Module 5 Study Guide

Question 1

How does pregnancy increase the risk of gestational diabetes (GDM)?

Answer 1

Hormones (HPL, progesterone, etc) made by the placenta produce increased glucose and make moms body resistant to insulin thus causing a build up of glucose in the blood. There is NOT a lack of insulin, it is just less effective.

Question 2

What are risk factors for GDM?

Answer 2

Obestiy/high BMI, family hx of diabetes, history of large baby >9lb, older than 25 y/o, race, pre-diabetes

Question 3

According to ACOG, who requires early screening for GDM?

Answer 3

Consider Testing if overweight or obese (BMI >25; Asian Americans BMI > 23) and one or more of the following factors:
Physical inactivity
1st degree relative with DM
High-risk race or ethnicity (AA, Latino, Native American, Asian American, Pacific Islander)
History of infant ≥ 4000 g (≈ 9 lbs)
History GDM
Hypertension (140/90 or on hypertension therapy)
HDL < 35 mg/dL, triglyceride level >250 mg/dL
Polycystic ovary syndrome
A1C ≥ 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
Other clinical conditions associated with insulin resistance (eg prepregnancy BMI > 40, acanthosis nigricans
History CVD

Question 4

What are the maternal implications of GDM (short and long term)?

Answer 4

Increased risk of PP DM II (50% develop)

Pre-E, HTN disorder, polyhydramnios, protracted labor, maternal birth trauma, operative delivery, PPH

Women with pregestational DM are more likely to develop additional probelms

Question 5

What are the fetal and newborn implications of GDM?

Answer 5

Stillbirth, macrosomia/LGA, birth trauma, shoulder dystocia, hyperinsulinemia->hypoglycemia, polycythemia, hyperbilirubinemia, RDS, early childhood obesity, metabolic syndrome, DM II

Question 6

What is the rationale for universal GDM screening?

Answer 6

GDM does not typically present with symptoms. Universal screening decreases maternal and fetal complications. Screening is recommened after 24 weeks (24-28w) in asymptomatic pts.

Question 7

When is the 50-g GDM screening used?

Answer 7

Used for step one of the two step approach. 50g of oral glucose given to pt and BS checked 1 hour post.

Question 8

When is the 100-g GDM screening used?

Answer 8

This is used as a diagnostic test when the 1-hour is elevated. The test is done in the morning with an overnight fast. 100g of glucose is injested by the patient and labs assesses at 1, 2, and 3 hours. Two or more elevated results is considered a diagnosis of GDM. Someone if one elevation is not diagnosed GDM but monitoring is recommended. Another 3h gtt can be given later, diet changes, or treat as GDM without diagnosis.

Question 9

When is the 75-g GDM screening used?

Answer 9

Outside of the U.S. this is commonly used as a 2 hour gtt test. One elevated result is considered a diagnosis of GDM.

Is also used PP to assess GDM resolution

Question 10

What is the GDM two-step testing approach?

Answer 10

A 1h screening test at 24-28w with 50g glucose
If failed 1h, follow with 3h diagnostic test with 100g glucose

Question 11

What is the GDM one-step testing approach?

Answer 11

A screening and diagnostic test of 75g 2 hour

GDM to be diagnosed when any one of the following values are exceeded
FBS 92 mg/dL or above
1-h 180 mg/dL or above
2-h 153 mg/dL or above

Question 12

What is the threshold value for a 1-hr, 50g GDM screening?

Answer 12

Threshold is 130-140 mg/dL for failure. 130 results in more false positive, 140 results in more false negatives.

> 200 can be diagnosed GDM

Question 13

What are the threshold values for a 3-hr, 100g GDM screening?

Answer 13

There are two different “cut-offs” used. The NDDG or the Carpenter/Coustan. There is not currently a recommendation on which should be used. One study comparing the two suggests the later has improved outcomes.

C/C is the lower threshold and NDDG the higher.

Two elevated labs results in GDM diagnosis

Question 14

Why does ACOG support a two-step testing versus one-step testing?

Answer 14

ACOG mentions that individual practices and organizations may choose to use the IADPSG’s 75-g, 2-hour OGTT recommendation if it is appropriate for that particular practice and community; however, ACOG supports the two step process (ACOG, 2018).

According to the ADA, there is insufficient data to strongly support the one vs. two step method.

Question 15

When is blood sugar monitoring indicated in GDM management? How many times a day should a patient monitor their blood sugar?

Answer 15

Four times a day. Fasting and 2 hours post meals

Question 16

What is the fasting threshold value in patient with GDM? What is the 2-hr PP threshold?

Answer 16

<95 mg/dL

<120 mg/dL

Question 17

What is the first-line management of GDM?

Answer 17

First-line is diet and exercise (aka. Non-pharm management)

Question 18

When are diet and exercise indicated in GDM management?

Answer 18

All patients diagnosed with GDM or DM should recieve dietician care and exercise education.
Patient should be advised to follow a diet of 33-40% complex carbs and eliminate simple sugars, 20-30% protein, and 40% fats. They should eat 3 meals with 2-3 snacks a day to maintain sugars.
Exercise increases glucose uptake and insulin sensitivity. Exercise can be comparable to insulin in glycemic control.

Encourage 30minute brisk walk five days a week, 10-15minute walk after each meal or sitting arm exercises for 10 minutes after each meal.

Question 19

When are medications indicated in GDM management?

Answer 19

If 2-hour postprandial values indicate hyperglycemia and poor glycemic control, or if fasting blood sugars (FBS) are high (diet modification has little effect on FBS) or if a perinatal individuals is not gaining weight, then pharmacologic intervention is indicated.

3-5 weeks should be given after education/diagnosis

Question 20

What medication is first-line in GDM management?

Answer 20

Insulin (2nd line is metformin)
Metformin can be used when insulin is declined, the patient cannot afford it, or it cannot be used. Note: metformin does cross the placenta.

Question 21

What oral medication is preferred in GDM management?

Answer 21

Metformin
Glyburine is associated with worse outcomes and increased need for insulin for good glycemic control.

Question 22

When is fetal antenatal surveillance required in GDM management?

Answer 22

Varney: for those with glycemic control without insulin; 40 weeks additional fetal monitoring is needed. Patients on insulin, NST twice weekly starting at 32 weeks.

ACOG: Pre-diabetic, GDM, and poor glycemic control, and medication controlled initiate at 32 weeks. Diet controlled; may not need additional monitoring until 40 weeks.

Question 23

What are the maternal and fetal indications for induction of labor for GDM?

Answer 23

Diet controlled: plan delivery after 39 weeks with expectant management until 40 6/7
Medication controlled: Delivery recommended 39-39 6/7 weeks
C/S is NOT required, patient can have IOL. C/S to be discussed for EFW >4,500g

Question 24

What is the primary intrapartum risk for a patient with GDM?

Answer 24

Hypoglycemia in the newborn due to uncontrolled glucose in labor

Question 25

How does the nurse-midwife manage a patient with GDM during the intrapartum period?

Answer 25

Should be comanaged if insulin is needed

Protocols vary for diet controlled. Some only require a blood sugar on admission. Others recommended monitoring during labor. Insulin is often recommended for BG >110 though some research suggest BG of 126-140 doesnt significantly increase risk of neonatal hypoglycemia.

Question 26

How does the nurse-midwife manage a patient with GDM during the postpartum period?

Answer 26

4-12 weeks PP, the patient should be given a 75g 2-hour OGTT to determine if GDM has resolved. It should then been repeated every 1-3 years.

Note: a failed test must be confirmed by a test on a subsequent day

Question 27

How does the nurse-midwife manage a patient with GDM during the postpartum period?

Answer 27

4-12 weeks PP, the patient should be given a 75g 2-hour OGTT to determine if GDM has resolved. It should then been repeated every 1-3 years.

Note: a failed test must be confirmed by a test on a subsequent day

Question 28

What are the signs and symptoms of newborn hypoglycemia?

Answer 28

Bluish-colored or pale skin.
Breathing problems, such as pauses in breathing (apnea), rapid breathing, or a grunting sound.
Irritability or listlessness.
Loose or floppy muscles.
Poor feeding or vomiting.
Problems keeping the body warm.
Tremors, shakiness, sweating, or seizures.

Question 29

What newborns are at risk for hypoglycemia?

Answer 29

Late preterm, small for gestational age, infants of diabetic mothers and large for gestational age.

Question 30

What are the optimal timing and intervals for glucose screening in the newborn?

Answer 30

Feed w/in 1 hr of birth and check BG 30 min after first feed
If refeed required, recheck 1 hr later
If BG good, feed on demand at least every 2-3 hr and recheck before feeds
Blood glucose levels initially fall to a nadir approx 1-2 hrs after birth.
The physiologic low occurs approx 1-1.5 hrs after birth
Levels stabilizing at 3-4 hrs

Question 31

What level of interprofessional collaboration (i.e. consultation, collaboration, or referral) is warranted for a newborn with hypoglycemia?

Answer 31

Referral

Question 32

What is the pattern of fundal height measurement with size > dates?

Answer 32

Should be consistently within 1-2cm of GA

Be concerned if 3+cm difference or inconcsistent

Question 33

What is the clinical definition of macrosomia? What is the difference between macrosomia and large for gestational age (LGA)?

Answer 33

Macrosomia= typically 4,000g -4500g (8lb 13oz-9lb 15oz)

LGA= weight >90% for gestation age (ex: 4,000g at 40w is 90%)

Question 34

What are risk factors for macrosomia?

Answer 34

Diabetes
Prior macrosomic Infant
Increased maternal prepregnancy weight
Increased maternal weight gain
Multiparity
Male fetus
Ethnicity
Ga >40w
Maternal birth weight
Maternal height
Maternal age <17
Abnormal 1h gtt with normal 3 h gtt

Question 35

What are the potential maternal implications of macrosomia and LGA?

Answer 35

Increased risk of cesarean section and labor abnormalities

Question 36

What are the potential fetal and neonatal implications of macrosomia and LGA?

Answer 36

Risk of clavicular fracture and brachial plexus injury (18-21 times higher)
What is the actual risk of shoulder dystocia?
The actual risks of shoulder dystocia are 0.2-3% of all births with 9-14% occurring among infants with weights 4,500g or more. The risk is highest when a birth weight of 4,500g or more is combined with maternal diabetes (20-40%). The reality is the majority of shoulder dystocias actually occur unpredictably among normal birth weight infants (ACOG, 2020).

Question 37

What is the midwifery intrapartum management for macrosomic and LGA fetuses?

Answer 37

Macrosomia is not an indication fo C/S. C/S is recommended for EFW >5000 or 4500g with DM or in a prolonged 2nd stage of arrest of 2nd stage.
Note: incidence of shoulder dystocia with a macrosomic baby 20-50%

Question 38

What is the clinical definition of polyhydramnios?

Answer 38

AFI ≥24cm (Normal is 6-24 cm)
Deepest vertical pocket of ≥8cm (Normal is 2-8)

Question 39

What is the clinical presentation of polyhydramnios?

Answer 39

Often the patient will have no or mild symptoms
Heartburn, nausea, vomiting, dyspnea, orthopnea, edema in lower extremities, oliguria
Fundal height >2cm different from GA OR increase from prior pattern of growth
Ballotable fetus, difficulty palpating fetal parts, fluid thrill
Muffled FHT

Question 40

What are risk factors for polyhydramnios?

Answer 40

Most cases are idiopathic
Poorly controlled DM
Congenital anomalies (duodenal atresia, gastroschisis, T-E fistula, diaphragmatic hernia, anencephaly, cystic hygromas, nonimmune hydrops, genetic syndromes, placental abnormalities)
Multifetal gestation (TTTS)
Isoummunization or infection

Question 41

How is polyhydramnios diagnosed?

Answer 41

By ultrasound though AFI or single deepest vertical pocket

Question 42

What are the potential fetal and neonatal implications of polyhydramnios?

Answer 42

Macrosomia, fetal intolerance, meconium, preterm labor, low cord PH, low APGAR, NICU admission

Question 43

What level of midwifery management (consult/collaborate/refer) is indicated in patients with polyhydramnios?

Answer 43

CONSULT for suspected or known polyhydramnios.
Note: do not trust the fetal lie and do not perform amniotomy without head being well applied.

Question 44

How accurate is ultrasound measurement in determining fetal weight?

Answer 44

At 7lb it is within a pound. Smaller babies, are more accurate. Larger babies are less accurate.

Question 45

What is the relationship between macrosomia, diabetes, and shoulder dystocia?

Answer 45

DM can result in macrosomic babies which can increase shoulder dystocia risk. DM with macro will have SD 20-50% of the time.

Question 46

According to the ACOG macrosomia bulletin, when is it appropriate to consider a cesarean birth for a large baby (with and without GDM)?

Answer 46

5,000g without DM
4,500g for those with DM