pregnancy endocrine disorders Flashcards
insulin resistance throughout pregnancy
Insulin sensitive 1st trimester. Insulin requirements decrease in pre-existing DM. Women at risk for severe nocturnal hypoglycemia 1st trim. Early pregnancy: Anabolic with lipogenesis. Insulin resistance late 2nd and 3rd with increased hPL, hPGH, TNFα. Women with pre-existing diabetes will double to triple their insulin requirements in 2nd and 3rd trimester
metabolism in late pregnancy
catabolic: increased lipolysis (less insulin suppression of lipolysis), Glycogen stores depleted rapidly due to fetal-placental growth requirements. Pregnant women shift from carb to fat metabolism within 12 hrs due to depleted glycogen. Pregnant women utilize fat as fuel to conserve glucose for fetal-placental unit resulting in increased ketones and risk of DKA.
Which women have fatter babies
obese women without gestational diabetes
plasma glucose levels in pregnancy
Normal pregnancy is associated with lower fasting plasma glucose, presumably due to an increase in glucose uptake by the fetoplacental unit. However, postprandial glucoses may be slightly higher and associated with hyperinsulinemia
gestational diabetes
•Glucose intolerance recognized for the first time during pregnancy. Undiagnosed Type 2 (or Type 1) with elevated A1C have risk for major malformations (3-10 weeks). Most women diagnosed before 24 weeks have IGT (pre-diabetes) and are at very high risk for developing Type 2 postpartum
pathophys of gestational diabetes
•Vast majority are overweight and insulin resistant.insulin resistance, impaired insulin secretion, and increased hepatic glucose production all contribute. The women who are not overweight have primarily an insulin secretion defect and may ave autoimmune form of diabetes.
GDM affects on fetus
The excessive transfer of glucose, amino acids, and FFAs from the mother to fetus induces fetal hyperglycemia, which results in fetal pancreatic islet hypertrophy and beta-cell hyperplasia with consequent fetal hyperinsulinemia.
infant morbidity associated with GDM
Excessive fetal growth places fetus at risk for shoulder dystocia and delivery complications. Also infant respiratory distress (hyperinsulinemia inhibits cortisol production of type II cells so lecithin is decreased), neonatal hypoglycemia (hyperinsulinemia), hyperbilirubinemia, mortality (increased insulin causes increased metabolic rate and hypoxemia) polycythemia and risk of childhood obesity/ diabetes
glucose tolerance test in GDM
blood sugar levels and insulin levels are higher in GDM
GDM risks to mom
•~50% Maternal risk of developing Type 2 DM in 5-10 years . Higher risk infection, C-section, Preeclampsia, preterm labor from polyhydramnios
GDM postpartum management
measure OGTT at 6-12 weeks post partum. If pre-diabetes us diet, exercise and possibly meds.
GDM diagnostic criteria
Following a 100g OGTT done at 24-48 weeks, or first prenatal visit if high risk: one or more of the following is diagnostic- Fasting blood glucose >95mg/dl, 1hr > 180, 2hr > 155, 3hr > 140
how is overt diabetes diagnosed during pregnancy
fasting blood glucose >126, A1C > 6.5% or random blood glucose > 200
Factors Associated with high BMI at 2-3 yr
maternal BMI, lipids, dietary fat, glucose (DM or GDM). Breast feeding is protective
Which form of diabetes is associated with major malformation of spine and heart
uncontrolled type 1 or type 2 diabetes in which hyperglycemia occurs during first trimester.
which criteria would support testing for diabetes at first prenatal visit
Obesity, Personal history of GDM or previous macrosomic infant, Family history of diabetes in a first degree relative, Polycystic ovarian ds (PCOS), High Risk Ethnic group, or Glycosuria most recs
what is the screening method used for GDM
50g OGTT. If glucose >140, use diagnostic 100g OGTT.
when does the ffetus start producing its own thyroid hormones
18 weeks- until then it relies on moms
thyroid function/ hormone levels during pregnancy
TSH is nl or slightly decreased during 1st and 2nd trimesters due to elevated hCG. Thyroid binding globulin increases due to estrogen. Total T4 and T3 increase by 50%, but free T4 is nl. Iodine requirements increase.
cretinism
mental retardation due to maternal and fetal iodine deficiency
maternal hypothyroidism
most due to hashimotos. Most wmen require 25% increase in thyroid hormone supplements early in gestation. Hypothyroidism can cause neurodevelopmental delay in offspring, pregnancy loss, preterm delivery, preeclampsia, abrptio placenta
most common cause of maternal hyperthyroidism
graves dz- but cant use a radioactive iodine thyroid scan during pregnancy to confirm
maternal hyperthyroidism sx
Normal pregnancy mimics thyroid excess- increased HR, C.O., flow murmur, heat intolerance, vasodilation.
subclinical hyperthyroidism
subclinical hyperthyroidism (suppressed TSH only) appears not to cause adverse pregnancy outcomes and treatment with antithyroid agents could be detrimental and result in fetal hypothyroidism
