Obstetrics Flashcards
Diagnostic criteria for gestational DM
Fasting glucose of >= 5.5
2 hour post glucose intake value of >=7.8
When to perform an GTT (glucose tolerance test)
- previous gestational DM
- certain gestational groups (eg asian descent)
- mother older than 40
- mothers over 90kg, or BMI > 40
- first degree family member
- Hx of diabetic symptoms (polydipsia, polyuria, vaginal candidiasis.
- Previous infant >4.5kg
- previous stillbirth of unknown cause
- severe polyhydramnios with no structural anomalies
- repeated glycosuria
- Polycystic ovarian syndrome
- Acanthosis nigricans
Which hormone produced by the placenta results in increased insulin resistence.
Human placental lactogen
Antepartum effects of diabetes on pregnancy
- Increased prevelence of congenital abnormalities
- cardiac
- neural tube
- skeletal - Macrosomia (N head, big body)
- Intrauterine death
- Polyhydramnios
Problems at delivery, diabetic mom
shoudler dystocia …Erbs palsy
Postpartum effects of diabetes on pregnancy
- Neonatal hypoglycaemia
- Polycythaemia
- Hyperbilirubinaemia
- Respiratory distress syndrome
*poor cardiac function due to fetal heart hypertrophy from excess glycogen stores
Which fetal complication may occur in a mother with longstanding mircrovasc disease due to DM
IUGR
Glucose values, management guidelines
Fasting below 5.5
2hr postprandial <7.0
HbA1c <6.5%
Type 1 Diabetic management
Insulin + good diet
- 3 injects (actrapid) breakfast, lunch, supper
- 1 intermediate acting insulin before bed…Protaphane
Type 2 diabetic management
Metformin 500mg BD
Can be increased to 850mg TDS
+
good diet
How to calculate total amount of insulin needed per day
0.4U/kg/day
*40% for late eve protophane
20% for each meal
When does reactive hyperglycaemia (somogyi) occur
When too much insulin is given at night, resulting in hypogylcaemia. Body reacts by starting glycogenolysis and gluconeogenesis
Rx: lower night time insulin amount
How should diabetic mother regulate her glucose at home
test 2 hour post meal + first thing in the morning (glucose profile)
Measured once every 2 weeks in health care setting, and then once weekly after 36wks
General Antenatal managament and investions in diabteic mother
- fundoscopy
- 24 hour urine protein test and renal functions
-rule out diabetic nepropathy - Ultrasound @ 13, for general wellbeing
23, to check for gross anomalies, nuchal translucency - 32 weeks, detailed scan.. check for anomalies
- 38weeks, for morphometry and to estimate weight
- HbA1c @ first visit, and then again at 8weeks
- Urine MC&S, asympto bacteruria
- CTG´s weekly from 34wks
- Patient should be made aware to look out for quiet pattern..count fetal movements
Wjat is issue with using Beta 2 receptor stimulants in diabetic mothers with preterm labour
B2 stimulants, stimulate the conversion of liver glycogen to glucose, which causes maternal hyperglycaemia
- adjust insulin dose accordingly
- Administer in saline solution, not dextrose
When do we deliver diabetic moms, and why
38weeks, due to danger of stillbirths
preferred method of delivery in diabetic mom
vaginal delivery
When do we do c sections in diabetic moms
When there are obstetric complications
fetal weight >4kg
If labour has lasted longer than 18 hours
Is oxytocin safe to use in diabetic mothers during delivery
yes
Delivery management in insulin dependant mom
- Induction in the morning
- Continuous IV insulin
- Short acting insulin 1U/ hour administered by infusion pump
- if no infusion pump, add 10U insulin to 1 litre of 5% dextrose
- Albumin first placed in vaculitre (prevents adherence of insulin on the sides ). Mixture given @ 100ml/ hr
4.Give 5% dextrose solution simultaneously @ rate of 100ml/hr.
Blood glucose monitored hourly
Pts on oral agents continue as per usual
Continuous monitoring of fetus throughout
All patients delivered in lithotomy position, with preparation for shoudler dystocia.
What to do if ketonuria present at delivery (diabetes)
Increase insulin and glucose dose
What to check in the newborn
Hourly blood glucose
haematocrit (polycythemia)
Clinical exam for anomalies (esp cardiac)
Examination of neonate for hyperbilirubinemia
Be alert for resp distress syndrome
Definitions of post partum hemorrhage
- blood loss 500ml with vag delivery
blood loss 1000ml with c section
2.Vag bleeding, or blood loss at csection with hypotension and tachy - Bleeding associated with drop in hematocrit of 10% or more
- Bleeding at delivery necessitating blood transfusion