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Blueprints OB/GYN: diabetes in pregnancy

Terms in this set (34)

gestational diabetes MELLITUS (gdm)
carbohydrate intolerance that first manifests during pregnancy.patients may have borderline carbohydrate metabolism impairment at baseline or be entirely normal in the nonpregnant
state. these women have a
four- to tenfold increased risk of developing type 2 diabetes during their lifetime. may occasionally include women with undiagnosed pregestational diabetes mellitus.
pathophysiology of GDM
during pregnancy, human chorionic somatomammotropin (a.k.a. human placental lactogen) and other
hormones produced by the placenta act as anti-insulin agents leading to increased insulin resistance and generalized
carbohydrate intolerance. these hormones increase in volume with the size and function of the placenta, the
carbohydrate metabolism abnormalities usually are not apparent until the late second trimester. so not at increased risk for congenital anomalies like women with pregestational
diabetes. but will have increased risk of fetal macrosomia and birth injuries as well as neonatal hypoglycemia,
hypocalcemia, hyperbilirubinemia, and polycythemia
risks with GDM.
since insulin resistance doesn't happen til 2nd trimester, neonate is not at increased risk for congenital anomalies like women with pregestational
diabetes. but will have increased risk of fetal macrosomia and birth injuries as well as neonatal hypoglycemia,
hypocalcemia, hyperbilirubinemia, and polycythemia
incidence of GDM
1% to 12% of pregnant women
Gestational diabetes is seen at higher rates in women of Hispanic/Latina,
Asian/Pacific Islander, and Native American descent, increasing maternal age, obesity, family history of diabetes, history of a
previous infant weighing more than 4,000 g, and previous stillborn infant
diagnosis of GDM
end of the second trimester between 24 and 28 weeks'
gestation in women with low risk for GDM.Patients with one or more risk factors should be screened at their first prenatal visit and, if negative, again in the early third
trimester. true gestational diabetics, fasting values are commonly normal while postprandial values are elevated. This is because the
pathophysiology is related to metabolism of large carbohydrate boluses rather than carbohydrate intolerance at baseline.
Class A1
Gestational diabetes; diet controlled
Class A2
Gestational diabetes; insulin controlled
Class B
Onset: age 20 or older Duration: less than 10 years
Class C
Onset: age 10 to 19 Duration: 10 to 19 years
Class D
Onset: before age 10 Duration: greater than 20 years
Class F
Diabetic nephropathy
Class R
Proliferative retinopathy
Class RF
Retinopathy and nephropathy
Class H
Ischemic heart disease
Class T
Prior renal transplantation
1 h after a 50-g glucose load (GCT)
Normal Glucose Level <140
if 130 or higher GTT is reccomended
FASTING
Normal Venous Blood Glucose Level 90
Normal Whole Plasma Glucose 105 (if only one valueis reported then it is this value)
1 h after a 100-g glucose load (GTT)
100 g given after 8-hour fast preceded by a 3-day special carbohydrate diet. If two or more of the four values are elevated, a diagnosis
of gestational diabetes is made.including fasting value.
Normal Venous Blood Glucose Level 165
Normal Whole Plasma
Glucose 190
2 h after a 100-g glucose load (GTT)
Normal Venous Blood Glucose Level 145
Normal Whole Plasma
Glucose 165
3 h after a 100-g glucose load (GTT)
Normal Venous Blood Glucose Level 125
Normal Whole Plasma
Glucose 145
treatment of gestational diabetes.
diet of 2,200 calories per day. recommended intake is approximately 200 to 220 g of carbohydrates per day. monitors her blood glucose levels four times per day, which includes a
fasting and three postprandial values. walk for 15 minutes about 30 to 40 minutes
after the meal.aiming for range fasting values <90 and 1 hour postprandial
values <140 mg/dL or 2 hour postprandial values <120 mg/dL. if diet doesnt work you have to add insulin. or oral hypoglycemia agents.
oral hypoglycemic agents in GDM
short-acting insulin in combination with an intermediate-acting insulin in the morning (to
cover breakfast and lunch) and a shortacting insulin at dinner. short-acting insulin is humalog (Lispro) or
novalog and the intermediate-acting insulin is NPH. glyburide crossed the placenta in undetectable levels. Because of the
ease of patient administration and possibly improved compliance, oral agents such as glyburide or metformin are seen as better for fetus.
fetal monitoring
fetal monitoring via nonstress test (NST) or
modified biophysical profile (BPP) is typically begun between 32 and 36 weeks' gestation and continued until delivery on a
weekly or biweekly basis. Because of the increased risk of macrosomia, these patients commonly receive an obstetric
ultrasound for an estimated fetal weight (EFW) between 34 and 37 weeks. this is done for A2 patients not likely for A1
GDM and delivery.
random glucose check on admission does not reveal significant hyperglycemia that requires correction to avoid neonatal
hypoglycemia, done with all patients even who aren;t GDM. induction of labor at 39 weeks of gestation is common in patients on insulin or a
hypoglycemic agent (class A2 gestational diabetes). because there
may be an increased risk of hypoglycemia as their placental function decreases toward the end of pregnancy. elective cesarean delivery is
offered to those with an EFW greater than 4,500 gm. more than 4,000 needs monitoring becasue increased risk of shoulder distocia.
follow up of GDM pregnancy
over 50% will experience GDM in subsequent pregnancies and 25% to
35% will go on to develop overt diabetes within 5 years. screened for type 2 DM at
the postpartum visit and every year thereafter. infants of patients with GDM have an increased incidence of childhood obesity and type 2 diabetes.
complications of diabetes during the first trimester of pregnancy
twice as likely to have a spontaneous abortion. risks of infection, polyhydramnios, postpartum hemorrhage, and
cesarean delivery are all increased. fivefold increase in perinatal death and a two- to threefold increase in the risk of congenital malformations including both cardiac anomalies and neural tube defects, and most
dramatically, caudal regression syndrome.. all of these on top of the general complications of DM like ketoacidosis and coma.
Fetal Complications of Diabetes Mellitus
Macrosomia which would cause Traumatic delivery, Shoulder dystocia, and Erb palsy. delayed organ maturity seen in Pulmonary, Hepatic, Neurologic systems and the Pituitary-thyroid axis. cardiac and neurla tube defects on top of Caudal regression syndrome, Situs inversus, Duplex renal ureter, IUGR and lastly fetal demise
indications for Fetal Complications of Diabetes Mellitus
HgbA1c, which gives an estimate of the
average blood glucose control over the prior 8 to 12 weeks. Patients with an HgbA1c <6.5% generally have good outcomes,
whereas patients with an HgbA1c of 12% or greater are estimated to have a 25% rate of congenital anomalies. co-morbidities like hypertension, pyelonephritis,
ketoacidosis.
type I diabetes
patients are extensively screened at their first visit (if not
preconceptionally). Routinely, patients should obtain an electrocardiogram (ECG), particularly those with longstanding disease,
hypertension, advanced maternal age (AMA), or renal disease. A 24-hour urine collection for creatinine clearance and protein
should be sent to assess baseline renal function. An HgbA1c is ordered to assess baseline glucose management as well as
thyroid function tests (TSH and free T4) since these patients are at risk for other autoimmune endocrinopathies. In addition, a
referral to an ophthalmologist should be made to check for baseline retinopathy
treatment of DM1 during pregnancy
first half of pregnancy, the patient's prior dosing regimen is usually increased slightly, but can increase substantially during the
latter half of pregnancy as insulin resistance increases. the previous regiment will need to be changed to optimally manage blood glucose levels. best option is insulin pump. exercise decreases blood glucose levels also.
type 2 diabetes and pregnancy
type 2 diabetics have peripheral insulin
resistance. Many type 2 diabetics are managed prior to pregnancy with oral hypoglycemic agents or diet alone. However, in
pregnancy, most will require insulin
type 2 diabetes treatment
insulin is started as NPH at bedtime to control fasting blood sugars and in the AM to provide a
longeracting substrate throughout the day. A short-acting insulin, usually humalog or Lispro, is used at meals to control
immediate carbohydrate intake
management of fetus of pregestational diabetes motehr
antenatal fetal assessment consisting of weekly NSTs until 36 weeks, at which time biweekly testing is
implemented, which includes weekly NST alternating with weekly modified BPP to assess amniotic fluid measurement as well.
In addition to the weekly testing, an ultrasound to assess fetal growth is usually obtained between 32 and 36 weeks' gestation.
postpartum management of diabetes
After delivery, maternal insulin requirements decrease significantly because of the removal of the placenta, which contains
many insulin antagonists. Type 2 diabetics may require no insulin during this period. However, type 1 diabetics should always be
maintained on at least a small amount of insulin because they do not produce any. diabetics should resume their prepregnancy regimens. no oral hypoglycemics if breast feeding becasue neonatal hypoglycemia can result.
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