Small for gestational age, HT disease of pregnancy, Maternal medicine

Question 1

What do we mean by small for gestational age?

Answer 1

● Estimated foetal weight less than the 10th centile.
○ Differs from intrauterine / foetal growth restriction (IUGR / FGR), which implies a
pathological restriction of full genetic growth potential (RCOG definition).
○ Severe SGA is defined at EFW less than 3rd centile.

Question 2

How can we measure foetal size?

Answer 2

Surveillance of foetal size can be performed with the following measurements:
1. Symphyseal fundal height (measured regularly at routine antenatal appointments
from 24+0 onwards).
2. Foetal abdominal circumference.
3. Femur length.
4. Head circumference / biparietal diameter.
5. Liquor volume / amniotic fluid index (normal = 5-25cm)

Question 3

What are the risk factors for small gestational age?

Answer 3

Maternal age >40
2. Smoker >11 cigarettes per day.
3. Maternal cocaine use in pregnancy.
4. Maternal daily vigorous exercise
5. Previous SGA baby
6. Previous stillbirth
7. Maternal SGA
8. Paternal SGA
9. Chronic hypertension
10. Diabetes with vascular disease
11. Renal impairment
12. Antiphospholipid syndrome
13. Nulliparity
14. Previous pre-eclampsia

Question 4

What are the investigations that we do for small gestational age?

Answer 4

● Routine monitoring:
○ First Line: SFH measurement
○ SFH is plotted on a customised growth chart.
■ Adjusted to maternal height, weight, parity and ethnicity.
○ Second Line: USS scan (see Foetal Measurement).
● Any single major risk factor:
○ Serial (2 weekly) USS and umbilical artery Doppler from 26-28 weeks.
● Any single SFH <10th centile or slow / static growth:
○ Serial USS and umbilical artery Doppler.

Question 5

What are some further investigations for SGA?

Answer 5

• umbilical artery doppler
• CMV and toxoplasmosis screening - indicated in severe SGA
• MCA Doppler

Question 6

Why do we use umbilical artery doppler for SGA?

Answer 6

• Normal low-resistance placenta allows continuous positive flow from foetus to placenta
  throughout the cardiac cycle (i.e. in systole and diastole).
• If end-diastolic flow is slowed / reversed, this suggests increased placental resistance, which
  implies placental compromise (for example due to pre-eclampsia) and is predictive of SGA.

Question 7

Why use MCA doppler for SGA?

Answer 7

• Measured in comparison to umbilical artery flow.
• Hypoxic foetus diverts blood flow to the brain to spare cerebral function - this increases MCA
  diastolic flow in relation to UA diastolic flow.
• MCA flow also increases in foetal anaemia.

Question 8

How do we manage SGA?

Answer 8

● RCOG recommends umbilical artery Doppler as the primary surveillance tool for an
SGA foetus.
● Current guidelines state, in general:
○ An SGA foetus should be delivered by caesarean section before 37 weeks
gestation.

Question 9

A woman is pregnant with her second baby - 20 weeks gestation – gush of fluid vaginally
Obstetrics think premature rupture of membranes
What do they do now?

Answer 9

Erythromycin for 10 days to reduce risk of chorioamnionitis

Question 10

A woman is pregnant with her second baby - 20 weeks gestation – gush of fluid vaginally
Obstetrics think premature rupture of membranes
What about steroids?

Answer 10

Too early for that
About 50% chance of delivery in the next 7 days

Question 11

When should we offer resuscitation?

Answer 11

1. Assess gestational age
2. Asess presence of non-modifiable risk factors
3. Assess modifiable Risk Factors

Question 12

How do we assess gestational age?

Answer 12

GA (weeks)
Extreme high risk: 22-23
High risk: 23-24
Moderate risk: 25-26

Question 13

Non - modifiable RFs for resuscitation- what increases gestational age (Decreases GA risk is opposite of these)

Answer 13

Gestational week: Beginning of week
Fetal growth: fetal growth restriction
Fetal sex: Male
Plurality: Multiple

Question 14

What are the modifiable risk factors for resuscitation which increase GA? Opposite for Decrease GA risk

Answer 14

Antenatal steroid: None
Setting for birth: Local Hospital

Question 15

Monitored maternal temperature & foetal growth
Nothing happens
Now 22 weeks gestation – should we offer resuscitation?
At Jessop survival sub 23 weeks is 30% at best – if you make it to the neonatal unit.
What intervention now to improve outcome?

Answer 15

12 mg betamethasone, 24 hours apart, hopefully up to 24 hours before delivery

Question 16

Monitored maternal temperature & foetal growth
Nothing happens
Now 22 weeks gestation
Given 12 mg betamethasone, 24 hours apart, hopefully up to 24 hours before delivery
Mother remains apyrexial
Foetal growth is faltering, down to second centile
Now 25 weeks gestation, estimated foetal weight 600 grams
What other assessments should they do?

Answer 16

• Foetal blood flow – using Doppler
• Absent end diastolic flow is a bad sign
• Reversed end diastolic flow is even worse

Question 17

Monitored maternal temperature & foetal growth
Nothing happens
Now 22 weeks gestation
Given 12 mg betamethasone, 24 hours apart, hopefully up to 24 hours before delivery
Mother remains apyrexial
Foetal growth is faltering, down to second centile
Now 25 weeks gestation, estimated foetal weight 600 grams
Still pregnant however, now 28 weeks, estimated foetal weight 650 grams
Reversed end diastolic flow.
High concern about foetal demise
What should we do now?

Answer 17

Another course of steroids – only last 1 to 4 weeks
Intravenous MgSO4 – as neuroprotection 30% reduction in risk of cerebral palsy if given within 24 hours of birth

Question 18

What are the birth weight categories?

Answer 18

 1500g Very low birth weight
 1000g Extremely low birth weight
 750g Incredibly low birth weight

Question 19

What are the different types of Hypertensive disease of pregnancy?

Answer 19

Pregnancy-induced hypertension, Pre-eclampsia, Eclampsia, HELLP syndrome

Question 20

What is PIH?

Answer 20

PIH: new-onset hypertension, developing after 20 weeks gestation.

Question 21

What is Pre- eclampsia?

Answer 21

new-onset hypertension associated with proteinuria or systemic
features*, developing after 20 weeks gestation.
spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.

Question 22

What is the presentation for PIH?

Answer 22

asymptomatic, headaches, blurred vision

Question 23

What is the presentation for pre- eclampsia?

Answer 23

• asymptomatic,
• headaches,
• upper abdominal pain,
• blurred vision,
• reduced foetal
  movements //
• brisk reflexes,
• systemic hypertension

Question 24

Classic triad of pre-eclampsia

Answer 24

Hypertension
Proteinuria
Oedema

Question 25

What is the pathophysiology of pre-eclampsia?

Answer 25

When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.

Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.

When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels

SHORTEN PLEASE

Question 26

What are the RFs for pre- eclampsia?

Answer 26

High-risk factors are:

Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease

Moderate-risk factors are:

Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia

Question 27

Which women are offered aspirin from 12 weeks gestation for pre- eclampsia?

Answer 27

Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Question 28

What are the symptoms of pre-eclampsia?

Answer 28

Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes

Question 29

What are the initial investigations for PIH and Pre- eclampsia?

Answer 29

○ blood pressure measurement (140/90mmHg, +30/+15 in pre-existing
hypertension)
○ urinalysis (protein 2+ on dipstick, >30mg/mmol protein-creatinine ratio)
○ sFLT : PlGF ratio (>85 is diagnostic)

Question 30

What are some further investigations for for PIH and Pre- eclampsia?

Answer 30

○ Bloods: FBC, U+E, LFT twice-weekly
○ Ultrasound scan: to assess foetal growth and AFI, 2-weekly
○ Umbilical Artery Doppler velocimetry: assess placental perfusion, 2-weekly
○ Cardiotocography: upon diagnosis, + if RFM, PV bleed, abdo pain, deterioration
○ Auscultation of foetal heart: offer at every appointment

Question 31

How do we make a diagnosis for pre-eclampsia?

Answer 31

The NICE guidelines (2019) advise a diagnosis can be made with a:

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:

Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Proteinuria can be quantified using:

Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 32

What is placental growth factor?

Answer 32

The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Question 33

What is the management for gestational HT without proteinuria?

Answer 33

• Treating to aim for a blood pressure below 135/85 mmHg
• Admission for women with a blood pressure above 160/110 mmHg
• Urine dipstick testing at least weekly
• Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
• Monitoring fetal growth by serial growth scans
  PlGF testing on one occasion

Question 34

What is the management for PIH and pre-eclampsia?

Answer 34

Prevention: 75mg aspirin OD from 12/40 onwards.
● First Line: labetalol (beta-blocker)
● Second Line: nifedipine
● Third Line: methyldopa
● Plus: consider early delivery at 37 weeks
● Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
● IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
● Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 35

What is given to women having a premature birth?

Answer 35

• Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.
• Blood pressure is monitored closely after delivery. Blood pressure will return to normal over time once the placenta is removed.

For medical treatment, NICE recommend after delivery switching to one or a combination of:

• Enalapril (first-line)
• Nifedipine or amlodipine (first-line in black African or Caribbean patients)
• Labetolol or atenolol (third-line)

Question 36

What are one of the main complications of pre- eclampsia?

Answer 36

Eclampsia: Tonic-clonic seizures in presence of pre-eclampsia

Question 37

How do we manage Eclampsia?

Answer 37

intravenous magnesium sulphate, emergency delivery via
LSCS.

Question 38

What is HELLP syndrome?

Answer 38

syndrome of Haemolysis, Elevated Liver enzymes, Low Platelets.

Question 39

Investigations for HELLP?

Answer 39

○ blood pressure measurement (140/90mmHg, +30/+15 in pre-existing
hypertension)
○ urinalysis (protein 2+ on dipstick, >30mg/mmol protein-creatinine ratio)
○ sFLT : PlGF ratio (>85 is diagnostic)

Question 40

What is the management for HELLP syndrome?

Answer 40

Prevention: 75mg aspirin OD from 12/40 onwards.
● First Line: labetalol (beta-blocker)
● Second Line: nifedipine
● Third Line: methyldopa
● Plus: consider early delivery at 37 weeks
● Expedite delivery

Question 41

What is the diagnostic criteria for severe pre-eclampisa requiring urgent hospital admission

Answer 41

1. Systolic BP > 160mmHg
2. Severe headaches, visual scotomata, N+V, Oliguria, epigastric pain, pulmonary oedema
3. Rising creatinine, elevated liver enzymes, thrombocytopenia

Question 42

Pathophysiology of pre- eclampsia?

Answer 42

1. Defective remodelling of maternal spinal arteries - inadequate oxygenation of trophoblastic tissue > oxidative stress
   1a. Stressted trophopblast releases pro-inflamm cytokines + sFLT into maternal circulation
   1b. Pro-inflamm cytokines distrupt maternal endothelium - leads to systemic inflamm response and reduced blood flow to maternal organs
   1c. HT due to impaired renal blood flow and reduced eGFR a s well as elevated sFLT
   1d. Proteinuria arises from glomerular changes of basement membrane and podocytes
2. Defective remodelling results in placental hypoperfusion - inadequate nutrient deliver to foetus causing IUGR
3. Systemic features arise from maternal endothelial dysfunction and resulting vasodilation - leads to hypovolemic shock
   3a. Seizures thought to be due to cerebral vasospasm

Question 43

What is obstetric cholestasis? (Definition)

Answer 43

● Obstetric condition causing increased serum bile acids and hepatic dysfunction.

Question 44

What is the pathophysiology for obstetric cholestasis?

Answer 44

○ Oestrogen inhibits hepatic bile acid receptors in genetically susceptible women,
leading to impaired bile acid homeostasis.
● Leads to deposition of bile salts in various tissues including skin and placenta.
● Skin deposition leads to pruritus (itching).
● Placental deposition causes raised foetal bile acid levels - this can cause acute foetal
deterioration - thought to be either foetal arrhythmia / cardiomyopathy or placental
vasoconstriction

Question 45

What are the S + S of obstetric cholestasis/ presentation?

Answer 45

● Pruritus (sparing hands and face).
● Excoriations (scratch marks).

Question 46

What are the investigations for obstetric cholestasis?

Answer 46

● Serum bile acids (raised above 19 micromol/L)
● Liver function tests

Question 47

What is the management for obstetric cholestasis?

Answer 47

● First Line: emollient plus antihistamine
● Second Line: ursodeoxycholic acid
● Plus: consider expedited delivery
○ Dependent on serum bile acid concentration
○ For example: delivery at 35-36 weeks for women with peak bile acid
concentration >100 micromol/L due to increased stillbirth risk.

Question 48

What is the definition of Gestational Diabetes mellitus?

Answer 48

● Chronic hyperglycemia and insulin resistance due to pregnancy

Question 49

What are the risk factors for gestational diabetes?

Answer 49

• Previous gestational diabetes
• Previous macrosomic baby (≥ 4.5kg)
• BMI > 30
• Ethnic origin (black Caribbean, Middle Eastern and South Asian)
• Family history of diabetes (first-degree relative)
• PCOS
• Maternal age >40

Question 50

What should anyone with RFs for with gestational diabetes do?

Answer 50

Anyone with risk factors should be screened with an oral glucose tolerance test at 24 – 28 weeks gestation. Women with previous gestational diabetes also have an OGTT soon after the booking clinic

Question 51

Screening and diagnosis of GDM in pregnancy?

Answer 51

Oral Glucose Tolerance Test (OGTT) at 24-28 weeks in women with risk factors

Women with previous GDM also have an early OGTT at 13-14 weeks

Fasting blood glucose and 2-hour blood glucose following 75g OGTT:
Fasting ≥ 5.6
2 hour ≥ 7.8

Question 52

Other indications to screen for GDM in pregnancy?

Answer 52

• Large for gestational age fetus > 90th centile
• Glycosuria of +2 or +1 or more than more occasion
• Increased fluid (polyhydramnios)

Question 53

What is the aetiology/ pathophysiology of gestational diabetes?

Answer 53

● In normal pregnancy, local and placental hormones stimulate peripheral insulin
resistance - the purpose of this is to spare glucose for delivery to the developing foetus.
● This is accompanied by lipolysis and gluconeogenesis, further increasing free fatty acid
and glucose levels.
● Hypertrophy and hyperplasia of pancreatic beta-cells occurs to protect maternal glucose
homeostasis.
● Failure of this protective mechanism due to beta-cell dysfunction, in combination with
insulin resistance, leads to GDM.

Question 54

What are maternal complications of gestational diabetes?

Answer 54

○ Pre-eclampsia
○ Chronic type 2 diabetes (60%)
○ Increased risk of cardiovascular disease

Question 55

What are the foetal complications of gestational diabetes?

Answer 55

○ Macrosomia, leading to shoulder dystocia
○ Neonatal hypoglycaemia (due to dependence on maternal hyperglycaemia
raising endogenous foetal insulin).
○ Childhood obesity (2x background risk).
○ Increased risk of metabolic syndrome and associated complications in later life
○ Large for dates fetus

Question 56

What are the risk factors for gestational diabetes?

Answer 56

● BMI > 30
● Previous macrosomia
● Previous GDM
● Family history of diabetes mellitus
● Ethnicity with high prevalence of diabetes
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)

Question 57

How do we perform an Oral Glucose Tolerance Test?

Answer 57

An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.

Normal results are:

Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.

Question 58

How do we diagnose women with gestational diabetes?

Answer 58

● Women with any one of the above risk factors should be screened for GDM at 24-28
weeks.
● Women with glycosuria detected at a routine antenatal appointment should be
screened at any time in their pregnancy.
● First Line: oral glucose tolerance test (OGTT)
○ Fasting blood glucose, followed by 75g carbohydrate drink, with a second blood
glucose test 2 hours later.

Question 59

Diagnostic criteria for gestational diabetes

Answer 59

● Diagnostic Criteria: 5678
○ Fasting plasma glucose > 5.6mmol/L or
○ 2 hour glucose > 7.8mmol/L

Question 60

What is the management for gestational diabetes?

Answer 60

● First Line: 2 week trial of diet, exercise and self-monitoring glucose levels
● Second Line: if not successful, metformin
● If FPG >7.0: start insulin immediately.
● Plus: extra growth scans at 28, 32, 36 weeks.

Question 61

What is the NICE management guidelines for gestational diabetes?

Answer 61

• Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
• Fasting glucose above 7 mmol/l: start insulin ± metformin
• Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
• Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.

Question 62

What does metformin do?

Answer 62

Metformin – acts on the liver to lower glucose production, decreases intestinal absorption of glucose and enhances insulin sensitivity

Question 63

What do women who need to monitor their blood sugar levels targets should be according to NICE?

Answer 63

Fasting: 5.3 mmol/l
1 hour post-meal: 7.8 mmol/l
2 hours post-meal: 6.4 mmol/l
Avoiding levels of 4 mmol/l or below

Question 64

What should women with pre-existing diabetes do when pregnant or before becoming pregnant?

Answer 64

They should take 5mg folic acid from preconception until 12 weeks gestation.

Question 65

Maternal risks of pre-existing diabetes?

Answer 65

• Miscarriage
• Three- to fourfold increased risk of pre-eclampsia. Increased if hypertension and/or renal disease
• Infection – urinary tract, respiratory, endometrial and wound
• Increased caesarean section rate

Question 66

Fetal risks of pre-existing diabetes

Answer 66

Congenital abnormalities - neural tube defects, skeletal abnormalities, congenital heart disease. Level of risk related to glycaemic control at time of conception and correlates with HbA1c

Perinatal and neonatal mortality – can be increased 5- 10-fold and relate to glycaemic control and HbA1c

Intrauterine fetal death

Fetal macrosomia – insulin is an anabolic, growth promoting hormone
- Can occur in women with good control, however more common with poor control
- Shoulder dystocia

Preterm birth
- Iatrogenic
- Idiopathic, can be related to polyhydramnios

Neonatal hypoglycaemia

Respiratory distress syndrome

Question 67

What should women with existing type 1 and type 2 diabetes aim for with insulin levels?

Answer 67

Same target levels as with gestational diabetes
Women with type 2 diabetes are managed using metformin and insulin, and other oral diabetic medications should be stopped.

Question 68

When should retinopathy screening be performed?

Answer 68

hould be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.

Question 69

What does NICE advise for a planned delivery for women with pre-existing diabetes?

Answer 69

advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).

Question 70

When is a sliding-scale insulin regime considered?

Answer 70

during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes

Question 71

Postnatal diabetes

Answer 71

Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth. They need follow up to test their fasting glucose after at least six weeks.

Question 72

What is the management of postnatal GDM?

Answer 72

• Stop medication
• Healthy lifestyle advice
• HbA1c at 13 weeks with GP
• 39-47mmol/L – at high risk of diabetes
• ≥ 48mmol/L diagnostic of type 2 diabetes
• Annual HbA1c

Question 73

What should women with existing diabetes do?

Answer 73

Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period. The insulin sensitivity will increase after birth and with breastfeeding.

Question 74

What are babies of mothers with diabetes at risk of?

Answer 74

Neonatal hypoglycaemia
Polycythaemia (raised haemoglobin)
Jaundice (raised bilirubin)
Congenital heart disease
Cardiomyopathy

Question 75

What do babies need for diabetes?

Answer 75

Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.

Question 76

What are the physiological changes in glucose metabolism in pregnancy? 1

Answer 76

Pregnancy is a state of physiological insulin resistance and relative glucose intolerance

Glucose handling is altered in pregnancy
Fasting levels are decreased
Serum levels following a meal/glucose load are increased compared to non pregnant state

In second and third trimesters insulin resistance increases

Question 77

What are the physiological changes in glucose metabolism in pregnancy? 2

Answer 77

Glucose tolerance decreases with increasing gestation after the first trimester
Largely due to anti-insulin hormones secreted by the placenta in normal pregnancy (human placental lactogen, glucagon and cortisol)

Normal women show an approx. doubling of insulin production from the end of the first trimester to the third trimester

Question 78

What are the effect of the physiological changes of the physiological changes of glucose metabolism?

Answer 78

Likely to underlie the increased insulin requirements of women with existing diabetes
Lead to the development of abnormal glucose tolerance in gestational diabetes - where there is insufficient insulin secretion to compensate for the insulin resistance

Question 79

What are the types of diabetes in pregnancy?

Answer 79

Pre-existing:
Type 1
Type 2
Cystic fibrosis related
Maturity onset diabetes of the young (MODY) – rare

Question 80

What is the importance of identifying GDM?

Answer 80

Women with GDM have a higher chance of fetal macrosomia and adverse pregnancy outcome than control population without GDM – modifiable with intervention

Women with GDM have a greatly increased risk (40-60%) of developing type 2 diabetes within 10-15 years

A small proportion (1 in 1000) or women identified as having GDM will have diabetes pre-dating the pregnancy (type 1 and 2 and rarely MODY)

Question 81

What are the risks of GDM?

Answer 81

Fetal macrosomia (estimated or birthweight > 4kg)
Shoulder dystocia and birth related trauma (fetal and maternal)
Perinatal mortality – in utero fetal death and neonatal death
Neonatal hypoglycaemia

Question 82

What is the obstetric management of GDM?

Answer 82

Monitoring for pre-eclampsia with regular BP and urine checks

Regular fetal growth scans (usually 28, 32 and 36 weeks) – to assess fetal size, growth velocity and enable delivery planning

Timing of delivery – induction of labour or planned caesarean section
For uncomplicated GDM – delivery by 40+6
For complicated GDM – 37 – 38+6

Intrapartum care
Fetal monitoring
Hourly monitoring of blood glucose
May need variable rate insulin infusion to maintain blood glucose

Question 83

What are complications of diabetes?

Answer 83

Infections – candida, Staph skin infections
Macrovascular arterial disease – coronary artery disease, cerebrovascular disease, peripheral vascular disease
Microvascular disease - retinopathy, nephropathy, neuropathy
Reduced life expectancy due to accelerated arterial disease (stroke, myocardial infarction)

Question 84

Effects of pregnancy on diabetes

Answer 84

Increased insulin dose requirement, particularly in the third trimester. Often women with type 2 diabetes start insulin in pregnancy

Women with diabetic nephropathy may have deterioration of renal function and worsening degree of proteinuria

Risk of progression or development of retinopathy. Due to rapid improvement in glycaemic control and increased retinal blood flow

Hypoglycaemia with relative hypo unawareness

Diabetic ketoacidosis – risk in hyperemesis, infection and steroid therapy

Question 85

Features of diabetic ketoacidosis

Answer 85

Hyperglycaemia (capillary blood glucose >11mmol/l)
Acidosis (venous pH <7.3 and/or venous bicarbonate <15)
Ketonaemia or ketonuria (capillary ketones >3 mmol/l or urine ketones more than 2+)

Question 86

Predisposing factors of DKA

Answer 86

infection, vomiting, poor control/non-compliance, beta sympathomimetic drugs and antenatal corticosteroids

Emergency that demands prompt and vigorous treatment to reduce the maternal and fetal morbidity and mortality

Question 87

Obstetric management of GDM

Answer 87

Folic acid 5mg ideally from preconception (or as early as possible) until 14 weeks

Early dating and viability scan

Dating and nuchal translucency scan and detailed anomaly scan

Aspirin 150mg once daily from 12 weeks until delivery – to reduce risk of pre-eclampsia

Ultrasound scans for fetal growth at 28, 32 and 36 weeks

Question 88

Obstetric management - timing of birth in GDM

Answer 88

1 or type 2 diabetes and no other complications between 37 weeks and 38 weeks plus 6 days of pregnancy
Induced labour
Caesarean section

Sometimes need to consider birth < 37 weeks in women who have maternal or fetal complications.

Question 89

Intrapartum care of GDM

Answer 89

Woman with type 2 diabetes and some type 2 diabetics will need variable rate insulin infusion from onset of labour

Variable rate infusion commenced if 2 blood glucose levels >7

Hourly blood glucose monitoring

Aim for blood glucose 4-7mmol/L

Question 90

Care of neonates in GDM

Answer 90

Women with diabetes should feed their babies as soon as possible after birth (within 30 minutes) – reduce hypoglycaemia

Blood glucose testing routinely at 2 to 4 hours after birth in babies of women with diabetes

Minimum 24-hour hospital stay

Question 91

Postnatal care of GDM

Answer 91

Postpartum, insulin requirements rapidly return to pre-pregnancy levels

Clear plan to reduce insulin doses / or stop if indicated

Dose adjustment in breastfeeding women – increased energy expenditure

Tight glycaemic control not as important in postpartum period

Contraception discussion and plan

Counselling about importance of planned pregnancy and pre-pregnancy counselling

Question 92

Pre - pregnancy counselling features

Answer 92

Women with diabetes should ideally be seen for specialist pre-pregnancy counselling

Importance of good glycaemic control, aim HbA1c ≤ 48mmol/L. Women with an HbA1c level above 86 mmol/mol (10%) should be advised against pregnancy

Pre-pregnancy folic acid 5mg (reduce risk of neural tube defects)

Optimisation of diabetic control

Assessment and modification of any diabetic complications