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Reproduction > Lec19 Maternal hyperglycaemia during pregnancy > Flashcards

Lec19 Maternal hyperglycaemia during pregnancy Flashcards

1
Q

What effect does maternal hyperglycaemia have on the foetus?

A

Very bad for the foetus and significant morbidity affecting the baby all its life

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2
Q

What can you do to improve the outcome for the foetus?

A

Improve the maternal blood glucose

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3
Q

Why does diagnosing maternal hyperglycaemia matter?

A

It is an opportunity to prevent:
Significant morbidity to the foetus
Consequences of the maternal hyperglycaemia will affect the foetus “from the uterus to the grave”
Exacerbation of the type 2 DM and obesity epidemic
Future type 2 DM in the mother - through educating her

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4
Q

In the antenatal clinic there are two groups of women, what are they?

A

Women with normal glucose tolerance

Women with abnormal glucose tolerance

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5
Q

Out of the women in the ANC with abnormal glucose tolerance, what are the two groups within them

A

Women with known diabetes or IGT

Women with unknown diabetes/ IGT

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6
Q

In pregnancy, IGT is the same as:

A

diabetes

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7
Q

What happens to women with known Type 1 DM when they get pregnant?

A

They go to specific clinics

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8
Q

When is gestational diabetes diagnosed?

A

Following a newly found abnormal GTT after the 1st trimester of pregnancy

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9
Q

What happens to insulin sensitivity during the 1st trimester?

A

The mother is slightly more sensitive to insulin so her glucose will go down but then up after the 1st trimester

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10
Q

What is the WHO criteria definition of gestational diabetes?

A

Fasting glucose >/= 5.6mmol/l

2 hour GTT >/= 7.8mmol/l

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11
Q

What is the main problem of maternal hyperglycaemia during pregnancy?

A

It can cause serious problems for the foetus

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12
Q

Describe the key events in the 1st trimester:

A

Organogenesis - carefully design essential components
avoid mistakes - teratogenesis
Placenta - construct and programme the placenta
key organ in pregnancy
if the placenta is incorrectly formed –> more likely to get pre-eclampsia and delivers excess glucose

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13
Q

Describe what happens in the 2nd trimester:

A

Further complex development and linkage

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14
Q

Describe what happens in the 3rd trimester

A

Accelerated growth - more glucose is delivered to the baby to facilitate the accelerated growth but with a malformed placenta - excess glucose will be delivered to the placenta
Excess fat is deposited around the organs in the abdomen - visceral fat

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15
Q

What is the maternal metabolism as pregnancy progresses?

A

Early pregnancy = facilitated anabolism

Later pregnancy = facilitated catabolism

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16
Q

What does facilitated anabolism mean?

A

Increased insulin sensitivity
Glucose concentration slightly lower
Increased maternal energy stores for accelerated growth periods

17
Q

What does facilitated catabolism mean?

A

Increased insulin resistance
Increased transplacental passage of nutrients
Which leads to rapid foetal growth

18
Q

What consequences are there for the foetus from 1st trimester maternal hyperglycaemia?

A

Foetal malformation

Fuel mediated teratogenesis

19
Q

Give examples of foetal malformation:

A

Hydrocephalus
Meningomyelocoele - neural tube defects more common in hyperglycaemic mothers than in the general population
Central cyanosis in congenital heart disease
Single ventricle and sacral dysgenesis
Renal agenesis

20
Q

Even in a woman with normal HbA1c the risk of malformations is increased above what percentage of the background population?

A

2%

21
Q

How do you prevent foetal malformation in hyperglycaemia of pregnancy?

A

Pre pregnancy counselling for known diabetes
Lifestyle modification
Good diabetes control in 1st trimester
Intensive glucose monitoring
Folic acid 5mg/day preconception - higher dose than normal
Get rid of oral hypoglycaemic agents and put mother on insulin

22
Q

Why do you put the mother on a higher dose of folic acid?

A

Because higher dose shown to reduce chances of congenital defects

23
Q

What is the ideal HbA1c before conception, but certainly once she knows she’s pregnant?

A

Down to 6%

24
Q

How do you identify unknown cases of diabetes/ IGT?

A

By checking women with risk factors

25
Q

What are the risk factors?

A 
Previous gestational diabetes 
Obesity
Polycystic Ovarian Syndrome 
FHx T2DM
High risk racial groups e.g. African, South east asian
26
Q

What are problems that may arise in the third trimester?

A

Macrosomia & associated problems
Pre-eclampsia
Foetal or neonatal death

27
Q

What are the associated problems of macrosomia?

A 
Shoulder dystocia 
Difficult birth
Breathing problems 
Jaundice
Hypoglycaemia
28
Q

What is the risk of shoulder dystocia?

A

The baby’s shoulder gets stuck during labour and freeing it can cause axillary nerve damage to the baby
These babies also get hypoglycaemia frequently

29
Q

Compared to normoglycaemic women, babies born to hyperglycaemia women have higher incidence of:

A 
Obesity
Insulin resistance 
Type 2 diabetes 
Dyslipidaemia 
Hypertension
Vascular disease
30
Q

When do NICE guidelines say you should screen mothers with risk factors?

A

At 26 weeks

31
Q

What is the vicious cycle of hyperglycaemia?

A

If the grandmother was hyperglycaemic, she was probe hyperglycaemic during pregnancy with the mother, the mother probably suffered with obesity and hyperglycaemia all her life and therefore when she has a baby, that baby also likely to be obese and hyperglycaemic

32
Q

Treatment of any pregnancy hyperglycaemia?

A

Good maternal glucose control through intensive blood glucose monitoring
Fasting & 1 hour post prandial minimum
Appropriate nutrition
Reasonable exercise
Ultrasound monitoring of foetal abdominal girth - weekly from 28 weeks
Maternal observation of foetal movements

33
Q

What would be the drug treatment pre-pregnancy/ 1st trimester?

A

Basal bolus insulin regimen

34
Q

What would be the drug treatment in “gestational diabetes”

A 
Metformin
Basal insulin
Basal bolus insulin
Glibenclamide 
Sulfonylureas are used when women don't want to take insulin
35
Q

What is advised postpartum?

A

Breastfeed for as long as possible - breast feeding reduces risks for mother an child & allows mother to reduce weight

36
Q

Women who lactated from 6-12 months or 12 months or longer had:

A

half the risk for diabetes

37
Q

Specific GDM management postpartum:

A 
Screen for diabetes 12 weeks pp
HbA1c +/- fasting glucose or GTT 
Lifestyle advice 
Advice re next pregnancy 
Annual glucose screening 
Combined OCP after 6 weeks/ Mirena intrauterine system
38
Q

The progesterone pill is more likely to cause what in GDM mothers?

A

Insulin resistance

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