Obesity and Diabetes in Pregnancy Flashcards
Should you still gain weight if you’re obese at when pregnant?
Yes, 6.7-11.2kg in overweight and obese women
Less than 6.7kg in morbidly obese
What is the major long term problem with GWG?
Most retain weight postpartum
Which conditions are associated with overweight/obesity?
Neural tube defects Exomphalos Heart defects Stillbirth Perinatal death
Why are there high rates of neutral tube defects in ow and obese?
Prepregnancy glucose control
Less response to standard folic acid intake
More likely to be on diets
More likely to be missed in antenatal scanning
What is macrosomia?
Birth weight over 4kg
Is VTE increased in ow and obese?
No evidence at the moment
When is labour more likely to occur?
Late
What are the difficulties with anaesthetics in ow and obese?
Epidurals are technically more difficult
Securing the airway in GAs is more difficult
Dosages for opiates differ
How does labour differ in ow and obese?
Increased need for induction of labour
Longer duration of labour
Higher rates of failure to progress
- Due to lower amplitude and frequency of contractions
What is the problem is CS in ow and obese?
The Pfannestiel incision is located at a typical location of a fat fold
What is the problem with lactation in ow and obese?
Less likely to commence
Less likely to still be breastfeeding at 6 months
More likely to have late arrival of milk
Why is diabetes more common in pregnancy?
- HPL, progesterone antagonize insulin
- Glucose is major energy substrate for fetus
- Pregnancy causes insulin resistance
What happens to diabetes during pregnancy?
- Increasing glucose intolerance
- Increasing insulin requirements
- Exacerbation of nephropathy
- Exacerbation of retinopathy
- Increased predisposition to ketoacidosis
- Increased predisposition to hypoglycaemia
What is the effect of diabetes on pregnancy?
• 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
What is the effect of diabetes on the fetus?
- Miscarriage
- Congenital abnormalities
- Macrosomia
- IUGR (esp if macrovascular disease)
- FDIU
- Prematurity (esp if polyhydramnios)
- Shoulder dystocia
What is caudal regression syndrome?
Sacral regression causing small atrophic lower limbs
What is the effect of diabetes on the neonate?
• Macrosomia • Fetal growth restriction • Birth trauma – Shoulder dystocia – Operative deliveries • Hypoglycaemia • Hypocalcaemia • Hypomagnesaemia • Polycythaemia / Hyperviscosity • Hyperbilirubinaemia • Respiratory distress syndrome – HMD – TTN • Risk of diabetes
Which medications are safe in pregnancy? Which aren’t?
Safe
- Insulin
- Metformin probably
Out
- Sulphonylurea
- Glitazones
- ACEi/AT2B
- Statins
What do you do pre-pregnancy for diabetics?
Optimise diabetes Detect and optimise other autoimmune diseases Folate supplementation at 5mg Smoking cessation Weight loss
How does antenatal care differ in diabetes?
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
What are the BSL targets?
Fasting and pre-prandial 4-5.5mmol/l
Post-prandial less than 7mmol/l at 2 hours - so more testing
Who is part of the multidisciplinary team in diabetic pregnancy?
Obstetrician Endocrinologist Diabetes educator Dietitian Neonatal paediatrician
What are the principles of intrapartum care?
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
What are the principles of postpartum care?
- 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
How do you manage neonates?
Early feeding
Monitor BSLs
Admit to SCN if maternal or neonatal risk factors
Management of hypoglycaemia - feeding>10% dextrose>glucagon
What is gestational diabetes?
Any diabetes that develops during pregnancy
How is GD diagnosed?
GTT
- Fast greater than 5.1
- 1 hour over 10
- 2 hours over 8.5
What are the additional risks of obesity in pregnancy?
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
What are the guidelines for weight gain in pregnancy?
Normal BMI: 10kg
BMI 25-40: 6.7-11.2kg
BMI over 40: less than 6.7
What model of care is preferred in obesity?
Obstetrician lead care
Can do modified shared care if multiparous
Not suitable for shared care, midwife care
What are the extra care requirements in obese antenatal care?
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
What are the extra requirements in intrapartum care?
More concern about failure to progress
Consider early epidural
When do you measure BSLs in GDM?
Fasting
2 hour postprandials
What are the glucose targets in GDM?
Fasting less than 5
Postprandial less that 6.7
How do we further investigate GDMs?
Hb1Ac
UEC
Protein/creatinine ratio
What are options for inducing?
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)
Must must have occurred before using synt? Why?
After rupture of membranes
Amniotic emboli
How do you decide on the measure of induction?
Bishops score on VE
- Cervical dilation, effacement, consistently, and position
- Station
How do you interrupt the bishops score?
Less than 2 - Higher dose of prostin
Less than 5 - Less prostin
Greater than 7 - ARM is possible
What is a side effect of prostin?
Hyperstimulation - can end in rapid labour or emergency CS
What are some risks of ARM and Synt?
Hyperstimulation
Cord prolapse
What do you do before starting synt?
Consent for CS
Warn about failure of induction of labour
What are the short term risks in GDM babies?
Shoulder dystocia
Hypoglycaemia - early feeding, SCN
Transient tachyopnoea of newborn, HMD
Jaundice
What is the management cascade for shoulder dystocia?
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
Who are at risk of for shoulder dyspocia?
Diabetic obese mothers
D: Diabetes
O: Obesity
P: Position
E: Everything else
