Obesity and DM in Pregnancy Flashcards
1
Q
What are the guidelines for pregnany women based on weight gain?
A
- normal = 11-16
- 6.7-11.2kg in overweight and obese women
- <6.7kg in morbidly obese patients
improved outcomes for normal weight gain regardless of original weight
- moderate 30min exercise 2x a week while pregnant.
2
Q
What are some problems associated with maternal obesity?
A
- decreased fertility
- recurrent miscarriage
- fertility treatment
- maternal health
- gestational DM
- pre-eclampsia
- maternal mortality
- lactation difficulties
- poorer breastfeeding - (late milk arrival, decreased commencement)
- mechanism? hormonal/body image
- decreased metabolic benefits
- poorer breastfeeding - (late milk arrival, decreased commencement)
- NOT A RISK OF PRE-TERM LABOUR
- fetal health
- fetal death
- increased NICU admissions
- macrosomia (big baby)
- congenital abnormalities
-
neural tube defects
- artefact - missing in early detection, restricted diet when concieve
- exomphalos
- heart defects
-
neural tube defects
- obstetric
- prolonged labour (preterm birth inconclusive - no association) - contractile problem in uterus.
- failure to progress
- spontaneous labour less likely
- anaesthetics. (dosing more difficult, epidrual failure rate)
- CS
- refer to tertiary center depending on weights for operating table - 120kg/BMI 40 Sandringham)
- increased risk of complications
- infections,
- hospital stay,
- costs
- prolonged labour (preterm birth inconclusive - no association) - contractile problem in uterus.
3
Q
Interventions for pregnancy weight gain?
A
- interventions dietary in nature did have effects on gestational weight gain.
- no difference for baby size, pre-eclampsia, gestational DM, preterm birth
- interventions of supervised exercise was unsuccessful.
4
Q
What is the Barker hypothesis?
A
Barker theory: intrauterine environment sets them up later in life. Epigenetic effects of having a baby while obese.
- e.g. schizophrenia
- e.g. Dutch babies and HTN
5
Q
Why is Pregnancy diabetogenic? What are the types?
A
- metabolism is in favour of high BSLs to promote fetal growth
- increased insulin resistance and
- 2 types:
- type 1 - lack of insulin - childhood onset. High complications by reproductive age
- type 2 - insulin resistance, obesity, ethnic group
6
Q
What are the effects of pregnancy on diabetes?
A
Effects:
- increased glucose intolerance
- increasing insulin requirements
- exacerbation of nephropathy and retinopathy
- increased predisposition to ketoacidosis (let themselves run high) and hypoglycemia
Affects DM:
- retinopathy
- nephropathy
- macrovascular - no statins allowed
- autonomic neuropathy not normally a major problem, will exacerbate though:
- gastroparesis
- orthostatic HTN
- hypoglycemic awareness
DM affects pregnancy:
- pre-eclampsia
- polyhydramnios (T1DM risk increased PPROM)
- idiopathic for diabetes
- miscarriage
- infection
- PPH
7
Q
What are some effects of DM on the fetus?
A
- abnormal size - macrosomia/FGR
- congenital abnormalities
- immature liver development
- lung development (HMD - hyaline membrane disease)
- caudal regression syndrome
- birth trauma (dystocia, operative)
- hypoglycemia/hypocalcemia
- miscarriage
8
Q
What are the effects of medications on the fetus during pregnancy?
A
- insulin is safe
- metformin is now safe (2 year studies fine)
- PCOS also started on metformin to concieve and continue
- sulfonylureas and glitazones out
- ACEI/ARBs not used (renal defects)
- statins out due to fetal malformations
9
Q
What is the pre-pregnancy management of mothers with diabetes?
A
- pre-pregnancy counselling
- no smoking
- screen for autoimmune disease in T1DM
- optimise control
- folate
- weight loss
10
Q
What is the antenatal management of diabetic mother?
A
Antenatal care
- multidisciplinary teams (obstetrician, endocrinologist, diabetes educator, dietician, +/- neonatal paediatrician)
- maintain BSLs in target range (fasting <5, post-prandial 6.7).
- basal-bolus insulin regime - if they have a pump though can use still.
- decreases indicates poor placental function - DELIVERY
- insulin
- monitor complications (protein excretion, ophthalmic review)
- antenatal screening - not worried about aneuploidy screening (rather see baby, nuchal translucency)
- aneuploidy screening
- morphology 18-20
- fetal growth 28-30
- CTG, dopplers (only if changes), biophysical
- Intrapartum
- regular BSL monitoring (4hrly)
- insulin/dextrose infusion, sliding scale, insulin pump
- continous CTG
- prepare for dystocia
- watch for PPH (polyhydramnios) - from uterine atony
11
Q
Postpartum diabetic mother care?
A
- early feeding - within 1 hr
- monitor BSLs
- admit to SCN (specialty care nursery)
- Maternal
- poor control during pregnancy
- BSL >8 during labour
- IV glucose at labour
- infant:
- unwel
- macrosomic
- preterm
- Maternal
- management of hypo (feeding, 10% IV glucose, glucagon)
Long term followup necessary.
12
Q
What is gestational diabetes? How is it relevant?
A
- anyone who is diagnosed with diabetes (CHO intolernace) during pregnancy
- ST:
- increase risks pre-eclampsia
- increased risks of operative delivery
- increased risk of macrosomia
- LT
- foetal effects of T2DM, and maternal T2DM development within 30-50%
- aims: fasting <5, post-prandial <6.7.
- diagnosis - FBG alone or GTT
- hyperglycemia adverse pregnancy outcomes (study)
- HbA1C not useful alternative.
13
Q
What are the models of care you can use to handle maternal obesity? What should you use in a BMI 32 patient?
A
- shared care with GP (for low risk pregnancy) - not suitable
- modified shared care - few extra obstetrician visits (mod-risk)
- hospital care:
- low risk
- mid-wifery led care (MLC)
- one-to-one midwifery = cosmos
- high risk
- obstetrician-led care (MFM)
- low risk
14
Q
What is some extra care you should offer an obese women who is pregnant?
A
- dietician
- early GTT = 16weeks (undiagnosed T2DM) - later its a pain
- growth scans (first at 30weeks, ideally every 3 weeks)
- can’t do symphyseal fundal height as a tool (can’t use normal exam)
- mediastinal fat pad (better indicator of macrosomia)
- HTN checks
- anaesthetics review:
- difficulty of regional anaesthetic
- risk of GA
15
Q
What decides if you can do induction of labour? What is the Bishop score? How do you interpret it?
A
- components: 5 things get 0-2.
- cervical
- position - (ripens go post - ant)
- consistency
- length/effacement
- dilation
- station (where head is)
- cervical
- interpretation
- 0-4 = unfavourable cervix - prostin/catheter needed
- 5-7 = practitioner discretion
- 8-10 = ARM/spontaneous labour
- types:
- mechanical dilatation (Cooke’s catheter - indication IUGR)
- prostin E2
- cervidil - tape around cervix - 4mg immediately, pull tape out if hyperstimulation
- mifepistone - progesterone antagonist - cervical ripening, adjunct to misoprostil (liscensed for Cushing’s - glucocorticoid ant.)
- misoprostil - only used for dead babies (in developing countries - cheap, not here)
- stretch and sweep (not induction - indistinguishable from spontaneous)
Complications of Induction?
- cord prolapse
- uterine hyperstimulation from prostaglandin
- foetal distress
- failed induction - CS
