Medication Management of Diabetes in Pregnancy ADA BOOK Flashcards
Are insulin pumps used safely and successfully during pregnancy?
Yes
In a comparison between multiple daily injections and continuous subcutaneous insulin infusion (CSII) in pregnancy, were there significant differences in pregnancy outcomes or glycemic control?
No
What is the usual basal infusion rate of insulin in pregnancy?
<50% of the total daily dose of insulin
How many infusion rates do many women require throughout the day?
At least three
During which time period is the lowest basal dose usually administered to help prevent nocturnal hypoglycemia? In pregnancy?
Midnight to 4:00 A.M.
Between which times should the basal rate of insulin be increased in response to earlier increased secretion of cortisol and growth hormone level?
4:00 A.M. and 10:00 A.M.
What the reason of increase in basal infusion rates, meal boluses, and insulin sensitivity factor in pregnancy?
Increase in contra-insulin hormones
What percentage of the total daily dose of insulin is given as meal boluses?
> 50%
How are fixed boluses for insulin pump therapy usually distributed throughout the day?
30% given at breakfast, 25% at lunch, 25% at dinner, and the remaining 15–20% given with snacks
What are the disadvantages of insulin pump therapy?
3 reasons?
Cost, potential for hyperglycemia, and potential for diabetic ketoacidosis
What is important for patients to do in order to anticipate insulin needs? 4 things
-Perform blood glucose monitoring and
-carbohydrate content of the upcoming meal,
-preprandial blood glucose,
-level of exercise
Do women with T1D using continuous glucose monitoring have improved neonatal outcomes?
Yes
Can correction dosing be continued in pregnancy?
Yes
How many times daily is it reasonable to measure blood glucose levels in women with T2D or GDM?
Four times
What are the essential principles for any successful insulin regimen?
Observation of glucose patterns and gradual dose adjustments
What factors need to be considered for dosage adjustments?
Medication compliance, life circumstances, exercise, and dietary patterns
What is the first-line agent for medication management of diabetes during pregnancy according to the American College of Obstetricians and Gynecologists?
Insulin
Which type of insulin is considered the least immunogenic?
Human insulin
What do insulin analogs tend to provide in terms of glycemic control and patient satisfaction?
Better glycemic control and patient satisfaction
According to a retrospective cohort study, does first-trimester exposure to insulin analogs increase the risk of major congenital anomalies compared to human insulin?
No, it does not increase the risk
What is the typical basal regimens during pregnancy?
Twice-daily injection of intermediate-acting NPH insulin or a daily or twice-daily injection of a long-acting insulin analog
What change did the Food and Drug Administration (FDA) make to the classification of insulin detemir during pregnancy?
Changed it to pregnancy category B
What is the FDA pregnancy category for insulin glargine?
Category C
Are there robust efficacy and safety data available for using glargine during pregnancy?
No, the data is not robust
Is there currently identified risks for using insulin degludec during pregnancy?
No, there are no currently identified risks
Which short-acting insulin analogs are considered safe to use during pregnancy?
Insulin lispro and insulin aspart
Are there sufficient data available for the use of glulisine during pregnancy?
No, data in pregnancy are limited
Why should premixed insulins be avoided during pregnancy?
Doses cannot be adjusted independently
Is detemir increasingly included in pregnancy insulin algorithms instead of NPH?
Yes, it is increasingly included
What must detemir not be mixed with?
Rapid-acting insulin
How is the total insulin amount divided when using long-acting and rapid-acting insulin?
40% is given using long-acting insulin, and 60% is given using rapid-acting insulin
What is the recommended blood glucose concentration during active labor?
Maintain blood glucose concentration in the desired range
70-110
> 120 start insulin infusion
What is the purpose of an insulin drip during labor?
Reduce the risk of neonatal hypoglycemia
What is the best regimen for a woman with an insulin pump during labor?
Typically discontinue the pump and utilize an IV insulin drip
What is the management for planned induction of labor?
Adjust insulin dose the night before elective induction
When should the bedtime dose of intermediate-acting insulin be given before planned elective cesarean delivery?
The night before surgery
What are the only oral diabetes medications widely used in pregnancy?
Glyburide and metformin
How does metformin act in the body?
Decreases hepatic gluconeogenesis, increases glucose uptake in peripheral tissues, and decreases glucose absorption in the gut
What is the starting dose of metformin?
500 mg
What are the possible positive effects of metformin?
Less gestational weight gain, lower rates of gestational hypertension, and neonatal hypoglycemia
What percentage of women treated with metformin will ultimately need insulin?
Up to one-half
Does metformin cross the placenta?
Yes
What is the primary difference in body fat composition in infants of mothers on metformin compared to insulin?
More subcutaneous than intra-abdominal fat
When should metformin be discontinued in pregnant women?
Upon achieving pregnancy if the indication was ovulation induction or polycystic ovarian syndrome
How does glyburide act in the body?
Increases insulin release from beta cells in the pancreas
What should be up-titrated to address elevated fasting blood glucose upon waking?
Evening or before-bed intermediate- or long-acting insulin
How can elevated preprandial blood glucose levels be addressed?
By up-titrating the morning intermediate- or long-acting insulin
What are the recommended steps to address episodes of hypoglycemia?
Take four glucose tablets or 1/2 cup of juice and recheck blood glucose in 15 min
What should be prescribed to patients expected to deliver before 32 weeks of gestation?
Magnesium sulfate
What should be avoided in women with diabetes to prevent rapid elevations in maternal glucose concentration?
Sympathomimetics like terbutaline and ritodrine
What medications may be used for tocolysis in women with diabetes?
Indomethacin or calcium channel blockers
What should be checked frequently during corticosteroid administration?
Blood glucose concentrations
What is the usual dose of betamethasone for fetal lung maturation?
Two doses of 12 mg given intramuscularly (IM) 24 h apart
What is the goal of maintaining plasma glucose concentration during labor?
Between 70 mg/dL
What are the potentially devastating effects of hyperglycemia on the fetus during pregnancy?
Risk of congenital defects with hemoglobin A1c >10% during organogenesis.
What are the long-term risks associated with hyperglycemia during pregnancy?
Macrosomia, preterm birth, respiratory distress, obesity, and type 2 diabetes later in life.
Why is blood glucose control more unstable in women with type 1 diabetes during the first trimester?
Transfer of glucose and gluconeogenic substrate to the fetus.
How do insulin requirements change in women with type 1 diabetes during the first trimester?
Insulin requirements often diminish by 10-20% compared to before conception.
When does the diabetogenic stress of pregnancy typically ensue?
In the mid-trimester.
What is the energy economy switch that occurs in the mother during the second trimester?
Switch from glucose-based to lipid-based energy economy to spare glucose for fetal growth.
How much can insulin requirements increase during the second and third trimesters?
As much as twice the total daily dosage of insulin needed before pregnancy.
What leads to evolving disease process or new diagnosis of gestational diabetes mellitus?
Failure of endogenous insulin production to increase.
What causes increased insulin resistance in pregnancy?
Increased maternal production of cortisol and placental production of contra-insulin hormones.
How do postpartum insulin requirements change in women with preexisting diabetes?
They often drop by 50% and must be recalculated based on postpartum weight, diet, exercise, and plans for breastfeeding.
When can medication be discontinued for women with gestational diabetes mellitus?
Immediately after delivery.
What is the total daily dosage of glyburide?
The total daily dosage of glyburide is 2.5–20 mg.
How is glyburide commonly prescribed?
Glyburide is most commonly prescribed in two daily doses.
Does glyburide cross the placenta?
Yes, glyburide does cross the placenta.
How does glyburide perform compared to insulin and metformin?
Glyburide generally performs poorly compared to insulin and metformin.
What are the higher rates associated with glyburide use?
Glyburide use is associated with higher rates of neonatal hypoglycemia and macrosomia.
Is long-term follow-up data available for children exposed to glyburide in utero?
No, there are no long-term follow-up data available for children exposed to glyburide in utero.
