Diabetes in Pregnancy

Post Partum monitoring?

-75 g OGTT or a fasting blood glucose level at 4-6 weeks postpartum, and q6 months - 1 year EVER after.

Post partum care?

-After delivery of the placenta, the levels of the diabetogenic hormones drop precipitously. -If insulin was required during pregnancy, blood sugars can fluctuate. -Continue checking postpartum, and intermittently in the following weeks. -If controlled with diet and orals, often normoglycemic within hours. -CONTINUE to monitor, b/c 60% of women with GDM WILL develop DM II within 15 years -Contraception!

Risk factors for gestational diabetes?

-Age greater than 25 years -Previous delivery of a baby greater than 9 pounds [4.1 kg] -Personal history of abnormal glucose tolerance -Prepregnancy weight ≥110 percent of ideal body weight or body mass index over 30 kg/m2 or significant weight gain in early adulthood, between pregnancies, or in early pregnancy. -A family history of diabetes, especially in first degree relatives -Member of an ethnic group other than caucasian -Previous unexplained perinatal loss or birth of a malformed child -Maternal birthweight greater than 9 pounds [4.1 kg] or less than 6 pounds [2.7 kg] -Glycosuria at the first prenatal visit -Polycystic ovary syndrome -Current use of glucocorticoids -Essential hypertension or pregnancy-related hypertension

Screening for over diabetes in pregnancy?

-Baseline renal function -Random urine sample for protein:creatinine ratio -Screen for evidence of diabetic vasculopathy (EKG, Dilated ophthalmologic exam, etc). -Thyroid function (up to 40% have coexistent) -Medication review (ACE-I and ARBs for hypertension should be discontinued).

GDM and delivery?

-Early delivery may be indicated for vasculopathy, nephropathy, poor glucose control or a prior stillbirth -C section if large, don't need to try labor if fetus >4500g Very hard to predict size!! Estimates can be off by 50% in the last weeks -sometimes can use EFW>4500g, plus prolonged second stage of labor/arrest of decent as indicators

GDM pharm treatment?

-Glyburide: 2nd gen sulfonlyureas don't cross cord blood -Metformin -Insulin (can be used, but risk of hypOglycemia makes it a less attractive choice)

Fetal surveillance for GDM?

-Ultrasound early for viability and firm dating. -Ultrasound 18-20 weeks for major anomalies. -Ultrasound periodically for fetal growth. -Fetal monitoring of some sort, usually weekly from 32-34 weeks fetal kick counts nonstress test biophysical profile contraction stress test. -From 36 weeks on twice weekly NST and AFI.

Unique consequences of PRE-gestational diabetes?

-Unexplained fetal demise -Intrauterine growth retardation (uteroplacental insufficiency) - SMALL BABIES! -Congenital anomalies - complex cardiac defects; central nervous system anomalies (anencephaly, spina bifida); skeletal malformations [caudal regression syndrome (sacral agenesis)] -Maternal end-organ deterioration - cardiac, renal, ophthalmic, peripheral vascular, gastroparesis, peripheral neuropathy

Other risk factors for developing DMII after GDM?

-Waist circumference and BMI are the strongest predictors developing DMII after GDM -Early gestational age at diagnosis (less than 24 weeks) -Need for insulin because dietary interventions were inadequate

Pathophys of consequences?

-at 12 weeks of gestation, maternal glucose crosses the placenta by facilitated diffusion, and fetal beta cells start producing insulin. The growth hormone effects of this insulin leads to fetal macrosomia

What reduces risk of developing GDM?

-regular exercise

When to screen high risk pts?

-screen on presentation, at 20 wks, and RE-screened at 24-28 weeks

Which blood sugar value is the most important on GDM?

-the 1 hr post prandial value is most important!! -it is the most closely associated with macrosomia

Way to screen high risk its?

1 hr glucose tolerance test 50g of sugar -check blood sugar 1 hr later >140 is 80% sensitive >130 is 90% sensitive -if +, repeat, but use 3 hr glucose tolerance test (Eat at least 150 g of carbs/day in the days before test, day of test, come in fasting, then give 100g, re-checked each hour after for 3 hrs)

Fetal kick counts:

10 movements in 2 hours

Which of the following puts dolores at increased risk for diabetes affecting this pregnancy? -Age >25 -Previous delivery of baby likely >9lbs -BMI 32 -Hispanic ethnicity -All of the above

All of the above

When to screening for GDM?

Controversial! -usually done between 24 - 28 weeks (too early you'll miss people who develop later, too late, and the consequences are already present

Use of Insulin in GDM?

Controversial!! -all types work, really depends on the patient and what they can handle -short acting (lispro) use, post-prandial, is often good to use to prevent 1hr post prandial rise -pts are often insulin resistant, and require 1 unit/kg of PRESENT pregnancy weight for optimal control

Why do the consequencces to the baby occur?

Hyperglycemia during organogenesis (the first 10 weeks) is teratogenic HgbA1C> 7.5 associated with 2-3X more congenital malformations and miscarriages

Which of the following is NOT a known consequence of diabetes in pregnancy for Moms? -Preeclampsia -Cesarean delivery -Developing type 2 diabetes later in life -Perineal trauma in delivery -Hypoglycemia

Hypoglycemia

Consequences of poorly controlled gestational diabetes for the babe?

Macrosomia Delayed organ maturity Organomegaly (cardiac hypertrophy, hepatomegaly, adrenal hypertophy pancreatic islet cells) Metabolic - hypoglycemia, hypo magnesia/calcemia, jittery, irritability, poor feeding, seizures Long term: obesity and diabetes, impaired fine and gross motor functions, increased rates of ADHD !these can be prevented with good diabetic control in the mother!

Contraction stress test:

Monitor fetal heart rate under the stress of contractions. Contractions (3/10mins) may be induced with nipple stimuation or with Oxytocin (IV). A negative result (no decelerations), indicates fetal wellbeing and anticipated tolerance of labor.

Nonstress test:

Monitor fetal heart rate. Expect to see two or more accelerations in fetal heart rate within 20-30 minutes. May use vibroacoustic stimulation, but contractions indicate an even more sensitive Contraction Stress Test. A nonreactive test requires further evaluation, usually to complete a BPP.

Biophysical profile:

NST + AFI + ultrasound observation of fetal tone, and spontaneous fetal breathing and limb movements.

Who is at highest risk for developing DMII after GDM?

Obese women!! -almost 100% go on to develop DM II

Obstetric complications of gestational diabetes for mom?

Obstetric complications: Polyhydramnios, preeclampsia, complications of traumatic delivery (hemorrhage, extensive perineal lacerations), operative delivery Diabetic complications: Hyperglycemia, worsening end-organ damage, infections, ketoacidosis, diabetic coma

Criteria for GDM dx?

On 3 hr GTT, Fasting >95 One hour >180 Two hour > 155 Three hour >140 2+ abnormal blood sugar values Random >200, or fasting >126 = GDM

Pathophys of GDM?

T-he endocrine and metabolic changes of pregnancy probably help ensure that the fetus has an ample supply of fuel and nutrients at all times. -In early pregnancy, higher levels of estrogen enhance insulin sensitivity. We can see maternal hypOglycemia, especially when associated with nausea and vomiting. -But by the 2nd and 3rd trimesters, we see increasing hyperglycemia due to insulin resistance, likely mediated by the elaboration of a number of placental hormones: Placental growth hormone Cortisol Human placental lactogen Progesterone Prolactin

What baseline testing would you do for a patient who presents for prenatal care with known, pre-existing DM? -None is necessary -Baseline hepatic function -Thyroid function testing -Screening for cognitive impairment -Screen for urinary tract infection

Thyroid function testing Screen for urinary tract infection

What do after a GDM dx?

again, controversial -often (60-95%) dietary changes are adequate b/c pts are extremely compliant!! Use tiered approach -Diet and Exercise. -Oral medications. -Insulin.

What is caudal regression syndrome?

aka- caudal agenesis, sacral dysgenesis, or caudal dysplasia sequence -occurs approximately 200 times more frequently in IDMs than in other infants, but it is not limited to IDMs. =a spectrum of structural defects of the caudal region, including incomplete development of the sacrum and, to a lesser degree, the lumbar vertebrae. Disruption of the distal spinal cord results in neurologic impairment, which ranges from incontinence to complete neurologic loss; decreased movement leads to severely limited growth and deformities of the legs.

Which of the following is NOT a known consequence of diabetes in pregnancy for newborns? -Macrosomia -Anemia -Shoulder dystocia -Hyperbilirubinemia -Hypoglycemia -Respiratory distress syndrome -Childhood Obesity

anemia

gestational diabetes:

any degree of carbohydrate intolerance with onset or first recognition during pregnancy.

Macrosomia:

baby >4000g and traumatic delivery

What did Hyperglycemia and Adverse Pregnancy Outcomes Study (HAPO) show?

complications occur along a continuum correlating to degree of hyperglycemia during pregnancy

Blood sugar goals?

fasting <95-105; 1 hour postprandial <130-140; 2 hour postprandial <120. -if >30% of values are above goal, add more treatment

Most common complication of pregnancy?

gestational diabetes

overt/pregestational diabetes:

those who were known to have diabetes before pregnancy.