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Obstetrics > Gestational Diabetes Mellitus > Flashcards

Gestational Diabetes Mellitus Flashcards

1
Q

What is the prevalence of Gestational diabetes?

A

7% of all pregnancies

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2
Q

What is the pathophysiology of GDM?

A

Increased insulin resistance from decreased tissue sensitivity to insulin and increased insulin clearance from the placenta

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3
Q

What causes decreased tissue sensitivity to insulin?

A

increased hormone levels : human chorionic somatomammotropin, progesterone, prolactin, cortisol

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4
Q

What causes increased insulin clearance by the placenta?

A

increased placental insullinase

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5
Q

What are the fetal and neonatal risks of GDM?

A

Macrosomia, Shoulder dystocia, Birth injuries, hyperbilirubinemia, hypoglycemia, RDS, perinatal death, childhood obesity

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6
Q

What are the maternal risks of GDM?

A

gHTN, PreE, CS delivery, increased risk of T2DM, shorter life expectancy

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7
Q

How much does having GDM increase your lifetime risk of developing T2DM?

A

increases lifetime risk by 50%

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8
Q

What proportion of women will have impaired glucose tolerance at 6 weeks PP?

A

33%

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9
Q

Treatment of GDM significantly decreases the risk of what outcomes?

A

Macrosomia, preE, CS delivery, shoulder dystocia

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10
Q

When should you screen women for GDM in pregnancy?

A

24- 28wga

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11
Q

What is the current recommended screening for GDM?

A

1 hr 50 g GTT followed by 3 hr 100g GTT if fails 1 hr

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12
Q

What are the indications for an early 1 hr GTT?

A

BMI > 25 + risk factor

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13
Q

What are the risk factors that should prompt early screening?

A

inactivity, high risk ethnicity, cHTN, PCOS, first degree relative with DM, HLD, previous GDM, previous BW > 4000g

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14
Q

at what gestational age should you screen women early for GDM who meet criteria? Should it be repeated?

A

Screen when patient presents to care, repeat at 24 - 28wga

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15
Q

What is the 1 hr GTT cutoff value that warrants a 3 hr GTT?

A

140 mg/dL

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16
Q

What is the 1 hr GTT cutoff value that automatically diagnoses a patient with GDM?

A

> 200 mg/dL

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17
Q

What are the cutoff values for the 3 hr GTT?

A

95, 180, 155, 140

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18
Q

How many abnormal values on the 3 hr GTT must a patient have to be diagnosed with GDM?

A

2 values

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19
Q

What are the dietary recommendations for GDM?

A

3 meals a day, 3 snacks. 1/3 calories from protein, 1/3 calories from fat, 1/3 calories from complex carbs

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20
Q

What are the Kcal recommendations per day for non-obese patient with GDM?

A

30 kCal/day prepregnancy weight

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21
Q

What are the Kcal recommendations per day for obese patient with BMI > 30 and GDM?

A

reduce calories by 30%, 20 kCal/day

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22
Q

How often should a patient with GDM check their CBGs?

A

4 times per day: fasting, 1hr or 2 hr post prandial following each meal

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23
Q

What is the fasting CBG goal?

A

< 95

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24
Q

What is 1 hr post prandial CBG goal ?

A

< 140

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25
Q

What is the 2 hr post prandial CBG goal?

A

< 120

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26
Q

What is the first line drug of choice to treat GDM?

A

Insulin

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27
Q

Does insulin cross the placenta?

A

No

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28
Q

Does metformin cross the placenta?

A

Yes

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29
Q

What drug crosses the placenta, possibly causes neonatal hypoglycemia and should not be used to treat GDM?

A

Glyburide

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30
Q

What is the recommendation for repeat US with GDM?

A

Growth US in the 3rd trimester

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31
Q

When should you start fetal testing for well controlled GDM?

A

34wga- 36wga

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32
Q

When should you start fetal testing for poorly controlled GDM or disease associated with LGA, polyhydramnios, cHTN?

A

32 wga

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33
Q

When should you deliver a patient with GDMA1?

A

39w0d - 40w6d

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34
Q

When should you deliver a patient with well controlled GDMA2?

A

39w0d - 39w6d

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35
Q

When should you deliver a patient with poorly controlled GDMA2 and other complications ?

A

37wga - 38w6d

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36
Q

When should a CS delivery be offered to a patient with GDMA?

A

When EFW > 4500g

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37
Q

How often should you check CBGs in active labor

A

Q 1-2 hrs

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38
Q

When should you start an insulin drip in labor?

A

if CBGs > 120

39
Q

How much do insulin requirements decrease in the post partum period?

A

Decrease by 80%

40
Q

When should you screen a patient with GDM for T2DM ?

A

6 - 12 weeks postpartum and then Q 3 years there after

41
Q

What is the definition of Class B by Whites Classification?

A

age of DM onset > 20, duration of disease < 10 years

42
Q

What is the definition of Class C by Whites Classification?

A

age of DM onset 10 - 19 years, duration of disease 10 - 19 years with benign retinopathy

43
Q

What is the definition of Class D by Whites Classification?

A

age of onset < 10 years, duration of disease > 20 years

44
Q

What is the definition of Class F by Whites Classification?

A

DM with Nephropathy

45
Q

What is the definition of Class R by Whites Classification?

A

DM with proliferative retinopathy

46
Q

What is the definition of Class H by Whites Classification?

A

DM with cardiovascular disease

47
Q

How do we diagnose diabetic nephropathy during pregnancy (Class F)

A

> 400 mg protein excretion/24 hr prior to 20 weeks

48
Q

Diabetic nephropathy affects what percent of pregnant patients with diabetes?

A

5- 10%

49
Q

what percent of patients with diabetic nephropathy in pregnancy will develop pre-eclampsia?

A

50%

50
Q

What is the greatest risk for developing PreE in a patient with diabetic nephropathy?

A

24 hr urine protein > 3g, Cr > 1.5

51
Q

what percentage of patients with diabetic nephropathy will develop renal failure within 10 years?

A

50%

52
Q

What is the leading cause of blindness in patients 24 - 64?

A

Diabetic proliferative retinopathy

53
Q

What percentage of patient will have proliferative retinopathy if they have had DM for > 20 years?

A

80%

54
Q

Treating blood sugars in pregnancy is associated with acute______ of retinopathy.

A

Progression

55
Q

How do you treat proliferative retinopathy?

A

laser photocoagulation

56
Q

What are the two major risk factors associated with pregestational diabetes?

A

SAB, Fetal Congenital Malformation

57
Q

A hA1c of 10% in early pregnancy is associated with what percent risk of fetal congenital malformations?

A

20 - 25%

58
Q

a hA1c of 5 - 6% in early pregnancy is associated with what percent risk of fetal congenital malformations?

A

None, no increased risk

59
Q

Congenital malformations are increased by _____ in patients with high hA1c in early pregnancy.

A

2-6 fold

60
Q

What is the most common congenital malformation associated with poorly controlled pregestational DM?

A

Cardiac defects

61
Q

What other congenital abnormality is associated with poorly controlled pregestational DM?

A

Caudal regression and sacral agenesis

62
Q

True or false: the risk of shoulder dystocia for any given BW increases if you have pre-gestational diabetes

A

True

63
Q

Fetal growth restriction is associated with what type of DM?

A

Type D or greater

64
Q

Neonatal risks of pregestational DM

A

RDS, hypoglycemia, hypocalcemia, hyperbilirubinemia, cardiac hypertrophy

65
Q

What is the risk of pre-eclampsia in a patient with pregestational DM and no nephropathy?

A

15 - 20%

66
Q

What is the risk of pre-eclampsia in a patient with pregestational DM and nephropathy?

A

50%

67
Q

What is the risk of CS delivery in patients with pregestational diabetes?

A

45%

68
Q

What labs should be obtained at the first prenatal visit for a patient with a history of pregestational diabetes?

A

TSH, EKG, 24 hr Urine protein, hA1c, opathmology apt

69
Q

What is the CBG goal for 2:00 - 6:00 CBG check for a patient with pregestational diabetes

A

> 60 mg/dl

70
Q

What fetal surveillance should be done for a patient with pregestational DM?

A

18 wk targeted US, Fetal echo at 24wga, serial growth US, NST/BPP starting at 32 wga, US for EFW prior to delivery

71
Q

When should you deliver a patient with well controlled pregestational DM?

A

39w0d - 39w6d

72
Q

when should you deliver a patient with poorly controlled pregestational DM, vascular compromise, or prior stillbirth?

A

36w0d - 38w6d

73
Q

True or false: It is safe to do an operative delivery in a patient with pregestational DM?

A

False

74
Q

How much should the the insulin dose be reduced following delivery for a pregestational diabetic?

A

decrease by 50%

75
Q

Diabetic Ketoacidosis affects ____ percent of pregnancies with pregestational DM

A

5- 10 %

76
Q

What are common lab abnormalities seen with DKA?

A

Hyperglycemia > 200, Acidosis pH < 7.3, HCO3 < 15 mEq/L, Anion Gap >12, decreased base excess < 4, positive serum acetone

77
Q

What labs should you get and how often in maternal DKA?

A

ABG, CH7, glucose, serum ketone q 1-2 hrs

78
Q

What is the typical fluid deficit in a patient with DKA?

A

100ml/kg of body weight

79
Q

How should you replete IVF in a patient with DKA?

A

Give 4-6L in the first 12 hrs, 1-2L/hr for the first hr followed by 250-500 cc/hr for the next 12 hrs

80
Q

What type of fluid should you use to manage DKA?

A

NS

81
Q

What should you fluid management be when the CBG < 200?

A

Switch to D5 1/2 NS at 150 - 250/hr, then after 8 hrs switch to 125ml/hr

82
Q

How should you replace K in DKA if < 3.3 ?

A

Give 20 - 30 meq until K > 3.3

83
Q

How should you replace K in DKA if K 3.3 - 5.3 ?

A

Give 20 - 30 meq until K 4 - 5

84
Q

How should you replace K in DKA if K > 5.3 ?

A

Do not hive KCL, recheck q 2 hrs

85
Q

How should IV insulin be administered initially in DKA?

A

Regular insulin 0.1 - 0.2 U/kg load then 0.1 U/kg/hr

86
Q

What happens if the glucose dose not fall by 50 - 70 mg/dl in the first hour?

A

Double the rate of insulin infusion

87
Q

What should the rate of insulin infusion be when glucose is < 200 mg/dl?

A

0.05 - 0.1 U/kg/hr

88
Q

What is the goal CBG range until resolution of DKA?

A

100 - 150 mg/dl

89
Q

In the treatment of DKA, how much bicarb should be given if Ph is > 7.0

A

None

90
Q

In the treatment of DKA, how much bicarb should be given if Ph is 6.9 - 7.0?

A

20 mmol NaHCO3 in 200 cc H20 with 10 meq KCL, repeat q 2 hrs until pH > 7.0

91
Q

In the treatment of DKA, how much bicarb should be given if Ph is < 6.9 ?

A

40 mmol NaHCO3 in 400cc H20 with 20 meq KCL, repeat q 2 hrs until pH > 7.0

92
Q

What is the fetal mortality rate associated with maternal DKA?

A

< 10%

93
Q

What is typically seen on fetal monitoring in a patient with DKA?

A

Decreased variability and recurrent late deceleration

Obstetrics (28 decks)

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