Antenatal - Gestational diabetes & acute fatty liver of pregnancy

Question 1

preexisting diabetes

Answer 1

SAFER

stop hypoglycaemic agents - switch to metformin and insulin, stop statins and diuretics

hba1c less than or = to 48, aspirin

folate - from 3 months before conception - 3 months after

explanation, pt education

renal and retinal screening, u&es, urine pcr

during pregnancy - blood glucose monitoring 4 times a day, retinopathy screening, plan delivery early, fetal growth scans from 28 weeks

blood glucose target levels -

cont. ctg, consultant led delivery unit, avoid hypoglycaemia, variable rate insulin infusion

Question 2

what is gestational diabetes?

Answer 2

reduced insulin sensitivity during pregnancy which resolves after birth

Question 3

what are the risk factors for gestational diabetes?

Answer 3

• previous gestational diabetes
• previous macrosomic baby >4.5kg
• BMI >30
• ethnic origin - black caribbean, middle eastern and south asian
• family history of diabetes

screen all of these at booking with oral glucose tolerance test

Question 4

what are some risks to the baby of gestational diabetes?

Answer 4

baby - macrosomia and complications eg shoulder complications, IUD, increased risk of hypoglycaemia once born, stillbirth

mother - risk of delivering large baby ie instrumental, CS, hypoglycaemia unawareness, pre eclampsia, infections, diabetic retinopathy, DKA, pubic symphysis dysfunction

Question 5

what is the screening test of choice for gestational diabetes?

Answer 5

oral glucose tolerance test - OGTT

Question 6

when is the OGTT used?

Answer 6

when there are risk factors for GD and when there are features that suggest GD such as

• large for dates fetus
• polyhydramnios
• glucose on urine dip stick

high risk - booking, everyone at 28 weeks

Question 7

how is the OGTT carried out and what are the results?

Answer 7

fast

drink 75g glucose drink

blood sugar measures fasting then 2 hours after

normal = fasting <5.6 mmol/l, 2 hours <7.8 mmol/l

(5-6-7-8)

Question 8

how is gestational diabetes managed?

Answer 8

4 weekly scans to check growth and amniotic fluid volume from 28-36 weeks

fasting glucose <7 = trial diet and exercise for 2 weeks, followed by metformin, then insulin

fasting glucose >7 = start insulin +/- metformin

fasting glucose >6 + macrosomia = insulin +/- metformin

Question 9

what needs to be done after delivery in GD?

Answer 9

• stop all meds
• 13 weeks OGTT or HBA1c
• lifestyle advice
• future pregnancy counselling
• yearly check ups as increased risk of type 2 DM

Question 10

what is an option in gestational diabetes for women who decline insulin or cannot tolerate metformin?

Answer 10

Glibenclamide (a sulfonylurea)

Question 11

what are the target blood glucose levels for women with gestational diabetes?

Answer 11

• Fasting: 5.3 mmol/l
• 1 hour post-meal: 7.8 mmol/l
• 2 hours post-meal: 6.4 mmol/l
• Avoiding levels of 4 mmol/l or below

Question 12

how should women with preexisting diabetes be managed during pregnancy?

Answer 12

• before becoming pregnant should aim for good glucose control
• take 5mg folic acid from preconception to 12 weeks
• aim for same glucose levels as GD
• T2DM - managed with metformin and insulin - other oral medications stopped
• retinopathy screening - after booking and at 28 weeks
• planned delivery between 37 and 38+6
• sliding scale considered during labour for T1DM
• dextrose and insulin infusion titrated to blood sugar levels - also consider for women with poorly controlled or GD

Question 13

when can women with GD stop taking their diabetic medications?

Answer 13

immediately after birth

diabetes improves immediately after birth

follow up test at 6 weeks

Question 14

what should women with existing diabetes be weary of in the postnatal period?

Answer 14

hypoglycaemia as insulin severity will increase after birth and with breastfeeding

Question 15

what are babies of mothers with diabetes at risk of?

Answer 15

• Neonatal hypoglycaemia - close monitoring with regular blood glucose checks and frequent feeds
• Polycythaemia (raised haemoglobin)
• Jaundice (raised bilirubin)
• Congenital heart disease
• Cardiomyopathy

Question 16

what should babies glucose be maintained above?

Answer 16

2 mmol/l

may need IV dextrose or nasogastric feeding if falls below

Question 17

what is acute fatty liver of pregnancy?

Answer 17

rare condition that occurs in the third trimester of pregnancy

rapid accumulation of fat within liver cells causing hepatitis

high risk of liver failure and mortality for both mother and fetus

Question 18

what is the pathophysiology of acute fatty liver?

Answer 18

impaired processing of fatty acids in the placenta

caused by a genetic condition in the feus that impairs fatty acid metabolism (most commonly long-chain 3-hydroxyacyl-CoA)

fetus and placenta are unable to break down fatty acids and they enter the maternal circulation and accumulate in the liver

Question 19

how does acute fatty liver present?

Answer 19

• General malaise and fatigue
• Nausea and vomiting
• Jaundice
• Abdominal pain
• Anorexia (lack of appetite)
• Ascites

Question 20

what blood will be deranged in acute fatty liver?

Answer 20

elevated ALT and AST

raised bilirubin

raised WBC

deranged clotting

low platelets

Question 21

how is acute fatty liver managed?

Answer 21

obstetric emergency

prompt admission and delivery of baby

treatment of acute liver failure - consider transplant