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27 Cards in this Set
- Front
- Back
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normal maternal plasma glucose (PG) level
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- lower than in non-pregnant adults
- fasting: 4.3 mmol/L - 1h postprandial: 6.1 mmol/L - 2h postprandial: 5.4 mmol/L - 24-hour mean: 5.3 mmol/L - higher in obese women |
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What cutoff for PG is associated lower incidence of fetal macrosomia?
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- mean PG < 6.0 mmol/L
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recommended glycemic targets for preconception and during pregnancy
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- pre-pregnancy HbA1c: =<7.0%
- during pregnancy: - fasting: 3.8-5.2 mmol/L - 1h postprandial: 5.5-7.7 mmol/L - 2h postprandial: 5.0-6.6 mmol/L - A1C: =<6.0% |
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complications in women w/ pregestational DM
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- perinatal mortality
- congenital malformations - HTN - preterm delivery - LGA infants - C-sections - neonatal morbidities |
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When should women w/ pregestational DM have ophthalmologic assessments for retinopathy?
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- before conception
- during T1 - as needed during pregnancy - w/in 1st year PP |
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Risk factors for progression of retinopathy
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- poor glycemic control during pregnancy
- chronic HTN - GHTN - pre-eclampsia - severe pre-existing retinopathy - pregnancy does NOT affect the long-term outcome of mild to moderate retinopathy |
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incidence of hypertension complicating pregnancy in women w/ DM1 and DM2
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- 40-45%
- DM1 more assoc. w/ pre-eclampsia - DM2 more assoc. w/ chronic HTN |
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risk factors for developing HTN in women w/ pregestational DM
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- poor glycemic control in early pregnancy
- increased proteinuria in early pregnancy |
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Should women w/ pregestational DM be screened for chronic kidney disease prior to conception?
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yes
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management for early CKD in pregnancy
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- random albumin-to-creatinine ratio q trimester
- estimated GFR from serum creatinine q trimester - |
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prognosis for women w/ CKD in pregnancy
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- microalbuminuria and overt nephropathy assoc. w/ increased maternal and fetal complications
- no adverse effects on long-term renal function in women w/ normal GFR provided BP and PG are well-controlled - in women w/ elevated serum creatinine, pregnancy can lead to a permanent deterioration in renal function |
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recommendation for folic acid supplementation in women w/ pregestational DM
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- folic acid 5mg QD >=3 months pre-conception until 12 weeks post-conception
- 0.4-1.0 mg folic acid from 12 weeks GA until 6 weeks PP and continuing as long as breastfeeding |
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reasons for hypoglycemia unawareness
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- blunting of the normal counter-regulatory hormone response to hypoglycemia
- risk of recurrent hypoglycemic episodes due to striving to reach glycemic targets |
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goals of nutrition in pregnant women w/ pregestational DM
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- promote euglycemia
- appropriate weight gain - adequate nutritional intake |
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Why are hypocaloric diets not recommended in pregnant women w/ pregestational DM?
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- result in weight loss
- significant ketosis - inadequate in required nutrients (eg. protein, calcium) |
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two modes of insulin delivery during pregnancy
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- multiple daily injections
- continuous subcutaneous insulin infusion/insulin pump |
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reason why oral hypoglycemic agents not recommended for glycemic control in pregnant women w/ DM2 at this time (2008)
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- increased perinatal mortality and pre-eclampsia in women treated w/ metformin/glyburide cf. those treated w/ insulin, despite similar glycemic control
- no increased incidence of congenital anomalies |
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additional reason to recommend breastfeeding in women w/ DM
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- may reduce offspring obesity (esp. in setting of maternal obesity)
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Are metformin and glyburide considered safe to use during breastfeeding?
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yes
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prevalence of GDM in Canada
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- non-Aboriginal (probably multiethnic): 3.7%
- Aboriginal: 8-18% |
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criteria for Dx of GDM
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- GDS:
- 1h post: >= 10.3 mmol/L - 7.8 mmol/L cutoff for OGTT - OGTT - 2 out 3 of: - fasting: >=5.3 mmol/L - 1h post: >= 10.6 mmol/L - 2h post: >= 8.9 mmol/L - if 1 out of 3; impaired glucose tolerance of pregnancy |
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timing for GDM screening
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- 24-28 weeks GA (all pregnant women)
- first trimester if multiple risk factors (and reassess in T2 if negative): - previous diagnosis of GDM - delivery of a macrosomic infant - high-risk ethnicity (Aboriginal, Hispanic, South Asian, Asian, African) - age >= 35 - BMI >= 30 - PCOS - acanthosis nigricans - corticosteroid use |
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when to initiate insulin for GDM or IGT
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- if glycemic targets are not achieved w/in 2 weeks from nutrition therapy alone
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Can metformin or glyburide be used in women w/ GDM at this time (2008)?
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- not approved indication in Canada, so off-label (but can be considered if cannot use insulin)
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What is the recommendation regarding women w/ GDM in terms of postpartum testing?
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- 75g OGTT between 6 weeks and 6 months PP
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elements included in pre-conceptional counseling in women w/ pregestational DM
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1. nutrition
2. target of HbA1C =< 7.0% (preferably 6.0% if safe) 3. 5mg folic acid supplementation 4. discontinue ACEI/ARB and statins 5. ophthalmology assessment 6. screening for nephropathy; if microalbuminuria or overt nephropathy found, glycemic and BP control should be optimized - DM2-specific: - switch from oral agents to insulin, except in PCOS |
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special screening for women w/ DM1 postpartum
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- for PP thyroiditis w/ TSH at 6 weeks PP
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