ICARE Endocrine: Diabetes in Pregnancy (Exam 2)

gestational diabetes

diabetes during pregnancy

pre-existing or pre-gestational diabetes

type 1 or 2 DM diagnosed before conception or becoming pregnant

risks of diabetes and pregnancy

spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, hyperbilirubinemia and neonatal resp distress syndrome

diabetes in pregnancy may increase the risk of what co-morbidities occurring in children later in life?

obesity, HTN and T2DM

is insulin sensitivity increased or decreased during early gestation?

increased

uptake of glucose is increased during pregnancy for what purpose?

glucose uptake into adipose stores in preparation for the energy demands of later pregnancy

as pregnancy progresses, a surge of what increases insulin resistance?

a surge of local and placental hormones

blood glucose is transported across the placenta for what purpose?

to fuel growth

is the breakdown or build up of fat stores and endogenous glucose production promoted during pregnancy?

breakdown -> this increases blood glucose and free fatty acid concentrations

what type of hormones play a large role in the pathophysiology of gestational diabetes?

placental hormones

key points that contribute to diabetes in pregnancy

beta cell dysfunction, insulin resistance, neurohormonal dysfunction and increased gluconeogenesis

risk factors for getting diabetes while pregnant?

overweight/obese

diet high in saturated fats, refined sugars and red/processed meats

advanced maternal age (>40)

family/personal history of GDM

other disease states that increase insulin resistance such as PCOS

preconception counseling in pre-existing DM pts

importance of maintaining euglycemia as safely as possible during pregnancy -> need good BG control

an A!C of <6.5% has been associated with what in regards to organogenesis?

associated with the lowest risk of congenital anomolies, pre-eclampsia and pre-term birth

who should be screened for gestational diabetes?

universal screening -> >90% of pregnant women have at least 1 risk factor for glucose impairment during pregnancy

when is screening typically done for gestational diabetes?

initial pre-natal visit and 24-28 weeks of pregnancy

describe the one-step GTT

75-grams OGTT over 2 hrs

what indicates if someone has gestational diabetes in regards to the one-step GTT test?

if one or more of the BG levels is above the number listed:

FBG: 92 mg/dL

1-hr: 180 mg/dL

2-hr: 153 mg/dL

describe the two-step GTT

1. 50g OGTT without regard to time of day/meals

2. measure venous plasma or serum glucose concentration at 1 hr after admin

3. glucose > 135-140 mg/dL is elevated and requires admin of a 100g OGTT

Step 2:

1. measure fasting venous plasma or serum glucose concentration

2. 100 g OGTT

3. measure venous plasma or serum glucose concentration at 1,2 and 3 hrs after administration

a + test is defined by elevated glucose concentrations at 2 or more points in time

carpenter/coustan plasma/serum goals for OGTT

Fasting: 95

1-hr: 180

2-hr: 155

National diabetic data plasma/serum goals for OGTT

Fasting: 105

1-hr: 190

2-hr: 165

gestational DM BG goals

FBG: <95 mg/dL

1-hr PPBG: <140 mg/dL

2-hr PPBG: <120 mg/dL

pre-existing DM BG goals

FBG: <95 mg/dL

Peak PPG: <140 mg/dL

A1C goal for pregnancy and diabetes

6-6.5%

glucose monitoring for pts with DM and pregnancy

intermittent self-monitoring before breakfast and at 1-2hrs after the beginning of each meal

keep a glucose and food log & consider CGM

treatment options for DM and pregnancy

1st line: medical nutritional therapy

2nd line: insulin

3rd line: metformin and glyburide

describe medical nutrition therapy

first line treatment

includes nutritional counseling, a personalized nutrition plan and a moderate exercise program

goals: achieve normoglycemia, prevent ketosis, facilitate adequate weight gain and fetal well-being

changes to diet for medical nutrition therapy

elimination or reduction of sugar-sweetened beverages -> subs for water

eat 3 small to moderate sized meals and 2-4 snacks per day

changes to exercise for medical nutrition therapy

30-60 minutes of moderate-intensity aerobic activity on most days of the week

when is insulin therapy initiated?

when glycemic targets cannot be met through medical nutrition therapy

what basal insulin is recommended for use?

NPH for basal insulin

why is NPH the preferred insulin?

low antigenicity -> minimizes transplacental transfer of insulin antibodies

what types of insulin are preferred for bolus insulin

regular, lispro and aspart

in pts with pre-existing T1DM and T2DM, regimens often need increased or decreased?

increased

dose recommendation for insulin

10-20 units of NPH and 4-10 units of rapid acting in the morning before breakfast

follow-up for insulin therapy

weekly follow-up

what is the threshold for hypoglycemia in pregnant pts

BG < 60 mg/dL

how to treat hypoglycemia in pregnant pts

rule of 15

who are metformin and glyburide last line therapy?

both cross the placenta -> long-term effects of transplacental passage are largely unknown

metformin and glyburide are only used in what instances?

when pts are unable or refuse to use insulin

dosing of metformin

follow the same dosing recommendation, but no titration is necessary -> just keep pt on lowest dose that will keep BG stable

dosing of glyburide

start at 2.5mg or 5mg QD and increase as needed

twice daily dosing is often needed to maintain BG

aspirin in pregnant women

pregnant females with T1DM or T2DM should use aspirin 100-150 mg/day starting at 12-16 weeks to lower risk of preeclampsia

BP threshold for pregnancy -> when do we start meds

> 140/90 mmHg

when is therapy de-intensified for BP?

BP < 90/60 mmHg

what drugs should be stopped in pregnancy

ACEi, ARB, statin

is metformin is being used for PCOS treatment, when should it be D/C'ed in pregnancy

D/C'd by the end of the 1st trimester

how do insulin requirements change postpartum?

roughly half of the pregnancy requirements for the initial ew days postpartum

if pt is T2DM pt and not on insulin before pregnancy, when can they stop insulin postpartum?

stop insulin immediately postpartum

what meds can be continued in breastfeeding individualks?

metformin, glyburide and insulin

meds and discontinuation in gestational DM pts

all meds can be immediately D/C'd postpartum

when and what women should be screened postpartum?

women with a recent history of GDM at 4-12 weeks postpartum using the 75g OGTT

how often should women be screened for pre-diabetes or T2DM

every 1-3 years