L20 - Diabetes and Pregnancy COPY Flashcards
INTRO
i) what does diagnosing maternal hyperglycaemia allow prevention of in the baby and mother? (3)
ii) what two groups of women are there within those with abnormal glucose tolerance?
iii) what is gestational diabetes?
i) can prevent morbidity in offspring
- can prevent exacerbation of obesity and T2DM in offspring
- can prev future T2DM diabetes in mother
ii) abnormal gluc tolerance = known diabetes OR unknown diabetes/impaired glucose tolerance
iii) GT is a newly found abnormal glucose tolerance after the first trimester of pregnancy (inc diabetes or impaired gluc tol)
GESTATIONAL DIABETES
i) after what time period is it diagnosed?
ii) what two states does it encompass according to WHO and NICE?
iii) what are the fasting glucose and 2 hour GTT results for GD?
iv) according to IADPSG criteria - which results for fasting/1 hour and 2 hour 75g GTT are diagnostic of hypergly/GD? how many of these need to be abnormal for a dx?
i) after the first trimester of pregnancy
ii) encompassess diabetes or impaired glucose tolerance
iii) fasting glucose >5.6mmol/l
2hr GTT >7.8mmol/l
iv) fasting >5.1mmol/K
- 1 hour >10mmol/l
- 2 hour > 8.5 mmol/l
(need one or more to be abnorm for a diagnosis)
MATERNAL METABOLIC CHANGES IN PREGNANCY
i) in early pregnancy what metabolic state is the mother in?
ii) how is insulin sensitivity impacted in early pregnancy? what is the glucose concentration in relation to non preg? what happens to maternal energy stores?
iii) in later pregnancy what metabolic state is the mother in?
iv) how is insulin resistance impacted in late pregnancy? how does transplacental passage of nutrients change? why is this?
i) early preg = facilitate anabolism (storing)
ii) early = increased insulin sensitivity, glucos tol is slightly lower and increased maternal energy stores
iii) later preg = faciliatated catabolism
iv) in later preg = increased insulin resistance (due to inc maternal glucose), increased transplacental passage of nutrients as there is rapid foetal growth
PROBLEMS DUE TO MATERNAL HYPERGLYCAEMIA
i) name two main problems that can arise in the first trimester? and three things these increase the risk of
ii) name two problems that can arise in late second and third trimester?
iii) how many epigenetics be implicated in maternal hyperglycaemia?
iv) which structural bone abnormality is almost exclusively associated with hypergly?
v) which renal abnormality may occur
i) increased foetal abnormalities - teratogenesis
- abnormal placental programmin/development - inc risk of pre eclampsia and excess glucose transport
ii) 2nd/3rd trimester - excessive fat deposition and adverse foetal programming
iii) adverse foetal programming can increase gene methylation
iv) sacral dysgenesis
v) renal agenesis
CONGENITAL MALFORMATIONS DUE TO MATERNAL HG
i) what does the likelihood of developing congen abnorms depend on?
ii) how can development of these abnormalities be avoided?
iii) name four congen abnorms that can develop due to maternal HG?
i) how bad hyperglycaemia is in the first trimester
ii) can be avoided a reduction of HbA1c before conception
iii) neural tube defects, congenital cardiac abnorms, sacral agenesis and renal agenesis
PREVENTING FOETAL MALFORMATIONS
i) in which trimester is it most important to have good diabetes control?
ii) name three ways in which this can be achieved
iii) what treatment may the mother be switched to from oral hyperglycaemics? name two techniques that can be used
iv) which mineral should be supplemented with? at what dose?
v) name four risk factors for a women having diabetes/IGT
vi) which intervention has the most impact on weight change in the first year of implem?
i) first
ii) lifestyle mod, intensive glucose monitoring, optimise insulin regimen
iii) switch from oral hyperglys to insulin
- basal bolus/pump or freestyle libre/cont glucose monitoring
iv) 5mg folic acid daily
v) previous GD, obesity, PCOS, fam hx of T2DM, high risk racial group
v) lifestyle
HYPERGLYCAEMIA IN THE 3RD TRIMESTER
i) what is the main effect of increased glucose crossing the placenta?
ii) name three problems this can cause
iii) name four clinical conditions it can cause? what is the biggest problem?
iv) what is the xincrease risk of perinatal mortality in women who have a) T1DM, b) T2DM?
i) macrosomia - big baby for gestational age
ii) can cause difficult birth, shoulder dystocia (ant shoulder gets caught on pubic bone) and breathing probs
iii) jaundice, hypocalcaemia, hypoglycaemia (biggest prob) and polycythaemia
iv) T1DM = x4 risk
T2DM = x9 risk
LIFELONG PROBLEMS DUE TO HG
i) name six problems the baby may experience if exposed to high glucose levels in late pregnancy
ii) how has the number of women with diabetes giving birth changed recently?
i) obesity, insulin resistance, T2DM, dyslipidaemia, hypertension, vascular disease
ii) women with diabetes giving birth has doubled
DETECTION/TX FOR HG IN PREGNANCY
i) name four factors that can make a woman high risk? what should be done for these women?
ii) which is the most commonly used screening tool for high risk women?
iii) what is the most important outcome of treatment? name three ways this can be achieved?
iv) name two other things that can help maternal HG in pregnancy
v) what can be monitored by US? how often does this happen?
vi) what can the mother also observe for herself?
i) previous GD/macrosomia, obesity, fam hx, older age, PCOS
ii) targeted screening GTT
iii) good maternal glucose control is most important
- achieved by intensive gluc monitoring, finger prick test and freestyle libre/cont gluc monitoring system
iv) good nutrition and exercise
v) US monitor foetal abdominal girth (to monitor size)
vi) maternal observation of foetal movement
TREATMENT FOR MATERNAL HG
i) what is the fasting glucose target? what is the 1hr post prandial target?
ii) what is the fetal abdominal girl target? (which centile)
iii) which treatment regimen can be given prepreg/1st trimester to allow tight glucose control
iv) what is first line tx for gestational diabetes? what is 2nd, 3rd and 4th line?
v) what drug is given in GD as a last resort? what drug class does it belong to?
i) fasting <5.1mmol/l
- 1hr post prandial <7mmol/l
ii) fetal abdo girth <70th centile
iii) 1 trimester = basal bolus insulin regimen
iv) first line for GD is lifestyle mod
2nd line is metformin
3rd line is basal insulin
4th is basal bolus
v) give glibenclamide if no other alternative
- sulphonyurea
DIABETES POST PARTUM CARE
i) what should be encouraged postnatally?
ii) name two reasons good glycaemic control should be maintained?
iii) what % decrease of obesity is there in children that have any breastfeeding? and those that have prolonged exclusive breastfeeding? what advantages does bf convey to mother?
i) breastfeeding
ii) to prevent excess glucose in the milk and to reduce maternal weight gain
ii) 30-50% decrease in child weight gain with any bf
- 67% decrease with prolonged exclusive bf
- helps reduce postnatal weight gain
SPECIFIC GD POSTNATAL MANAGEMENT
i) what is screened for at 12 wks post partum? which two things may be measured?
ii) what may be done of there is a family history of autoimmune disesae?
iii) what advice may be given regarding the next pregnancy? (2)
iv) how often should they have a glucose screening? what % develop T2DM in 10 years?
i) screen for diabetes
- either do HbA1c with or without fasting glucose or GTT
ii) do antibody status
iii) optimise exercise and nutrition and maybe do a pre pregnancy GTT to catch HG early
iv) annual glucose screen as 50% chance of dev diabetes in 10 yrs
SUMMARY - THE PROBLEM
i) what can maternal HG ultimately result in if not controlled?
ii) what happens early in preg (1st trimester)
iii) what four things are at increased risk in later pregnancy?
i) serious fetal problems
ii) early = teratogenesis (congenital malforms)
iii) late preg = macrosomia, hypogly, breathing probs
- pre eclampsia
- late fetal death
- jaundice/polycythaeimia
SUMMARY 2 - MANAGEMENT
i) which supplement is given in the first trimester?
ii) which drug can be given prophylactically to reduce risk of pre eclampsia?
iii) what is important to maintain throughout pregnancy?
iv) what type of monitoring is done in the last trimester? what can the mother monitor herself?
i) 5mg folic acid daily if high RFs or obese
ii) aspirin
iii) good glucose control
iv) fetal ultrasound monitoring
- mother can do maternal monitoring of fetal movements
SUMMARY 3 - SCREENING
i) when are high risk women screened for GD?
ii) when may universal or targted screening take place?
iii) how many weeks post partum is mother screened for diabetes?
iv) how often do women with GD have their glucose checked post natally?
i) high risk > screen at 12-14wks
ii) universal/targeted at 28wks
iii) 12 wks post partum
iv) annual glucose screening
