Flashcards in 07 Gestational Diabetes Besinque Deck (52):
What complications to the FETUS does pregnancy in a women with pre-existing diabetes have?
Macrosomia/Large for gestational age (LGA) infants. Stillbirth. Neonatal death. Major congeintal malformations. Hypoglycemia, hyperbilirubinema. Jaundice
What complications to the MOTHER does pregnancy in a women with pre-existing diabetes have?
Hypoglycemia. HTN. Worsening of retinopathy, nephropathy. Increased maternal mortality
What are some pre-pregnancy couseling tips for women with diabetes?
Weight loss to BMI < 27. Keep A1c < 6.1% before conceiving. Strive for good glycemic control before/during pregnancy. Begin folic acid from PRE-conception to at least 12 weeks (5mg/day). Eye exam and nephropathy assessment pre-conception
Patients with DM often have other co-morbidities, what medications should be discontinued before pregnancy?
Statins, ACE-I/ARBs. Some OHGA. Convert to insulins that have safety record with pregnancy (Regular human, aspart, lispro, NPH)
What is a concern with women using insulin in early pregnancy?
Hypoglycemia. Counsel about warning signs. Provide glucose tablets
What are the insulin requiremens like during pregnancy?
Early (first trimester) insulin requirements decrease. After 12th week (placental formation) insulin requirements rise and require frequent adjustments (hyperglycemia concern). During labor and delivery insulin requirements decrease (hypoglycemia)
What are the premeal, bedtime, and overnight glucose goals for women with type 1 or 2 DM?
What is the peak postprandial glucose goal for women with type 1 or 2 DM during pregnancy?
What is the goal A1c for pregnant women with DM?
What are the insulin requirements for women with DM who are pregnant?
Basal and prandial insulin with intensified insulin regimens (multiple dose regimens). Women using detemir or glargine can be transitioned to NPH insulin twice or three times daily. Match prandial insulin doses to carbohydrate intake, pre-meal blood glucose, and activity level. Rapid-acting insulin analogs such as lispro or aspart may produce better postprandial control with less hypoglycemia compared with the use of pre-meal regular insulin
What is the definition of gestational diabetes mellitus (GDM)?
Carbohydrate intolerance first recognized DURING pregnancy
What are the two different classifications of DM occurring during pregnancy?
Overt diabetes. Gestational diabetes
What is Overt Diabetes?
Diagnosis when a women meets any of the criteria at the 1st prenatal visit: 1) Fasting plasma glucose >126. 2) A1c > 6.5. 3) Random plasma glucose > 200 that is subsequently confirmed by elevated fasting plasma glucose or A1c, as noted above
What is Gestational Diabetes?
Diagnosis can be made when a women meets either criteria: 1) FPG > 92 but < 126 at any gestational age (FPG > 126 is overt diabetes). 2) At 24-28 weeks of gestation: 75 gram two hour OGTT with at least one abnormal result (one hour > 180 or two hour > 153)
What is the prognosis like for women with GDM?
True GDM resolves after delivery. Women with GDM may be at higher risk for DM later in life. Offspring may be more likely to develop DM
What have studies on gestational diabetes shown?
Recent studies have demonstrated significant benefits from treatment of GDM (infant or mother). Treatment is considered essential
What are some risk factors for GDM?
FHx of DM. Pre-pregnancy weight >110% IDW or BMI >30. Age > 25. Previous baby > 9lbs. Ethnicity. Previous unexplained perinatal loss of child. Mothers weight at birth was >9lbs or < 6lbs. Glycosuria at first prenatal visit. Polycystic ovary syndrome. Current use of glucocorticoids. Essential HTN or pregnancy-related HTN. Increased weight gain during pregnancy
How does glucose tolerance work in a normal pregnant person?
There is insulin sensitivity (1st trimester) followed by insulin resistance (2nd and 3rd trimester). Normal women are able to increase insulin output to counter the increased insulin resistance
How does glucose intolerance occur in GDM?
GDM is thought to develop when insulin secretion does not increase enough to counteract the decrease in sensitivity
During pregnancy, what do the hormones cause?
Lower glucose levels. Increased fat deposition. Delayed gastric emptying. Increased appetite. This leads to an increased insulin production and secretion and insulin resistance at peripheral sites
What are the hormones like in patients with GDM?
Higher fasting insulin levels. Delayed insulin response to a glucose load. A decreased production of insulin after a glucose load than normal pregnant patients
How does GDM cause a larger fetus?
Mothers blood brings extra glucose to fetus (can cross the placental barrier, but maternal insulin does not). Fetus makes more insulin to handle the extra glucose. Extra glucose gets stored as fat and fetus becomes larger than normal
What is Screening vs. Diagnostic Testing for GDM?
Screening is usually performed as a two-step process. Diagnostic testing can be limited to these high risk individuals and avoided in low risk individuals. Alternatively, a diagnostic test can be administered to all individuals, which is a one-step process
What is the "Two Step" approach for screening?
Most widely used approach for identifying pregnant women with diabetes. 1) A 50g oral glucose load is given without regard to the time since the last meal and plasma glucose is measured one hour later; a value > 130 or > 140 is considered abnormal, some providers use > 130 as the threshold. 2) Second step is to give a 75g OGTT, using same criteria as one step approach
What is the "One Step" approach?
Endorsed by the ADA, but not by ACOG. Simplifies testing for diabetes in pregnancy to a 75g two hour OGTT and requires only a single elevated value for diagnosis, rather than the previous three hour GTT requiring two elevated values for diagnosis
For the two hour 75g oral glucose tolerance test, what values are diagnostic for GDM?
Fasting > 92 or One-hour > 180 or Two-hour > 153
If you do a 100gm 3 hours GTT the values that you look for a somewhat similar, what is the 3 hour measurement you look for to diagnose?
Three-hour > 140
What are the 2011 Recommendations for screening?
Screen for undiagnosed T2DM (at 1st prenatal visit in those with risk factors, using standard diagnostic criteria (FPG, A1c, Random BG +/- OGTT)). In pregnant women not known to have diabetes, screen for GDM at 24-28 weeks of gestation, using a 75g 2h OGTT
What should you do with women who had GDM and already delivered the baby?
Screen women with GDM for persistent diabetes 6-12 weeks postpartum. Women with history of GDM should have LIFELONG screening for the development of diabetes or pre-diabetes at least every 3 years
What is the protocol for pregnancies less than 24 weeks of gestation?
Draw blood for FBG, Random glucose, or A1c in women at high risk for diabetes
When blood is drawn for pregnancies less than 24 weeks, what is done when FBG >92 and <126?
GDM, no further testing
When blood is drawn for pregnancies less than 24 weeks, what is done when FBG >126 or A1c >6.5 or random BG > 200
Overt diabetes, no further testing
When blood is drawn for pregnancies less than 24 weeks, what is done when FBG <200?
75g 2h OGTT at 24-28 weeks
What is the protocol for pregnancies >24 weeks of gestation?
75g 2h OGTT
What is the general Patient Centered Approach to GDM?
Nutritional management. Physical activity. Monitoring blood glucose. Goal of therapy is to prevent, detect, and treat acute and chronic complications
How often should women with GDM monitor their blood glucose?
Four times daily (while fasting and two hours after meals) and when they have symptoms of hyperglycemia or hypoglycemia
What are the target maternal capillary glucose goals for GDM?
FPG 95 and either 1h post-meal 140 or 2h post-meal 120
What are the overall goals in treating GDM?
Normoglycemia. Avoid ketosis. Adequate (but not excess) weight gain
What do the dietary strategies include for GDM treatment?
Caloric restriction (especially in overweight patients). Reduction in fat intake. Substitution of complex carbohydrates for refined carbohydrates
What is the general rule for weight gain in pregnancy?
Women at ideal body weight before pregnancy have a higher amount of weight they can put on than women who are obese before pregnancy. Generally ~30lb gain is the limit for normal women
What should the meal pattern be like for pregnant women?
Three or more meals daily. Frequent snacks are encouraged (low calorie). 40% carbs, 20% protein, 40% fat
What should exercise be like for pregnant women?
Exercise may increase glucose utilization and improve insulin sensitivity. Exercise in GDM should involve the upper body and place low stress on the lower body and trunk regions. New or extensive exercise programs are not indicated, should stick with the exercise routine that was done pre-pregnancy
When is drug therapy usually given for GDM?
Women who fail to achieve control with diet therapy should be given drug therapy
What is the drug of choice for GDM?
Human insulin (R, N) is the drug of choice (insulin analogs such as lispro or aspart may also be used)
What oral medication has been studied with good results for GDM?
Glyburide. Not FDA approved
What are the target ADA glucose goals for GDM?
FPG < 95. One-hour <120
What type of insulins are used for GDM?
Regular, NPH have most experience. Lispro and aspart have minimal placental crossing and no evidence of fetal risk. Begin with a simplified, once or twice-daily regimen of regular insulin and NPH insulin. Dose based on glucose levels. Whatever the initial regimen, all dosages must be adjusted based on self-monitoring blood glucose levels
What are the uses of Glyburide for GDM?
Most studied of all OHGA during pregnancy. Not recommended as first line treatment. Can be used in women who fail diet and will not use insulin. Preferred to other OHGA because it does not cross the placental barrier extensively
What is the MOA of Metformin?
Biguanides lower blood glucose levels by decreasing hepatic gluconeogenesis, increasing peripheral glucose disposal and reducing intestinal glucose absorption
What is the MOA of Thiazolidinediones?
Act by improving insulin sensitivity in adipose tissue, muscle, and liver
What is treatment for GDM like at delivery?
Discontinue hypoglycemic agents immediately after birth. Insulin requirements and glucose level decrease dramatically at delivery. Infant and maternal hypoglycemia monitoring is needed. For most patients, delivery cure GDM