Lec19 Maternal hyperglycaemia during pregnancy

Question 1

What effect does maternal hyperglycaemia have on the foetus?

Answer 1

Very bad for the foetus and significant morbidity affecting the baby all its life

Question 2

What can you do to improve the outcome for the foetus?

Answer 2

Improve the maternal blood glucose

Question 3

Why does diagnosing maternal hyperglycaemia matter?

Answer 3

It is an opportunity to prevent:
Significant morbidity to the foetus
Consequences of the maternal hyperglycaemia will affect the foetus “from the uterus to the grave”
Exacerbation of the type 2 DM and obesity epidemic
Future type 2 DM in the mother - through educating her

Question 4

In the antenatal clinic there are two groups of women, what are they?

Answer 4

Women with normal glucose tolerance

Women with abnormal glucose tolerance

Question 5

Out of the women in the ANC with abnormal glucose tolerance, what are the two groups within them

Answer 5

Women with known diabetes or IGT

Women with unknown diabetes/ IGT

Question 6

In pregnancy, IGT is the same as:

Answer 6

diabetes

Question 7

What happens to women with known Type 1 DM when they get pregnant?

Answer 7

They go to specific clinics

Question 8

When is gestational diabetes diagnosed?

Answer 8

Following a newly found abnormal GTT after the 1st trimester of pregnancy

Question 9

What happens to insulin sensitivity during the 1st trimester?

Answer 9

The mother is slightly more sensitive to insulin so her glucose will go down but then up after the 1st trimester

Question 10

What is the WHO criteria definition of gestational diabetes?

Answer 10

Fasting glucose >/= 5.6mmol/l

2 hour GTT >/= 7.8mmol/l

Question 11

What is the main problem of maternal hyperglycaemia during pregnancy?

Answer 11

It can cause serious problems for the foetus

Question 12

Describe the key events in the 1st trimester:

Answer 12

Organogenesis - carefully design essential components
avoid mistakes - teratogenesis
Placenta - construct and programme the placenta
key organ in pregnancy
if the placenta is incorrectly formed –> more likely to get pre-eclampsia and delivers excess glucose

Question 13

Describe what happens in the 2nd trimester:

Answer 13

Further complex development and linkage

Question 14

Describe what happens in the 3rd trimester

Answer 14

Accelerated growth - more glucose is delivered to the baby to facilitate the accelerated growth but with a malformed placenta - excess glucose will be delivered to the placenta
Excess fat is deposited around the organs in the abdomen - visceral fat

Question 15

What is the maternal metabolism as pregnancy progresses?

Answer 15

Early pregnancy = facilitated anabolism

Later pregnancy = facilitated catabolism

Question 16

What does facilitated anabolism mean?

Answer 16

Increased insulin sensitivity
Glucose concentration slightly lower
Increased maternal energy stores for accelerated growth periods

Question 17

What does facilitated catabolism mean?

Answer 17

Increased insulin resistance
Increased transplacental passage of nutrients
Which leads to rapid foetal growth

Question 18

What consequences are there for the foetus from 1st trimester maternal hyperglycaemia?

Answer 18

Foetal malformation

Fuel mediated teratogenesis

Question 19

Give examples of foetal malformation:

Answer 19

Hydrocephalus
Meningomyelocoele - neural tube defects more common in hyperglycaemic mothers than in the general population
Central cyanosis in congenital heart disease
Single ventricle and sacral dysgenesis
Renal agenesis

Question 20

Even in a woman with normal HbA1c the risk of malformations is increased above what percentage of the background population?

Answer 20

2%

Question 21

How do you prevent foetal malformation in hyperglycaemia of pregnancy?

Answer 21

Pre pregnancy counselling for known diabetes
Lifestyle modification
Good diabetes control in 1st trimester
Intensive glucose monitoring
Folic acid 5mg/day preconception - higher dose than normal
Get rid of oral hypoglycaemic agents and put mother on insulin

Question 22

Why do you put the mother on a higher dose of folic acid?

Answer 22

Because higher dose shown to reduce chances of congenital defects

Question 23

What is the ideal HbA1c before conception, but certainly once she knows she’s pregnant?

Answer 23

Down to 6%

Question 24

How do you identify unknown cases of diabetes/ IGT?

Answer 24

By checking women with risk factors

Question 25

What are the risk factors?

Answer 25

``` Previous gestational diabetes Obesity Polycystic Ovarian Syndrome FHx T2DM High risk racial groups e.g. African, South east asian ```

Question 26

What are problems that may arise in the third trimester?

Answer 26

Macrosomia & associated problems Pre-eclampsia Foetal or neonatal death

Question 27

What are the associated problems of macrosomia?

Answer 27

``` Shoulder dystocia Difficult birth Breathing problems Jaundice Hypoglycaemia ```

Question 28

What is the risk of shoulder dystocia?

Answer 28

The baby's shoulder gets stuck during labour and freeing it can cause axillary nerve damage to the baby These babies also get hypoglycaemia frequently

Question 29

Compared to normoglycaemic women, babies born to hyperglycaemia women have higher incidence of:

Answer 29

``` Obesity Insulin resistance Type 2 diabetes Dyslipidaemia Hypertension Vascular disease ```

Question 30

When do NICE guidelines say you should screen mothers with risk factors?

Answer 30

At 26 weeks

Question 31

What is the vicious cycle of hyperglycaemia?

Answer 31

If the grandmother was hyperglycaemic, she was probe hyperglycaemic during pregnancy with the mother, the mother probably suffered with obesity and hyperglycaemia all her life and therefore when she has a baby, that baby also likely to be obese and hyperglycaemic

Question 32

Treatment of any pregnancy hyperglycaemia?

Answer 32

Good maternal glucose control through intensive blood glucose monitoring Fasting & 1 hour post prandial minimum Appropriate nutrition Reasonable exercise Ultrasound monitoring of foetal abdominal girth - weekly from 28 weeks Maternal observation of foetal movements

Question 33

What would be the drug treatment pre-pregnancy/ 1st trimester?

Answer 33

Basal bolus insulin regimen

Question 34

What would be the drug treatment in "gestational diabetes"

Answer 34

``` Metformin Basal insulin Basal bolus insulin Glibenclamide Sulfonylureas are used when women don't want to take insulin ```

Question 35

What is advised postpartum?

Answer 35

Breastfeed for as long as possible - breast feeding reduces risks for mother an child & allows mother to reduce weight

Question 36

Women who lactated from 6-12 months or 12 months or longer had:

Answer 36

half the risk for diabetes

Question 37

Specific GDM management postpartum:

Answer 37

``` Screen for diabetes 12 weeks pp HbA1c +/- fasting glucose or GTT Lifestyle advice Advice re next pregnancy Annual glucose screening Combined OCP after 6 weeks/ Mirena intrauterine system ```

Question 38

The progesterone pill is more likely to cause what in GDM mothers?

Answer 38

Insulin resistance