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Questions and Answers
What is the recommended macronutrient distribution for a balanced meal?
What is the recommended macronutrient distribution for a balanced meal?
What is the maximum daily dose of Metformin for a pregnant woman?
What is the maximum daily dose of Metformin for a pregnant woman?
Which of the following is an advantage of using Metformin in gestational diabetes?
Which of the following is an advantage of using Metformin in gestational diabetes?
What is the side effect most commonly associated with Glyburide?
What is the side effect most commonly associated with Glyburide?
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When is Metformin recommended for use during pregnancy?
When is Metformin recommended for use during pregnancy?
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What type of insulin is specified in the administration protocol?
What type of insulin is specified in the administration protocol?
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How should insulin be administered according to the protocol?
How should insulin be administered according to the protocol?
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What action should be taken if the fasting blood sugar (FBS) is greater than 95 mg/dL?
What action should be taken if the fasting blood sugar (FBS) is greater than 95 mg/dL?
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What is the insulin dose for a 2-hour postprandial (PP) blood glucose level between 120-160 mg/dL?
What is the insulin dose for a 2-hour postprandial (PP) blood glucose level between 120-160 mg/dL?
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How often should blood glucose levels be checked after the third day until metabolic goals are met?
How often should blood glucose levels be checked after the third day until metabolic goals are met?
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What is the minimum urinary protein excretion required for a diagnosis of proteinuria during pregnancy?
What is the minimum urinary protein excretion required for a diagnosis of proteinuria during pregnancy?
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What is a common sign of end organ damage in pregnancy-induced hypertension?
What is a common sign of end organ damage in pregnancy-induced hypertension?
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Which screening test is recommended at every antenatal visit for proteinuria?
Which screening test is recommended at every antenatal visit for proteinuria?
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What symptom could indicate chronic hypertension with superimposed pre-eclampsia after 20 weeks of pregnancy?
What symptom could indicate chronic hypertension with superimposed pre-eclampsia after 20 weeks of pregnancy?
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Which of the following is considered the gold standard diagnostic test for proteinuria in pregnant women?
Which of the following is considered the gold standard diagnostic test for proteinuria in pregnant women?
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What is a potential long-term risk for women who experienced diabetes during pregnancy?
What is a potential long-term risk for women who experienced diabetes during pregnancy?
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Which complication is associated with oligohydramnios in diabetic pregnancies?
Which complication is associated with oligohydramnios in diabetic pregnancies?
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Which symptom is NOT typically associated with hypoglycemia?
Which symptom is NOT typically associated with hypoglycemia?
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What is a key treatment for hypoglycemia during pregnancy?
What is a key treatment for hypoglycemia during pregnancy?
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Which of the following is a potential maternal complication of diabetes during pregnancy?
Which of the following is a potential maternal complication of diabetes during pregnancy?
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What is the blood pressure threshold that defines Pregnancy Induced Hypertension?
What is the blood pressure threshold that defines Pregnancy Induced Hypertension?
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How does the presentation of chronic hypertension in pregnancy differ from Pregnancy Induced Hypertension?
How does the presentation of chronic hypertension in pregnancy differ from Pregnancy Induced Hypertension?
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Which condition is characterized by the presence of proteinuria after 20 weeks of pregnancy?
Which condition is characterized by the presence of proteinuria after 20 weeks of pregnancy?
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What occurs to the blood pressure of individuals with Pregnancy Induced Hypertension after delivery?
What occurs to the blood pressure of individuals with Pregnancy Induced Hypertension after delivery?
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In which of the following conditions is end organ damage present?
In which of the following conditions is end organ damage present?
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What is the main consequence of fetal hyperinsulinemia due to maternal hyperglycemia?
What is the main consequence of fetal hyperinsulinemia due to maternal hyperglycemia?
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Which complication is specifically associated with uncontrolled diabetes during pregnancy?
Which complication is specifically associated with uncontrolled diabetes during pregnancy?
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What condition may arise from fat deposition around the fetal shoulder?
What condition may arise from fat deposition around the fetal shoulder?
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What is a common neonatal complication due to increased fetal insulin levels at birth?
What is a common neonatal complication due to increased fetal insulin levels at birth?
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Which of the following does NOT typically contribute to stillbirth in infants of diabetic mothers?
Which of the following does NOT typically contribute to stillbirth in infants of diabetic mothers?
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For a patient with GDM controlled on drugs, when is the latest safe point for delivery if the condition is well controlled?
For a patient with GDM controlled on drugs, when is the latest safe point for delivery if the condition is well controlled?
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What is the proper mode of delivery for a gestational diabetes patient with a baby weighing 4.5 kg or more?
What is the proper mode of delivery for a gestational diabetes patient with a baby weighing 4.5 kg or more?
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During labor, what additional condition must be maintained alongside NPO status for a patient with mild GDM on medical management?
During labor, what additional condition must be maintained alongside NPO status for a patient with mild GDM on medical management?
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Which blood sugar level requires an addition of 6 units of insulin in 500 ml NS during the intrapartum management?
Which blood sugar level requires an addition of 6 units of insulin in 500 ml NS during the intrapartum management?
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When should a postpartum follow-up OGTT (75g 1-hr) take place to check for GDM?
When should a postpartum follow-up OGTT (75g 1-hr) take place to check for GDM?
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What is the first and most effective maneuver for managing difficult labor?
What is the first and most effective maneuver for managing difficult labor?
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Which complication is most commonly associated with maternal care during difficult labor?
Which complication is most commonly associated with maternal care during difficult labor?
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What does the Zavanelli maneuver involve as a last resort during difficult labor?
What does the Zavanelli maneuver involve as a last resort during difficult labor?
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Which of the following maneuvers involves manual rotation of both shoulders?
Which of the following maneuvers involves manual rotation of both shoulders?
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What is a common nerve injury during the McRoberts maneuver?
What is a common nerve injury during the McRoberts maneuver?
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What characterizes mild pre-eclampsia compared to severe pre-eclampsia?
What characterizes mild pre-eclampsia compared to severe pre-eclampsia?
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Which of the following is NOT a common feature of mild pre-eclampsia?
Which of the following is NOT a common feature of mild pre-eclampsia?
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In management of mild pre-eclampsia, what is a recommended action?
In management of mild pre-eclampsia, what is a recommended action?
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What is a possible outcome if mild pre-eclampsia is left untreated?
What is a possible outcome if mild pre-eclampsia is left untreated?
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Which statement about mild pre-eclampsia is true?
Which statement about mild pre-eclampsia is true?
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What is the significance of a Lecithin/Sphingomyelin ratio of 2:1 in amniotic fluid?
What is the significance of a Lecithin/Sphingomyelin ratio of 2:1 in amniotic fluid?
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At what lamellar body count in amniotic fluid does the lungs have 100% maturity?
At what lamellar body count in amniotic fluid does the lungs have 100% maturity?
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Which test for fetal lung maturity is considered the best and is done at or beyond 235 weeks of gestation?
Which test for fetal lung maturity is considered the best and is done at or beyond 235 weeks of gestation?
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What does the presence of orange cells in the Nile blue sulphate test indicate?
What does the presence of orange cells in the Nile blue sulphate test indicate?
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What is a key feature of shoulder dystocia during delivery?
What is a key feature of shoulder dystocia during delivery?
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Study Notes
Insulin Administration Protocol
- Insulin type: Human pre-mix insulin (30% short-acting, 70% intermediate)
- Insulin vial: 40 IU
- Storage: 4-8°C
- Syringe usage: Reusable 14 times
- Insulin requirements: Increase with advancing pregnancy, decrease during labor
- Administration: Subcutaneous injection 30 minutes before breakfast
- Dosage: Adjust based on 2-hour postprandial (PP) blood glucose levels
- Between 120-160 mg/dL: 4 IU
- Between 160-200 mg/dL: 6 IU
- More than 200 mg/dL: 8 IU
Monitoring and Adjustments
- Check blood glucose levels on the 3rd day
- If fasting blood sugar (FBS) > 95 mg/dL, add 2 units of insulin before dinner
- If 2-hour postprandial (PP) blood sugar > 120 mg/dL, add 2 units of insulin before breakfast
- If goals are met, continue the same insulin dose
- Check blood glucose levels every 3 days until metabolic goals are met
- Once goals are met, check weekly in T2 and weekly in T3
Medical Nutrition Therapy
- Balanced carbohydrate-controlled diet: 40% Carbohydrate, 40% Fat, 20% Protein
- Distributed over 3 meals + 3 snacks
- Caloric requirement:
- Add 350 kcal to all pregnant women
- BMI < 18.5: Extra 500 kcal/day
- BMI > 25: Subtract 500 kcal/day
OHAS (Oral Hypoglycemic Agents)
Metformin
- Recommended by the GOI (Government of India)
- Used only in GDM (Gestational Diabetes Mellitus), not in pre-GDM
- Used only after 20 weeks of pregnancy
- First-line drug
- Advantages:
- Decreases chances of excessive maternal weight gain
- Decreases risk of neonatal hypoglycemia
- Decreases chances of large for gestational age (LGA) fetus
- Decreases risk of macrosomia
- Preferred in obese women
- Dose: 500mg/day up to 2g/day
- If dose required > 2g/day, add insulin
- Side effects:
- Most common: Gastrointestinal side effects
- Most dangerous: Lactic acidosis
Glyburide
- Dose: 2.5mg/day up to 20mg/day
- Side effects:
- Increased risk of neonatal hypoglycemia
Maternal Complications
Hyperglycemia
- Asymptomatic bacteruria
- Candidiasis
- Puerperal sepsis
Infections
- Increased risk of infections
Polyhydramnios
- Decreased fetal lung maturity
- Preterm labor (PTL)
- Premature rupture of membranes (PROM)
- Cord prolapse
- Postpartum hemorrhage (PPH)
- Subinvolution
Oligohydramnios
- If diabetic vasculopathy/PIH+
- Big placenta (Placentomegaly)
- Swelling of chorionic villi due to hyperglycemia
- Increased risk of PIH, placenta previa
Increased Risk of
- Type 2 Diabetes Mellitus (T2DM) in the future
- Cesarean section
- Ketoacidosis
Pre-Gestational Diabetes
- During pregnancy, retinopathy worsens
- Conduct baseline fundus examination in all females with pre-GDM
Hypoglycemia
- Blood sugar < 70 mg/dL
- Symptoms:
- Tremors
- Sweating
- Palpitations
- Treatment: 3 teaspoons glucose in 100 mL water, or, 6 teaspoons sugar in 100 mL water
Pregnancy Induced Hypertension (PIH): Part 1
Findings
Proteinuria
- Excretion of protein in urine ≥ 300mg/24 hours
- Protein/Creatinine ≥ 0.3 (in urine)
- Urine dipstick (OPD basis): ≥ +2 (In NICE & ACOG guideline ≥ +2)
Signs & End Organ Damage
- Platelet Count < 1 lakh
- Liver enzymes (SGOT/SGPT) raised ≥ 2 times normal
- S.Creatinine ≥ 1.1 mg/dL
- Pulmonary edema
- Visual symptoms/cerebral edema
ALP
- Produced by placenta
- Heat stable
Antenatal visit and PIH
- At every visit:
- Measure BP (If ≥ 140/90 mm Hg)
- Repeat BP after 4 hours
- Screening test: Urine dipstick for proteinuria (≥+1)
- Diagnostic test: 24 hours urine protein excretion (Gold standard)
Chronic HTN with Superimposed Pre-eclampsia
- Hypertensive female conceives + At 20 weeks suddenly develops any one of the following:
- Uncontrollable BP
- New onset proteinuria
- New onset signs of end organ damage
- Bad prognosis
- Prevention: All pregnant chronic HTN patients
- Low dose Aspirin started daily from 12 weeks (to prevent superimposed PE)
Definition
- Blood Pressure (BP) ≥ 140/90 mm Hg on at least two occasions 4 hours apart in a pregnant person
- Exception: If BP ≥ 160/110 mm Hg, repeat measurement in 15 minutes and consider starting anti-hypertensive medication
Chronic HTN in Pregnancy vs Pregnancy Induced HTN (PIH)
| Feature | Chronic HTN in Pregnancy | PIH |
|---|---|---|
| Presentation | Hypertensive person has conceived | Normotensive person who has conceived |
| Increased BP | Present prior to pregnancy | Develops after 20 weeks of pregnancy |
| Normalisation of BP | Remains elevated post pregnancy | Normalizes within a few weeks following delivery |
Pre-eclampsia vs Gestational HTN
| Feature | Pre-eclampsia | Gestational HTN |
|---|---|---|
| Increased BP | Elevated BP develops after 20 weeks pregnancy | Elevated BP develops after 20 weeks of pregnancy |
| Proteinuria | Present | Absent |
| Signs of end organ damage | Present | Absent |
Management of Difficult Labor
- Mnemonic: HELPERR
HELPERR Maneuvers
-
Call for help:
- Liberal episiotomy.
-
Legs maneuver (McRobert's maneuver):
- 1st and most effective maneuver.
- Flexion and abduction of the leg against the abdomen.
- Straightening of the sacrum increases space (↑ Available space).
-
Suprapubic pressure + McRoberts maneuver:
- Sustained in thrusts
-
Enter maneuver:
- Manual rotation of shoulders.
- Wood's corkscrew maneuver (Both shoulders).
- Rubin's maneuver (Only one shoulder).
-
Remove (Deliver) posterior arm of baby:
- Jacquemier maneuver.
-
Roll on all four limbs:
- 4-limb (Gaskin) maneuver
-
Zavanelli maneuver:
- Last step
- Push fetal head back into the uterus → cesarean
-
Problems in the procedure:
- Dead babies: Fractured clavicle (cleidotomy).
- Obsolete: Symphysiotomy (dividing pubic symphysis of mother).
- Other measures: Fundal pressure (C/I in mx).
Complications
Fetal
- Erb's palsy (most common)
- Injury to C5, C6
- Arm position: Internally rotated, adducted, and pronated
Maternal
- Postpartum hemorrhage (PPH) (most common)
Medical and Surgical Complications in Pregnancy
Late Complications in Child
- T2DM: 1-3%
- Obesity
- Metabolic X syndrome
Lung Maturity Test
Lecithin/Sphingomyelin ratio
- Most common test
- Mature ≥ 2:1
- Immature < 2:1
Phosphatidyl Glycerol
- Best test (Done ≥ 235 weeks)
- Present: mature
- Absent: immature
Lamellar body count
- Type A pneumocytes produce surfactant and released as packets: lamellar bodies
- 50,000/mL: 100% lungs mature
- Positive test: 30,000 - 40,000/mL AF
Bedside test/Shake test/Bubble test
- Obsolete
Nile blue sulphate test
- Obsolete
Principle
- Amniotic fluid (AF) has fetal skin cells that mature at the same time as lungs.
Procedure
- Take AF in a test tube.
- Prepare a slide.
- Examine under a microscope.
Interpretation
-
50% orange cells → Lungs mature
- Blue cells → Immature skin cells
- Orange cells → Mature skin cells
Shoulder Dystocia
- Obstetric emergency
- Features:
- Inability to deliver fetal shoulder within 1 min of head delivery
- Turtle sign +ve: Receding of fetal head into perineum
Mild vs Severe Pre-eclampsia
| Feature | Mild Pre-eclampsia | Severe Pre-eclampsia |
|---|---|---|
| BP | 140/90 - 159/109 mm Hg | ≥ 160/110 mm Hg |
| Proteinuria | 300mg/24 hours or less | ≥ 5g/24 hours |
| Signs of end organ damage | Absent | Present |
| Symptoms | Headache, visual disturbances, edema | Seizures, pulmonary edema, hepatic dysfunction |
Termination of Pregnancy
- Well-controlled on diet (Type A1) ≥ 39 weeks
- GDM controlled on drugs (Type A2)
- Well controlled: > 39 weeks
- Not well controlled: > 37 weeks
- Mode of delivery: Vaginal
- Indications for cesarean section: Weight of baby ≥ 4.5 kg
Intrapartum Management
- Mild GDM, on medical management: skip morning dose
- Hourly blood sugar monitoring with glucometer
- During labor:
- NPO
- IV NS @ 100 ml/hr
-
- Insulin, depending on blood sugar levels
Blood Sugar Levels and Insulin
| 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 |
- If blood glucose < 70mg/dL (hypoglycemia) → Start IV 5% dextrose
Postpartum Management
GDM
- Check blood sugar: Day 3 post delivery
- Discharge: 6 weeks
- Follow up: 75g 1-hr OGTT
- Normal
- Confirmation of GDM
- Advise
- Annual 75g OGTT (↑ risk of developing T2DM)
Pre GDM
- Insulin requirement ↓
- From day 2 of delivery
- Shifted back to OHA
- Refer to endocrinologist if needed
Fetal Complications in Diabetes During Pregnancy
Pederson's Hypothesis
- Maternal hyperglycemia
- Stimulates fetal pancreas
- Fetal hyperglycemia
- Hyperinsulinemia
- ↑ Growth
- Macrosomia
Lipolysis
- Fat deposition around fetal shoulder
- Shoulder dystocia
Complications
- Macrosomia: Prolonged labor, increased chances of cesarean section
- IUGR: Only if diabetic vasculopathy/PIH+
- Risk of abortion: In uncontrolled diabetes
- Risk of still birth: Due to
- Oxygen demand
- Oxidative stress
- Edema of chorionic villi
- ↓ Oxygen transport
- Congenital malformations: Only in fetus of pre-GDM (m/c in last 2 weeks of pregnancy)
- Hormone needed for fetal growth: Insulin, IGFs
Neonatal Complications
- Neonatal hypoglycemia:
- Maternal hyperglycemia
- Fetal hyperglycemia
- ↑ Fetal insulin
- At birth: Connection between mother & fetus lost. No source of glucose, but insulin ↑
- Hypocalcemia
- Hypokalemia
- Hypomagnesemia
- Respiratory distress syndrome
- Necrotising enterocolitis (NEC)
- Hypoxia: ↑ Erythropoetin → Polycythemia → HOCM (High Output Cardiac Murmur)
- Hyperviscosity
- Hyperbilirubinemia
- Anemia is not a common complication.
- Surfactant production is ↑
- Insulin suppresses surfactant production
- Hormone needed for fetal growth: Insulin, IGFs
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Description
Test your knowledge on the insulin administration protocol, including dosage adjustments, monitoring requirements, and specific considerations during pregnancy. This quiz covers guidelines for human pre-mix insulin use and best practices for maintaining blood glucose levels.
