Varney's Ch 24: Medical Complications in PREG Flashcards
What is the collective term for Type 1 and Type 2 Diabetes?
PGDM (pregestational diabetes mellitus)
Which types (2) of diabetes are forms of insulin resistance?
T2DM and GDM
What are the 2 categories of GDM?
A1GDM-diet controlled GDM
A2GDM-medically controlled GDM
Does insulin resistance increase or decrease throughout pregnancy?
Increases gradually and peaks in the late second to third trimester.
Which hormones produced by the placenta increase cellular resistance to insulin resulting in a higher blood glucose in pregnancy?
hPL (human placental lactogen) and other diabetogenic hormones. Peaks at 26-28 weeks GA.
Are both the fetus and placenta stimulated toward hypergrowth in GDM?
Yes
T/F. The fetus produces more insulin in response to increased maternal glucose.
True
T/F. GDM does not increase the chances for the infant to develop childhood obesity.
False. It increases chances for Type 1, Type 2, and metabolic syndrome.
T/F. Gestational diabetes can cause fetal growth restriction.
False. It causes macrosomia.
What are the complications related to GDM for the baby?
- macrosomia=shoulder dystocia
- neonatal hypoglycemia=NICU
- neonatal jaundice=NICU
- congenital heart defects
What is the criteria and time frame for diagnosing PGDM (pregestational diabetes mellitus)?
Timing: Diagnosed in the first trimester or early second trimester.
Criteria:
1) HbA1c >6.5%
2) fasting >126, –OR–
3) 2-hour 75-gm >200 mg/dL
What are the complications related to GDM for the mother?
1) preeclampsia
2) shoulder dystocia
3) cesarean birth
What are the target levels for glucose during pregnancy?
1) Fasting,
2) 1-hr postprandial (after meal)
3) 2-hr postprandial (after meal)
4) HbA1c
1) Fasting <95
2) 1-hr <140
3) 2-hr <120
4) HbA1c <6%
How much exercise is recommended for GDM?
30 mins of moderate intensity at least 5 days a week.
What is the preferred medication for treatment of A2GDM?
Insulin at 0.7-1.0 unit/kg daily divided into long-acting or intermediate-acting doses with short-acting doses throughout the day.
Does insulin cross the placenta?
No
Does Metformin cross the placenta
Yes.
What is the dosing of Metformin for GDM
1st week - 500 mg nightly
After - increase to 500 mg twice daily
At what weeks postpartum will you assess for T2DM for those with GDM?
Week 4-12 PP and Lifelong screening every 3 years.
At what weeks gestation would you provide a ultrasounds for GDM patients?
28, 32, and 36 weeks for fetal growth, polyhydramnios, and macrosomia.
What screening elements are included in the first trimester for patients with PGDM?
- HbA1c
- thyroid function
- electrocardiogram
- eye exam - retinopathy
- 24 hr urine collection
What are the recommendations for women with PGDM regarding folic acid and ASA?
1) 400 mcg folic acid to reduce the chances of neural tube defects that are increased with PGDM.
2) Aspirin - 81 mg daily after 12 weeks to reduce preeclampsia risk.
A2GDM ultrasounds are recommended how often after 32 weeks?
Twice weekly.
For T1DM mothers, are insulin requirements higher or lower in the first trimester?
Lower, creating an increased risk of hypoglycemia.
T/F Fetuses of women with diabetes develop respiratory maturity later than those without diabetes?
True, which increases risk of respiratory distress if delivered early.
When is induction recommended for a diabetic pregnant mother?
39.0 - 39.6 weeks GA
At what week does a qualifying pregnant woman take aspirin for preeclampsia prevention?
12 weeks.
Hypertension is the leading cause of postpartum readmission. T or F?
True
How is hypertension diagnosed in pregnancy?
- sitting for at least 10 mins
- BP >140/90 x 2 (>4 hours apart)
What BP is considered a severe-range and is a medical emergency?
BP >160/110 x 2 (>15 mins apart)
20%-50% of women with chronic HTN will develop preeclampsia. T or F?
True
What is the onset and diagnostic criteria superimposed preeclampsia?
- prior to pregnancy or <20 weeks
- BP >140/90
OR - Using HTN meds prior to PG
AND - New finding-proteinuria, elevated liver enzymes, thrombocytopenia, pulmonary edema, vision changes, renal insufficiency.
What is the onset and diagnostic criteria of gHTN ?
- > 20 weeks
- BP >140/90 x 2 (>4 hrs apart)
- withOUT proteinuria or features
What is the onset and diagnostic criteria of preeclampsia?
<100,000 platelets
- NEW ONSET HTN >140/90 x2 (>4hrs)
- proteinuria >300 mg/24 hrs
OR 2+ dipstick
OR >0.3 mg/dL protein/creatinine ratio - If no proteinuria, can include:
- twice elevated liver enzymes
- <100,000 platelets
- >1.1 serum creatinine or doubling
- pulmonary edema
- vision changes
What is the onset and diagnostic criteria of preeclampsia with SEVERE FEATURES?
BP >160/110
Same criteria for preeclampsia with one of the following:
- BP >160/110 x 2 (>15 mins)
- <100,000 platelets
- >1.1 serum creatinine or doubling
- severe RUQ pain
- pulmonary edema
- NEW ONSET cerebral or vision changes
What labs are used to evaluate chronic hypertension?
- serum creatinine
- electrolytes
- uric acid
- liver enzymes
- platelet
- urine protein
What symptom is the difference between preeclampsia and eclampsia?
Seizures
What is the diagnostic criteria for postpartum HTN?
- up to 12 weeks PP
- BP >140/90
Do antihypertensive medications cross the placenta?
YES
Which antihypertensive medications can cause fetal malformations if taken during pregnancy?
- ACEs
- ARBs
- spironolactone
- direct renin inhibitors
Can statins in pregnancy cause fetal harm?
Yes, they are teratogenic
Are salt-restricted diets and weight loss recommended for chronic HTN during pregnancy?
No
What medications are used to treat hypertension in a pregnant woman?
- nifedipine
- labetalol
- methyldopa
- amlodipine
When should serial fetal growth ultrasounds begin in a woman with chronic HTN that is controlled with medication?
32 weeks, weekly or bi-weekly depending on severity.
What are preeclampsia warning signs?
- persistent or severe headach
- visual disturbances
- new onset swelling of face or sudden weight gain
- new N/V in second half of PG
- RUQ or epigastric pain
- new onset dyspnea, orthopnea
What is the cause of hemoconcentration in preeclampsia?
fluid shifts from intravascular to extracellular spaces, reducing plasma volume that abnormally concentrates the Hgb and Hct.
Does creatinine clearance go up or down in preeclampsia?
It goes down.
What causes thrombocytopenia in preeclampsia?
Inappropriate activation of leukocytes, complement, and clotting factors depletes platelets, increases clotting time, and leads to hemolysis.
What causes FGR (fetal growth restriction) in preeclampsia?
Inadequate remodeling of spiral arteries leading to vasoconstriction and reduced placental perfusion.
How many risk factors for preeclampsia are found in this case scenario?
A 36 yo G1P0 with in vitro conception with twins. Family hx of her sister having preeclampsia. Med Hx of BMI 40, Type 2 DM, and chronic HTN.
EIGHT risk factors:
1. >35 years
2. nulliparity
3. In vitro conception
4. multifetal gestation
5. family hx of preeclampsia
6. >30 BMI
7. T2DM
8. chronic HTN
How many minutes should treatment be given after finding severe-range hypertension?
30 mins
How soon do you need to reevaluate BP postpartum for a woman who had severe hypertension?
within 72 hours after birth and again by day 7-10.
What does HELLP stand for?
H-hemolysis
EL-elevated liver enzymes
LP-low platelet count
What are the symptoms of HELLP syndrome?
- elevated BP
- RUQ or epigastric pain
- persistent HA
- visual changes
- significant weight gain
- malaise
- dyspnea
- N/V
What is the symptom associated with hepatic rupture?
Severe pain in the RUQ.
What are the classes of HELLP syndrome?
Class 1 (severe) = platelets <50 K
Class 2 (moderate) = platelets 50-100 K
Class 3 (mild) = platelets 100-150
When is birth recommended in cases of preeclampsia?
37 weeks
When is birth recommended in cases of severe hypertension or HELLP?
34 weeks
When can antihypertensive medications be discontinued postpartum?
Once BPs remain controlled for at least 48 hours.
What does the acronym TORCH stand for?
T-toxoplasmosis
O-syphilis
R-rubella
C-cytomegalovirus
H-herpes
