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1

What % of pregnancy has insulin resistance?

50%
- women must increase insulin secretion (in liver) by 2-3x to maintain euglycemia

2

80% of the energy needs of fetus comes from what?

Glucose

3

Women are insulin ______ in 1st trimester

sensitive
- dont feel low glucose
- women at risk for severe nocturnal hypoglycemia in 1st trimester and wont wake up

4

Women are insulin _____ in late 2nd and 3rd trimester

resistant

- with increase hPL, hPGH, TNFa

5

Prolonged fasting in preg women -->?

Starvation ketosis
(accelerated starvation of pregnancy)
- high risk of DKA in pregnancy
- decreased buffering capacity

6

fasting blood glucose (FBG) in preg women

lower FBG but slightly higher postprandial (after lunch/dinner) glucoses and hyperinsulinemia

7

Gestational diabetes (GDM)

glucose intolerance recognized for the first time during preg.
- occurs LATER in pregnancy 24 weeks
- vast majority are overweight and insulin resistant

caused by:
1. Insulin resistance
2. Impaired insulin secretion
3. Increased hepatic glucose production

*50% of pts with GBM will be declared as having T2D in the next 10 yrs

8

IGT (prediabetes)

diagnosed before 24 weeks and at very high risk for developing T2D post partum

9

thin pt with "gestational diabetes"

latent autoimmune diabetes

LANA or MODY (mature onset diabetes of the young)

10

Why is GDM a burden to mom?

1. More doctor stuff
2. Higher risk of infxn
3. C Section
4. Preeclampsia
5. ~50% MATERNAL RISK OF DEVELOPING T2D in 5-10 yrs
- target for primary prevention

11

Does breastfeeding increase or decrease risk of T2D ?

Decreases risk

12

Infant of woman with diabetes

1. fatter baby (abdominal) - get stuck in birth canal --> C section or shoulder dystocia
2. Macrosomia
3. infant respiratory distress syndrome
4. neonatal hypoglycemia
5. Hyperbilirubinemia

13

GLucose vs insulin in the placenta

GLucose crosses placenta, insulin doesnt

*baby sees too much glucose --> dev. High insulin --> pancreatic hyperplasia -->
after birth and moms glucose goes away --> baby bcomes hypoglycemic

14

Insulin fx in babies

insulin is a growth hormone causing excess fat deposition

hyperinsulinemia --> pancreatic hyperplasia

15

Long term implications of GDM

1. T1D, T2D, GDM -->
- increased fetal insulin and leptin
- neonatal adiposity
- enlargement of pancreas + heart
2. Appetite regulation --> neonatal obesity and impaired glucose tolerance in childhood
3. Higher risk of devel diabetes in offspring

16

TBG in pregnancy

Increase due to estrogen

- so mom needs to make more TH (T4 to maintain nl free T4)
(which requires more iodine, plasma vol, and GFR).

17

fetal brain has what transporters?

T4

DO NOT USE T3 IN PREGNANCY

18

Maternal and fetal iodine deficiency --> ?

Cretinism

*recommendation is for preggos to take 250 ug/day

19

Maternal hypothyroidism

most cases due to hashimotos

T4 needed for trophoblast fxn

Most women require 25% increase in thyroid hormone supplements early in gestation

20

Hypothyroidism can do what to the placenta?

1. neurodev. delay
2. preg loss
3. preterm delivery

*remember that T4 needed for trophoblast fxn

21

Causes of hyperthyroidism in pregnancy

1. Graves disease ~85%

2. hCG induced

3. Toxic multinodular goiter

4. Toxic adenoma

22

Post partum thyroiditis

2 phases:
1. hyperthyroid phase : 2-4 mo postpartum
- destruction of thyroid gland --> release thyroid hormone

2. Continued destruction 4-8 mo: hypothyroid

23

The placenta has which hormone, that hydrolyzes maternal TG to FFAs for utilization?

Lipoprotein lipase
- FFAs important for fetal fat accretion/neonatal adiposity

24

What id diagnostic for GDM?

at 24-28 weeks:
Give 50 gram oral glucose load

if abnl (>140): give 3 hour 100gm OGTT
- fasting glucose >92
- 1 hr glucose >180

*in T2D: fasting glucose > 95, and 1 hr glucose is >180

*women at higher risk should be screen at first prenatal visit

25

Risks for getting GDM

1. obesity
2. Personal hx of GDM or prev macrosomic infant
3. Fam hx of diabetes in first degree relative
4. PCOS
5. High risk ethnic group
6. Glycosuria

26

The fetus is dependent on maternal thyroid hormon until when?

18 weeks
then it has its own that can be affected that transplacental transfer of maternal antibodies and antithyroid medication

27

Most common cause of hyper and hypothyroidism

Hyper: graves disease

Hypo: hasimotos
(in developed country, iodine deficiency in developing)

28

Graves disease presentation in pregnancy

Exacerbation in first trimester and postpartum

Improvement in 2nd and 3rd trimester as a result of declining TSH receptor antibodies which are stimulating thyroid stimulating immunoglobulin (TSI)

29

Women with hyperthyroidism have what risk for developing preeclampsia?

5 fold greater

30

Hyperthyroidism has an increased risk of what during pregnancy?

1. severe preeclampsia
2. low birth weight
3. prematurity
4. placental abruption (directly related to maternal T4)