Diabetes and Pregnancy

Question 1

which relevant drugs nmust be stopped

Answer 1

all oral hypoglycaemics except Metformin

ACEi, statin

Question 2

what extra medication needs to be taken

Answer 2

folic acid 5 not 4

any type of diabetes is a risk factor for pre-eclampsia - 75mg aspirin from 12 weeks until delivery

Question 3

do you deliver the baby at teh same time?

Answer 3

no, deliver at 38 weeks, earlier if complications

Question 4

what is the biggest risk factor for GDM

Answer 4

previous GDM

Question 5

outline the pathophysiology of GDM

Answer 5

• degree of insulin resistnace develops through pregnancy, partly because hPL, cortisol, hPHG, oestrogen and progesterone are insulin antagonists
• the beta cells can compesnate to an extent by producing more insulin, eventually this fails
• in people with comorbidities/risk factors pancreas wont be able to compensate for as long
• serum glucose level rise and when excessive they can cause foetal complications

Question 6

there are 2 types of screening for GDM, tell me about them

Answer 6

• positive risk factors identified at booking - OGTT at 24-28 weeks
• previous GDM - OGTT at booking

Question 7

how is the OGTT performed

Answer 7

fast overnight, meausre venous fasting BG, administer 75g glucose and measure BG 2 hours later

Question 8

OGTT results - diagnosis of GDM

Answer 8

• fasting plasma glucose level of 5.1 mmol/litre or above or a 2‑hour plasma glucose level of 8.5 mmol/litre or above

Question 9

what other clinical finding would make you consider an OGTT

Answer 9

urine found on dipstick at any point

Question 10

what is monitored during pregnancy in someone with GDM

Answer 10

• BP
• blood glucose
• pre eclampsia
• serial US to monitor foetal growth and liquor volume

regularly !

Question 11

management of GDM generally

Answer 11

weight, lifestyle

metformin

insulin

Question 12

when is the baby delivered in GDM

Answer 12

early! the risk of stillbirth increases closer to full term in macrosomic babies

offer IOL around 38 weeks

Question 13

can you have a vaginal delivery in GDM ?

Answer 13

yes, it is not contraindicated by macrosomia but there are risks, such as shoulder dystocia, failure to progress etc

also more pain???

Question 14

what weight of the baby is an indication for C section and why

Answer 14

>4.5kg

there is a significant risk of cephalopelvic disproportion and shoulder dystocia

Question 15

how is glucose control managed during delivery

Answer 15

if it is >7 would usually give an insulin sliding scale

Question 16

what is the mother more prone to getting with GDM

Answer 16

skin and urinary tract infections due to hyperglycaemia

Question 17

what is the mechanism behind polyhydramnios in GDM

Answer 17

foetal polyuria

Question 18

what is the mechanism behind IUGR in GDM

Answer 18

poor matenreal nutrition and placental vascular dysfucntion

Question 19

what problems can macrosomia cause during delivery

Answer 19

genital tract lacerations, bleeding, uterine rupture, shoulder dystocia

Question 20

what neurological problem can shoulder dystocia cause

Answer 20

Erb’s palsy (C5 and 6) - waiters tip

Question 21

what is the mechanism behind respiratory distress in neonates

Answer 21

delayed pulmonary surfactant production

Question 22

complciations in neonates with GDM

Answer 22

• respiratory distress
• hypoglycaemia secondary to hyperinsulinaemia
• polycythaemia
• jaundice

Question 23

why do you et polycythaemia in the neonate

Answer 23

because the intrauterine hypoxia is a stimulus for EPO production

Question 24

how do you manage the mother after delivery in GDM

Answer 24

stop the insulin

monitor baby for comlpications

Question 25

what are the risks for teh mother after having had GDM

Answer 25

50% develop T2DM in 10 years

and risk of recurrence

Question 26

with this in mind, what check is done on the mother’s glucose levels post partum

Answer 26

check maternal fasting blood glucose 6 weeks after to ensure remission