-
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
English
Deutsch
Español
Français
Italiano
Português
Русский
Preferences
-
What places mothers at higher risk of future type 2 DM
- Preterm birth (28-36 wks)
- LGA babies
-
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
-
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
-
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
-
What is the critical goal in pregnancy with preexisting diabetes
ACHIEVE NORMOGLYCEMIA BEFORE PREGNANCY
-
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
-
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
-
A1 class of DM
controlled with diet or oral meds (any age onset)
-
A2 class DM
on insulin with no complications
-
Class B DM
ADULT onset, <10 yr duration, on insulin, and no complications
-
Class C DM
Juvenile diabetic, 10-19 yrs, no complications, on insulin
-
Class D&R
- age onset <10, duration >20yrs,
- Retinopathy
-
-
Class G DM
Cardiac complications
-
Bad signs of pregnancy
- Pyelo
- Ketoacidosis
- PID
- Delayed/inadequate prenatal care
-
What is a normal result for the 50G Glucose challenge test
<140
-
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
-
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
-
Name some pregnancy complications from DM
- PTL
- HTN
- Stillbirth
- Retinopathy
- Infection
- POLYhydramnios
- C/S
-
What are fetal effects from DM
- Asphyxia
- Birth injury
- Congenital malformation (caudal regression)
- hypoglycemia
- macrosomia
- Cardiomyopathy
- RDS
-
What is the characteristic defect with an insult prior to 7 wks gestation
Caudal regression
-
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
-
Define Macrosomia (20-25% of DM preg)
Weight >90% for gestation age
Birth weight >4kg - 4000g
-
What is the adipose distribution in a macrosomic baby?
Trunk and shoulder >head
Visceral organ hypertrophy
-
What are some macrosomia outcomes?
- #1 - Shoulder dystocia
- HYPOglycemia
- asphyxia
- hyperbilirubinemia
- ↑ risk for DM and obesity risk later in life
-
What is affected in pulmonary maturation delay or RDS
Hyperglycemia and hyperinsulinemia interfere with pulmonary surfactant biosynthesis
-
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.
-
What does routine managment for GDM include
- Opthamology visit
- Baseline renal function
- Endocrine referral
- Nutrition referral
- Fasting glucose part of annual exams
-
Diet management for GDM
2000-2500 cal/day
- Exclude simple carbohydrates
- 60G protein daily
-
Therapeutic objectives for blood sugar
60-90 fasting
<120 2 hrs after meal
-
What medications are contraindicated in GDM?
1st Gen sulfonyureas (tolbutamide & chlorpropamide)
(Stimulate fetal insulin secretion causing PROFOUND NEONATAL HYPOGLYCEMIA
-
Early pregnancy GDM testing <20 wks
- Early sonogram, 18-22 wks
- AFP
- Retinal exams monthly
- Q 1-2 wk prenatal visits
-
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
-
6 wk PP check
- Check for diabetic comp:
- (retinopathy, nephropathy)
- AIC
- Renal function, TSH
|
|