Gestational Diabetes/Diabetes in Pregnancy

Question 1

Infant risks of diabetic mothers

Answer 1

1. hyperbili
2. hypoglycemia
3. birth trauma
4. operative delivery
5. macrosomia
6. shoulder dystocia

Question 2

when to do early 1 hr gtt

Answer 2

1. obese
2. h/o impaired gluose metabolism
3. h/o GDM

Question 3

Why treat gestational diabetes?

Answer 3

1. reduces risk of PreE
2. LGA
3. bad outcomes: shoulder dystocia, perinatal death, birth trauma–fx/nerve palsy)

Question 4

What glucose values (preprandial, fasting, postprandial) are most predictive of fetal macrosomia/morbidity? What are the numeric levels that can reduce the risk of macrosomia?

Answer 4

Postprandial

• -1 hr 140
• -2 hr 120

Question 5

Dr. should be able to counsel diabetic pt on 3 things

Answer 5

1. caloric allotment
2. caloric distribution
3. carbohydrate intake

Question 6

% of calories from fat, protein, carbs in diabetic diet

Total calories per day

Answer 6

33-40% carbs
40% fat
20% protein
2200-2400kcal/day

Question 7

What type of exercise improves tissue sensitivity to insulin?

Answer 7

Weight training –> improves lean muscle mass, but more for nonpregnant

Question 8

Should diabetic pregnant women be on exercise program?

Answer 8

Yes, moderate exercise

Question 9

oral or insulin more efficacious?

Answer 9

equivalent in efficacy

Question 10

When to start medications? What blood glucose levels?

Answer 10

Fasting persistently >95; 1 hr PP >140; 2hr PP > 120

Question 11

Dosing insulin

Answer 11

0.7 (early pregnancy)-1.0 units (at term)/kg total daily in divided doses
Total daily dose AM 2/3 ; PM 1/3 total dose…
AM Dose = 2/3 total NPH, 1/3 Regular
PM dose = 1/2 NPH and 1/2 Regular

Question 12

Does insulin cross the placenta?

Answer 12

NOPE

Question 13

What type of drug is glyburide, what does it do?

Answer 13

Sulfonylurea = binds to pancreatic beta cell ATP Ca channel receptors to increase insulin secretion and insulin sensitivity of peripheral tissues

Question 14

Metformin type of drug?

Answer 14

“Have you ever MET a big one-eyed monster?”

Biguanide: inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissue

Question 15

For PCOS pts, should you cont metformin?

Answer 15

Yes, through first trimester, but has not shown reduction in SAB

Question 16

What if pregestational diabetic already on metformin

Answer 16

Usually continue metformin and add insulin to regimen if needed

Question 17

Glyburide/Metformin safe in pregnancy?

Answer 17

Glyburide may cross placenta, long term outcomes understudied

Question 18

Should we increase fetal monitoring in GDM?

Answer 18

Pregestational–YES
Poorly controlled GDM–YES
Well controlled GDM–no firm recs

Question 19

When do we delivery Pregestational Diabetes well controlled vs. well controlled GDM?

Answer 19

Pregestational DM well controlled delivery 39 wks or greater

GDM well controlled: no consensus when to deliver

Question 20

Risk of diabetes if you have GDM?

Answer 20

7x increased risk individually

50% of women with GDM get diabetes in the future

Question 21

How and when should you screen for overt DM PP?

Answer 21

Fasting plasma glucose (disadvantage is can’t dx insulin insensitivity) or 2hr GTT 6-12 wks PP.

Question 22

If normal 2 hr GTT what is the management?

Answer 22

assess glucose status q3 yrs: rec wt loss, exercise, diet

Question 23

What if 2hr GTT shows impaired glucose tolerance/impaired fasting glucose?

Answer 23

reassess glucose status every year, counseling. Consider METFORMIN if both present

Question 24

Low risk for GDM, not to screen:

Answer 24

1.

Question 25

How many times should GDM eat per day?

Answer 25

3 meals and 2-3 snacks (midnight snack important because reduces AM hypoglycemia)

Question 26

Distribution % of calories and meals

Answer 26

B-fast: 25%
Lunch: 30%
Dinner: 30%
Midnight snack 15%