Diabetes in Preg

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Author:
rhondak
ID:
221014
Filename:
Diabetes in Preg
Updated:
2013-05-24 19:40:01
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OB
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Description:
DM
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  1. Name the risk factors for gestational DM
    • Ethnicity (Black, hispanic, native am, mid east)
    • Advanced maternal age
    • family hx
    • unexplained stillbirth
    • congenital anomaly
    • Maternal obesity
    • HTN

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  2. What places mothers at higher risk of future type 2 DM
    • Preterm birth (28-36 wks)
    • LGA  babies
  3. What happens with insulin in pregnancy
    Preg is a diabetogenic state.

    • ↑ in insulin resistance
    • Insulin sensitivity ↓ by 50-60%

    Pancreatic beta cells respond to fetal-placental demands in pregnancy
  4. When is glycosuria not normal in pregnancy?
    Glycosuria can be normal (↓ tubular reabsorption)


    If glycosuria with 2nd voided urine, more likely to be true intolerance
  5. What happens in embryo with preexisting DM
    Growth delay (proportional to degree of hyperglycemia)

    ↑ fetal glucose levels, ↑ pancreatic stimulation

    Fetal hyperinsulinemia causes excess fetal growth, contributes to IU death, RDS, hypoglycemia
  6. What is the critical goal in pregnancy with preexisting diabetes
    ACHIEVE NORMOGLYCEMIA BEFORE PREGNANCY
  7. What antihypertensive is contraindicated and what are other recommended therapies
    Discontinue ACE inhibitors likely to cause birth defects

    Recommend switch to Methylopa (Aldomet) or Labetolol
  8. Which type of diabetes has the highest potential for congenital anomalies?
    DM type 1 has highest risk (important for glucose control prior to conception)

    AIC >10 has 50% malformation rate
  9. A1 class of DM
    controlled with diet or oral meds (any age onset)
  10. A2 class DM
    on insulin with no complications
  11. Class B DM
    ADULT onset, <10 yr duration, on insulin, and no complications
  12. Class C DM
    Juvenile diabetic, 10-19 yrs, no complications, on insulin
  13. Class D&R
    • age onset <10, duration >20yrs, 
    • Retinopathy
  14. Class E
    Neuropathy
  15. Class G DM
    Cardiac complications
  16. Bad signs of pregnancy
    • Pyelo
    • Ketoacidosis
    • PID
    • Delayed/inadequate prenatal care
  17. What is a normal result for the 50G Glucose challenge test
    <140
  18. Why is a glocose challenge require to identify Gest DM
    Most will have normal FBS

    FBS naturally lower in early preg due to metaboliam changes
  19. Why is preconceptual counseling so important
    Because decreased glucose levels stimulate growth factors and new cell formation.

    Poor control preconceptually and good control in early preg at highest riks for deterioration
  20. Name some pregnancy complications from DM
    • PTL
    • HTN
    • Stillbirth
    • Retinopathy
    • Infection
    • POLYhydramnios
    • C/S
  21. What are fetal effects from DM
    • Asphyxia
    • Birth injury
    • Congenital malformation (caudal regression)
    • hypoglycemia
    • macrosomia
    • Cardiomyopathy
    • RDS
  22. What is the characteristic defect with an insult prior to 7 wks gestation
    Caudal regression
  23. What level is neonatal hypoglycemia
    Blood glucose <40 during the first 12 hrs

    • severity depends on:
    • b cell proliferation in fetal pancreas in last 1/2 of pregnancy

    >90 BS in labor
  24. Define Macrosomia (20-25% of DM preg)
    Weight >90% for gestation age

    Birth weight >4kg - 4000g
  25. What is the adipose distribution in a macrosomic baby?
    Trunk and shoulder >head

    Visceral organ hypertrophy
  26. What are some macrosomia outcomes?
    • #1 - Shoulder dystocia
    • HYPOglycemia
    • asphyxia
    • hyperbilirubinemia
    • ↑ risk for DM and obesity risk later in life
  27. What is affected in pulmonary maturation delay or RDS
    Hyperglycemia and hyperinsulinemia interfere with pulmonary surfactant biosynthesis
  28. What are the proposed causes of stillbirth among preg diabetics
    Chronic intrauterine hypoxia

    the increased insulin causes increased oxygen demand

    decrease in uterine blood flow.
  29. What does routine managment for GDM include
    • Opthamology visit
    • Baseline renal function
    • Endocrine referral
    • Nutrition referral
    • Fasting glucose part of annual exams
  30. Diet management for GDM
    2000-2500 cal/day

    • Exclude simple carbohydrates
    • 60G protein daily
  31. Therapeutic objectives for blood sugar
    60-90 fasting

    <120 2 hrs after meal
  32. What medications are contraindicated in GDM?
    1st Gen sulfonyureas (tolbutamide & chlorpropamide)

    (Stimulate fetal insulin secretion causing PROFOUND NEONATAL HYPOGLYCEMIA
  33. Early pregnancy GDM testing <20 wks
    • Early sonogram, 18-22 wks
    • AFP
    • Retinal exams monthly
    • Q 1-2 wk prenatal visits
  34. Late pregnancy GDM testing
    • NSTs 2x weekly at 32-34 wks
    • US to rule out macrosomia 
    • Fetal echo
    • Continue retinal exams and HTN screen
    • BPP 
    • Kick counts
  35. 6 wk PP check
    • Check for diabetic comp:
    • (retinopathy, nephropathy)
    • AIC
    • Renal function, TSH

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