Term
| what is more common: gestational or pregestational diabetes |
|
Definition
90% gestational
10% pregestational |
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|
Term
| what is the number one factor in improving outcome of diabetic pregnant moms |
|
Definition
| preconception and antepartum care |
|
|
Term
| what is a later complication of gestational diabetes |
|
Definition
| 50% develop type II diabetes later in life |
|
|
Term
| what are the 3 ADA classifications of diabetes |
|
Definition
type I diabetes: tydiagnosed in childhood, often brittle and difficult to control
type II diabetes: adult onset glucose intolerance
gestational diabetes: identified in pregnancy |
|
|
Term
| what are the A-T white classification of maternal diabetes |
|
Definition
A: gestational diabetes: onset in pregnancy
B: onset after age 20, duration <10y, no vascular disease
C: onset 10-19yo, dration 10-19y, no vascular disease
D: onset <10yo, duration >20y, some vascular disease (retina, legs)
E: pelvic arteriosclerosis by x-ray
F: vascular nephritis
R: proliferative retinopathy
T: transplantation |
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|
Term
| what are the 4 hormones that change in pregnancy due to diabetes |
|
Definition
HPL (human placental lacrogen)
estrogen and progesterone
insliunase
glucosuria |
|
|
Term
| HPL: where is it made, what does it do 5 |
|
Definition
made in placenta,
increases free FA lipolysis,
decrease glucose uptake and gluconeogenesis,
insulin antagonist
increass as a pregnancy progress |
|
|
Term
| what does estrogen and progesterone do in pregnancy |
|
Definition
| interfere with insulin glucose relationship |
|
|
Term
| what is an acceptable amount of glucose in urine in pregnancy |
|
Definition
|
|
Term
| what are the maternal complications in gestational diabetes 6 |
|
Definition
hyperglycemia
glucosuria
diabetes ketoacidosis
increased UTI (pressure/glucose)
PHI/preeclampsia
retinopathy 15% increase |
|
|
Term
| fetal/neonatal effects of gestational diabetes |
|
Definition
congenital abnormalities 4x risk in enbryogenesis
macrosomia >4500 g
IUGR 2nd to uteroplacental insuff
hypoglycemia
hyperbilirubinemia
hypocalcemia
polycythemia
polyhydraminos
intrauterine fetal demise |
|
|
Term
| what is polyhydraminos, 3 complications |
|
Definition
AFI > 20
increased risk abruption
preterm labor
atony |
|
|
Term
| what congenital malformations occur with gestatioal diabetes which is most common 7 |
|
Definition
spina bifidia
hydrocephalus
anencephalus
anal/rectal atresia
heart anomalies - most common
renal anomalies
caudal regression |
|
|
Term
| what heart anomalies form in gestational diabetes 3 |
|
Definition
| transposition, VSD, ASD, situs inversus |
|
|
Term
| what renal anomalies form in gestational diabetes 3 |
|
Definition
agenesis
cystic kidneys
ureteral duplication |
|
|
Term
| what is caudal regression |
|
Definition
| portion of LE up to hips will not form |
|
|
Term
| what are the first things you should do when you eveluate a pregnant women with diabetes first time |
|
Definition
opthalamogic study: retinopathy test
24h urine CR and protein
cardiac exam |
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|
Term
| why do you do a 24h urine CR and protein on all newly pregnancy diabetic mothers |
|
Definition
tests for neuropathy, preeclampsia
they have 2x risk of preeclampsia and progression end stage renal disease in patients with diabetic retinopathy (ENCOURAGE NOT TO BECOME PREGNANT) |
|
|
Term
| what are the 7 areas in which you should continoously monitor diabetic pregnant women |
|
Definition
glucose checking
hypoglycemic agent control
preeclampsia checks
HBAIC checks
ketacidosis monitoring
infection: esp pyelonephritis
patient compliance checks |
|
|
Term
| why is high maternal glucose bad in pregnancy |
|
Definition
| causes fetal hyperglycemia and hyperinsulinemia leading to fetal macrosomia, death in utero, and dealyed pulmonary maturation |
|
|
Term
| in what frequency and times should a diabetic pregnancy women be checking her glucose, what are the normal levels for her, what is the overall goal for glucose levels |
|
Definition
4x/d fasting and 2h post prandial
fasting <100
post parandial <130
euglycemia is goal |
|
|
Term
| what is the best gaugeof fetal size in a diabetic mother |
|
Definition
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|
Term
| how should hypoglycemic agents be adjusted in a diabetic pregnant mother, what can she take, what is one alternative |
|
Definition
DC oral agents
start insulin regular atmeals and NPH long acting
glyburide: used instead of insulin |
|
|
Term
| women with polycystic ovarian syndrome are taking metformin, what needs to happen with this medication if they become pregnant |
|
Definition
| only continued thruough 1st trimester |
|
|
Term
| how can you monitor for preeclampsia |
|
Definition
| check urine every visit for proteins |
|
|
Term
| when should HBA1C be checked in pregnant diabetic woman |
|
Definition
|
|
Term
| how is HBA1C correlated with fetal status |
|
Definition
| if <10 during embryogenesis (<9wks) incidence of abnormalities is the same as non-diabetic |
|
|
Term
| what monitoring needs to be done on a fetus in a duabetic mother and when 6 |
|
Definition
APF: 16wks
fetal echocardiography: 20-22wks
agressive fetal monitoring: 28wk, 2x/wk begning at 30wks
daily kick count recordings
serial ultrasound for fetal growth
ultrasound for AFI and NST (BPP) |
|
|
Term
| why do you do a fetal echocardiography |
|
Definition
| check for anomalies: 4 chambers, limbs, etc |
|
|
Term
| what are 5 risks for mom developing gestational diabetes |
|
Definition
obesity
persistant glucose in urine
previous unexplained still birth or misscarriage
previous infant >4000g
strong family hx diabetes |
|
|
Term
| what is the normal screening schedule to check if mom has developed gestational diabetes |
|
Definition
24-28 wks glucose screen
if positive..
1h GTT screen
if positive...
3h GTT screen |
|
|
Term
| how does a GTT screen work |
|
Definition
1 hour: 50g glucose challenge with no glucose preperation with sampling at 1 hour post challenge
3h: 100g fasting glucose challenge at 1, 2, 3h if they have 2 or more abnormal values their diagnosed if any one of the 3 is over 300 their diagnosed |
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|
Term
| what type of patient education does a diabetic mother need 6 |
|
Definition
diabetic counseling
discussion of risk factors and the importance of blood sugar control
daily blood sugar monitoring: fasting and 2h post prandials,
assessment of need for insulin
diet: 2200-2400 calories |
|
|
Term
| fetal assessment in diabetic mother 6 |
|
Definition
daily kick counts
blood sugar monitoring
ultrasound near term for fetal weight (macrosomia)
modified BPP ultrasound
AFP 16-20wks
anatomical scan 20-22 wks limb and heart |
|
|
Term
| when can you deliver a baby from a diabetic mother vaginally 2 |
|
Definition
when diabetes isnt severe
baby is stable, wait for maturity |
|
|
Term
| when should you deliver a baby from a diabetic mother c-section 2 |
|
Definition
severe diabetes
fetus isnt stable (positive CST/BPP, IUGR, PIH)
macrosomia >4500g (offer C section) |
|
|
Term
| what is the complication of delivering a baby with macrosomia |
|
Definition
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|
Term
| how can you judge fetal lung maturity 7 |
|
Definition
amniocentesis
lenth of gestation
L/S ratio
phosphatidylglycerol
shake test/foal stability test
lamellar body counts
FLM (flourescence test) |
|
|
Term
| how does amniocentesis judge lung maturity |
|
Definition
| needle under ultrasound guidance aspirates amniotic fluid |
|
|
Term
| what are the week markers for judging lung maturity |
|
Definition
24 wk alveolar sacs develop
type II pneumocytes develop after. they secrete lechtin then phospadylglycerol surfactants |
|
|
Term
| how can L/S ratio tell you lung maturity |
|
Definition
23-33 wks lechtin and sphingomyelin are equal
35 wks lechtin:sphingomyelin is 2:1 and risk of respiratory distress drops |
|
|
Term
| what L/S ratio do we say a fetus of a diabitc mom should have before delivery |
|
Definition
2.5 - 3
higher because development of surfactant is delayed |
|
|
Term
| how does phosphatidylglycerol tell you about lung maturity |
|
Definition
sign of advanced fetal lung maturity so pesence is good
blood and meconium do NOT interfere with determination |
|
|
Term
| explain the shake test for lung maturity |
|
Definition
ethanol + amniotic fluid + surfactant --> foam
ethanol + amniotic fluid --> no foam
value 47 means mature |
|
|
Term
| how does lamellar body counts signify maturity |
|
Definition
| 30,000-50,000 packages of surfactant means mature |
|
|
Term
| how does FLM indicate maturity |
|
Definition
measures ratio of surfactant:albumin
55 or greater indicates maturity |
|
|
Term
|
Definition
| fetal shoulder stuck behind mom's symphysis |
|
|
Term
| risk factors for shoulder dystosia 5 |
|
Definition
macosomia: majority in diabetes
post-datism: bigger babies
males: broader shoulders
maternal obesity: more soft tissue in way
second stage labor disorders |
|
|
Term
| effects of shoulder dystosia on the baby, risks |
|
Definition
brachial plexus injury most common 95% (erbs palsy C5-6) (waitor's tip)
risk of permanent injury is about 0.3-1%
>4000g 10% chance
>4500g 30% chance
<4000g 50% chance! |
|
|
Term
| 7 fixes for shoulder dystosia |
|
Definition
McRoberts maneuver: hyperflexion of legs brings both pelvus inlet/outlet into a more ventral portion
rotate anterior shoulder to oblique lie
woods/corckscrew: rotate posterior shoulder 180deg pass under pubic rami, as it rotates anterior it should come out
follow posterior arm to elbow, arm then flexed and swept out over infants chest and delivered over posterior perineum, rotation of the trunk beinging the posterior arm anterior may be required
fracture of clavivle or humerus
symphsiotimy: cut pubic syphysis
zavanelli maneuver: fetal head placed in vagina in flexed position and c section done |
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|
Term
| why do babies of diabetic mothers often get neonatal hypoglycemia |
|
Definition
| maternal DM > increases placenta glucosa > increases fetal pancreas insulin production > glucose load is gone once baby leaves placenta > insulin still made in pancreas > hypoglycemia |
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|
Term
| other than hypoglycemia, what do you need to watch out for in neonates of diabetic mothers 2 |
|
Definition
hyperbilirubinemia
hypocalcemia |
|
|
Term
| what are mom's new insulin requirments after she givs birth |
|
Definition
drops 50% immediatly when placenta and its hormones are gone
gestational diabetics should have glucose tolerance screen |
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