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Flashcards in DM in pg'y Deck (24)
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why does GDM dvp?

placental hrms and HPL are anti-insulin hrms => increased IR


when does GDM usually manifest itself?

3rd tri


who is at increased risk of congenital anomalies, GDM or pregestational DM?

pregestational DM


GDM pts are at increased risk of what in fetus? in mom?

of fetal macrosomia, birth injuries, neonatal hypoG, hypoCa2+, hyperBr, polycythemia

moms are at increased risk of dvp'ing DMII during lifetime


who is at risk of GDM?

hispanics, Asians, NAm, ob women, fhx of DM, previous infant weighing +4000g, previous stillbirth


when to screen for GDM?

if 1 or more RFs present, screen at first prenatal visit and at each trimester. Otherwise, at 24-28weeks (end of 2nd tri)


methods of screening for GDM?

O'sullivan test (50-g G load then measure plasma G 1 hr later. If plasma G is > 140, its +. Need to follow up with 3-hr GTT.


what is the GTT?

3-d special CHO diet, then overnight fast, then measure fasting G levels in a.m., then 100mg oral G, then measure G levels at 1, 2, and 3 hours. GDM is dx'd if 2 or more of following are +:

Fasting > 95
1h > 180
2h > 155
3h > 140


tx of GDM:

start on DM'c diet - 2200 cal/d, limit CHO intake to 200-220g/d, check blood G QID, and do mild exercise (walking)


what is the White classification of GDM?

class A1 = diet-controlled (brings fasting G < 90, 1-hr post-prandial < 140, 2-hr postprandial < 120)
class A2 = medication-controlled


which is usually elevated in GDM, fasting, postprandial or both?

postprandial, b/c its an impairment in metab of large CHO boluses.


what kind of IN is used if needed?

long-acting in morning (NPH)
short-acting at dinner (Lispro or humalog)

glyburide is also qqf used


what kind of fetal monitoring is necessary in GDMs?

If A2 GDM, need NST or BPP weekly or biweekly starting b/w 32 and 36w until delivery. Also do an u/s b/w 34 and 37w to eval for macrosomia.

if A1, no monitoring necessary.


delivery mgt in pts w/GDM?

do an adm random G to r/o severe hyperG. Needs t/b corrected to avoid neonatal hypoG.
Can schedule induction at 39w to prevent hypoG as pg'y progresses and placental fct decreases. Prepare for shoulder dystocia.
can do elective c/s for pts w/estimated fetal weight > 4500g.


postpartum f/u?

screen for DMII at postpartum visit, and annually with fasting blood G


what is caudal regression syndrome?

impaired dvp of sacrum, vertebrae, pelvis. C/=> flaccid paralysis, incontinence. See increased risk of this in fetuses w/DM'c moms.


ideally, a DM pt who wishes to become pg should be counseled on what?

the importance of tight G control before and during pg'y, risk of worsening renal dis if its already present, risk of congenital anomalies, increased risks of NTDs.


what kind of diet should a DM pt be on before and during pg'y?

2200 cal diet, restricting CHO's. Maintain during pg'y but with increased caloric needs up by 300.


how to screen T1DM pts before pg'y or at initial visit?

24-hr urine collection for protein & creatinine clearance
ophtho referral


how will IN requirements change during pg'y in a pt w/T1DM?

IN dose slightly increased during first half, then may increase a lot during 2nd half 2/2 increasing IR.
IN pump can be placed prepregnancy or after 1st tri if having difficulty managing w/IN injections


guidelines for adjusting IN doses:

1) establish a fasting G level b/w 70-90 mg/dL
2) only adjust one dosing level at a time
3) Do not change any dosage by more than 20% per day.
4) wait 24h b/w dosage changes to evaluate the response

remember to account for physical activity, and weekday-weekend differences


how will mgt of pre-gestational DMII change during pg'y?

most will require IN. Usually maintain hypoG meds that they were on before, but most still need IN. Start w/bedtime NPH and humalog or Lispro at mealtimes.


how is delivery managed in a well-controlled pregestational IN-dependent diabetic w/no complications?

fetal lung maturity testing at 37w, deliver if mature. Or, can induce at 38-39 weeks without fetal lung maturity testing. Need to deliver earlier though if nonreassuring fetal status, poor G control, worsening or unctl'd HTN, worsening renal dis, poor fetal growth

During delivery, need dextrose and IN drips to maintain adequate increased G needs during labor. Maintain blood G b/w 100 and 120.

After delivery, a T1DM mom may not need any IN b/c of removal of placental hrms. T1DM will need at least a small amt of IN.


what f/u is needed post-partum?

do not resume oral hypoglycemic agents if breastfeeding
if pregestational, resume prepregnancy regimens.
24-h urine collectiojn at 6 weeks postpartum
ophtho f/u