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Year 2 RE > Pregnancy and Diabetes > Flashcards

Pregnancy and Diabetes Flashcards

1
Q

When blood glucose levels rise, what hormone is important for helping cells absorb the glucose in the blood?

A
  • insulin
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2
Q

Insulin allows cells to absorb the glucose in the blood. What type of receptors does insulin bind with?

A
  • receptors tyrosine kinase
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3
Q

Once insulin has bound to receptor tyrosine kinase glucose can be absorbed. What transporters carry glucose into the cells?

A
  • glucose transports that migrate to the cell surface because of insulin
  • 1-4 are on different cells and have different sensitivity
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4
Q

Once inside the cell, what does insulin trigger the cell to do with glucose?

A
  • initiate glycogen synthesis (storing glucose as glycogen) called glycogenesis
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5
Q

Over 700,000 women in England and Wales give birth each year. What % of these have complications related to diabetes?

A
  • 5%
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6
Q

Over 700,000 women in England and Wales give birth each year, 5% of which have complications related to diabetes. What are the 3 types of diabetes that this presents as and which is the most common?

A

1 - gestational diabetes = 87.5%
2 - T1DM = 7.5%
3 - T2DM = 5%

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7
Q

Over 700,000 women in England and Wales give birth each year, 5% of which have complications related to diabetes. Gestational diabetes is the most common form, of which the prevalence is increasing. What are 2 of the most common risk factors contributing to the increased prevalence?

A

1 - pregnancy in later life

2 - obesity

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8
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. What happens to glucose production in the liver during pregnancy?

A
  • hepatic glucose production increases by 16-30%

- gluconeogenesis increases throughout pregnancy

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9
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. What happens to insulin sensitivity during pregnancy?

A
  • insulin resistance increases

- aprox 50-70% less effective by 3rd trimester

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10
Q

Why is increased insulin resistance and gluconeogenesis important in pregnancy, especially during the 3rd trimester (weeks 29-40)?

A
  • insulin resistance and gluconeogenesis ensure hyperglycaemia
  • means there will always be glucose available to the foetus
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11
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. When does gluconeogenesis and insulin resistance peak during pregnancy?

A
  • 3rd trimester (weeks 29-40)
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12
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. As insulin resistance increases, hepatic glucose production is able to respond to the excess insulin production. In normal pregnancy and gestational diabetes what % of hepatic glucose production is suppressed by increased insulin concentration in the blood?

A
  • normal pregnancy = 96% suppression

- gestational diabetes = 80% suppression, which means patient remains in a higher hyperglycaemic state

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13
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. The foetus is able to secrete a hormone that opposes insulin. This hormone causes increased insulin sensitivity in an attempt to cause hyperglycaemia and ensure there is constant blood glucose supply to the foetus. What is this hormone called?

A
  • human placental lactogen
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14
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. In addition the mothers lipid metabolism changes during pregnancy. What initially happens to triglycerides (TAG) and very low density lipoproteins (VLDL) during pregnancy?

A
  • both are reduced
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15
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. In addition the mothers lipid metabolism changes during pregnancy. Triglycerides (TAG) and very low density lipoproteins (VLDL) initially drop during pregnancy, before doing what by week 8?

A
  • progressively increase >8 weeks
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16
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. In addition the mothers lipid metabolism changes during pregnancy. Triglycerides (TAG) and very low density lipoproteins (VLDL) initially drop during pregnancy, before progressively rising by week 8. What are 2 hormones that have been linked with increased TAG?

A
  • estrogen

- insulin (insulin resistance)

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17
Q

In pregnancy the mothers glucose and insulin homeostasis changes and glucose is re-directed towards the foetus. In addition the mothers lipid metabolism changes during pregnancy. Triglycerides (TAG) and very low density lipoproteins (VLDL) initially drop during pregnancy, before progressively rising by week 8. What enzyme is decreased in the mother due to increased activity in the placenta that contributed to increased circulating lipids?

A
  • lipoprotein lipase

- extracts lipids from lipoproteins in blood

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18
Q

What happens to HDL levels by week 12 during pregnancy?

A
  • increase
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19
Q

What happens to total and LDL-cholesterol during the 2nd and 3rd trimester of pregnancy?

A
  • all initially decrease in pregnancy

- then gradually increase in 2nd and 3rd trimester

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20
Q

What happens to lipolysis during pregnancy and why?

A
  • lipolysis = triglyceride metabolism into glycerol and free fatty acids
  • ensure continues energy to foetus through fatty acids and gluconeogenesis
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21
Q

In pregnancy there is increased hyperglycaemia and insulin resistance. What does the pancreas do in an attempt to mitigate this?

A
  • increases insulin production

- attempts to restore euglycemia (normal blood glucose)

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22
Q

In pregnancy there is increased hyperglycaemia and insulin resistance. The pancreas, in an attempt to mitigate this does the following:

  • increases insulin production
  • attempts to restore euglycemia (normal blood glucose)

In women who are pregnant and who are unresponsive to the increased insulin secretions, what condition occurs?

A
  • gestational diabetes
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23
Q

If a woman develops diabetes during pregnancy, what are the 3 main maternal risks?

A

1 - pre-eclampsia (high BP and proteinuria)
2 - preterm labour
3 - worsening of diabetic retinopathy

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24
Q

If a woman develops diabetes during pregnancy, what are the 5 main neonatal risks?

A
  • congenital malformations
  • macrosomia (larger than normal baby)
  • birth injury
  • perinatal mortality, still birth and miscarriage
  • postnatal hypoglycaemia (can impact babies cognitive development)
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25
Q

What are the 4 HAPO (Hyperglycemia and Adverse Pregnancy Outcomes) primary findings that were observed in pregnant women with gestational diabetes?

A
  • babies birth weight >90th % for gestational age
  • primary caesarean delivery
  • clinical neonatal hypoglycaemia
  • cord-blood serum C-peptide level above the 90th %
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26
Q

In babies who’s mother has gestational diabetes the cord-blood serum C-peptide levels are above the 90th %. What does this indicate?

A
  • C-peptide is a marker if insulin but no real function

- elevated insulin was delivered to the baby during pregnancy

27
Q

The 4 HAPO (Hyperglycemia and Adverse Pregnancy Outcomes) primary findings that were observed in pregnant women with gestational diabetes were:

  • babies birth weight >90th % for gestational age
  • primary caesarean delivery
  • clinical neonatal hypoglycaemia
  • cord-blood serum C-peptide level above the 90th %

What are the main secondary outcomes that were observed?

A
  • premature delivery (before 37 weeks of gestation)
  • shoulder dystocia or birth injury
  • increased need for intensive neonatal care
  • hyperbilirubinemia
  • pre-eclampsia
28
Q

What is polyhydramnios?

A
  • excessive amniotic fluid in amniotic sac
29
Q

Polyhydramnios is excessive amniotic fluid in amniotic sac. This can be dangerous and lead to what 3 outcomes?

A
  • premature delivery (< 37 weeks)
  • waters breaking early
  • prolapsed umbilical cord
30
Q

When a woman is planning on having a baby, what should be the target plasma glucose levels for:

  • a fasting plasma glucose (FPG)
  • plasma glucose (PG) throughout the day

to help reduce the risks associated with diabetes in pregnancy?

A
  • FPG = 5-7mmol/L

- PG throughout the day = 4-7mmol/L

31
Q

What is the diagnosis of gestational diabetes in:

  • a fasting plasma glucose (FPG) or
  • 2 hour oral glucose tolerance test (OGTT) level
A
  • FPG = >5.6mmol/L or an OGTT of = >7.8mmol/L
32
Q

When a woman is planning to become pregnant, a BMI greater than what would trigger advice on losing weight given to the mother?

A
  • BMI >27 kg/m2
33
Q

When a woman is planning to become pregnant, what supplement should be provided until 12 weeks of gestation?

A
  • folic acid (B9)

- crucial for DNA and RNA and reduces risks of neural tube defects

34
Q

What testing on the eyes should be performed in a female during the pre-conception phase who is or is at risk of developing diabetes?

A
  • retinal screening through digital imaging
35
Q

What 3 measures on the kidneys should be performed in a female and would require referral to a nephrologists during the pre-conception phase who is or is at risk of developing diabetes?

A

1 - creatinine of >120micromol/L
2 - urinary albumin:creatinine ratio >30mg/mol
3 - eGFR <45ml/minute/1.73m2

36
Q

In a woman who is considering becoming pregnant and has or is at risk of diabetes, what blood test should be done monthly?

A
  • HbA1c test
37
Q

In a woman who is considering becoming pregnant and has T1DM, what should they be advised to do in relation to their blood glucose levels?

A
  • self monitor more regularly
  • ketone testing
  • may require increased blood glucose control medication
38
Q

What is the HbA1c target for women who are considering becoming pregnant?

A
  • <48mmol/L
39
Q

If a woman has a HbA1c >86mmol/L (10%) and is considering becoming pregnant, what advise should they be given?

A
  • do not become pregnant until HbA1c is better controlled
40
Q

What are the 2 diabetic medications are permitted in pregnancy?

A

1 - insulin

2 - metformin (inhibit hepatic gluconeogenesis)

41
Q

Some women may be on cholesterol and blood pressure medications prior to pregnancy. What 3 medications are common, but should be stopped during conception?

A
  • statins
  • angiotensin-converting enzyme inhibitors
  • angiotensin-II receptor antagonists
42
Q

When assessing a woman, what are the 5 main risk factors for developing gestational diabetes?

A 
1 - BMI >30kg/m2
2 - previous macrosomic baby >4.5kg
3 - previous gestational diabetes
4 - first degree relative with diabetes
5 - ethnic minority with high incidence of diabetes
43
Q

If a women has any of the risk factors for gestational diabetes below:

1 - BMI >30kg/m2
2 - previous macrosomic baby >4.5kg
3 - previous gestational diabetes
4 - first degree relative with diabetes
5 - ethnic minority with high incidence of diabetes

What test should be performed prior to becoming pregnant and between weeks 24-28?

A
  • oral glucose tolerance test (OGTT)
44
Q

In a patient with gestational diabetes, what is the first line treatment?

A
  • lifestyle change (diet and exercise)
45
Q

In a patient with gestational diabetes, the first line treatment is diet and exercise. If this fails (fasting plasma glucose is 7mmol/L) after 2 weeks what should the patient initially be prescribed?

A
  • metformin
46
Q

In a patient with gestational diabetes, the first line treatment is diet and exercise, following by metformin (after 2 weeks). If this fails after 2 weeks (fasting plasma glucose is 7mmol/L) what should the patient then be prescribed?

A
  • insulin
47
Q

Insulin may be prescribed to a patient with gestational diabetes. What is the main risk of this?

A
  • hypoglycaemia

- must be monitored closely

48
Q

In a female patient with gestational diabetes, what should be tested if the patient already has T1DM?

A
  • ketones

- if patient presents with hyperglycaemia or is unwell they should be tested for ketonaemia immediately

49
Q

What 2 diabetic medications can help reduce glucose absorption in the GIT?

A

1 - metformin

2 - acarbose

50
Q

What diabetic medications can help increase lipogenesis in adipose tissue and the liver (excess energy stored as TAG)?

A
  • insulin
51
Q

What diabetic medications can help increase glucose uptake in the muscles?

A
  • metformin
52
Q

What diabetic medications can help increase glycogenesis in the muscles and liver?

A
  • insulin
53
Q

What diabetic medications can help decrease gluconeogenesis in the liver?

A
  • metformin
54
Q

What diabetic medications can help increase glucose excretion through the kidneys?

A
  • SGLT2 inhibitors
55
Q

During birth and labour hourly continuous capillary blood glucose monitoring should be performed. What is the levels the blood glucose should remain within?

A
  • 4-7mmol/L

- if not within this range then a variable rate infusion of insulin should be administered

56
Q

During birth and labour what do patients with T1DM require?

A
  • variable rate infusion of insulin
57
Q

Following birth the baby should also be monitored, called neonatal care. If they have no clinical indications, what should happen to the baby?

A
  • should remain with mum
58
Q

Following birth the baby should also be monitored, called neonatal care. What blood measures should be taken from the baby following delivery?

A
  • capillary blood glucose
  • polycythaemia (high RBC count)
  • hyperbilirubinaemia
  • hypocalcaemia
  • hypomagnesaemia
59
Q

if a baby has indications of cardiac malformations that may occur due to gestational diabetes, what test should be performed?

A
  • echocardiogram
60
Q

Following birth, women with existing diabetes, what happens to their diabetes management?

A
  • return to pre-pregnancy care providing no issues
61
Q

Following birth, women with gestational diabetes, what happens to their diabetes management?

A
  • assess blood glucose for hyperglycaemia

- if ok then transfer to GP and explain about hyperglycaemia and future risk of gestational diabetes

62
Q

If a woman had gestational diabetes, there is a risk of them developing diabetes. When should a fasting plasma glucose (FPG) and/or HbA1c be tested following birth to asses the patients risk pf developing diabetes?

A
  • FPG = 6-13 weeks

- HbA1c = 13 weeks

63
Q

If a woman had gestational diabetes, there is a risk of them developing diabetes. Looking at the values below, match them with low and high risk of developing diabetes and a diagnosis of T2DM:

  • FPG = <6.0 mmol/L or HbA1c = <39 mmol/mol
  • FPG = >7.0 mmol/L or HbA1c = >48 mmol/mol
  • FPG = 6.0-6.9 mmol/or LHbA1c =39-47 mmol/mol
A
  • LOW RISK = FPG = <6.0 mmol/L or HbA1c = <39 mmol/mol
  • HIGH RISK = FPG = 6.0-6.9 mmol/or LHbA1c =39-47 mmol/mol
  • T2DM = FPG = >7.0 mmol/L or HbA1c = >48 mmol/mol

Year 2 RE (53 decks)

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