increased insulin resistance
hypertorphy of the beta cells– increase in beta cell mass (pancreas), impaired insulin secretion
increased hepatic glucose production

Question 6

Establishing diagnosis of GDM

Answer 6

2-step screening at 24 weeks: 50-g non-fasting oral glucose challenge. If failed, follow with a 100-g oral glucose tolerance test.

1-step screening at 24 weeks: 75-g oral glucose tolerance test

Question 7

Risks of GDM to infant

Answer 7

macrosomia
shoulder dystocia
clavicular fracturles
fetal distress
low APGAR scores
neonatal hypoglycemia
risk of developing diabetes

Question 8

treatment strategy for GDM

Answer 8

1. Diet and Exercise
   include glucose monitoring
2. Pharmacotherapy (usually insulin)
   - indicated for the following reasons:
   inadequate glucose control
   lack of expeted weight gain
   patient consistently hungry
   Fasting glucose > 95 or 1-hr postprandial glucose > 130-140 mg/dL, or 2-hr postprandial glucose > 120 mg/dl

Question 9

Fetal surveillance

Answer 9

Screening for congenital abnormalities
Recommended for women who present with evidence of preexisting hyperglycemia
A1C level greater than 7%
Fasting glucose level > 120 mg/dL
Diagnosis of gestational diabetes in the first trimester

Monitoring for fetal well-being

Ultrasound assessment for estimated fetal weight

Question 10

risks for developing type 2 diabetes

Answer 10

50% of women with GDM develop type 2 diabetes within 5-10 years

Question 11

Postpartum screening

Answer 11

Insulin and other agents can typically be discontinued after delivery.
Blood glucose levels can be checked prior to discharge.
Screening 6-12 weeks postpartum with a 2-hr 75-g OGTT
Screening should occur every 3 years after