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Flashcards by Anna Walker, updated more than 1 year ago
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Created by Anna Walker
over 9 years ago
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| Question | Answer |
| What happens to glucose tolerance in pregnancy? | It decreases due to altered CHO metabolism and the antagonistic effects of human placental lactogen, progesterone and cortisol. |
| What is the definition of GDM? | Carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy (NICE 2008). NICE uses a fasting glucose level of >7.0mmol/L or >7.8mmol/L 2 hours after a 75g glucose load (GTT). This definition encompasses 3.5% of pregnant UK women. |
| Why does Gestational Diabetes occur? | Because pregnancy is 'diabetogenic' - women without diabetes but with impaired or potentially impaired glucose tolerance often deteriorate enough in pregnancy to be classified as diabetic. This is GDM. |
| Why may a pregnancy woman get glycosuria at physiological blood glucose levels. | In a non-pregnant woman, the kidney will start to excrete glucose at a threshold level of 11mmol/L. In pregnancy this threshold level varies more and often decreases. |
| What do raised fetal blood glucose measurements induce? | They induce fetal hyperinsulinaemia, causing fetal fat deposition and excessive growth (macrosomia). |
| What must you tell women who are taking insulin to control their diabetes will happen when they are pregnant? | Increasing amounts will be required throughout pregnancy to maintain normoglycaemia. |
| What are the fetal complications of diabetes in pregnancy? | These are related to blood glucose levels so GDMs are less affected, and types I and II are similarly affected. CONGENITAL ABNORMALITIES: Esp NTDs and cardiac defects, are 3-4 times more common in established DM, and are related to preconceptual glucose control. PRETERM LABOUR: Natural or induced, occurs in 10% of established DM, and FETAL LUNG MATURITY at any gestation in a diabetic is less than that of a non-diabetic. BIRTHWEIGHT is increased as fetal pancreatic islet cell hyperplasia leads to hyperinsulinaemia and fat deposition. This leads to increased urine output and POLYHYDRAMNIOS is common. As the fetus is usually larger, birth trauma is more common, esp shoulder dystocia. FETAL COMPROMISE, FETAL DISTRESS in labour and SUDDEN FETAL DEATH are more common and are particularly related to poor control in the 3rd trimester. |
| What are the maternal complications of diabetes in pregnancy? | INSULIN REQUIREMENTS normally increase a lot by the end of pregnancy. KETOACIDOSIS is rare, but HYPOGLYCAEMIA may result from attempts to achieve optimum glucose control. UTI and WOUND or ENDOMETRIAL INFECTION after delivery are more common. Pre-existing HTN is detected in up to 25% of overt diabetics and PRE-ECLAMPSIA is more common. Pre-existing IHD often worsens. CAESAREAN or INSTRUMENTAL DELIVERY is more likely because of fetal compromise and increased fetal size. Diabetic NEPHROPATHY (5-10%) is associated with poorer fetal outcomes but doesn't usually deteriorate. Diabetic RETINOPATHY often deteriorates and may need to be treated in pregnancy. |
| What is the general management for a woman who is pregnant with pre-existing DM? | Precise glucose control and fetal monitoring for evidence of compromise are the cornerstones of management. CLC. MDT. Woman needs to be educated as how to optimise control. |
| What preconceptual care would you ideally give a woman who is diabetic and planning to become pregnant? | Insulin-dependent women should have their renal function, BP and retinae assessed. Glucose control should be optimised and folate 5mg/day is prescribed. Optimal control at conception reduces risk of congenital abnormalities and preterm labour. Labetalol and methyldopa are used if antihypertensives are required. Unfortunately this seldom happens. |
| How is DM monitored and treated in pregnancy? | Aim for a HbA1c under 7% (<8% is acceptable). Visits occur fortnightly up to 34w, and weekly thereafter. Glucose levels are checked by the woman several times daily, before and after food, and before bed, with a home 'glucometer'. The ideal is levels consistently below 6mmol/L. In type II diabetics, hypoglycaemic drugs might need to be supplemented by insulin. Usually control is achieved with one long-acting night time and 3 pre-prandial short acting injections. Doses will need to be increased as time goes on and glucagon should be prescribed in case of hypoglycaemia. |
| What fetal monitoring is appropriate for a diabetic pregnancy? | In addition to the usual scans, fetal echos are indicated. USS used to measure fetal growth and liquor vol. Even where glucose control has been good, macrosomia and polyhydramnios can occur. Umbilical artery Doppler not useful inless pre-eclampsia or IUGR develop. |
| How should diabetic complications be prevented? | Renal function should be checked and the retinae screened for retinopathy. Aspirin, 75mg daily from 12 weeks is advised to reduce the risk of pre-eclampsia. DKA is a medical emergency and should be treated appropriately. |
| How would you manage delivery in a diabetic pregnancy? | Delivery should be by 39 weeks. Birth trauma is more likely and although US prediction is inaccurate, ECS is often used where birth weight is estimated at >4kg. During labour, glucose levels are maintained with a 'sliding scale' of insulin and a dextrose infusion. |
| Describe the differences in the neonate and the puerperium when the woman has been diabetic in pregnancy. | The neonate commonly develops hypoglycaemia as it has become accustomed to the hyperglycaemic environment, and its insulin levels are high. RDS occasionally occurs, even after 38 weeks. Breast feeding is strongly advised. The dose of insulin can be rapidly changed to prepregnancy doses. |
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