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22 Cards in this Set
- Front
- Back
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Describe the pathophysiology of gestational DM
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Occurs around 24-28 wks GA, anti-insulin factors (human placental lactogen, progesteron, hCG, cortisol)produced by placenta and high maternal cortisol levels created increased peripheral insulin resistance --> higher fasting glucose --> GDM and/or exacerbating pre-existing DM
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RF for gestational DM
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> 25
obesity family history previous history from diabetes prone ethnic group previous child with birthweight > 4kg fetal macrosmia persistant glycosuria |
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When should woman be screened for gestational DM
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24-28 wks GA
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How should woman be screened for gestaional DM
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At 24-28 weeks
Oral glucose challenge test - Pt drinks 50g glucose drink - 1hr later - BSL PG should be < 7.8 if > 10.3 = GDM no need for GTT PG 7.8 - 10.3 - do 2 hr 75g OGTT OGTT - 150mg carb loading 3 days prior; Fast 14 hrs; Measure BSL; Drink glucose; test every hour for 3 hours FG > 5.3; 1 hr > 10.6, 2 hrs > 8.9 --> 2/3 = GDM 1/3 = impaired glucose tolerance |
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Management of diabetes in pregnancy
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Diet management = first line
if blood glucose not well controlled - insulin or if developing fetal macrosomia Maintain normal blood glucose levels, take folic acid, have good diet, preferably change to insulin therapy if on hypoglycaemia agents |
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What is an HBA1c value > 140% of pre pregnancy value associated with?
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Risk of spontaneous abortions and congenital malformation
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What fetal complications are associated with DM in pregnancy
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Growth abnormalities: macrosomia; IUGR
Delayed lung maturity (hyperglycaemia interferes with surfactant synthesis) Congenital anomalies (DM1 and 2 NOT GDM b/e develops after critical period of organogensis) Preterm labour/prematurity, stillbirth, birth trauma Neonatal hypoglycaemia, hyperbilirubinaemia and jaundice, hypocalcaemia, polycythemia (hyperglycaemia stimulates fetal EPO production) |
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Maternal complications of DM in pregnancy
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Hypertension/pre-eclampsia
Polyhydramnios Hypoglycaemia, ketoacidosis, diabetic coma End-organ involvement or deterioration (not GDM retinopathy, nephropathy) Pyelonephritis Increased incidence of spontanous abortion (DM1 and 2 not GDM) - related to pre-conception glycaemic control |
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What is the risk of GDM mothers developing type 2 diabetes?
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2 different stats
4x10 risk 50% risk in the next 20 years |
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Can oral hypoglycaemics be used in pregnancy?
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NO - safety has not been established
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Should mums with DM have a C/S
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if diet controlled - can progress naturally
If insulin - induce at 39 weeks or if EFW > 4.5kg |
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What is cholestatic jaundice of pregnancy
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clinical syndrome characterised by intense pruritus that precedes jaundice by 7-14 days
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Clinical features of cholestatic jaundice in pregnancy
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intense pruritus (classically worst on palms and soles of feet) +/- icterus 1-2 weeks later
ALT < 500 IU, ALP, GGT markedly elevated Steatorrhea unusual |
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What are the complications with cholestatic jaundice in pregnancy?
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Can cause reduced Vit K absorption --> PPH
Increased risk of prematurity, foetal distress, and foetal loss |
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At what stage GA is cholestatic jaundice in pregnancy typically seen?
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17-29 weeks
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How do you manage cholestatic jaundice in pregnancy?
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manage itch with cholestyramine
Prophylactic Vit K before delivery Ursodeoxycholic acid daily |
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What is acute fatty liver of pregnancy?
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Form of hepatic failure with coagulopathy and encephalopathy that is characterised by microvesicular fatty infiltrates in liver parenchyma
Pathogenisis unknown |
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When does acute fatty liver of pregnancy usually occur?
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3rd trimester (28-40 weeks GA)
Resolution of hepatic function with delivery or termination of pregnancy |
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Risk factors for acute fatty liver of pregnancy
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Primigravidas
Male gestation Long chain acyl-CoA dehydrogenase deficiency with at least one allele for the G1528 mutation in either mother or fetus NO recurrence with subsequent pregnancies |
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Clinical features of acute fatty liver of pregnancy
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acute N/V, severe upper abdominal pain preceding jaundice
confusion pre-eclampsia pruritus range in presentation mild - fulminant: GI bleeding, hepatic coma, renal failure, true hepatic failure (coagulopathy and encephalopathy) |
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How do you diagnose acute fatty liver of pregnancy?
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Elevated PTT and low serum fibrinogen
AST>ALT hypoglycaemia Pre-eclampsia and HELLP liver biopsy to establish diagnosis US/MRI/CT not consistently useful in confirming AFLT but if liver biopsy is not impossible CT is more helpful in showing a reduced attentuation of the liver that is compatible with AFLP |
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Management of acute fatty liver of pregnancy?
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early diagnosis with prompt delivery followed by maxiamal supportive care
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