43. Gestational Diabetes Flashcards

1
Q

T/F: pregnancy is an insulin resistant state

A

True

It is mediated by GH, CRH, placental lactogen

Increase in prolactin, progesterone, cortisol

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2
Q

Glucose intolerance diagosed in pregnancy

A

Gestational diabetes

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3
Q

Gestational diabetes is typically diagnosed based on ________ Classification System

A

White’s

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4
Q

Compare/contrast type A1 vs. type A2 based on White’s classification system

A

Type A1 = gestational diabetes; diagnosed in pregnancy and controlled with diet alone (no meds)

Type A2 = gestational diabetes; diagnosed in pregnancy and controlled with diet and glyburide or insulin

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5
Q

Risk factors for gestational diabetes

A

Overweight (BMI >25) and…

  • FH of diabetes
  • High risk race/ethnicity
  • Previous LGA infant
  • Previous GDM
  • HTN
  • PCOS
  • A1c >5.7%
  • Hx of CVD
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6
Q

When do you typically screen for gestational diabetes?

A

24-28 weeks

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7
Q

T/F: physicians should screen on risk factors for GDM alone

A

False, then we would miss 50% of cases

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8
Q

What are the current screening recommendations for GDM?

A

Screen ALL patients between 24-28 wks

2 step approach: 1 hr glucola (50g glucose tolerance test) — abnormal result is 130-140 mg/dL, if abnormal proceed to 3 hr GTT

If initial result is >200 mg/dL proceed to diabetic education

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9
Q

What is the difference between the 1 hr glucola and 3 hr GTT?

A

1 hr glucola does not need to be fasting as result is not dependent on prior oral intake

3 hr GTT must be fasting, requires 2 abnormal values to be diagnostic

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10
Q

What are some alternative screening regimens for GDM?

A

2 hr GTT (75 g load)

HgA1c

Fasting glucose

Random glucose monitoring

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11
Q

What are the 2 first line antepartum guidelines for GDM?

A

Dietary changes: caloric intake based on weight - baseline 30 kcal/kg, 50% carbs, 25% protein, 25% fat

Exercise: moderate exercise 3-5x/week with goal of 150 min/week, walking after meals which greatly improves glucose control

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12
Q

What is the testing regimen like for GDM?

A

Daily monitoring — fasting and 1 or 2 hr postprandial

[peak postprandial glucose occurs at 90 min]

may not need to test as much for well controlled pts

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13
Q

Fasting glucose should be ______

1 hr postprandial should be ____

2 hr postprandial should be ____

A

<95 mg/dL

<140 mg/dL

<120 mg/dL

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14
Q

T/F: with dietary changes, 70-80% of those with GDM can achieve euglycemia

A

True

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15
Q

What are examples of oral hypoglycemic agents?

A

Glyburide

Metformin

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16
Q

In terms of medication, what is first line tx for GDM? Why?

A

Insulin; bc it does not cross placenta

17
Q

MOA of metformin

A

Inhibits hepatic gluconeogenesis and glucose absorption

Stimulates glucose uptake in peripheral tissues

18
Q

Why is metformin chosen less frequently than insulin for GDM?

A

It crosses the placenta, although there are no recorded long term data on neonatal effects

19
Q

Adverse effects of metformin

A

Diarrhea, abdominal pain

26-46% will still require tx with insulin

20
Q

Benefits of metformin

A

Good option for cost, administration, and compliance

21
Q

MOA of glyburide

A

Binds pancreatic beta cell ATP/K receptors

Increases insulin sensitivity in peripheral tissues

22
Q

Studies are mixed about glyburide, but placental crossing is likely minimal. However, fetal _____ may be a side effect

A

Hypoglycemia

23
Q

Maternal risks associated with GDM

A

Preeclampsia
LGA
Delivery trauma

24
Q

Mothers with GDM have a 4x higher likelihood of developing _____ in the first 5 years

A

T2DM

[also 10x more likely in first 10 years, 60% of latin american women develop within 5 yrs of pregnancy]

25
Q

Fetal risks of GDM

A

Macrosomia

Neonatal hypoglycemia

Hyperbilirubinemia

Shoulder dystocia

Birth trauma

Stillbirth

Increased risk of childhood and adult onset obesity and diabetes

26
Q

When and how do you monitor a mother with GDM?

A

Monitoring of fetus begins at 32 weeks with NST and biophysical profiles

Serial amniotic fluid measurements

US for growth

27
Q

Which form, A1 or A2, has lower risk with less monitoring required?

A

A1

28
Q

When is delivery recommended for mothers with GDM?

A

A1DM = deliver after 39 wks

A2DM = deliver after 39 wks

Preexisting diabetes = 38-39 wks

Poorly controlled = 37-39 wks

29
Q

In terms of intrapartum management, the goal of identification and management are reduction of fetal risks of what 3 conditions?

A

Preeclampsia
LGA
Shoulder dystocia

30
Q

What are other goals of intrapartum management in mothers with GDM?

A

Optimal glycemic control during labor, which allows effective contractions/labor progression, and optimal environment for infant at delivery

31
Q

Goals for postpartum GDM management

A

2 hr oral GTT after 6 wks postpartum

PCP f/u

Preventative therapy — impaired fasting glucose, impaired glucose tolerance, diabetes

Repeat screening every 1-3 years after delivery