Diabetes in pregnancy Flashcards Preview

Obstetrics and Gynaecology > Diabetes in pregnancy > Flashcards

Flashcards in Diabetes in pregnancy Deck (44):
1

Definition of gestational diabetes

Glucose intolerance onset/first recognised in pregnancy

2

Percentage of women with GDM who develop DM in the following 20 years

50%

3

Risk factors for GDM

Previous GDM
Previous elevated BGL
Previous macrosomic infant
Obesity (BMI >30), PCOS
Steroids
Age >25
Multiples
Family history
Asian

4

Diagnosis of GDM criteria

OGTT (preferred test for diagnosis) 24-28 weeks
One or more of:
• Fasting ≥ 5.1 mmol/L
• 1 hour ≥ 10 mmol/L
• 2 hour ≥ 8.5 mmol/L
If fasting >7 of 2 hour post >11.1= DM in pregnancy

5

If OGTT cannot be done, alternative

HbA1c (if OGTT not suitable)
• 1st trimester only
• Result ≥ 41 mmol/mol (or 5.9%)

6

Physiology of GDM

Pregnancy= relative insulin resistance= +production
Fasting levels lower and post prandial hgiher
HPL +lipolysis, sparing glucose for fetus

7

Hormones which reduce glucose uptake

Progesterone
Prolactin
Cortisol
Placental lactogen->large glucagon like effect

8

Effects of GDM on neonate

Polyhydramnios
Macrosomia
+Skin thickness, abdominal adiposity
Neonatal hypoglycemia
Preterm
Hyperbilirubinemia (polycythemia)
Poor lung maturation (polycythemia)
Polycythemia
Hypocalcemia
Jaundice

9

Maternal effects of GDM

Gestational HTN
Pre-eclampsia
C-section
Risk of future GDM, DM
Birth injruy
Bacterial infections

10

Management goals of GDM

MDC-> dietician, diabetes educator, endocrinologist, obstetrician
Diet, exercise, glucose monitoring
Insulin, metformin
Monitoring growth of fetus
Intrapartum glycemic control
Fetal sugars post delivery

11

Are congenital defects + in GDM

No, but increased in pregestational diabetes

12

When should the OGTT be done before 26-28 weeks

When +risk factors, done in first trimester

13

Risks of macrosomia for infant

Shoulder dystocia - risk increases as fetal weight increases
Bone fracture
Nerve palsy
Caesarean section birth
Hypoxic-ischaemic encephalopathy (HIE)
Death

14

Antenatal care of GDM- initial visit

Review history
Diabetes educator
Dietitian w/i 1 week
Psychosocial if required
Commence self monitoring
BMI->discuss healthy weight gains
Physical activity, smoking, alcohol
Baseline USS at 28-30 weeks
Initial laboratory investigations (routine tests, creatinine)
If diabetes in pregnancy->optometrist, opthalmologist, microalbuminuria
Fetal growth monitoring-->first trimester scan, 20 week morphology, 28/34 week scan for macrosomia
Glucose monitoring 4 X daily (fasting, 2 hr post meals)
If good control can reduce
Insulin if indicated
Diet, exercise, limit pregnancy weight gain

15

Indications for insulin

Fasting >5.5 one+/week
Post prandial >7.5 2+/week in absence of dietary non-compliance

16

Antenatal care of GDM- each visit

Surveillance->review for complications (preeclampsia, features of infection)
Review weight gain, diet, exercise
Test urine for protein/ketones
Check BGL patterns
Psychosocial
Fetal well being USS 2-4 weekly as indicated
F/U for pharmacology, diabetes educator review
Review suitability of model of care
Review next contact requirements

17

Intrapartum management of GDM-->vaginal delivery

If on metormin->cease when labouring
Insulin-->
Cease when labour
If morning IOL: eat breakfast and give usual rapid acting insulin, omit morning long/intermediate
If afternoon IOL: Give usual meal/bedtime insulin
Monitor BGL 2/24

18

Intrapartum management of GDM C-section

Day before- cease metformin 24 hours before, give insulin dose at night
Day of morning procedure- fast from 2400, omit morning insulin
Monitor BGL 2/24

19

BGL >7 in labor

Review clinical circustance-->stage of labour, intake
Option 1-->repeat BGL in 1 hour and reassess
Option 2--> Consider insulin infusion

20

BGL

Cease insulin
If symptomatic-treat hypo and BGL in 15 m/60
If asymptomatic and receiving insulin, reassess BGL in 15/60
If asymptomatic, not receiving insulin, repeat BGL in 1 hour and reassess

21

Postpartum care for all GDM when pharmacological therapy

Cease insulin/metformin immediately after birth
Target BGL medical review, IV fluid 12 hourly
>7-->medical review. Insulin rarely required postpartum
If BGL >4, diet tolerated, cease mainine IV fluids after borth
All routine care
Support and encourage breastfeeding
Keep newborn warm. Feed within 30-60 minutes.
Fed-->BGL before second feed
XFed->BGL at 2 hours
BGL every 4-6 hours pre-feeds until monitoring ceases

22

Discahrge

Advise benefis of optimising diet, exercise and weight
Repeat OGTT at 6-12 weeks
Lifelong screening
Early glucose screening in future pregnancy

23

Monitoring postpartum for GDM mother not on pharmacotherapy

Cease monitoring after birth

24

Reasons cesarean section incidence in insulin dependant women is 2-3 times higher than the normal population (4)

Failed induction
Fetal distress in early labour
Disproportion
An abnormal lie

25

Immediate care of the baby

Pediatrician present at delivery
Resuscitate if required
Dry, keep warm
Check BG at 30 mins, 1 hour, 4 hour, 8 hour, 12 and 24 hour
Treat CHD, NTD
Measure serum bilirubin->hyperbilirubinemia

26

What should be checked for at 22-24 week scan

Fetal heart, check for congenital heart abnormalities.

27

Are GDM at increased risk of pyelonephritis

Yes- 4 X risk

28

Congenital abnormalities associated with pre-existing diabetes

NTD
Cardiac abnormalities
Skeletal abnormalities
Orofacial clefts

29

Pregnancy effects on diabetic patient

Nephropathy->+risk of pre-eclampsia, impaired renal function
Gastroparesis
+Proliferative retinopathy
+Asymmetrical growth, SGA, pretern

30

Preconception care for diabetics

Contraception until ready for pregnancy
Screen women with T1DM for TSH antibodies
Counsel regradingglycemic state in pregnancy, maternal/neonatal complications->risk to pregnancy, fetus,
Diet, exercise, weight, folic acid
Cease ACEi/ARB- use labetolol
Evaluation complications and comorbidities->refer to those when necessary:
nephrology, opthalmology etc

31

Antenatal care of woman with pre-existing diabetes- FIRST VISIT

First visit-->all normal investigations. Cease other meds-insulin only.
Education with diabetes educator
Diet, exercise, weight
Glucose monitoring
Potential to need to increase insulin
Risks of poor glycemic control

32

At each subsequent antenatal visit with pre-existing DM

Regular vist investigations etc
Diabetic record of home monitoring
BP
Symptoms of pre-eclampsia, UTI
Fetal growth

33

When can delivery wait for spontaneous labour

Blood glucose control satisfactory
Normal fetal growth
No complications

34

When should IOL occur

Poor metabolic control at 38 weeks
Polyhydramnios
Macrosomia
No spontaneous labour at term

35

Management if delivery required

Betamethasone 11.4mg X 2 doses 24 hours apart
Admission for insulin sliding scale
Consult physician/endocrinologist

36

When should C section be considered with large baby->in diabetic and non-diabetic

In diabetic- 4.5kg
Non-diabetic 5kg

37

Do insulin requirements typically increase or decrease on delivery of placenta and with breast feeding

Reduction, may be able to cease insulin for several hours following delivery

38

When would you consider umbilical artery blood flow measurement

Fetal macrosomia
IUGR
Hypertension
Smoker
Poor glycemic control
Evidence of microvascular or macrovascular disease

39

Type 1 diabetic wanting to become pregnant- important points in history

GynaeC, obstetric, medical/family/social, iron/folate, immunisations
Blood glucose control, monitoring
HbA1C, review->any evidence of opthalmology, vasculopathy (retinopathy, kidney, heart, feet)

40

"What are the risks for me and my baby" T1DMM

If there is no evidence of significant diabetic vasculopathy, pregnancy will not have an adverse effect on her health.
If glucose not controlled in earl pregnancy->fetal abnormalities can occur double risk (normal risk 2-3%)
Poor control in later pregnancy->macrosomia and stillbirth->abnormal fat distribution, metabolic dysfunction and stillbirth.

41

Risk to maternal health if pre-existing renal, HTN, severe retinopathy

Blindness
Renal failure requiring dialysis
Termination must be discussed

42

"Is there any way to reduce the risk to my baby" and follow up

Need good sugar control before and during
See endocrinologist prior to conception->insulin regimen may need to be tweaked
FBC, rubella, varicella
Take folic acid 5mg now until end of first trimester
Important investigations:
->Early dating scan
->CFTS 10-13 weeks
->USS at 18 weeks: if severe abnormalities detected, option to terminate
->USS 22-24 weeks to detect cardiac abnormalities (50% of the abnormalities seen in diabetic pregnancies

43

Fetal abnormalities associated with diabetes

NTD
Cardiac
Bowel
Urinary tract
Sacral agenesis

44

Advice to diabetic patient about care in later pregnancy

1. Good sugar control
2. Regular growth scans from 24 weeks->looking at disproportionate growth, polyhydramnios
3. Increased risk of shoulder dystocia, still birth, cesaerean
4. Following birth->hypoglycemia, neonatal respiratory distress, low calcium and magnesium, jaundice, polycythemia
5. With good sugar control can expect a live healthy baby