Pregestational Diabetes

Question 1

What are maternal risks of pregnancy in patients with pre-existing type 2 DM?

Answer 1

-Preeclampsia -Gestational hypertension -Cesarean section -Perineal trauma -Hemorrhage

Question 2

What are fetal risks of pregnancy in patients with pre-existing type 2 DM?

Answer 2

-Polyhydramnios -Fetal macrosomia -Shoulder dystocia -Birth trauma -Preterm delivery

Question 3

What are maternal risks of pregnancy in patients with type 1 DM?

Answer 3

-Preeclampsia -Gestational hypertension -Cesarean section -Perineal trauma -Hemorrhage -DKA -Renal disease -Retinopathy -Cardiac disease -Hypothyroidism

Question 4

What are fetal risks of pregnancy in patients with pre-existing type 1 DM?

Answer 4

-Fetal growth restriction -Polyhydramnios -Fetal macrosomia -Shoulder dystocia -Birth trauma -Preterm delivery

Question 5

How is HbA1c associated with fetal anomalies?

Answer 5

HbA1c of 10% increases the risk of anomalies by 20% - 25%. cardiac anomaly is number 1 cause

Question 6

What are the most common fetal anomalies complicating pregnancy with preexisting diabetes?

Answer 6

CNS: anencephaly, spina bifida, microcephaly, and holoprosencephaly) Skeletal system: caudal regression syndrome, sacral agenesis, and limb defects Renal system: renal agenesis, hydronephrosis, and ureteric abnormalities Cardiovascular system: transposition of the great vessels, ventricular septal defects, atrial septal defects, coarctation of the aorta, cardiomyopathy, and single umbilical artery Gastrointestinal system: duodenal atresia, anorectal atresia, and small left colon syndrome

Question 7

What is the pathognomonic fetal anomaly in patients with preexisting diabetes?

Answer 7

Caudal regression

Question 8

What is a normal hemoglobin A1c level?

Answer 8

HbA1c less than 5.7% Prediabetes: 5.7-6.4% Diabetes: > or 6.5%

Question 9

What baseline laboratory/non-laboratory evaluation do you perform in pregnancy with type 1/2 DM?

Answer 9

-baseline 24 hour urine protein and creatinine clearance -baseline CBC -baseline CMP -add TSH if type 1 DM -baseline ECG if patient has other comorbidities -baseline echocardiogram if ECG is abnormal or with other comorbidities -Assess for proliferative retinopathy with ophthalmology consultation -Podiatry referral pending physical exam and symptoms -Assess immunity to flu and pneumococcal pneumonia

Question 10

Outline your antepartum management of patients with type 1 and type 2 DM in pregnancy

Answer 10

Establish due date in the first trimester and assess for NT Detailed anatomic survey at 18-20 weeks Fetal echocardiogram at 20-22 weeks Fetal growth monthly Antenatal testing at 32 weeks twice weekly Delivery between 39 weeks and 39 weeks and 6 days if stable Deliver after 36 weeks if uncontrolled DM

Question 11

How do you counsel patients on continuing metformin in pregnancy?

Answer 11

First line and gold standard is insulin. It is effective and does not cross the placenta. 0.7–0.8 units/kg actual body weight/day in the first trimester, to 0.8–1 units/kg/day in the second trimester, to 0.9–1.2 units/kg/day in the third trimester. Metformin was not suspected of increasing the risk of birth defects in a rat study; however, the reported data are not the kind typically used to evaluate pregnancy risk. Human experience with metformin in pregnancy has been reassuring, although the number of exposed pregnancies is limited.

Question 12

How do you counsel the patient with DM on nutritional requirements during pregnancy?

Answer 12

Carbohydrate allocation ranges might be 30–45 g at breakfast, 45–60 g at lunch and dinner, and 15-g snacks approximately 2–3 hours after each meal.

Question 13

What are your target glucose values in pregnancy?

Answer 13

Fasting: <95mg/dL 1 hour glucose postprandial: <140mg/dL 2 hour glucose postprandial: <120mg/dL

Question 14

How does diagnosis of diabetic retinopathy impact pregnancy outcome?

Answer 14

Screening for retinopathy by a qualified ophthalmologist is recommended before pregnancy and again during the first trimester for patients with pregestational diabetes because of the demonstrated effectiveness of laser photocoagulation therapy in arresting progression.

Question 15

How does pregnancy impact diabetic retinopathy progression?

Answer 15

Progression to proliferative diabetic retinopathy occurred in only 2.2% of their subjects, and moderate progression occurred in 2.8%. However, progression was significantly greater in women who had had diabetes for more than 10 years (10% versus 0%).

Question 16

How do you assess for preexisting diabetic nephropathy?

Answer 16

24 hour urine protein and creatinine clearance. 24 hour urine should be less than 300mg Creatinine clearance should be more than 87-107 mL/min due to increased GFR

Question 17

How do you counsel a patient regarding pregnancy risks if she has diabetic nephropathy?

Answer 17

-Worsening disease in pregnancy -Increased risk for hypertensive disease in pregnancy

Question 18

Describe how you will calculate the starting dose of insulin for a pregnant patient with diabetes?

Answer 18

0.7–0.8 units/kg actual body weight/day in the first trimester, to 0.8–1 units/kg/day in the second trimester, to 0.9–1.2 units/kg/day in the third trimester.

Question 19

How do you counsel a patient regarding the risks and benefits of insulin verses oral hypoglycemic agents in pregnancy?

Answer 19

First line and gold standard is insulin. It is effective and does not cross the placenta. Metformin was not suspected of increasing the risk of birth defects in a rat study; however, the reported data are not the kind typically used to evaluate pregnancy risk. It can be used to decrease insulin resistance in patients with high dose of insulin

Question 20

Describe how you will manage insulin in labor in pregestational DM patients.

Answer 20

Discontinue all hypoglycemic agents Obtain blood sugar via finger sticks every 2 hours in latent labor and every hour in active labor Titrate the insulin drip as follow: Blood glucose less than 60mg/dl - HOLD insulin and start D5 in 0.45NS at 125ml/hr 61-90mg/dl - HOLD infusion and start D5 in 0.45NS at 125ml/hr 91-120mg/dl - 0.5 UNIT/hr use with D5 in 0.45NS at 125ml/hr 121-150mg/dl - 1 UNIT/hr use with 0.45NS at 125ml/hr 151-180mg/dl - 2UNITS/hr use with 0.45NS at 125ml/hr 181-220mg/dl - 3UNITS/hr use with 0.45NS at 125ml/hr 221-250mg/dl - 4UNITS/hr use with 0.45NS at 125ml/hr >250mg/dl - 5UNITS/hr use with 0.45NS at 125ml/hr

Question 21

Describe how you will manage glucose control in the immediate postpartum period for type 1 and type 2 DM patient.

Answer 21

Continue insulin infusion until for 2 hours after starting subcutaneous insulin and eating to ensure there is no gap in insulin action and decrease risk for DKA

Question 22

How do you counsel your patient regarding her insulin dosing and management prior to a scheduled cesarean delivery?

Answer 22

Patient can continue NPH or other long acting insulin the night before induction or cesarean section. Remain NPO and do not use short acting the morning of procedure.

Question 23

How do you manage insulin pump at time of scheduled cesarean delivery?

Answer 23

Continue pump with basal rate if patient is well controlled or discontinue and start insulin drip until delivery then restart pump

Question 24

In patients with diabetes, at what estimated fetal weight do you recommend cesarean delivery?

Answer 24

4500 grams

Question 25

What are the types of brachial plexus injury and list their locations?

Answer 25

Erb’s palsy (Waiter’s tip) C5-C6 Klumpke’s palsy (claw hand deformity) C8-T1 Horner’s syndrome (ptosis, mitosis, anhydrosi) T1 sympathetic roots

Question 26

What are the signs and symptoms of diabetic ketoacidosis?

Answer 26

-Malaise -N/V/ Headache -Polyuria/polydipsia -Dry mouth -Shortness of breath -Abdominal pain -Mental status change

Question 27

How is diabetic ketoacidosis diagnosed?

Answer 27

Blood gas + blood sugar + anion gap + serum ketones Acidosis: pH less than 7.35 Anion gap: >12 (Na - (Cl + HCO3)) - the lower the HCO3, the higher the ketoacidosis Blood glucose is typically greater than 200

Question 28

Management of diabetic ketoacidosis:

Answer 28

• Admit to ICU or labor and delivery
• Strict intake and output
• Obtain CBC, CMP, chest x-ray, sepsis work-up

TREATMENT: -Fluid replacement (6L in 12 hours, start with 0.9NS then 0.45NS add D5 when BS is less than 200)

• Insulin therapy (0.1U/kg/hr bolus then 0.1U/kg/hr, decrease to 0.05U/kg/hr if BS is less than 200)
• Potassium replacement (maintain above 5.3, monitor every 2 hours)
• If treatment does not work then: Bicarbonates (if pH is less than 7.0) can cause metabolic alkalosis which can lead to cerebral acidosis and obtunded mental status

***Avoid use of betamimetic and steroids while in DKA

Question 29

Action profile for commonly used insulins:

Answer 29

Question 30

A hemoglobin A1c of 8% is approximately how much of mean blood glucose level:

Answer 30

HbA1c of 8% = 180mg/dl of glucose

Each 1% change = 30mg/dl of glucose there after

Question 31

A unit of short acting insulin is expected to drop the capillary blood glucose by how many mg/dl:

Answer 31

30mg/dl

Question 32

A unit of glucose is expected to cover how much grams of carbohydrate in a meal:

Answer 32

A unit of insulin is expected to cover 10 grams of carbohydrate in a meal

Question 33

How much does 10 grams of carborhydrate increase the capillary blood glucose?

Answer 33

10 grams of carbohydrate increases the capillary blood glucose by 30 grams