Diabetes in Pregnancy

Question 1

Outline the changes in insulin requirements in pregnancy

Answer 1

insulin is needed less in the first trimester because you are barfing a lot and not eating much (less glucose), but as baby’s needs are increased metabolically, you eat more food, and you need more insulin

Question 2

which glucose receptors are prsent on the placenta?

Answer 2

GLUT1- similar to in certain brain cells (astrocytes and endothelial cells in the brain)

Question 3

3 key counter regulatory hormones that lead to insulin resistance

Answer 3

1. human placental grwoth hormone
2. TNFalpha
3. progresterone

Question 4

Why is hyperglycermia a teratogen of pregnancy?

Answer 4

Modulates expression of apoptosis regulatory gene
even prior to implantation

Question 5

outline adverse pregnancy outcomes related to glucose control in 1st, 2nd and 3rd trimesters>

Answer 5

1. increased fetal malformations

2 and 3rd trimester: increse risk of big baby and metabolic complications

Question 6

fetal abnormalities in poorly controlled type 1 and 2 diabetic pregnancies

Answer 6

Cardiac • Multiple organs • CNS – spina bifida, ancephaly • Situs inversus • Renal agenesis • Duplex ureter • Caudal regression • Miscarriage

Question 7

why does diabetes (uncontrolled) lead to larger babies/

Answer 7

• high maternal and fetal glucose causes fetal hyperinsulinemia
• promotes excess nutrient storage, resulting in a big fetus
• Energy assoc. with conversion of excess glucose into fat
• *causes depletion in fetal O2 levels** Relative fetal hypoxia –
• *increase EPO**

Question 8

How does high maternal and fetal glucose levels cause hyperbilirubinemia?

Answer 8

Energy assoc. with conversion of excess glucose into fat
causes depletion in fetal O2 levels Relative fetal hypoxia –
increase EPO

• fetal hypoxia results in surges in CATECHOLAMINE, causing: 1. hypertension 2. cardiac hypertrophy 3. stimualtion of EPO, red cell hyperplasia, polycythemia
• high HCT leads to vascular sludging, poor circulation and post natal hyperbilirubinemia

Question 9

Question 11

4 management steps of diabetes in pregnanyc

Answer 11

1. preconsception counseling
2. management during pregnancy
3. management in labour
4. post partum considerations

Question 12

5 conditions that are preventing if you have a lower A1c PRECONCEPTION

Answer 12

1. spontaneous abortion

2 .congenital anomalies

3. pre-eclampsia
4. progression of retinopahty in pregnancy
5. intrauterine fetal death

Question 13

preconception A1C goal, and during pregnancy A1c goal?

Answer 13

preconception A1c <7. During preganncy A1c <6.5

• fasting PG <5.3, 2h post prandial PG <6.7
• need to be monitoring blood sugars at least 4-7 times a day

Question 14

women with diabetes and pregnant should be screened for nephropathy. how?

Answer 14

assess creatinine and urin microalbulin/creatinine ratio (ACR)

• women with micro albuminuir a or overt nephropathy are at increased risk for hypertension and preeclampsia and preterm delivery

Question 15

Preconception Checklist for Women with Type 1 or 2 Diabetes

1. Attain a preconception A1C of ≤__% (≤ __% if
safe)

2. Assess for and manage any complications

3. Switch to __ if on __ agents

4. __ __ 1 mg/d: 3 months pre-conception to 12
weeks post-conception

5. Discontinue potential embryopathic meds:
__-inhibitors/__ (prior to or upon detection of
pregnancy)

__ therapy

Answer 15

1. Attain a preconception A1C of ≤7.0% (≤ 6.5% if
safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 1 mg/d: 3 months pre-conception to 12
weeks post-conception

5. Discontinue potential embryopathic meds:
Ace-inhibitors/ARB (prior to or upon detection of
pregnancy) Statin therapy

Question 16

why should women with diabetes have a reliable form of BC?

Answer 16

becuase Metformin may improve fertility.

Question 17

Outline teh IOM Guidelines for Gestational Weight Gain

Answer 17

generally, the heavier you are pre-pregnancy, the less weight you should gain

Question 18

More evidence for poor
glycemic control & __

Answer 18

stillbirth

Question 19

a greater than 15% insulin requirement drop leasd to:

Answer 19

more pre-eclampsia, more SGA in 1 study, likelihoog to be delivered earlier y 1.2 weel, and more frequent NICU admission

Question 20

a large drop in insulin requirementes can lead to more pre-eclampsia, more SGA in 1 study, likelihoog to be delivered earlier y 1.2 weel, and more frequent NICU admission.

what should you do in the setting of a large drop in insulin requirements?

Answer 20

1. consider possible explanations
2. review risks for stillbirth: look at glycemic control, previous still birth, gestational age, late materal age, smoking history etc.
3. don’t be overly reassured by normal fetla monitoring
4. check ketones even if euglycemic, and for SOB and nausea vomiting and abdominal pain

Question 21

risks for still birth

Answer 21

Glycemic control - retinopathy - previous stillbirth - Gestational age - obesity - late maternal age - smoking history - SGA

Question 22

Delivery Timing in Pre-existing Diabetes. When should you deliver before?

Answer 22

• uncomplicated delivery between 38-39 weeks to reduce risk of still birth.
• deliver BEFORE THAT if there are fetal indications, or poor glycemic control

Question 23

why should you switch to inuslin instead of oral agents in pregnancy? What is the exception?

Answer 23

oral agents are more likely to cross the placental barrier and also be in breasmilkd, and is associated with 2 fold increased risk of neonatal hypoglycemia.

One excpetion is metformin– metformin use in type 2 DM has shown positive results because there is reduced maternal weight gain and improved glycemic control. there is lower infant adisposity and fewer cases of macrosomic infants.

Question 24

3 aspects of fetal surveillance

Answer 24

1. ultrasounds
2. NSTs
3. After 32-34 weeks, weekly assessments of fetal health and growth to help plan delivery

Question 25

Delivery Glycemic Control

Goal: ___ mmol/l

• Monitor glucose 1-2 hours
• If glucose rises above__ mmol/l then give I.V. __

Answer 25

Goal: 4-7 mmol/l

• Monitor glucose 1-2 hours
• If glucose rises above 7.0 mmol/l then I.V. insulin

Question 26

Post partum, should you increase or decrease insulin compared to third trimester?

Answer 26

adjust theinsulin lower. you are at risk for hypoglycemia. Use less than pre-pregnancy doses.

Question 27

post partum, you should Screen for postpartum __ in T1DM

Answer 27

Screen for postpartum thyroiditis in T1DM. check TSH 2 to 6 months post partum

Question 28

Question 29

gestational diabetes predisposes a high risk of ____ diabetes later in life

Answer 29

high risk of TType II diabetes

Question 30

8 gestational diabetes risk factors

Answer 30

Question 31

outline the 2 step testing process for GDM. When should you test?

Answer 31

around 24 weeks, you should do a glucose challenge test, with PG 1 hour later. If glucose level is 7.8-11, gotta do a fasting gluocse (noramlly should be below 5.3)

Question 32

fasting glucose and 2h post prandial glucose glycemic targets during pregnancy

Answer 32

eat healthy: don’t starve yourself. Avoid hypocaloric diet cause that can lead to weight loss + ketosis

Question 33

Question 34

Question 35

Postpartum GDM Management Checklist

1. Encourage ___
2. ___ ___ test between 6 weeks - 6 months
   postpartum to detect diabetes
3. Discuss increased long-term risk of
   diabetes – Importance of returning to pre-
   pregnancy weight

• Screen for __ before next conception

Answer 35

1. Encourage Breastfeeding
   2. 75g OGTT between 6 weeks - 6 months
   postpartum to detect diabetes
2. Discuss increased long-term risk of
   diabetes – Importance of returning to pre-
   pregnancy weight

- Screen for diabetes before next conception

Question 36

T/F: breasfeeding Reduces or at least delay mother’s risk of diabetes and
metabolic syndrome

Answer 36

true. breastfeeding also is a reduced risk to offspring of diabetes, obesity and impaired glucose tolerance

Question 37

T/F maternal DMI is a strong predictor of child obesity

Answer 37

true

Question 38