OB-DM in pregnancy
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What are 6 risk factors for GDM?
- 1. Ethnicity
- 2. AMA
- 3. Fm Hx
- 4. Unexplained stillbirth, congenital anomaly, or macrosomnia
- 5. maternal obesity
- 6. HTN
If develops GDM, what's the risk of developing DM in next 10-20years?
T or F. Pregnancy is a diabetogenic state (even when not diabetic).
True--> pregnancy causes increase in insulin resistance by (50-60%)
Increase insulin release from B-cells promotes _________________.
T or F. There is a close correlation between fetal glucose uptake and maternal blood levels.
What are 2 problems associated with pre-existing DM on fetal growth?
- 1. fetal growth delay (~6 days, proportional to degree of hyperglycemia)
- 2. Glucose fluctuations >normal
- **increase fetal glucose make pancreas work harder
Hgb A1C >10 creates a potential for malformation at what percent?
According to White's classification, which populations make up the classes A1, A2, B, C?
- A1- newly diagnosed GDM w/out insulin
- A2- newly diagnosed GDM needing insulin
- B- Adult onset DM with insulin use
- C- juvenile onset DM with insulin use
(others are associated with complications from aging w/ DM)
What are Pedersen's Bad signs of pregnancy?
- 1. Pyelo
- 2. Ketoacidosis
- 3. PIH
- 4.. Delay/inadequate prenatal care
What is the Carpenter-Coustan fasting BG normal?
What's the normal for Carpenter-Coustan's 3hr at 1hr, 2hr, 3hr?
- 1hr- <180
- 2hr- <155
- 3hr- <140
What glucose level is automatically considered abnormal with a GTT?
>190 (any reading)
T or F. Retinal disease at baseline strongly is strongly predictive of adverse fetal/maternal outcomes
True (although long-term effects probably minimal)
T or F. DM unable to increase filtration rate
What are 3 complication of nephropathy in severe DM disease.
- 1. Infant survival high
- 2. Maternal kidney damage probably & obstetric complication increase
- 3. HTN, PIH, pre-eclampsia
Dm ketoacidosis is most commonly precipitated by _______________.
Name 7 complications related to GDM pregnancies.
- 1. PTL
- 2. Infection
- 3. HTN & consequences
- 4. Stillbirth
- 5. DM retinopathy
- 6. Polyhydramnios (PTL, PROM, unstable lie, cord prolapse)
- 7. C/S rate
What are some fetal effects from GDM pregnancies?
- 1. Asphyxia
- 2. Birth injury
- 3. congenital malformation (caudal regression)
- 4. HF
- 5. Cardiomyopathy
- 6. Increased blood vol.
- 7. Neuro instability
- 8. Organomegaly
- 9. Polycythemia
Congential malformations usually occur from insults < ___________ weeks.
(30-50% of perinatal deaths are caused by malformations
What CNS and cardiac malformations have high occurance in infants of Type I moms?
- -CNS: (15x) ancephaly, spina bifida
- -Cardiac: (18x likely) VSD, transposition
Increased glucose, ketones, & episodes of hypoglycemia predispose to congenital malformations by what 2 processes?
- 1. Inhibition of glycolysis (needed for embryogenesis)
- 2. Functional deficiency of arachidonic acid (CNS defects)
What are fetal/neonatal problems associated with GDM?
- 1. Congenital malformation
- 2. hypergilirubinemia/polycythemia
- 3. Neonatal hypoglycemia
- 4. Macrosomia
- 5. IUGR
- 6. Respiratory distress
- 7. death
What is fetal polycythemia bad?
-Causes relative hypoxia in utero
What blood glucose level significantly increases fetal problems in L&D.
- >90 mg/dl
Why is uncontrolled blood sugar an issue in late pregnancy?
-Increase fetal hyperglycemia causes B-cel proliferation in fetal pancreas
What are 7 bad outcomes of macrosomnia?
- 1. shoulder dystocia
- 2. brachial plexus injury
- 3. Hyperbilirubinemia
- 4. Hypoglycemia
- 5. neonatal acidosis
- 6. asphyxia
- 7. increased risk for obesity & DM in later life
- ***tight control may not help
T of F. Tight control of blood sugar can almost eliminate RDS
T--> hyperglycemia delays pulmonary maturation
What is the hypothesis for increased (3x) fetal death in DM?
-increased insulin with increased oxygen demand and decreased uterine blood flow results in insufficient uteroplacental blood flow
What are 5 risk factors for fetal death after 36 weeks in DM moms?
- 1. Poor glycemic control
- 2. Pre-E
- 3. Hydramnios
- 4. Fetal macrosomnia
- 5. vascular disease
What is the general BG level you want to keep DM women at during pregnancy?
120 or below
- **careful monitoring in 3rd trimester
- ** daily glucose monitoring (daily & 2hr p meals)
Therapeutic objectives for BG are:
- FG---> 60-90
- 2hr after meal --> <120
- Monitor A1c
Why should 1st gen sulfonylureas not be given to DM moms?
-cross placenta and stim fetal insulin secretion and have profound hypoglycemia at birth
T or F. Insulin requirements may drop initially and slowly increase until 20 weeks
When do insulin needs accelerate during pregnancy?
after 26 weeks
How often should retinal exams be performed in a pregnant women with established disease?
**Once or each trimester is no disease initially
T or F. Is glyberide a clinically effective alternative to insulin therapy.
When is a sonogram performed to assess for congenital anomaly?
How many times should a DM receive NST (starting 32-34)?
What are you assessing for during U/S in late pregnancy?
- -Fetal growth
- - estimating fetal weight
- -detecting hydramnios
- -deteching malformations
- -focus on ABDOMINAL CIRCUMFERENCE (most predictive of fetal macrosomnia
When should BPPs start being performed?
-weekly after 36 weeks
If a mom's BPP is "positive", what is the plan of care?
-Amnio if preterm, or delivery
To decrease the risk of neonatal hypoglycemia, how should glycemic control be maintained during labor?
IV insulin (D5 drip as needed). Monitor BG q 1 hr
What happends to glucose levels right after delivery?
Insulin requirement immediately drop towards pre-pregnancy needs. BF decreases this another 25%.
What labs should be verified at the 6 week postpartum check for gestational DM?
- Check A1C (normal < 7.5)
- 75mg oral GTT (normal 1&2hr <200)
- FBG <140
**evaluate q 3-5 years, check renal function, TSH, DM complications
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