Pregnancy and GDM

Question 1

For those with pre-existing diabetes, what is the goal A1C during pregnancy?

Answer 1

<7%

Question 2

Why is planned pregnancy important?

Answer 2

Fetal organ formation takes place in first 8 weeks and uncontrolled glucose may result in spontaneous abortion or congenital abnormalities (neural tube, heart, kidneys)

Question 3

What happens at 18 weeks gestation when the placenta is fully grown and functioning?

Answer 3

The fetus can now develop metabolic complications secondary to the maternal hyperglycemia

Question 4

What are the metabolic complications from maternal hyperglycemia?

Answer 4

Macrosomia, increased risk childhood obesity, glucose intolerance, stillbirth, respiratory distress syndrome, and hyperbilirubinemia

Question 5

What is the most common complication of the second and third trimester maternal hyperglycemia?

Answer 5

Neonatal hypoglycemia

Question 6

How is neonatal hypoglycemia defined?

Answer 6

35 mg/dl or less in full term OR

25 mg/dl or less in preterm infants

Question 7

What is macrosomia?

Answer 7

Abnormally high birth weight

Question 8

What are the maternal complications of uncontrolled glucose?

Answer 8

Hypertension
Preterm labor and delivery
C-section
Pyelonephritis

Question 9

What is pregnancy-induced hypertension also known as?

Answer 9

Preeclampsia

Question 10

How is chronic hypertension treated in pregnant women with diabetes?

Answer 10

Calcium channel blocker and labetalol are substituted. ACE and ARB are CONTRAINDICATED.

Question 11

What is the target blood pressure in pregnant diabetic?

Answer 11

110/65 to 129/79 mmHg

Question 12

What is the most significant risk factor for progression of retinopathy in pregnancy?

Answer 12

Hypertension

Question 13

Under what circumstances might C-section be the best option?

Answer 13

1. Proliferative retinopathy (to prevent the Valsalva maneuver, which could lead to retinal hemorrhage)
2. High birth weight neonate

Question 14

What is the chance of having a Type 1 in a mother with Type 1?

Answer 14

2%

Question 15

What is the chance of having a Type 1 in a father with Type 1?

Answer 15

6%

Question 16

What is gestational diabetes?

Answer 16

Carbohydrate intolerance at onset or first recognition in pregnancy

Question 17

What is the screening for GDM?

Answer 17

Screen all women at first prenatal visit.
Test between 24-28 weeks for those with average risk.
Use 75 gram oral glucose tolerance test (OGTT)

Question 18

When is GDM diagnosed?

Answer 18

One of the following:
Fasting blood glucose >92 mg/dl
1 hour post-OGTT is >180 mg/dl
2 hour post-OGTT is >158 mg/dl

Question 19

Women at high risk for diabetes should be tested ASAP and those risk factors include:

Answer 19

History of GDM
Family history of diabetes
Obesity
Glycosuria

Question 20

Why is pregnancy considered a diabetogenic state?

Answer 20

Hormones in pregnancy (progesterone, human placental hormone, and prolactin) lead to insulin resistant state

Question 21

What happens to blood sugar levels in the third trimester?

Answer 21

They double or triple due to increased needs of the placenta

Question 22

True or false: Ketones are harmful to the fetus.

Answer 22

True, so avoid this by refraining from unsupervised weight loss (and check for ketones late in pregnancy)

Question 23

What happens immediately postpartum?

Answer 23

Insulin sensitivity increases due to hormonal changes, though they typically promptly return to normal insulin requirements.

Question 24

Blood glucose level targets for GDM:

Answer 24

Premeal/bedtime/overnight: 60-99 mg/dl

Peak postprandial: 100-129 mg/dl

Question 25

What medications are used to treat GDM?

Answer 25

Insulin mostly, though glyburide and metformin have also been studied.

Question 26

What is a woman’s risk of diabetes within 10 years after having GDM?

Answer 26

40-60%

Question 27

What is recommended postpartum after GDM?

Answer 27

Self-monitor blood glucose until normoglycemic and 6 week OGTT

Question 28

What follow-up tests should be done after having GDM?

Answer 28

Fasting plasma glucose test annually and 75 gram OGTT every 3 years.

Question 29

True or false: Breastfeeding is contraindicated if the mother has diabetes

Answer 29

FALSE

Question 30

What can ketones cause in fetus?

Answer 30

Exposure is associated with fetal demise and lower IQ scores.

Question 31

Indications for ketone testing in GDM:

Answer 31

Blood glucose >200 mg/dl
Significant vomiting with morning sickness/illness
**Infection is the most common cause of ketosis.

Question 32

When ketones are present with normal or low blood glucose, what is suspected?

Answer 32

Inadequate food intake

Question 33

When ketones are present with high blood glucose, what is suspected?

Answer 33

Ketosis will be imminent

Question 34

If vomiting occurs after taking a short-acting premeal insulin, what should the patient do?

Answer 34

Take enough glucagon to raise blood glucose 30-40 mg/dl to prevent hypoglycemia. This works for 1-2 hours, to allow for food to be taken. Monitor closely and more glucagon if the patient can’t eat until time for peak action of the insulin is reached.