Diabetes in pregnancy Flashcards by Shaileigh Gordon

Definition of gestational diabetes

Glucose intolerance onset/first recognised in pregnancy

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

50%

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Risk factors for GDM

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

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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

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If OGTT cannot be done, alternative

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

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Physiology of GDM

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

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Hormones which reduce glucose uptake

Progesterone
Prolactin
Cortisol
Placental lactogen->large glucagon like effect

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Effects of GDM on neonate

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

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Maternal effects of GDM

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

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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

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Are congenital defects + in GDM

No, but increased in pregestational diabetes

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When should the OGTT be done before 26-28 weeks

When +risk factors, done in first trimester

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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

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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

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Indications for insulin

Fasting >5.5 one+/week

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

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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

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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

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Intrapartum management of GDM C-section

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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

BGL >7 in labor

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

BGL

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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

Postpartum care for all GDM when pharmacological therapy

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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

Discahrge

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

Monitoring postpartum for GDM mother not on pharmacotherapy

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Cease monitoring after birth

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

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Failed induction
Fetal distress in early labour
Disproportion
An abnormal lie

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

What should be checked for at 22-24 week scan

Fetal heart, check for congenital heart abnormalities.

Are GDM at increased risk of pyelonephritis

Yes- 4 X risk

Congenital abnormalities associated with pre-existing diabetes

NTD Cardiac abnormalities Skeletal abnormalities Orofacial clefts

Pregnancy effects on diabetic patient

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

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

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 ```

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 ```

When can delivery wait for spontaneous labour

Blood glucose control satisfactory Normal fetal growth No complications

When should IOL occur

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

Management if delivery required

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

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

In diabetic- 4.5kg | Non-diabetic 5kg

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

When would you consider umbilical artery blood flow measurement

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

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)

"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.

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

Blindness Renal failure requiring dialysis Termination must be discussed

"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

Fetal abnormalities associated with diabetes

``` NTD Cardiac Bowel Urinary tract Sacral agenesis ```

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

Diabetes in pregnancy Flashcards

(44 cards)