Diabetes

Question 1

What happens to insulin in pregnancy and why?

What is this due to?

Answer 1

• to maintain normal glucose, insulin must double in 2nd and 3rd trimester
• pregnancy insulin resistant state, due to placental secretion of oestrogen, progestogen and lactogen, changing peripheral insulin receptors
• foetus receives insulin due to glucose crossing placenta, therefore 1mmol lower than mum

Question 2

What can hyperinsulinaemia cause in the foetus?

Answer 2

• anabolic hormone, causes macrosomia, organomegaly and increased erythropoiesis
• also causes surfactant deficiency, therefore more chance of RDS

Question 3

What should diabetic women be counselled on antenatally?

What drug should they be given?

Answer 3

• achievement of optimal control to reduce risk of miscarriage
• assess severity (e.g. retinopathy, nephropathy etc)
• stop smoking, optimise weight and alcohol
• folic acid 5mg (increased risk of NTD)
• rubella status

Question 4

What advice should they be given for labour?

Answer 4

• elective induction between 37-39 weeks

- postpartum insulin requirements dramatically fall therefore reduce insulin

Question 5

What are the risk factors for GDM?

Answer 5

• FH of 1st degree relative with diabetes
• BMI >30
• previously large baby (>4kg)
• unexplained stillbirth
• previous GDM
• PCOS
• polyhydramnios
• glycosuria

Question 6

What test can be done?

Answer 6

• OGTT ASAP then at 24-28 weeks if previous GDM

- only at 24-28 weeks if they have risk factors

Question 7

What is the management of GDM?

Answer 7

• diet and exercise if <7.0
• metformin otherwise
• insulin if still not controlled
• advise induction labour by 40+6 if no complications

Question 8

what are maternal the complications of diabetes in pregnancy?

foetus

Answer 8

• UTI, recurrent vulvovaginal candidiasis, pre-eclampsia, obstructed labour, increased diabetic complications
• miscarriage and congenital abnormalities if poor control
• pre-term labour, polyhydramnios (25%), macrosomia (25-40%), IUGR, unexplained IUD

Question 9

neonatal complications of diabetes in pregnancy?

Answer 9

• polycythemia
• jaundice
• hypoglycaemia
• low Mg and Ca
• cardiomegaly
• birth trauma
• RDS