Diabetes in Pregnancy Flashcards
(36 cards)
1
Q
What advice is given to people at risk of gestational diabetes?
A
- Weight loss (aiming to decrease BMI to <30 prior to next pregnancy) - refer to dietician
- Folic acid 5mg OD
- Alcohol reduction/smoking cessation/exercise + diet
- Screening for end-organ dysfunction - retinal and nephropathy screening
- Advise to use reliable contraception until HbA1c is at target and there is significant weight reduction
- NICE recommend a target fasting level of 5.3 + 1hr post meal 7.8. BMs should be maintained >4 to avoid hypoglycaemia complications.
2
Q
What are some medications that are safe to use in pregnancy?
A
- Amoxicillin
- Cyclizine
- Metformin
3
Q
What medications should be used with caution in pregnancy?
A
- Nitrofurantoin: should be avoided in pregnancy at term/>36/40 due to haemolytic anaemia
- Citalopram: SSRIs associated with increased risk of congenital heart disease in 1st trimester, if required for maternal health then continue.
- Carbimazole: associated with a rare skin disorder if taken in 1st trimester - aplasia cutis
- Lamotrigine: considered safest AED, still some concern regarding congenital malformations
- Propylthiouracil: severe liver disease/failure in some pregnancies
- Sodium valproate: HIGH association of congenital malformations
- Trimethoprim: interferes with folic acid pathway so teratogenic when taken in 1st trimester, generally safe after then
4
Q
What medications are contraindicated in pregnancy?
A
- Ramipril: ACEi should be avoided in 2nd and 3rd trimester due to increased risk of fetal renal damage
- NSAIDs: increased risk oligohydramnios and premature closure DA, sometimes used for severe inflammatory conditions
- Isotretinoin: used to treat acne
5
Q
What are the complications of diabetes in pregnancy?
A
- Macrosomia
- Polyhydramnios - can lead to preterm labour or cord prolapse
- Shoulder dystocia
- Stillbirth
- Neonatal hypoglycaemia
- Expedited delivery
- Pre-eclampsia
- Congenital malformations
6
Q
What are the risks for pregnancy in high BMI mothers?
A
- Pre-eclampsia
- VTE
- Difficulties intrapartum including monitoring of the foetus and anaesthetic risk
- Postpartum risks including PPH, infection and DVT
7
Q
What hormones cause gestational diabetes?
A
- hPL (human placental lactogen)
- Cortisol
- GH
- Progesterone (causes insulin resistance)
These cause the mother’s body to increase blood glucose so that the glucose goes to the foetus. But these hormones make the mother’s body resistant to insulin so blood glucose remains high, to decrease glucose usage by mum and increase glucose usage by foetus.
8
Q
When should pregnant women be screened for GDM?
A
- BMI >30
- Previous baby >4.5kg
- Previous GDM
- FH (1st degree relative)
- Ethnic origin - South Asian, black Caribbean or Middle Eastern
9
Q
What values indicate a diagnosis of GDM?
A
Fasting glucose >/= 5.6
2 hr post-GTT >/= 7.8
10
Q
What is the treatment in pregnancy for diabetes and GDM?
A
- Diabetes treatment is the same in pregnancy, a woman can carry on taking her normal diabetes meds (diet, metformin, insulin)
- Give insulin treatment immediately in pregnancy with GDM
11
Q
What are risk factors for shoulder dystocia?
A
- Previous SD
- High BMI
- Induction of labour
- Epidural
- Instrumental delivery
12
Q
What is the risk with GDM after birth?
A
Increases risk of overt diabetes after pregnancy is over, so 6 week follow up after birth to check mum’s glucose
13
Q
What is the optimal time of delivery for diabetic patients?
A
- NICE recommend delivery of diabetic patients on insulin by 38/40. Otherwise, optimal timing for lower segment C-section (LSCS) in non-diabetic patients is >39/40.
- LSCS <39/40 is associated with increased risk of acute respiratory distress syndrome (ARDS) in neonate and higher rates of admission to NICU.
- Those undergoing LSCS <39/40 should receive steroids for foetal lung maturity. But steroids can worsen hyperglycaemia which occurs at a peak 24-48hrs following the first steroid dose - may need supplementary insulin sliding scale for short period of time.
14
Q
What difficulties come with increased BMI in LSCS?
A
- Anaesthetic difficulties
- Surgical access
- PPH
- Increased infection risk
- VTE risk
15
Q
What are the complications of pre-gestational diabetes?
A
Can cause miscarriage when the foetus is undergoing organogenesis, as it needs lots of glucose.
16
Q
What is the mechanism of foetal macrosomia?
A
- When mother’s glucose is high the foetus glucose is high > increases foetal insulin > stimulates fat storage and organogenesis in foetus > leads to bigger foetus
- In pre-gestational diabetes, impaired glucose control is more likely to have complications such as kidneys, vasculature, retina etc and pregnancy can worsen these - important to monitor.
17
Q
What are the maternal effects of diabetes on pregnancy?
A
- Increased miscarriage
- Increased risk PET
- Worsening renal disease - hypoalbuminaemia, anaemia
- Infections
- Increased induction and LSCS rate
18
Q
What are the fetal effects of diabetes on pregnancy?
A
- Increased congenital malformations (skeletal, cardiac NTDs) pathopneumonic for diabetes in sacral aegenesis
- Unexplained stillbirth
19
Q
What pregnancy complications are obese women more at risk of?
A
- Antenatal: miscarriage, congenital malformations, pre-eclampsia toxaemia (PET), GDM, macrosomia + VTE
- Intrapartum complications > monitoring of baby during labour (may require FSE - foetal scalp electrode), difficulties in sitting regional anaesthetics and with GA
- Postpartum complications - PPH (post partum haemorrhage), wound infections, VTE
- Poor glycaemic control can also predispose to sacral agencies (sacral doesn’t form properly in foetus)
20
Q
What advice would you give to obese people in pregnancy?
A
- May need aspirin 75mg OD and prophylactic LMWH for VTE risk
- Advised to reduce weight and adopt a healthier diet. Aim for a BMI <30, if they become pregnant prior to this, advise about minimising weight gain and exercise.
- They require higher doses of folic acid 5mg and vit D 10mg
21
Q
What diabetic medications are safe and avoided in pregnancy?
A
- Safe: metformin, insulin
- Avoid: glibenclamide, statins, ACEi
22
Q
What HTN medications are safe and avoided in pregnancy?
A
- Safe: labetalol, nifedipine (methyldopa, associated with postnatal depression, usually switched within 2/7 delivery to avoid), doxazosin
- Avoid: ACEi (increased CV and neuro malformations), angiotensin II blockers and diuretics
23
Q
What haematological medications are safe and avoided in pregnancy?
A
- Used: LMWH
- Avoid: warfarin
24
Q
What epileptic medications are safe and avoided in pregnancy?
A
- Used: lamotrigine (safest but still higher congenital abnormalities risk)
- Avoid: phenobarbitone, phenytoin, sodium valproate
25
What endocrine medications are safe and avoided in pregnancy?
- Use: carbimazole (can cause aplasia cutis - rare skin disorder with patches of absent skin), propylthiouracil (PTU) (has some association with liver failure, usually avoided after 1st trimester)
- Avoid: radioactive iodine, sex hormones
26
What medications for inflammatory conditions are safe and avoided in pregnancy?
- Use: sulfalazine, mesalazine (require 5mg folic acid supplement), prednisolone
- Avoid: methotrexate, cyclophosphamide, NSAIDs
27
What are complications of macrosomia?
- Higher incidence of induction
- Dysfunctional labour
- Shoulder dystocia
- PPH
28
What is cord prolapse?
Umbilical cord drops through open cervix into vagina ahead of baby, cord can then become trapped against the baby's body during delivery.
29
What complications result from foetal hyperinsulinaemia?
- Chronic foetal hypoxia stimulating haemopoesis and resultant polycythaemia and jaundice. This can lead to splenomegaly.
- Following delivery the high circulating levels of insulin can result in neonatal hypoglycaemia
30
What are the blood glucose targets for diabetic patients in pregnancy?
- HbA1c < 48
- Higher HbA1c at conception: more likely to have complications
- HbA1c >86 - much higher risk of congenital malformations and miscarriages
- Fasting glucose <5.3mmol/l
- 1 hr past meal <7.8
- Maintain >4mmol/l
- T1DM - test for ketones regularly
- If urine PCR >30mg/mmol, eGFR <45 referral to nephrologist
31
What monitoring needs to be done in pregnancy for pre-existing diabetic patients?
- Learn to measure blood glucose on their own: fasting, pre-meal, 1hr post meal and at bedtime
- Regular contact with a member of the MDT at least every 2/52
- Retinal assessment at 1st appointment (unless done within 3/12) and at least 28/40. In presence of retinopathy offer at 16-20/40 also.
- Renal assessment at 1st and refer to nephrologist as per preconception advice.
32
What antenatal care needs to be done for all diabetic patients?
USS appointments:
- Routine dating at 11-13/40
- Routine anomaly at ~20/40
- Serial growth scans to assess fetal size and monitor for macrosomia and polyhydramnios every 4/52 from 28/40
- Women with other co-morbidities should be considered for anaesthetic assessment by the 3rd trimester.
33
What modes of delivery are offered to women with diabetes?
- Offer all women with uncomplicated Type 1 and 2 between 37-38 + 6/40 elective delivery (either by LSCS or IOL)
- Offer prior to 37/40 if women have maternal or fetal complications
- Offer delivery before 40+6 in women with GDM
- Diabetic pregnancies with evidence of macrosomia and an EFW of >4.5kg should be offered elective LSCS as an alternative to vaginal delivery due to concerns regarding shoulder dystocia (for non-diabetic, consider elective delivery if EFW >5kg)
34
What extra measures need to be encouraged around birth for women with diabetes?
- Women with T1DM or who cannot maintain a BM within target in labour - start insulin dextrose sliding scale during labour
- Encourage breastfeeding - ideally 1st feed should occur within 30 mins and fetal blood sugars checked every 2-4 hrs aiming to maintain above 2mmol/l (due to risk of neonatal hypoglycaemia). Then feed at frequent intervals (2-3 hrs) until pre-meal blood glucose levels are maintained at 2mmol/l.
35
What is the post partum care for diabetic patients?
- Post delivery insulin requirement rapidly fall
- Women with pre-existing diabetes should restart their pre-pregnancy dose (reduced by 25-40% if they are breastfeeding)
- Women with GDM usually stop all glucose reducing agents immediately after delivery
36
What is the association between GDM and T2DM?
- Fasting plasma glucose test should be offered to all women with GDM at 6-12/40 to test for T2DM
- 1-2/3 of women who have diabetes in one pregnancy will have recurrence in further pregnancies. This can be reduced via diet and weight loss.
- Overweight women who had diabetes in pregnancy have a 50-70% chance of developing T2DM in future
- Women who test negative for diabetes at their postnatal review - offer annual screen for diabetes because of the strong association
