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Year 2 Medicine > Pregnancy and Diabetes > Flashcards

Pregnancy and Diabetes Flashcards

1
Q

Maternal Hyperglycemia during pregnancy … for the fetus

A

Maternal Hyperglycemia during pregnancy is bad / very bad for the Fetus

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2
Q

Why does Diagnosing Maternal Hyperglycemia matter?

  • It affords an opportunity to prevent
    • … in the offspring “from the uterus to the …”
    • An exacerbation of the … & … epidemic
    • Future … in the mother
A
  • It affords an opportunity to Prevent
    • –Morbidity In the offspring “from the uterus to the grave”
    • –An exacerbation of the obesity & Type 2 diabetes epidemic
    • –Future Type 2 diabetes in the mother
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3
Q

Hyperglycemia of Pregnancy

  • At Ante Natal Care booking there are 2 groups:
      1. Women with …
      1. Women with …
        * Known …
        * Unknown … or …
A
  • At ANC booking there are 2 groups
      1. Women with Normal Glucose tolerance
      1. Women with Abnormal Glucose tolerance
        * Known Diabetes
        * Unknown Diabetes or IGT (impaired glucose tolerance)
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4
Q

Hyperglycaemia during Pregnancy - Possible Scenarios

  • Pre-… Hyperglycaemia
    • Type 1 Diabetes
    • Type 2 Diabetes
      • Known
      • Unknown
    • … Diabetes
    • … (IGT)
  • “… Diabetes” (GDM)
    • Any newly found Abnormal GTT after the … trimester of pregnancy ( i.e. Diabetes or IGT )
A
  • Pre-gestational Hyperglycaemia
    • –Type 1 Diabetes
    • –Type 2 Diabetes
      • Known
      • Unknown
    • Monogenic Diabetes
    • Impaired Glucose Tolerance (IGT)
  • “Gestational Diabetes” (GDM)
    • Any newly found Abnormal GTT after the 1st trimester of pregnancy ( i.e. Diabetes or IGT )
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5
Q
A
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6
Q

What is “Gestational Diabetes” (GDM)? - Practical Definitions

  • WHO criteria ( and NICE)
    • Diabetes OR Impaired Glucose Tolerance
      • Fasting glucose =/ > … mmol/l
      • 2 hour GTT glucose =/ > … mmol/l
  • International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria
    • Outcome based (HAPO study)
A
  • WHO criteria ( and NICE)
    • Diabetes OR Impaired Glucose Tolerance
      • Fasting glucose =/ > 5.6 mmol/l
      • 2 hour GTT glucose =/ > 7.8 mmol/l
  • International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria
    • Outcome based (HAPO study)
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7
Q

WHO criteria for Gestational Diabetes:

  • Fasting glucose =/ > … mmol/l
  • 2 hour GTT glucose =/ > … mmol/l
A
  • Fasting glucose =/ > 5.6 mmol/l
  • 2 hour GTT glucose =/ > 7.8 mmol/l
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8
Q

International Association of Diabetes & Pregnancy Study Group (IADPSG) criteria - Gestational Diabetes

  • Outcome based (HAPO study)
  • What numbers in a glucose … test were associated with increased … for the fetus
A
  • Outcome based (HAPO study)
  • What numbers in a glucose tolerance test were associated with increased risk for the fetus
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9
Q

Hyperglycaemia of Pregnancy IADPSG Criteria

  • 75 g Glucose Tolerance test
    • Fasting … mmol/l
    • 1 hour … mmol/l
    • 2 hours … mmol/l
  • Diagnose if 1 or more abnormal
A
  • 75 g Glucose Tolerance test
    • Fasting 5.1 mmol/l
    • 1 hour 10.0 mmol/l
    • 2 hours 8.5 mmol/l
  • Diagnose if 1 or more abnormal
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10
Q

Hyperglycaemia in Pregnancy : The Problem

A
  • Any degree of Maternal Hyperglycaemia during pregnancy can cause serious problems for the fetus
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11
Q

Hyperglycemia during pregnancy - Consider management

  • .. pregnancy
  • .. pregnancy
  • .. pregnancy
A
  • Before pregnancy
  • During pregnancy
  • After pregnancy
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12
Q

Stages of Pregnancy - Simple Endocrinologist’s view!

  • 1st Trimester
    • O…
      • Carefully design the … components
      • Avoid Mistakes (T..)
      • Construct & programme the …
  • 2nd Trimester
    • Further … development & linkage
  • 3rd Trimester
    • Accelerated …
A
  • 1st Trimester
    • Organogenesis
      • Carefully design the essential components
      • Avoid Mistakes ( Teratogenesis)
      • Construct & programme the placenta
  • 2nd Trimester
    • Further complex development & linkage
  • 3rd Trimester
    • Accelerated growth
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13
Q

Maternal Metabolism changes as Pregnancy progresses

  • Early pregnancy = Facilitated A…
    • Increased Insulin …
    • Glucose concentration slightly …
    • … maternal energy stores
  • Later Pregnancy = Facilitated C…
    • Increased Insulin …
    • Increased … passage of nutrients
    • -> Rapid fetal …
A
  • Early pregnancy = Facilitated Anabolism
    • Increased Insulin sensitivity
    • Glucose concentration slightly lower
    • Increased maternal energy stores
  • Later Pregnancy = Facilitated Catabolism
    • Increased Insulin resistance
    • Increased transplacental passage of nutrients
    • -> Rapid fetal growth
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14
Q

Maternal Hyperglycaemia - How does this mess with the system?

  • 1st Trimester
    • Increased Fetal …
      • Fuel Mediated T…
    • Abnormal … programming & development
      • Increased risk of Pre-…
      • Excessive … transport
  • Late Second & 3rd Trimester
    • Excessive … deposition
    • Adverse Fetal … ( epigenetics )
A
  • 1st Trimester
    • Increased Fetal abnormalities
      • Fuel Mediated Teratogenesis
    • Abnormal placental programming & development
      • Increased risk of Pre-eclampsia
      • Excessive glucose transport
  • Late Second & 3rd Trimester
    • Excessive fat deposition
    • Adverse Fetal programming ( epigenetics )
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15
Q

First Trimester Maternal Hyperglycaemia leads to fetal malformation- , such as:

  • Hydro…
  • Meningo…
  • … … in Congenital Heart Disease
  • Single … and Sacral …
  • … Agenesis
A
  • Hydrocephalus
  • Meningomyelocoele
  • Central Cyanosis in Congenital Heart Disease
  • Single Ventricle and Sacral Dysgenesis
  • Renal Agenesis
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16
Q

This graph is showing the percentage of … … in diabetes vs women without diabetes

A

Congenital Malformations

17
Q

Congenital Malformations due to Maternal Hyperglycemia

  • … tube defects
  • Congenital … abnormalities
  • … Agenesis
  • … problems
A
  • Neural tube defects
  • Congenital cardiac abnormalities
  • Sacral Agenesis
  • Renal problems
18
Q

Preventing Fetal Malformation in Hyperglycaemia of Pregnancy
- Start Preconception for known Diabetes

  • Good Diabetes Control in … Trimester
    • … counselling
      • … Modification
      • Intensive … monitoring
      • If not on … commence …
      • Optimize … Regimen
        • B… Bolus or Pump
        • Freestyle … or continuous … monitoring
  • … Acid 5mg / day
A
  • Good Diabetes Control in 1st Trimester
    • Prepregnancy counselling
      • Lifestyle Modification
      • Intensive glucose monitoring
      • If not on Insulin commence Insulin
      • Optimize Insulin Regimen
        • Basal Bolus or Pump
        • Freestyle Libre or continuous glucose monitoring
  • Folic Acid 5mg / day
19
Q

Primary care & Prevention of Fetal Malformation due to Hyperglycaemia of Pregnancy

  • Identify Unknown cases of Diabetes / IGT by checking women with risk factors
    • Previous … Diabetes
    • O…
    • … … syndrome
    • Family history of …
    • High risk … group
A
  • Identify Unknown cases of Diabetes / IGT by checking women with risk factors
    • Previous Gestational Diabetes
    • Obesity
    • Polycystic ovarian syndrome
    • Family history of type 2 diabetes
    • High risk racial group
20
Q

Prevention in Primary care
DPP - Mean Weight Change

  • Green = ?
  • Yellow = ?
  • Blue = ?
A
  • Green = Placebo
  • Yellow = Metformin
  • Blue = Lifestyle
21
Q

What is Macrosomia?

A

Macrosomia is a term that describes a baby who is born much larger than average for their gestational age, which is the number of weeks in the uterus.

22
Q

Hyperglycaemia in the third trimester = lead to …

A

Macrosomia (larger than average baby)

23
Q

Macrosomia - Hyperglycaemia in 3rd Trimester - leads to…

  • Difficult …
  • … Dystocia
  • … Problems
      • J…
    • …glycaemia
    • Hypo…
    • Poly…
A
  • Difficult birth
  • Shoulder Dystocia
  • Breathing Problems
    • + Jaundice
    • Hypoglycaemia
    • Hypocalcaemia
    • Polycythaemia
24
Q
  • Women with Diabetes vs No Diabetes - Increased … Mortality
  • T2 Diabetes = x …
  • T1 Diabetes = x …
A
  • Increased Perinatal Mortality = T2 Diabetes x 9, T1 Diabetes x 4
25
Q

Hyperglycaemia in Pregnancy - Lifelong Fetal Sequele

  • O…
  • … resistance
  • … diabetes
  • Dys…
  • …tension
  • … disease
  • Adverse … outcomes?
A
  • Obesity
  • Insulin resistance
  • Type 2 diabetes
  • Dyslipaemia
  • Hypertension
  • Vascular disease
  • Adverse neurodevelopmental outcomes?
26
Q

Compounding the Problem - Pregnancy and Diabetes

  • The number of women with diabetes during pregnancy giving birth has more than … recently,
    • a finding that raises health concerns for both mothers-to-be and babies.
  • USA Today 28/04/2008​
A
  • The number of women with diabetes during pregnancy giving birth has more than Doubled recently,
    • a finding that raises health concerns for both mothers-to-be and babies.
  • USA Today 28/04/2008​
27
Q

“One in … women in the United Kingdom is obese at antenatal booking”,

  • BMJ 2013
A

“One in five women in the United Kingdom is obese at antenatal booking”,

  • BMJ 2013
28
Q

Detecting Hyperglycemia of Pregnancy - Early Screening for high risk women

  • Previous … or M..
  • Obesity ( BMI > …)
  • … history
  • High risk … group
  • … age
  • … … syndrome
      • Universal or Targeted Screening & …-… weeks
A
  • Previous GDM or MACROSOMIA
  • Obesity ( BMI > 30)
  • Family history
  • High risk racial group
  • Older age
  • Polycystic ovary syndrome
      • Universal or Targeted Screening & 26-28 weeks
29
Q

Treatment of any Pregnancy Hyperglycaemia

  • Good maternal … control
    • Intensive blood … …
      • … prick tests
        • Fasting + 1 hour post … minimum
        • Fasting + 1 hr post … + pre…
      • … Libre (or continuous monitoring system)
  • Appropriate n…
  • Reasonable e…
  • Utrasound monitoring of Fetal … girth
    • Monthly from … weeks
  • Maternal observation of Fetal …
A
  • Good maternal glucose control
    • Intensive blood glucose monitoring
      • Finger prick tests
        • Fasting + 1 hour post prandial minimum
        • Fasting + 1 hr post prandial + preprandial
      • Freestyle Libre (or continuous monitoring system)
  • Appropriate nutrition
  • Reasonable exercise
  • Utrasound monitoring of Fetal abdominal girth
    • Monthly from 28 weeks
  • Maternal observation of Fetal movements
30
Q

Targets for Hyperglycaemia of Pregnancy

  • Fasting glucose < … mmo/l
  • 1 hour postprandial glucose < … (…) mmol/l
  • Fetal Abdominal girth < …th centile
    • Less in A…
A
  • Fasting glucose < 5.1 mmo/l
  • 1 hour postprandial glucose < 7 (7.8) mmol/l
  • Fetal Abdominal girth < 70th centile
    • Less in Asians
31
Q

Drug treatment to achieve good Maternal Glucose control in pregnancy

  • Prepregnancy /1st trimester hyperglycaemia
    • … … Insulin regimen
  • “Gestational” diabetes
    • M…
    • Basal …
    • Basal … Insulin
    • G… (ONLY IF NO ALTERNATIVE)
A
  • Prepregnancy /1st trimester hyperglycaemia
    • Basal bolus Insulin regimen
  • “Gestational” diabetes
    • Metformin
    • Basal Insulin
    • Basal bolus Insulin
    • Glibenclamide (ONLY IF NO ALTERNATIVE)
32
Q

Diabetes / GDM – Post Partum

  • Encourage … …
  • Maintain good … control
    • To prevent excess … in …
    • Reduce maternal … …
  • Advice re next pregnancy
  • C.. advice
  • Encourage long term … control
A
  • Encourage Breast Feeding
  • Maintain good Glycaemic control
    • To prevent excess glucose in milk
    • Reduce maternal weight gain
  • Advice re next pregnancy
  • Contraception advice
  • Encourage long term glycemic control
33
Q

Breast Feeding & Obesity

  • Child
    • Any reduces risk by …-…%
      • 19 studies 3-19 years
      • 6 studies 4-18 years
    • Prolonged exclusive reduces by …%
  • Mother
    • Reduces postpartum … …
A
  • Child
    • Any reduces risk by 30-50%
      • 19 studies 3-19 years
      • 6 studies 4-18 years
    • Prolonged exclusive reduces by 67%
  • Mother
    • Reduces postpartum weight gain
34
Q

What did this study show?

A

Women who lactated for either 6–12 months or 12 months or longer had half the risk for diabetes

35
Q

“Specific GDM” Management - Post Partum

  • Screen for diabetes at … weeks post partum
    • HbA1c +/- Fasting glucose, ( or GTT )
  • Review GAD ect. antibody status if done
  • Lifestyle advice
  • Advice re next pregnancy
    • Optimize exercise & Nutrition
    • Pre pregnancy GTT
  • … glucose screening
    • …% develop type 2 diabetes at 10 years
A
  • Screen for diabetes at 12 weeks post partum
    • HbA1c +/- Fasting glucose, ( or GTT )
  • Review GAD ect. antibody status if done
  • Lifestyle advice
  • Advice re next pregnancy
    • Optimize exercise & Nutrition
    • Pre pregnancy GTT
  • Annual glucose screening
    • 50% develop type 2 diabetes at 10 years
36
Q

GDM & Primary Care – Post Partum - Contraceptives & Diabetes / IGT

  • … … pill
  • … … ( low dose) after … weeks
  • Mirena … system
  • Sterilisation / Vasectomy
A
  • Progestagen only pill
  • Combined OCP ( low dose) after 6 weeks
  • Mirena Intrauterine system
  • Sterilisation / Vasectomy
37
Q

Hyperglycaemia in Pregnancy - Summary 1 – The Problem

  • Maternal Hyperglycaemia leads to Serious … problems
    • Early - T…
    • Late
      • M… / hypo… / lung problems
      • Pre-…
      • Late Fetal …
      • Perinatal J…, poly…
A
  • Maternal Hyperglycaemia leads to Serious fetal problems
    • Early - Teratogenesis
    • Late
      • Macrosomia / hypoglycaemia / lung problems
      • Pre-eclampsia
      • Late Fetal death
      • Perinatal Jaundice, polycythemia
38
Q

Hyperglycaemia in Pregnancy Summary 2 - Management

  • Folic acid …mg in 1st Trimester
  • Aspirin … - … mg/day from 12/40
    • if less than 16/40
  • Attendance at … one stop clinic
  • Tight … control throughout pregnancy
  • Fetal … monitoring in last trimester
  • Maternal monitoring of Fetal …
  • Appropriate delivery strategy (NO …!!)
A
  • Folic acid 5mg in 1st Trimester
  • Aspirin 75 - 150 mg/day from 12/40
    • if less than 16/40
  • Attendance at multidisciplinary one stop clinic
  • Tight glucose control throughout pregnancy
  • Fetal Ultrasound monitoring in last trimester
  • Maternal monitoring of Fetal movements
  • Appropriate delivery strategy (NO DOGMA!!)
39
Q

Hyperglycaemia in Pregnancy - Summary 3 - Screening

  • Screen to detect “… diabetes”
    • High risk women at …-… weeks
    • At … weeks
      • Everyone (Universal screening ) or
      • Targeted (NICE)
  • Postpartum Screen “GDM women” for Diabetes
    • At … week post Partum
    • Annually for Diabetes (…% by 15 years)
A
  • Screen to detect “Gestational diabetes”
    • High risk women at 12-14 weeks
    • At 28 weeks
      • Everyone (Universal screening ) or
      • Targeted (NICE)
  • Postpartum Screen “GDM women” for Diabetes
    • At 12 week post Partum
    • Annually for Diabetes (50% by 15 years)

Year 2 Medicine (162 decks)

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