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343 f > Diabetes in Pregnancy > Flashcards

Diabetes in Pregnancy Flashcards

1
Q

Diabetes in Pregnancy: 2 Categories

A 
Pregestational diabetes
- Pregnancy in pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Gestational diabetes
- Diabetes diagnosed in pregnancy
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2
Q

Dysglycemia in Pregnancy can Result in

Adverse Pregnancy Outcome

A

• Elevated glucose levels can have adverse effects on the fetus
• 1st trimester à ↑ fetal malformations
• 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications

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3
Q

Diabetes in Pregnancy: Consider Phases

A 
Pregestational diabetes
(T1D and T2D)
1. Preconception counseling
2. Management during pregnancy 
3. Management in labour 
4. Postpartum considerations

Gestational diabetes

  1. Prevention, Screening & Diagnosis
  2. Management during Pregnancy
  3. Management in labour
  4. Postpartum considerations
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4
Q

Gestational Diabetes (GDM) Diagnosis

A

50g GCT does not identify fasting
hyperglycemiaà straight to OGTT if high risk

Screen earlier if risk factors for GDM:
Previous GDM 
BMI ≥30 kg/m2
Prediabetes
Polycystic ovarian syndrome
High risk population (nonCaucasian)
Current fetal macrosomia or
polyhydramnios
Age ≥35 years 
History of macrosomic infant
Corticosteroid use Acanthosis nigricans
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5
Q

Pathophysiology

A

In normal pregnancy, insulin resistance occurs in 2nd trimester
–> thought to ensure glucose supply to fetus
• Pregnancy hormones are thought to interfere with insulin binding at receptor causing insulin resistance
• If insulin resistance also in context of existing insulin resistance or beta cell defect –> GDM

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6
Q

Hormones contributing to insulin resistance during pregnancy:

A 
• Placental Lactogen
• Placental growth
hormone
• Progesterone
• Cortisol
• Prolactin
• Estrogen
• hCG
• Leptin
• TNFa
• Resistin
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7
Q

GDM increases risk of:

for mother

A 
Mother
Trauma from LGA infant
C-section
Pre-eclampsia
Pregnancy induced hypertension

Longer term
Development of T2D
Development of heart disease
Development of HTN

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8
Q

GDM increases risk of:

for child

A 
LGA and trauma from getting stuck:
• shoulder dystocia
• Erb’s palsy/nerve injury
• Brain injury
Prematurity
Prematurity
Immature lung function
Jaundice
Neonatal ICU admission

Longer term
Obesity and dysglycemia
Premature puberty in girls

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9
Q

Multidisciplinary team

A
  • Patient: recording and reflecting on glucose checks, meals, and physical activity
  • Team: glucose, nutrition, weight gain, BP, fetal health
  • Close follow up
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10
Q

GDM: Management During Pregnancy

A

• Insulin first-line
• May use aspart, lispro, glulisine: perinatal outcomes similar
• Metformin may be used as an alternative to insulin
• Good safety data in pregnancy
• Evidence of less maternal weight gain, less large-for-gestational-age, less neonatal
hypoglycemia
• Women should be informed that it crosses the placenta
• Safety data in offspring postpartum up to 2 years
• Insulin necessary in 40% on metformin
• Glyburide may be used in women who refuse insulin and not well
controlled on metformin

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11
Q

Target BG values

A

• Perform SMBG fasting and postprandially
• Glycemic targets during pregnancy:
Fasting and preprandial BG <5.3 mmol/L
1h postprandial BG <7.8 mmol/L
2h postprandial BG <6.7 mmol/L
f glycemic targets not achieved within 1-2 weeks,
initiate pharmacologic therapy

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12
Q

Adjusting Insulin in GDM

A

q If fasting high, increase evening NPH
q If post Brk high, increase Brk analogue
q If post Lun high, increase Lun analogue
q If post Sup high, increase Sup analogue
If above target for two consecutive days,
increase appropriate insulin, typically by 2 units
And don’t stop increasing insulin until targets achieved

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13
Q

GDM: Postpartum Management

A
  1. Encourage Breastfeeding
    • Reduce neonatal hypoglycemia, childhood obesity & diabetes, AND
    maternal risk of diabetes & hypertension
  2. 75 g OGTT between 6 weeks - 6 months postpartum
    to detect prediabetes or diabetes. Suggest phone
    calls/email reminders to improve testing rates
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14
Q

Dysglycemia in Pregnancy can Result in

Adverse Pregnancy Outcome

A

• Elevated glucose levels can have adverse
effects on the fetus
• 1st trimester à ↑ fetal malformations
• 2nd and 3rd trimester: ↑ risk of macrosomia and
metabolic complications

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15
Q

Preexisting DM increases risk of:

A

Worsening preexisting vascular
complicationsàRETINOPATHY
Fetal malformations if maternal glucose high
in first trimester

LGA and trauma from getting stuck:
• shoulder dystocia
• Erb’s palsy/nerve injury
• Brain injury

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16
Q

Congenital Malformations – First Trimester

A
  • Caudal regression
  • Situs inversus
  • Duplex ureter
  • Renal agenesis
  • Cardiac abnormalities
  • Anencephaly
17
Q

Pre-existing Diabetes

Preconception care

A

b) Strive to attain a preconception A1C ≤7.0% (or A1C ≤6.5% if can
safely be achieved) to decrease the risk of:
• Spontaneous abortion [Grade C, Level 3]
• Congenital anomalies [Grade C, Level 3]
• Preeclampsia [Grade C, Level 3]
• Progression of retinopathy in pregnancy [Grade A, Level 1 for type 1 diabetes; Grade
D, Consensus for type 2 diabetes]
• Stillbirth [Grade C, Level 3]

18
Q

Preconception Checklist for Women with

Pre-existing Diabetes

A

ü Use reliable birth control until adequate glycemic control
ü Attain a preconception A1C of ≤7.0% (≤ 6.5% if safe)
ü May remain on metformin + glyburide until pregnancy, otherwise switch to
insulin
ü Assess for and manage any diabetes complications (eyes, kidneys)
ü Folic Acid 1 mg/d: 3 months pre-conception to 12 weeks post-conception
ü Discontinue potential embryopathic meds:
ü ACE inhibitors / ARB (prior to or upon detection of pregnancy in those with
significant proteinuria)
ü Statin therapy

19
Q

Recommendation 11
Pre-existing Diabetes
Management in pregnancy

A
  1. Aspart, lispro or glulisine may be used in women with pre-existing
    diabetes to improve postprandial BG [Grade C, Level 2 for aspart; Grade C, Level
    3 for lispro; Grade D, Level 4 for glulisine] and reduce the risk of severe
    maternal hypoglycemia [Grade C, Level 3 for aspart and lispro; Grade D,
    Consensus for glulisine] compared with human regular insulin
20
Q

Recommendation 12
__________may be
used in women with pre-existing diabetes as an alternative to NPH and is associated with similar perinatal outcomes

A
  1. Detemir [Grade B, Level 2] or glargine [Grade C, Level 3] may be
    used in women with pre-existing diabetes as an alternative to
    NPH and is associated with similar perinatal outcomes
21
Q

Pregnancy Management for Pre-existing Diabetes

A

• Type 1 diabetes: Basal-bolus insulin therapy (3-4 injections per day) or continuous subcutaneous insulin infusion (CSII)
• Type 2 diabetes: Switch to insulin (MiTy study will
determine if efficacious to add metformin)
• Individualize insulin therapy with close monitoring
• Bolus insulin: May use aspart or lispro instead of regular insulin
• Basal insulin: May use detemir or glargine as alternative to NPH
(type 2 diabetes: NPH is acceptable

22
Q

Pregnancy Management for Pre-existing Diabetes

A 
• Perform SMBG pre- and postprandially (7x/day!)
Target BG values
Fasting and pre-prandial BG <5.3 mmol/L
1h postprandial BG <7.8 mmol/L
2h postprandial BG <6.7 mmol/L
  • Aim for A1C ≤6.5% (≤6.1% if possible)
  • Lower late stillbirth & infant death
  • Individualize targets in those with severe hypoglycemia/unawareness
23
Q

Pregnancy Management for Pre-existing Diabetes

A
  • Type 1 diabetes: Continuous glucose monitoring should be considered in all women
  • ê LGA, NICU >24 hrs, neonatal hypoglycemia, infant length of hospital stay
  • Encourage weight gain according to Institute of Medicine recommendations
  • ASA to reduce the risk of pre-eclampsia, starting at 12-16 weeks gestational age
24
Q

Recommendation
Pre-existing Diabetes
Postpartum

A
  1. Insulin doses should be decreased immediately after delivery below prepregnant doses and titrated as needed to achieve good glycemic control [Grade D, Consensus]
  2. Women with pre-existing diabetes should have frequent blood glucose monitoring in the first days postpartum, as they have a high risk of hypoglycemia [Grade D, Consensus]
25
Q

. For women with pre-existing diabetes,
_____________ should be encouraged immediately
postpartum to reduce neonatal hypoglycemia

A
  1. For women with pre-existing diabetes, early neonatal feeding should be encouraged immediately
    postpartum to reduce neonatal hypoglycemia [Grade C, Level 3]. Breast feeding should be encouraged for a
    minimum of 4 months to reduce offspring
    obesity [Grade D, Consensus] and later risk of
    developing diabetes [Grade C, Level 3]. Women with preexisting diabetes should receive assistance and
    counseling on the benefits of breastfeeding, in order to
    improve breastfeeding rates, esp
26
Q

Key Clinical Points

A

• Be supportive, pregnancy is stressful time à avoid negative
judgement of behaviours à compassion and empathy
• Focus on positive actions—past, present, and future àblood sugar
accounting isn’t helpful if the underlying issues are not dealt with
• Try and help patients navigate cost/access issues, reach out directly to
medical team when needed

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