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Hugh's MD3 Women's > Obesity and Diabetes in Pregnancy > Flashcards

Obesity and Diabetes in Pregnancy Flashcards

1
Q

Should you still gain weight if you’re obese at when pregnant?

A

Yes, 6.7-11.2kg in overweight and obese women

Less than 6.7kg in morbidly obese

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2
Q

What is the major long term problem with GWG?

A

Most retain weight postpartum

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3
Q

Which conditions are associated with overweight/obesity?

A 
Neural tube defects
Exomphalos
Heart defects
Stillbirth
Perinatal death
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4
Q

Why are there high rates of neutral tube defects in ow and obese?

A

Prepregnancy glucose control
Less response to standard folic acid intake
More likely to be on diets
More likely to be missed in antenatal scanning

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5
Q

What is macrosomia?

A

Birth weight over 4kg

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6
Q

Is VTE increased in ow and obese?

A

No evidence at the moment

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7
Q

When is labour more likely to occur?

A

Late

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8
Q

What are the difficulties with anaesthetics in ow and obese?

A

Epidurals are technically more difficult
Securing the airway in GAs is more difficult
Dosages for opiates differ

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9
Q

How does labour differ in ow and obese?

A

Increased need for induction of labour
Longer duration of labour
Higher rates of failure to progress
- Due to lower amplitude and frequency of contractions

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10
Q

What is the problem is CS in ow and obese?

A

The Pfannestiel incision is located at a typical location of a fat fold

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11
Q

What is the problem with lactation in ow and obese?

A

Less likely to commence
Less likely to still be breastfeeding at 6 months
More likely to have late arrival of milk

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12
Q

Why is diabetes more common in pregnancy?

A
  • HPL, progesterone antagonize insulin
  • Glucose is major energy substrate for fetus
  • Pregnancy causes insulin resistance
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13
Q

What happens to diabetes during pregnancy?

A
  • Increasing glucose intolerance
  • Increasing insulin requirements
  • Exacerbation of nephropathy
  • Exacerbation of retinopathy
  • Increased predisposition to ketoacidosis
  • Increased predisposition to hypoglycaemia
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14
Q

What is the effect of diabetes on pregnancy?

A 
• Pre-eclampsia
– Increased risk if diabetic nephropathy
• Polyhydramnios
– PPROM, premature labour
• Miscarriage
• Operative delivery (CS rate 50%)
• Increased risk of infection (UTI, chorioamnionitis, wound infections)
• PPH
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15
Q

What is the effect of diabetes on the fetus?

A
  • Miscarriage
  • Congenital abnormalities
  • Macrosomia
  • IUGR (esp if macrovascular disease)
  • FDIU
  • Prematurity (esp if polyhydramnios)
  • Shoulder dystocia
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16
Q

What is caudal regression syndrome?

A

Sacral regression causing small atrophic lower limbs

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17
Q

What is the effect of diabetes on the neonate?

A 
• Macrosomia
• Fetal growth restriction 
• Birth trauma
– Shoulder dystocia
– Operative deliveries
• Hypoglycaemia
• Hypocalcaemia
• Hypomagnesaemia
• Polycythaemia / Hyperviscosity 
• Hyperbilirubinaemia
• Respiratory distress syndrome
– HMD
– TTN
• Risk of diabetes
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18
Q

Which medications are safe in pregnancy? Which aren’t?

A

Safe

  • Insulin
  • Metformin probably

Out

  • Sulphonylurea
  • Glitazones
  • ACEi/AT2B
  • Statins
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19
Q

What do you do pre-pregnancy for diabetics?

A 
Optimise diabetes
Detect and optimise other autoimmune diseases 
Folate supplementation at 5mg 
Smoking cessation
Weight loss
20
Q

How does antenatal care differ in diabetes?

A 
Frequency visits
Multidisciplinary team
Maintain BSL's within target range
Maintain Hb1ac within normal range
Avoid hypos
Avoid ketacidosis
Basal-bolus regime of insulin
Monitor Complications
– Protein excretion
– Opthalmology review
21
Q

What are the BSL targets?

A

Fasting and pre-prandial 4-5.5mmol/l

Post-prandial less than 7mmol/l at 2 hours - so more testing

22
Q

Who is part of the multidisciplinary team in diabetic pregnancy?

A 
Obstetrician
Endocrinologist
Diabetes educator
Dietitian
Neonatal paediatrician
23
Q

What are the principles of intrapartum care?

A

Aim for term
Avoid post maturity
Vaginal delivery unless
– significant risk of macrosomia (EFW >4250g)
– Risk of growth restriction (esp with abnormal Dopplers)
BSL monitoring, avoid hypo’s and hyper’s
Sliding scale and insulin infusion if required
Continuous CTG, anticipate shoulder dystocia

24
Q

What are the principles of postpartum care?

A
  • Insulin requirements fall rapidly
  • Monitor BSL’s closely
  • Recomence pre-pregnancy insulin
  • Avoid oral hypoglycaemic agents in lactation
  • Allow mild hyperglycaemia to prevent hypoglycaemia
  • Caution with hypoglycaemia with breast feeding
  • Contraception
25
Q

How do you manage neonates?

A

Early feeding
Monitor BSLs
Admit to SCN if maternal or neonatal risk factors
Management of hypoglycaemia - feeding>10% dextrose>glucagon

26
Q

What is gestational diabetes?

A

Any diabetes that develops during pregnancy

27
Q

How is GD diagnosed?

A

GTT

  • Fast greater than 5.1
  • 1 hour over 10
  • 2 hours over 8.5
28
Q

What are the additional risks of obesity in pregnancy?

A 
GDM
PIH + PE
Post dates
Fetal growth restriction - that it will be missed due to obese abdomen 
Infertility
Macrosomia
Neutral tube defects, heart defects, exomphalos 
Miscarriage
Prolonged labour and CS
Maternal mortality
29
Q

What are the guidelines for weight gain in pregnancy?

A

Normal BMI: 10kg
BMI 25-40: 6.7-11.2kg
BMI over 40: less than 6.7

30
Q

What model of care is preferred in obesity?

A

Obstetrician lead care
Can do modified shared care if multiparous

Not suitable for shared care, midwife care

31
Q

What are the extra care requirements in obese antenatal care?

A

Growth scans: 30 weeks, ideally 3 weeks afterwards
Early OGTT: 16 weeks for unrecognised type 2
5mg folate
See the anaesthetist about not being able to do regional anaesthesia and CS requirement

32
Q

What are the extra requirements in intrapartum care?

A

More concern about failure to progress

Consider early epidural

33
Q

When do you measure BSLs in GDM?

A

Fasting

2 hour postprandials

34
Q

What are the glucose targets in GDM?

A

Fasting less than 5

Postprandial less that 6.7

35
Q

How do we further investigate GDMs?

A

Hb1Ac
UEC
Protein/creatinine ratio

36
Q

What are options for inducing?

A

ARM and synt with prostin for priming
Balloon catheter
Stretch and sweep
Cervidil - tap around the cervix applies prostin directly

Mifepristone and misoprostol (for miscarriages usually)

37
Q

Must must have occurred before using synt? Why?

A

After rupture of membranes

Amniotic emboli

38
Q

How do you decide on the measure of induction?

A

Bishops score on VE

  • Cervical dilation, effacement, consistently, and position
  • Station
39
Q

How do you interrupt the bishops score?

A

Less than 2 - Higher dose of prostin
Less than 5 - Less prostin
Greater than 7 - ARM is possible

40
Q

What is a side effect of prostin?

A

Hyperstimulation - can end in rapid labour or emergency CS

41
Q

What are some risks of ARM and Synt?

A

Hyperstimulation

Cord prolapse

42
Q

What do you do before starting synt?

A

Consent for CS

Warn about failure of induction of labour

43
Q

What are the short term risks in GDM babies?

A

Shoulder dystocia
Hypoglycaemia - early feeding, SCN
Transient tachyopnoea of newborn, HMD
Jaundice

44
Q

What is the management cascade for shoulder dystocia?

A

H: Call for help and note the time
E: Evaluate for episiotomy and reposition the mum
L: Legs, McRoberts manoeuvre
P: Suprapubic pressure
E: Enter: internal manoeuvres - corkscrew
R: Remove posterior arm
Zavenelli restitution

45
Q

Who are at risk of for shoulder dyspocia?

A

Diabetic obese mothers

D: Diabetes
O: Obesity
P: Position
E: Everything else

Hugh's MD3 Women's (68 decks)

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