Medication Management of Diabetes in Pregnancy ADA BOOK

Question 1

Are insulin pumps used safely and successfully during pregnancy?

Answer 1

Yes

Question 2

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?

Answer 2

No

Question 3

What is the usual basal infusion rate of insulin in pregnancy?

Answer 3

<50% of the total daily dose of insulin

Question 4

How many infusion rates do many women require throughout the day?

Answer 4

At least three

Question 5

During which time period is the lowest basal dose usually administered to help prevent nocturnal hypoglycemia? In pregnancy?

Answer 5

Midnight to 4:00 A.M.

Question 6

Between which times should the basal rate of insulin be increased in response to earlier increased secretion of cortisol and growth hormone level?

Answer 6

4:00 A.M. and 10:00 A.M.

Question 7

What the reason of increase in basal infusion rates, meal boluses, and insulin sensitivity factor in pregnancy?

Answer 7

Increase in contra-insulin hormones

Question 8

What percentage of the total daily dose of insulin is given as meal boluses?

Answer 8

> 50%

Question 9

How are fixed boluses for insulin pump therapy usually distributed throughout the day?

Answer 9

30% given at breakfast, 25% at lunch, 25% at dinner, and the remaining 15–20% given with snacks

Question 10

What are the disadvantages of insulin pump therapy?
3 reasons?

Answer 10

Cost, potential for hyperglycemia, and potential for diabetic ketoacidosis

Question 11

What is important for patients to do in order to anticipate insulin needs? 4 things

Answer 11

-Perform blood glucose monitoring and
-carbohydrate content of the upcoming meal,
-preprandial blood glucose,
-level of exercise

Question 12

Do women with T1D using continuous glucose monitoring have improved neonatal outcomes?

Answer 12

Yes

Question 13

Can correction dosing be continued in pregnancy?

Answer 13

Yes

Question 14

How many times daily is it reasonable to measure blood glucose levels in women with T2D or GDM?

Answer 14

Four times

Question 15

What are the essential principles for any successful insulin regimen?

Answer 15

Observation of glucose patterns and gradual dose adjustments

Question 16

What factors need to be considered for dosage adjustments?

Answer 16

Medication compliance, life circumstances, exercise, and dietary patterns

Question 17

What is the first-line agent for medication management of diabetes during pregnancy according to the American College of Obstetricians and Gynecologists?

Answer 17

Insulin

Question 18

Which type of insulin is considered the least immunogenic?

Answer 18

Human insulin

Question 19

What do insulin analogs tend to provide in terms of glycemic control and patient satisfaction?

Answer 19

Better glycemic control and patient satisfaction

Question 20

According to a retrospective cohort study, does first-trimester exposure to insulin analogs increase the risk of major congenital anomalies compared to human insulin?

Answer 20

No, it does not increase the risk

Question 21

What is the typical basal regimens during pregnancy?

Answer 21

Twice-daily injection of intermediate-acting NPH insulin or a daily or twice-daily injection of a long-acting insulin analog

Question 22

What change did the Food and Drug Administration (FDA) make to the classification of insulin detemir during pregnancy?

Answer 22

Changed it to pregnancy category B

Question 23

What is the FDA pregnancy category for insulin glargine?

Answer 23

Category C

Question 24

Are there robust efficacy and safety data available for using glargine during pregnancy?

Answer 24

No, the data is not robust

Question 25

Is there currently identified risks for using insulin degludec during pregnancy?

Answer 25

No, there are no currently identified risks

Question 26

Which short-acting insulin analogs are considered safe to use during pregnancy?

Answer 26

Insulin lispro and insulin aspart

Question 27

Are there sufficient data available for the use of glulisine during pregnancy?

Answer 27

No, data in pregnancy are limited

Question 28

Why should premixed insulins be avoided during pregnancy?

Answer 28

Doses cannot be adjusted independently

Question 29

Is detemir increasingly included in pregnancy insulin algorithms instead of NPH?

Answer 29

Yes, it is increasingly included

Question 30

What must detemir not be mixed with?

Answer 30

Rapid-acting insulin

Question 31

How is the total insulin amount divided when using long-acting and rapid-acting insulin?

Answer 31

40% is given using long-acting insulin, and 60% is given using rapid-acting insulin

Question 32

What is the recommended blood glucose concentration during active labor?

Answer 32

Maintain blood glucose concentration in the desired range 70-110 > 120 start insulin infusion

Question 33

What is the purpose of an insulin drip during labor?

Answer 33

Reduce the risk of neonatal hypoglycemia

Question 34

What is the best regimen for a woman with an insulin pump during labor?

Answer 34

Typically discontinue the pump and utilize an IV insulin drip

Question 35

What is the management for planned induction of labor?

Answer 35

Adjust insulin dose the night before elective induction

Question 36

When should the bedtime dose of intermediate-acting insulin be given before planned elective cesarean delivery?

Answer 36

The night before surgery

Question 37

What are the only oral diabetes medications widely used in pregnancy?

Answer 37

Glyburide and metformin

Question 38

How does metformin act in the body?

Answer 38

Decreases hepatic gluconeogenesis, increases glucose uptake in peripheral tissues, and decreases glucose absorption in the gut

Question 39

What is the starting dose of metformin?

Answer 39

500 mg

Question 40

What are the possible positive effects of metformin?

Answer 40

Less gestational weight gain, lower rates of gestational hypertension, and neonatal hypoglycemia

Question 41

What percentage of women treated with metformin will ultimately need insulin?

Answer 41

Up to one-half

Question 42

Does metformin cross the placenta?

Answer 42

Yes

Question 43

What is the primary difference in body fat composition in infants of mothers on metformin compared to insulin?

Answer 43

More subcutaneous than intra-abdominal fat

Question 44

When should metformin be discontinued in pregnant women?

Answer 44

Upon achieving pregnancy if the indication was ovulation induction or polycystic ovarian syndrome

Question 45

How does glyburide act in the body?

Answer 45

Increases insulin release from beta cells in the pancreas

Question 46

What should be up-titrated to address elevated fasting blood glucose upon waking?

Answer 46

Evening or before-bed intermediate- or long-acting insulin

Question 47

How can elevated preprandial blood glucose levels be addressed?

Answer 47

By up-titrating the morning intermediate- or long-acting insulin

Question 48

What are the recommended steps to address episodes of hypoglycemia?

Answer 48

Take four glucose tablets or 1/2 cup of juice and recheck blood glucose in 15 min

Question 49

What should be prescribed to patients expected to deliver before 32 weeks of gestation?

Answer 49

Magnesium sulfate

Question 50

What should be avoided in women with diabetes to prevent rapid elevations in maternal glucose concentration?

Answer 50

Sympathomimetics like terbutaline and ritodrine

Question 51

What medications may be used for tocolysis in women with diabetes?

Answer 51

Indomethacin or calcium channel blockers

Question 52

What should be checked frequently during corticosteroid administration?

Answer 52

Blood glucose concentrations

Question 53

What is the usual dose of betamethasone for fetal lung maturation?

Answer 53

Two doses of 12 mg given intramuscularly (IM) 24 h apart

Question 54

What is the goal of maintaining plasma glucose concentration during labor?

Answer 54

Between 70 mg/dL

Question 55

What are the potentially devastating effects of hyperglycemia on the fetus during pregnancy?

Answer 55

Risk of congenital defects with hemoglobin A1c >10% during organogenesis.

Question 56

What are the long-term risks associated with hyperglycemia during pregnancy?

Answer 56

Macrosomia, preterm birth, respiratory distress, obesity, and type 2 diabetes later in life.

Question 57

Why is blood glucose control more unstable in women with type 1 diabetes during the first trimester?

Answer 57

Transfer of glucose and gluconeogenic substrate to the fetus.

Question 58

How do insulin requirements change in women with type 1 diabetes during the first trimester?

Answer 58

Insulin requirements often diminish by 10-20% compared to before conception.

Question 59

When does the diabetogenic stress of pregnancy typically ensue?

Answer 59

In the mid-trimester.

Question 60

What is the energy economy switch that occurs in the mother during the second trimester?

Answer 60

Switch from glucose-based to lipid-based energy economy to spare glucose for fetal growth.

Question 61

How much can insulin requirements increase during the second and third trimesters?

Answer 61

As much as twice the total daily dosage of insulin needed before pregnancy.

Question 62

What leads to evolving disease process or new diagnosis of gestational diabetes mellitus?

Answer 62

Failure of endogenous insulin production to increase.

Question 63

What causes increased insulin resistance in pregnancy?

Answer 63

Increased maternal production of cortisol and placental production of contra-insulin hormones.

Question 64

How do postpartum insulin requirements change in women with preexisting diabetes?

Answer 64

They often drop by 50% and must be recalculated based on postpartum weight, diet, exercise, and plans for breastfeeding.

Question 65

When can medication be discontinued for women with gestational diabetes mellitus?

Answer 65

Immediately after delivery.

Question 66

What is the total daily dosage of glyburide?

Answer 66

The total daily dosage of glyburide is 2.5–20 mg.

Question 67

How is glyburide commonly prescribed?

Answer 67

Glyburide is most commonly prescribed in two daily doses.

Question 68

Does glyburide cross the placenta?

Answer 68

Yes, glyburide does cross the placenta.

Question 69

How does glyburide perform compared to insulin and metformin?

Answer 69

Glyburide generally performs poorly compared to insulin and metformin.

Question 70

What are the higher rates associated with glyburide use?

Answer 70

Glyburide use is associated with higher rates of neonatal hypoglycemia and macrosomia.

Question 71

Is long-term follow-up data available for children exposed to glyburide in utero?

Answer 71

No, there are no long-term follow-up data available for children exposed to glyburide in utero.