Obstetrics Marrow Pg 375-384 (Medical & Surgical complication of Pregnancy)
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Which of the following is NOT an increased risk associated with pre-existing gestational diabetes mellitus (Pre-GDM)?

  • Gestational hypertension (correct)
  • Fetal macrosomia
  • Polyhydramnios
  • Increased insulin resistance

    • Fetal echocardiograms (ECHO) are performed at 22-24 weeks to rule out congenital heart defects.

    True

    What is the minimum time interval between growth scans during pregnancy monitoring?

    3 weeks

    What is the minimum time gap required between tests for diagnosing gestational diabetes?

    <p>4 weeks</p> Signup and view all the answers

    The urine dipstick test is used to check for __________ at each antenatal visit.

    <p>proteinuria</p> Signup and view all the answers

    Glycosylated hemoglobin A1c (GCA) is utilized in diagnosing gestational diabetes.

    <p>False</p> Signup and view all the answers

    At what weeks of pregnancy is the repeat test for gestational diabetes recommended?

    <p>24-28 weeks</p> Signup and view all the answers

    Match the following ultrasound examinations with their purpose:

    <p>Level I USG = Screening for anomalies Targeted Imaging (TIFFA/Target) scan = Detailed anatomical assessment at 18-20 weeks Fetal echocardiogram (ECHO) = Assess for ventricular septal defect (VSD) Growth scans = Monitor fetal growth and development</p> Signup and view all the answers

    Gestational diabetes occurs due to increased insulin resistance in women with normal blood sugar levels, and the final test is done at ______ weeks of pregnancy.

    <p>28</p> Signup and view all the answers

    Match the following components of gestational diabetes diagnosis with their descriptions:

    <p>First antenatal visit = First test 75g glucose in 300ml water = Glucose solution for the test 2-hour postprandial = Time for blood glucose level check Repeat test on another day = Procedure if previous tests were abnormal</p> Signup and view all the answers

    What is the first-line medication for diabetes during pregnancy?

    <p>Insulin</p> Signup and view all the answers

    Termination of pregnancy is indicated at 239 weeks or later.

    <p>False</p> Signup and view all the answers

    What are the indications for performing an Umbilical Artery Doppler?

    <p>Diabetic vasculopathy and development of PIH.</p> Signup and view all the answers

    Low-dose aspirin is used to prevent _____ in pregnancy.

    <p>PIH</p> Signup and view all the answers

    Match the treatment strategies with their categories:

    <p>Weight counseling = Medical Management Induction of labor = Obstetric Management Medical Nutrition Therapy = Medical Management Cesarean Section = Obstetric Management</p> Signup and view all the answers

    What is the action required if the 1 hr postprandial (PP) glucose value is between 140-199 mg/dL?

    <p>MNT x 2 weeks</p> Signup and view all the answers

    If the 1 hr PP value is ≥ 200 mg/dL, the immediate action is to start metformin.

    <p>False</p> Signup and view all the answers

    What is the target fasting blood sugar (FBS) level for managing gestational diabetes?

    <p>less than 95 mg/dL</p> Signup and view all the answers

    A minimum frequency to check 2 hr PP levels in the 3rd trimester is _______.

    <p>weekly</p> Signup and view all the answers

    Match the following glucose levels with their corresponding actions:

    <p>&lt; 140 at 1st visit = Repeat at 24-28 weeks ≥ 140 at 1st visit = GDM &lt; 140 at 24-28 weeks = Not diabetic ≥ 200 at 24-28 weeks = Rx with insulin</p> Signup and view all the answers

    What is the typical change in the size of the thyroid gland during pregnancy?

    <p>Increased size</p> Signup and view all the answers

    Pregnancy is considered a hyperthyroid state.

    <p>False</p> Signup and view all the answers

    What is the Recommended Dietary Allowance (RDA) of iodine during pregnancy?

    <p>150 mcg/day</p> Signup and view all the answers

    The total levels of T3 and T4 are ___ during pregnancy.

    <p>increased</p> Signup and view all the answers

    Match the following thyroid components with their descriptions:

    <p>TSH = Normal/slightly increased during pregnancy TBG = Increased due to estrogen Free T3 = Generally remains normal Total T4 = Increased during pregnancy</p> Signup and view all the answers

    What is the primary hormone associated with increased insulin resistance during pregnancy?

    <p>HPL</p> Signup and view all the answers

    Maternal insulin crosses the placenta to regulate fetal glucose levels.

    <p>False</p> Signup and view all the answers

    At what weeks of gestation does significant insulin resistance typically develop?

    <p>24-48 weeks</p> Signup and view all the answers

    Glycosuria is considered __________ during pregnancy.

    <p>normal</p> Signup and view all the answers

    Match the pregnancy complications of diabetes with their descriptions:

    <p>Fasting hypoglycemia = Avoid fasting to prevent low blood sugar Glycosuria = Normal in pregnancy Hyperglycemia = Feto-toxic condition Congenital malformations = Caused by free radicals crossing the placenta</p> Signup and view all the answers

    What type of insulin is used in the administration protocol during pregnancy?

    <p>Human pre-mix insulin (30% short-acting, 70% intermediate)</p> Signup and view all the answers

    Insulin requirements decrease during labor.

    <p>True</p> Signup and view all the answers

    How often should blood glucose levels be checked once metabolic targets are met?

    <p>Weekly</p> Signup and view all the answers

    Insulin dose is calculated based on the __________ blood glucose levels.

    <p>2-hour postprandial</p> Signup and view all the answers

    What is a key characteristic of gestational diabetes?

    <p>It usually develops between 24-28 weeks.</p> Signup and view all the answers

    Pre-gestational diabetes resolves within 6 weeks postpartum.

    <p>False</p> Signup and view all the answers

    Match the insulin requirements to their conditions:

    <p>Increases with advancing pregnancy = Insulin Requirements Decreases during labor = Insulin Administration Subcutaneous injection before breakfast = Insulin Administration Check levels on the third day = Monitoring Protocol</p> Signup and view all the answers

    At what weeks during pregnancy do blood sugar levels typically begin to be monitored for gestational diabetes?

    <p>24-28 weeks</p> Signup and view all the answers

    Gestational diabetes is characterized by diabetes that develops in a normoglycemic female during ________ weeks of pregnancy.

    <p>24-28</p> Signup and view all the answers

    What is the most common congenital malformation associated with pregestational diabetes?

    <p>Ventricular Septal Defect (VSD)</p> Signup and view all the answers

    Match the types of diabetes with their descriptions:

    <p>Pre-gestational Diabetes = Diabetes present in a female before pregnancy Gestational Diabetes = Diabetes that develops during pregnancy Type A Gestational Diabetes = GDM controlled on diet Non Type A Pregestational Diabetes = GDM controlled on insulin or metformin</p> Signup and view all the answers

    An HbA1c level of 10% increases the risk for congenital anomalies to 15-20%.

    <p>True</p> Signup and view all the answers

    What is the recommended diagnostic tool for assessing fetal anomalies in pregestational diabetes?

    <p>TIFFA</p> Signup and view all the answers

    The most specific cardiac malformation associated with pregestational diabetes is ______.

    <p>Transposition of Great Arteries (TGA)</p> Signup and view all the answers

    Match the following HbA1c levels with their associated risk for congenital malformations:

    <p>6.5% = 3% risk 10% = 15-20% risk 7% = Unknown risk 8.5% = Moderate risk</p> Signup and view all the answers

    At what gestational age is termination of pregnancy indicated for GDM controlled on drugs, but not well controlled?

    <p>37 weeks</p> Signup and view all the answers

    Hourly blood sugar monitoring is required during labor for a patient with GDM.

    <p>True</p> Signup and view all the answers

    What is the immediate action if blood glucose levels fall below 70 mg/dl?

    <p>Start IV 5% dextrose.</p> Signup and view all the answers

    If blood sugar levels are between 120-140 mg/dl, the amount of insulin added in 500 ml NS should be _____ units.

    <p>4</p> Signup and view all the answers

    Match the postpartum management for GDM to the correct follow-up action:

    <p>Check blood sugar = Day 3 post delivery Discharge after = 6 weeks Follow up OGTT = 75g 1 hour Annual testing = 75g OGTT</p> Signup and view all the answers

    Study Notes

    Diabetes in Pregnancy: Part 1

    • Pregnancy induced hypertension (PIH) is a possible complication of pre-gestational diabetes mellitus (GDM).
    • Polyhydramnios, a condition where there is too much amniotic fluid, is more common in pregnancies with pre-GDM.
    • Asymptomatic bacteriuria, a type of urinary tract infection, is more frequent in women with pre-GDM.
    • Insulin resistance increases throughout pregnancy, and this increase is more pronounced in women with pre-GDM.
    • Fetal macrosomia, a larger than average baby, is a possible outcome of pregnancy with pre-GDM.

    Managing Pre-GDM

    • Weight, blood pressure, and protein in the urine are monitored at every antenatal visit.
    • Blood glucose monitoring is done more frequently in the second and third trimesters: every 2 weeks in the second trimester and every week in the third trimester.
    • Fundal examination is done to rule out diabetic retinopathy which is a complication of diabetes that affects the eyes.

    Investigations for Pre-GDM

    • All pregnant women undergo a screening USG or Level I USG.
    • A Targeted Imaging (TIFFA/Target) scan is performed at 18-20 weeks.
    • A fetal echocardiogram (ECHO) is done at 22-24 weeks to rule out a ventricular septal defect (VSD).
    • A urine routine and microscopy test is part of routine antenatal care.
    • Urine culture and sensitivity tests are done if needed.
    • Fetal monitoring begins at 32 weeks of pregnancy.
    • A non-stress test (NST) is performed weekly along with a biophysical profile score (BPS).
    • Growth scans are performed every 3 weeks with at least two scans at 28-30 weeks and 34-36 weeks.

    Gestational Diabetes

    • Gestational diabetes occurs due to increased insulin resistance (IR) in a woman with normal blood sugar levels.
    • The complications of gestational diabetes are similar to those of pre-gestational diabetes mellitus (GDM).
    • The management and investigations for gestational diabetes are similar to those for pre-gestational diabetes, except for fetal echocardiography (ECHO) which is not done.

    Diagnosing Gestational diabetes: Using Dipsi Criteria

    • The Dipsi criteria is a standard approach for diagnosing gestational diabetes in India.
    • The first test is done at the initial antenatal check-up.
    • Tests are repeated at 24-28 weeks and again at 28 weeks.
    • The minimum time gap between tests is 4 weeks.
    • Fasting is not required for the test.
    • 75g of glucose dissolved in 300ml of water is administered.
    • Patients are instructed to consume the glucose solution within 5-10 minutes.
    • Blood glucose levels are measured 2 hours after ingestion, using a plasma calibrated glucometer.

    Special Instructions

    • If the patient vomits, the test is repeated within 30 minutes, then repeated again after 30 minutes.
    • If the initial tests are abnormal, the Dipsi test is repeated on a different day.

    Umbilical Artery Doppler

    • This test is used to assess blood flow in the umbilical artery.
    • Performing this test is indicated in cases of diabetic vasculopathy and pre-eclampsia.
    • This test is performed for all cases of gestational diabetes except when there is no suspicion of cardiovascular anomalies.

    Treatment of Diabetes in Pregnancy

    • Weight counseling and medical nutrition therapy (MNT) are essential parts of diabetes management during pregnancy.

    • Insulin is the first line medication for diabetes in pregnancy.

    • Low dose aspirin is recommended to prevent PIH.

    • Obstetric Management*

    • Ideally, termination of pregnancy (TOP) or induction of labor (IOL) is performed at 39 weeks.

    • Vaginal delivery is the preferred mode of delivery.

    • A Cesarean section may be necessary if the baby's weight is greater than or equal to 4.5 kg.

    Managing Gestational Diabetes: Based on 1 hour PP values

    • 1 hour postprandial (PP) blood glucose values determine the initial management approach:
      • 140-199 mg/dL: Medical Nutrition Therapy (MNT) is prescribed for two weeks.
      • ≥ 200 mg/dL: Immediate insulin therapy is initiated with an initial dose of 8 units.

    Metabolic Goals for Diabetes Management during Pregnancy

    • Fasting blood sugar (FBS) less than 95 mg/dL
    • 1 hour postprandial (PP) blood glucose less than 140 mg/dL
    • 2 hour postprandial (PP) blood glucose less than 120 mg/dL
    • HbA1c less than 6%
    • Average capillary glucose less than 100 mg/dL

    Interpreting 1 hour PP Blood Glucose Levels

    • First Antenatal Visit:
      • Less than 140 mg/dL: Repeat the test at 24-28 weeks.
      • ≥ 140 mg/dL: Gestational diabetes is diagnosed.
      • ≥ 200 mg/dL: Pre-gestational diabetes (pre-GDM) is diagnosed.
    • 24-28 Weeks:
      • Less than 140 mg/dL: Not diabetic.
      • ≥ 140 mg/dL: Gestational diabetes is diagnosed.
      • ≥ 200 mg/dL: Insulin therapy is required.

    Achieving Metabolic Goals in Gestational Diabetes Management

    • If metabolic goals are met: Continue with MNT.
    • If metabolic goals are not met: Start metformin therapy, or alternatively, start insulin therapy along with MNT.
    • Weight counselling is provided for both scenarios (goals met or not met).
    • Aspirin is not administered for weight counselling.

    Additional Instructions for Gestational Diabetes Management

    • Patients are advised to walk for 30 minutes daily.
    • 2-hour postprandial (PP) blood glucose levels are monitored every 2 weeks in the second trimester and every week (or at least monthly) in the third trimester.

    GOI (Government of India) Guidelines for Gestational Diabetes Treatment

    • Diagnosed before 20 weeks: Insulin therapy.
    • Diagnosed after 20 weeks: Metformin therapy.
    • 2 hr PP greater than 200 mg/dL (regardless of gestational weeks): Insulin therapy.

    Thyroid Disorders in Pregnancy

    • During pregnancy, the size of the thyroid gland increases, although this is generally considered a physiological change.
    • Pregnancy is considered an euthyroid state even though there are changes in thyroid hormone levels.
    • Thyroid-stimulating hormone (TSH) levels are either normal or slightly elevated during pregnancy.
    • Total T3 and T4 levels increase during pregnancy because of increased thyroid binding globulin (TBG).
    • Free T3 and T4 levels remain normal despite the increases in total T3 and T4, because of the increase in TBG.
    • The recommended daily allowance (RDA) of iodine for pregnant women is 150 mcg/day.
    • Maternal thyroxine crosses the placenta.
    • Maternal insulin does not cross the placenta.
    • Maternal glucose crosses the placenta and the fetus depends on the mother for glucose requirement.
    • Glycosuria is considered normal during pregnancy.

    Insulin Management Protocol

    • Type of Insulin: Human pre-mix insulin (30% short-acting, 70% intermediate)

    • Vial: 40 IU

    • Storage: 4-8°C

    • Syringe: Reusable up to 14 times.

    • Insulin requirements increase during pregnancy and decrease during labor as the patient is NPO (nothing by mouth).

    • Insulin administration: Human insulin (30:70 premix) is given as a subcutaneous injection 30 minutes before breakfast every day.

    • Dosage adjustments: Based on 2-hour postprandial (PP) blood glucose levels.

    Insulin Dosage Chart

    Two-hour PP Levels Insulin Dose (Units)
    Between 120-160 4
    Between 160-200 6
    More than 200 8

    Monitoring and Adjustment Protocol

    • Goal: Meet metabolic goals
    • Blood Glucose Check: On the third day of insulin therapy
    • Adjust Insulin Dose:
      • If FBS > 95 mg/dL: Add 2 units of insulin before dinner.
      • If 2-hour PP > 120: Add 2 units of insulin before breakfast.
    • Continue Insulin Dose: If metabolic goals are met.

    Follow-up Monitoring

    • Blood glucose levels are checked every 3 days.
    • Insulin dosage is adjusted until metabolic targets are met.
    • Once metabolic targets are met, blood glucose levels are checked weekly in the second trimester and weekly in the third trimester.

    Carbohydrate Metabolism in Pregnancy

    • Hormonal Influences:
      • Human placental lactogen (HPL), estrogen, progesterone, prolactin (PRL), and cortisol all contribute to insulin resistance.
      • Human chorionic gonadotropin (hCG) does not contribute to insulin resistance.
    • Progression of Pregnancy and Insulin Resistance: As gestation progresses, HPL secretion increases, leading to increased insulin resistance.
    • Significant Insulin Resistance: Develops around 24-48 weeks of gestation.
    • Diabetogenic State: Pregnancy creates a diabetogenic state in the body.

    Gestational Diabetes: A Diabetogenic State

    • Normoglycemic women who become pregnant often experience increased insulin resistance, which can lead to the development of gestational diabetes.
    • Maternal thyroxine is able to cross the placenta.

    Pregnancy Complications of Diabetes

    • Fetal:
      • Decreased fetal glucose absorption
    • Maternal:
      • Fasting hypoglycemia: Advice to avoid fasting.
      • Postprandial hypoglycemia: Due to increased insulin resistance.
      • Fasting/vomiting/diarrhea: Can lead to hypoglycemia and the formation of acetone bodies.
    • High Risk Pregnancy:
      • Hyperglycemia: Fetotoxic (toxic to the fetus).
      • Increased free radicals: Crosses the placenta and can lead to congenital malformations in the fetus.
      • Ketosis is possible.

    Pre-gestational Diabetes

    • Criteria for Diagnosis:
      • Fasting Blood Sugar (FBS) ≥ 126 mg/dL
      • 2-hour Postprandial Blood Sugar (PPBS) ≥ 200 mg/dL
      • Random Blood Sugar (RBS) ≥ 200 mg/dL
      • Hemoglobin A1c (HbA1c) ≥ 6.5%
      • DIPSI test: Recommended by the Government of India at the first antenatal visit.

    HbA1c: Risk Assessment Tool

    • HbA1c levels are used to assess the risk of congenital malformations or gross congenital anomalies (GCA).
    • Risk of GCA:
      • HbA1c 6.5%: 3% risk
      • HbA1c ≥ 10%: 15-20% risk
    • Goal of Therapy: To minimize the risk of CNS (Central Nervous System) malformations.
    • Most Common Congenital Malformation: Ventricular Septal Defect (VSD) is more common than Neural Tube Defect (NTD).

    VSD: Most Common Cardiac Malformation

    • Ventricular Septal Defect (VSD) is the most frequent cardiac malformation.
    • Transposition of Great Arteries (TGA) is the most specific cardiac congenital malformation.
    • Hypertrophic Obstructive Cardiomyopathy (HOCM) is the most common cardiac finding.

    Diagnostic Tools

    • TIFFA (Targeted Imaging for Fetal Anomalies) is a diagnostic tool used to identify congenital malformations.
    • Karyotyping is not used to detect gross congenital anomalies (GCA) but rather to identify chromosomal abnormalities.

    Preventing Gross Congenital Anomalies (GCA)

    • Strict glucose control (HbA1c < 6.5%) during the first trimester is crucial to prevent GCA.

    Classifying Diabetes in Pregnancy

    • Pre-gestational Diabetes (PGDM): AKA Overt diabetes; diabetic female conceives; blood sugar is elevated from day one.
    • Formation of Free Radicals and Congenital Malformations: An increase in free radicals can lead to congenital malformations.
    • Non-Resolving Nature: Pre-gestational diabetes does not resolve after delivery.

    Priscila White Classification

    • Type A Gestational Diabetes: GDM controlled on diet.
    • Non Type A Pregestational Diabetes: GDM controlled on medications - insulin or metformin.

    Gestational Diabetes (GDM)

    • Definition: Normoglycemic female conceives and develops diabetes.
    • Timing of Elevated Blood Sugar: Blood sugar levels become elevated between 24 and 28 weeks gestation.
    • Free Radicals and Congenital Malformations: Free radical formation can occur after organogenesis, which is the formation of organs, therefore does not usually cause congenital malformations.
    • Resolution After Delivery: GDM typically resolves within 6 weeks after delivery.

    Development of Gestational Diabetes

    • Typically appears between 24-28 weeks.
    • Can occur earlier or later than 24-28 weeks.

    Termination of Pregnancy

    • Well-controlled on diet (Type A1): Pregnancy is allowed to continue to a full term of 39 weeks.
    • GDM controlled on drugs (Type A2):
      • Well controlled: Allow pregnancy to continue to a full term of 39 weeks.
      • Not well controlled: Terminate pregnancy by 37 weeks gestation.
    • Mode of Delivery: Vaginal delivery.
    • Indications for Cesarean Section: Weight of baby greater than or equal to 4.5 kg

    Intrapartum Management

    • Insulin dose may be skipped during the morning in women with mild GDM who are being managed medically.
    • Hourly blood sugar monitoring is done using a glucometer during labor.
    • NPO: No food or drink is allowed during labor (patients are nil per os).
    • IV Fluids: IV normal saline (NS) is given at a rate of 100 ml/hr.
    • Adjusting Insulin: Insulin dose is adjusted depending on blood sugar levels.

    Blood Sugar Levels and Insulin Dosage

    Blood Sugar Level Amount of Insulin Added in 500 ml NS
    90-120 mg/dl
    120-140 mg/dl 4U
    140-180 mg/dl 6U
    ≥ 180 mg/dl 8U
    • Hypoglycemia: If blood glucose drops below 70 mg/dL, IV 5% dextrose is administered.

    Postpartum Management

    GDM

    • Blood Sugar Check: On day 3 post delivery.
    • Discharge: 6 weeks after delivery.
    • Follow-up: 75g 1-hour oral glucose tolerance test (OGTT):
      • If normal: No further follow-up required.
      • If GDM is confirmed: Provide advice and monitoring.
      • Annual 75 g OGTT (Increased risk of developing type 2 diabetes mellitus).

    Pre-GDM

    • Decreased Insulin Requirements: Insulin dosage may be reduced from day 2 after delivery.
    • Switching to Oral Hypoglycemic Agents (OHA): Patients may be switched back to oral medications.
    • Referral to Endocrinologist: Referral to an endocrinologist may be necessary.

    Document Information

    • Obstetrics: v1.0
    • Marrow: 8.0
    • Date: 2024

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    Test your knowledge on the risks, diagnosis, and management of gestational diabetes mellitus. This quiz covers essential aspects such as ultrasound examinations, growth scans, and medication recommendations. Perfect for students and healthcare professionals alike!

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