Term
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Definition
| autoimmune destruction of pancreas, insulin deficient, insulin sensitive, requires exogenous insulin. Usually begins in childhood but not always. High risk for ketoacidosis. |
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Term
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Definition
| makes insulin but either not enough or the insulin that is made is not effective or both. Insulin deficient and relative insulin resistance. Cells become resistant to insulin and the pancreas compensates by secreting more insulin in order to get the same amount of glucose into cells which eventually exhausts the beta cells. Over time, insulin secretion goes down and hyperglycemia occurs. |
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Term
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Definition
| early signs of beta cell exhaustion |
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Term
| Define gestational diabetes |
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Definition
| most common metabolic complication of pregnancy. Carbohydrate intolerance of various severity first recognized during pregnancy (so we may miss if it we are screening in third trimester) |
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Term
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Definition
| Diet controlled gestational diabetes |
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Term
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Definition
| Medication controlled gestational diabetes |
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Term
| What hormonal changes in early pregnancy (9-15 weeks) predispose a woman to diabetes? |
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Definition
- Higher levels of estrogen and progesterone stimulate insulin production
- Promotes increased movement of glucose into cells and decreased glucose in maternal blood stream
- May result in maternal hypoglycemia in particularly in type 1 diabetics
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Term
| What changes in later pregnancy (18-38 w) increase the risk of GDM? |
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Definition
- Increased placental production of human placental lactogen, estrogen, progesterone, prolactin, cortisol and TNF- alfa
- Decreased tolerance to glucose
- Increased insulin resistance
- Increased hepatic glucose production
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Term
What is the risk of birth defects in a normoglycemic mother?
What about a hyperglycemic mother? |
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Definition
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Term
What is the risk of miscarriage in a normoglycemic mother?
Hyperglycemic? |
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Definition
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Term
What is the risk of macrosomia in a normoglycemic mother?
Hyperglycemic? |
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Definition
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Term
What is the risk of newborn hypoglycemia in a normoglycemic mother?
Hyperglycemic? |
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Definition
rare after initial 2-3 hours of life
vs
up to 50%, persists in 1st 24 hrs |
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Term
What is the risk of DM, obesity, CVD, HTN for self and offspring in a normoglycemic mother?
Hyperglycemic? |
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Definition
No increased risk.
Increased risk. |
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Term
| What leads to increased stillbirth with DM? |
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Definition
chronic intrauterine hypoxia
Typically seen after 36 weeks gestation in women with vascular disease, poor glycemic control, hydramnios, fetal macrosomia, or preeclampsia. May be linked to ketoacidosis or preeclampsia. |
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Term
| Poor glycemic control around what weeks of gestation can lead to increased risk of congenital malformations? |
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Definition
| Weeks 3-8 of development (later fetus produces own insulin) |
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Term
| What is the primary risk of macrosomia in DM? |
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Definition
| GDM infants also have higher fat mass, and disproportionate growth with fat deposits in the chest and shoulders which contribute to higher rates of shoulder dystocia and birth trauma. |
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Term
| What are two causes of increased RDS in babies born to mothers with DM? |
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Definition
1. hyperinsulinemia appears to interfere with timing of surfactant synthesis
2. the higher rate of cesarean section in diabetic women leads to a subsequent increase in RDS. |
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Term
| What were the 4 primary outcomes measured in the HAPO study? |
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Definition
1. Birth weight about 90th percentile for gestational age
2. Primary cesarean delivery
3. Clinical neonatal hypoglycemia
4. Cord-Blood serum C-peptide level above 90th percentile (fetal hyperinsulinemia) |
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Term
| What were the signficant findings of the HAPO study? |
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Definition
Asociations between increasing levels of fasting, 1-hour, and 2-hour plasma glucose obtained on oral glucose-tolerance testing and:
-birth weight above the 90th percentile
-cord-blood serum C-peptide level above the 90th percentile
Weaker associations between glucose levels and:
-primary cesarean delivery
-clinical neonatal hypoglycemia
We also found positive associations between increasing plasma glucose levels and each of the five secondary outcomes examined: premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinemia, and preeclampsia. |
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Term
| Subjective data related to GDM |
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Definition
- DM in 1st degree relative
- Prior history of:
- GDM or use of metformin
- Macrosomia (>4kg) or LGA baby
- Unexplained IUFD
- Malformed infant
- Member of high risk ethnic group: Hispanic, Asian, Indian, African American (according to IADPSG)
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Term
| Objective data collected for GDM |
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Definition
- Current glucosuira (100 mg/dl)
- BMI >30
- Labs (GLT and GTT)
- New possible recommendations: either fasting BS or Hgb A1C or random BS with prenatal labs on all women
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Term
| What tests can be done to look for DM in the first trimester? |
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Definition
- GLT 1 hour
- A1C
- 2 hour GLT, fasting
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Term
| Describe the 1-step GCT and results |
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Definition
100 g oral glucose test, fasting, diagnostic
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Term
Describe the two-step oral glucose test |
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Definition
| 1 hour 50 g GCT test followed by the 3 hour 100g GTT test if 50 g test screens positive |
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Term
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Definition
| 2 hour, 75 g oral glucose test, fasting, diagnostic |
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Term
| SFGH screening recommendations for first trimester |
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Definition
- Obesity (BMI >30, pre-pg weight)
- DM in first degree relative
- Prior hx of:
- GDM, glucose intolerance, metformin use
- macrosomia (>4000g or 8 lbs 8 oz) or LGA (>90th percentile) baby
- unexplained stillbirth
- malformed infant
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Term
| Without risk factors, when are most women screened for GDM? |
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Definition
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Term
| Describe results and management for 50 g GCT |
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Definition
- </=139 mg/dl: routine PNC
- 140-179: schedule 3 hour OGTT (100g--diagnostic) within one week; if one value elevated (>95 fasting, >/=180 at 1 hour; >/=155 at 2h; >/=140 at 3 h) refer for nutrtional counseling, no further testing necessary, and repeat test not necessary if performed at 24.0+ weeks. If two or more values elevated, tx as GDM.
- >/=180 mg/dl: Schedule fasting glucose ASAP (FS ok, if pt. is fasting). If fasting <95, proceed with 100g 3 h OGTT; if >/=95, refer to HiROB
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Term
| Who needs postpartum DM testing? When? |
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Definition
All pts dx with GDM need to be tested for overt DM 6-8 weeks PP and annually thereafter. Test can be a 75g 2 hour GTT (preferred) or a fasting glucose (if pt declines 75g GTT). Dx may be made according to the following levels:
a) 75g OGTT: >/= 200 mg/dL is overt DM; 140-199 is impaired glucose tolerance; <140 is normoglycemic
b) Fasting glucose: >/=126 is overt DM; 110-126 is impaired fasting glucose; <100 is normoglycemic. Dx of overt DM should have tests repeated on a different day if not in an acute/decompensatory state. |
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Term
| How do we manage DM testing in women who are late to care? |
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Definition
<36 weeks, tx as 24-28 weeks
>36 weeks or impending labor regardless of GA: fasting glucose >105 should be managed as GDM; random glucose (second choice) >200 should be managed as GDM. |
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Term
| Patient instructions for 3 hour 100g GTT |
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Definition
| Fast for 8-14 hours; water is okay. Eat “normally” for at least three days before the test. Your fasting plasma will be drawn, and you will then be given a 100g glucose drink to drink in under five minutes. You cannot smoke. Your blood will be drawn again at 1, 2, and 3 hours from when you started to drink the sugary drink. |
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Term
| Patient instructions for OGCT |
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Definition
| No fasting or dietary restriction required, will be admin during regular office hours. You will be give 50g of glucose (sugary drink) to drink in under five minutes. You cannot smoke before the test. Blood plasma level is drawn one hour after beginning to ingest the glucose. |
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Term
| GDMA1 antepartum management |
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Definition
- kick counts starting 32 weeks
- check blood sugar at home, fasting first thing in a.m. and 1 hr postprandial
- NST if at 40 (41) weeks and not yet delivered
- diabetes educator (how to monitor blood glucose levels)
- nutritionist (Sweet success program - how to eat, count carbs, portion control, no juice, read labels etc)
- social work (if more support needed)
- MD (for complications and monitoring risks of GDM)
- CNM (for all the normal, lovely parts of pregnancy that she still gets to experience, monitoring for GDM, and consulting).
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Term
| GDMA2 antepartum management |
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Definition
- Will be under OB care
- Start insulin or oral glycemics when:
- >20% glucoses beyond target despite diet and exercise: 3 or more elevated fastings and or 6 post meal elevations in one week.
- kick counts starting 32 weeks
- NST if at 40 (41) weeks and not yet delivered
- diabetes educator (how to monitor blood glucose levels)
- nutritionist (Sweet success program - how to eat, count carbs, portion control, no juice, read labels etc)
- social work (if more support needed)
- MD (for complications and monitoring risks of GDM)
- CNM (for all the normal, lovely parts of pregnancy that she still gets to experience, monitoring for GDM, and consulting).
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Term
| Intrapartum management of GDMA1 |
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Definition
If BG >110, they are to be given:
Non caloric (no- carb) clears
Non glucose containing IV
If BG < 80 with mod-lg ketones, they are to receive:
15 gms CHO (equivalent to 4 ounces juice- dilute with water) q 2-4 hrs or
IV D5 @ 100-125/hr (5 gms glucose per hour)
Check BG q 2- 4hrs |
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Term
| Postpartum management of GDM |
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Definition
- Insulin needs are cut in half!!!!
- Aim of therapy is to keep blood glucose in the following range
- For T1 and T2: FBG< 100 and 1 hr post-meal <150
- For GDMs (A1 and A2) BG targets same as pregnancy
Postpartum Insulin Management
- For type 1: cut IV algorithm in half. Continue until taking food. Restart SC basal/bolus insulin @ half the pregnancy dose.
- For GDMA2 or T2: D/C IV insulin after placenta. Or continue at half the algorithm until BG is <130 or food has been resumed.
- Type 2 may continue SC insulin (halved) or restart orals-metformin or glyburide.
GDM Follow up
- obtain @4-6 weeks
- 75g OGTT-obtain both fasting and 2hr. most sensitive test to identify prediabetes and diabetes in this high risk population
- Obtain @ 1 year and every 3 years thereafter, OGTT and fasting lipid panel. Obtain fasting yearly
- Continue healthy lifestyle
- Avoid Progesterone only birth control-IUD is best
- Plan future pregnancies and get tested for DM before and at the first PNV.
- Breastfeed!
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