Large for Dates Pregnancy (Diabetes)

Question 1

What is gestational diabetes?

Answer 1

Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition in pregnancy

Question 2

Complications of diabetes in pregnancy are always related to what?

Answer 2

Poor diabetic control

Question 3

What are some complications of diabetes in pregnancy which are specific to pre-existing diabetes?

Answer 3

Miscarriage, intra-uterine death and congenital anomalies

Question 4

What are some complications of diabetes in pregnancy which can be seen with both pre-existing and gestational diabetes?

Answer 4

Pre-eclampsia, polyhydramnios, macrosomia, shoulder dystocia and neonatal hypoglycaemia

Question 5

What is the demographic of mothers who have type 1 diabetes?

Answer 5

Young, white, slim

Question 6

What is the demographic of mothers who have type 2 diabetes?

Answer 6

Older, overweight, Asian/Caribbean/African

Question 7

What are the 4 main things to discuss at pre-pregnancy counselling for those with pre-existing diabetes?

Answer 7

HbA1c control, stopping embryopathic medications, determining any current micro or macrovascular complications, start taking folic acid

Question 8

Before getting pregnant, mothers with diabetes should aim for an HbA1c of what? Pregnancy should be avoided if there is an HbA1c of what?

Answer 8

48mmol/mol / > 86mmol/mol

Question 9

What medications must women with diabetes stop taking before getting pregnant? What could be a replacement option?

Answer 9

ACE inhibitors and statins - could replace with labetalol

Question 10

Describe how folic acid should be taken in women with pre-existing diabetes?

Answer 10

5mg 3 months before conception until 12 weeks gestation

Question 11

What medication should women with pre-existing diabetes take from 12 weeks gestation until delivery?

Answer 11

Low dose (75mg) aspirin daily

Question 12

Women with pre-existing diabetes should undergo regular screening throughout pregnancy for which complication?

Answer 12

Retinopathy

Question 13

What hypoglycaemic agents can be used during pregnancy?

Answer 13

Insulin and metformin

Question 14

When should women with diabetes (pre-existing and gestational) receive growth scans?

Answer 14

Every 4 weeks from 28 weeks onwards

Question 15

When should a baby of a pre-existing diabetic mother be delivered, providing there are no complications? Why is this done?

Answer 15

38 weeks, to reduce the risk of late stillbirth

Question 16

What are some risk factors for gestational diabetes?

Answer 16

Previous GD, previous macrosomic baby, diabetes in a 1st degree family member, South Asian/Caribbean ethnicity, BMI > 30

Question 17

When is screening for gestational diabetes carried out?

Answer 17

At 24-28 weeks, if risk factors are present

Question 18

Describe briefly the pathophysiology of gestational diabetes?

Answer 18

Placental hormones such as hPL, cortisol and growth hormone promote insulin resistance. To maintain stable glucose levels, the normal response to this would be to produce more insulin, however this does not happen in gestational diabetes and so the woman becomes hyperglycaemic.

Question 19

Why do babies of diabetic mothers become macrosomic?

Answer 19

Because there is overgrowth of insulin sensitive tissues

Question 20

Describe what happens after a baby with a diabetic mother is born?

Answer 20

These babies are used to having high glucose levels, so they have a high basal rate of insulin. Once they are born, the maternal source of glucose is taken away and so they become hypoglycaemic. This leads to hypoxia which triggers erythropoiesis, polycythaemia and eventually jaundice.

Question 21

Foetal metabolic reprogramming seen in babies of diabetic mothers can have what long term consequences?

Answer 21

Increased risk of obesity, insulin resistance and diabetes in the future

Question 22

If there has been a previous episode of gestational diabetes, what is the chance of this recurring? What is different about testing women who have had gestational diabetes previously?

Answer 22

> 50% / these women receive an oral glucose tolerance test at booking, and if this is negative then they get tested again at 24-28 weeks. They can also monitor their own blood glucose levels early in a pregnancy.

Question 23

Describe how the oral glucose tolerance test is done?

Answer 23

The woman will undergo an overnight fast, her fasting blood glucose levels will be measured and then she will drink a solution containing 75g of glucose and then after 2 hours her glucose levels will be measured again

Question 24

A fasting blood glucose of what is diagnostic of gestational diabetes? A 2 hour blood glucose of what is diagnostic of gestational diabetes?

Answer 24

5.1mmol/l + / 8.5mmol/l +

Question 25

Having gestational diabetes increases a woman's risk of developing what later in life?

Answer 25

70% risk of developing type 2 diabetes

Question 26

How often should blood sugar be monitored in women with gestational diabetes? When?

Answer 26

4 times a day, before each meal and before bed

Question 27

In gestational diabetes, what is a normal a) fasting glucose? b) hour after eating glucose?

Answer 27

a) 3.5-5.5mmol/l b) < 7.8mmol/l

Question 28

How are 80-90% of cases of gestational diabetes managed?

Answer 28

By diet, exercise and weight control

Question 29

When should the use of hypoglycaemic agents be considered in the treatment of gestational diabetes?

Answer 29

If diet and exercise are failing to maintain blood glucose levels, or if the baby is macrosomic on US

Question 30

What are the advantages of using an oral hypoglycaemic agent for gestational diabetes?

Answer 30

Avoidance of hypoglycaemia, less weight gain and easier to use

Question 31

When should short acting insulin be taken? When should long acting insulin be taken?

Answer 31

Before meals / before bed

Question 32

Does insulin cross the placenta? What is the risk of treating gestational diabetes with insulin?

Answer 32

No / hypoglycaemia

Question 33

When should a mother with gestational diabetes deliver her baby if a) managed with insulin? b) managed with metformin? c) managed with diet alone?

Answer 33

a) 38 weeks b) 39-40 weeks c) 40-41 weeks

Question 34

When should a mother with gestational diabetes deliver earlier than 38 weeks?

Answer 34

If there is foetal macrosomia, IUGR or PET

Question 35

When should a C-section always be used in gestational diabetes?

Answer 35

If the baby is macrosomic i.e. > 4.5kg

Question 36

What happens in terms of treatment for diabetes (both pre-existing and gestational) following delivery of a baby?

Answer 36

Pre-existing will go back to previous treatment regime and gestational will stop all medications

Question 37

What are the main risk factors for developing type 2 diabetes following an episode of gestational diabetes?

Answer 37

Obesity, use of insulin, impaired glucose tolerance post-partum and ethnicity

Question 38

Following delivery after an episode of gestational diabetes, what follow up is required?

Answer 38

OGTT 6-8 weeks after deliver, and annual HbA1c measurements