Flashcards in Chapter 20: Endocrine Disorders Deck (21)
How does glucose metabolism change during pregnancy?
Glucose metabolism in pregnancy: human placental lactogen (hPL) is produced in abundance by the placenta and promotes lipolysis and increased levels of circulating fatty acids, decreasing our glucose metabolism, like an anti-insulin. Insulinase also made by the placenta in small amounts to break apart insulin.
Increased renal blood flow gives less time for us to grab glucose from our urine, leading to normal glucosuria
If you have DM duringpregnancy, what is the risk to fetus?
6x more likely for congenital abnormalities from normal 1-2%, increasing if your HbA1c is elevated entering pregnancy, with >9.5% associated with 22% change of congenital malformation.
Why do babies get larger with diabetes and what complication can arise for labor because of it?
Increased glucose transfer across the placenta means a bigger baby. >4500 grams means we recommend C-S
Polyhydramnios (fluid > 2000 mL) also possible. Increased uterine size and fluid increases the chances of placental abruption and preterm labor as well as postpartum uterine atony
How does a baby due after labor coming from a diabetic mom
Post-partum imbalances: Baby increases production of insulin to counter mom's glucose. When baby is born and no longer has this glucose being added, the extra insulin causes hypoglycemia. These infants are also at an increased risk for neonatal hyperbilirubinemia, hypocalcemia, and polycythemia, and an increased risk of respiratory distress syndrome.
How do we manage pre-gestational diabetes patients becoming pregnant?
Pregestational diabetes management: US at 18-20 weeks to check for congenital anomalies, and another at 32-34 weeks to check for antepartum fetal monitoring (nonstress test, biophysical profile, contraction stress test).
Also, these moms are at an increased risk for Pre-ecclampsia, so 24 hour urine tests for protein and creatinine clearance are indicated
What do we do about retinopathies with pregnant moms who are diabetic?
Diabetic retinopathy also increases in 15% of these patients, so laser coagulate as needed to prevent loss of vision
When in pregnancy is a dangerous time for mom and why if she has diabetes?
Insulin levels during pregnancy will increase, particularly between weeks 28 and 32, so keep monitoring this stuff. See these patients every 1-2 weeks at first and then weekly after 28-30 weeks
How common is gestational diabetes?
Gestational diabetes occurs in 7% of pregnancies, with an increasing rate due to our increasing obesity. 50% of patients have no history signifying that this could occur.
How do we screen for gestational diabetes?
We screen for this with a 50 gram 1 hour oral glucose challenge at 24-28 weeks. If patient value exceeds 140mg/dL, they get a standard 3 hour glucose tolerance test using 100g of glucose. 2 or more abnormal 100g tests = gestational diabetes. 15% will have abnormal 1 hour test with 15% of those patients going on to 3 hour having issues there as well.
What values are we looking for in our gestational diabetes pregnant patient as we treat them?
Diet and glucose monitoring: We want fasting glucoses of
If patients suck at diet, what can we do to control their diabetes in pregnancy?
NPH and fast acting insulin like lispro right before breakfast and right before dinner to suppress gluconeogenesis and counter rises in glucose with other meals. Glyburide also a newer option, does not cross the placenta and is a lot like insulin.
Why do we worry about infection in diabetic moms
Infection chances are x2 in diabetic moms, since glucose in the urine is a great place for bacteria to thrive.
How do we manage a diabetic mom during labor?
Once labor begins or when glucose levels drop below 70, start 5% dextrose continuous unless glucose levels rise above 100. Assess every 1-2 hours. Monitor maternal ketonuria. Once placenta is removed and hPL is gone (short half life) glucose stabilization often occurs within hours.
How do we manage diabetic moms AFTER labor?
95% of women post partum stop having diabetes, but 50 of these folks will get Type II later in life. Do glucose tolerance screening 2 to 4 months after labor to detect that 5% that keeps the diabetes (75 grams for 2 hours). Follow up from that every 3 years.
What is post-partum thyroiditis?
Postpartum thyroiditis: Autoimmune inflammation of the thyroid gland that presents as new-onset, painless hypothyroidism, transient thyrotoxicosis, or thyrotoxicosis followed by hypothyroidism within 1 year postpartum.
How do iodine levels and thyroid levels change in pregnancy?
Levels of TBG normally increase in pregnancy. This causes an increase in Total T4, total triiodothyronine, and resin triiodothyronine uptake. First trimester may also see a rise in free T4. Plasma iodide levels decrease in pregnancy, which may cause an increase in thyroid size in 15% of women.
Do we screen all moms for thyroid issues?
Only screen patients with history of thyroid issues or who present with findings concerning for thyroid dysfunction.
How do we treat hyperthyroid pregnant patients?
PTU crosses placenta less so use this. Methimazole causes aplasia cutis (scalp defects) and choanal atresia and should be avoided first trimester (crosses placenta REAL easy).
However, switch to methimazole after first trimester because PTU after this point can cause hepatotoxicity. Both are ok for breastfeeding.
What is our goal with thyroid management during pregnancy?
Goal: maintain free T4 or FTI in the nigh normals using lowest dosage of exposure
How about Grave's patients getting pregnant?
Those with Grave's taking thionamides may want to reduce use as this can cause neonatal goiter and decreased thyroid function