Pregnancy- DM, Nutrition, Exercise

Diet/Exercise

100

What is the weight gain expected in a patient with pre-pregnancy BMI of 22?

Expected weight gain 25-35 lbs

200

What is the prescribed exercise regimen for an OB patient with diabetes?

30 minutes of moderate-intensity aerobic exercise at least 5 days a week or minimum 150 minutes per week

• Improvement seen with walking 10-15 minutes after each meal

300

What is the recommended additional calorie intake for patients starting with BMI 22?

1st tri compared to 2nd/3rd tri

Not eating for two!

150 calories/day additional in first trimester

300 calories/day additional in later trimesters

**Use SmartText "Eating Plan for Pregnant Women"** for AVS

400

What are some nutritional recommendations for patients with GDM?

3 meals + 2 snacks per day to limit/prevent large fluctuations

33-40% carbohydrates (complex preferred over simple)

20% protein

40% fat

GDM

100

What percentage of patients with GDM will go on to have DM in 5-10 years postpartum?

50-60%

DOUBLE Jeopardy:

what is the White classification of diabetes in pregnancy? given an example using the classification

200

At how many weeks do we screen for GDM?

24-28 weeks

DOUBLE JEOPARDY:  When is the peak insulin resistance?

300

Who needs an early 1 hr GTT?

Concerns for pre-existing DM

•Patient is overweight with BMI of 25 (23 in Asian Americans), and one of the following:

•Physical inactivity

•Known impaired glucose metabolism

•Previous pregnancy history of:

•GDM

•Macrosomia (≥ 4000 g)

•Stillbirth

•Hypertension (140/90 mm Hg or being treated for hypertension)

•HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L)

•Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L)

•PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and other conditions associated with insulin resistance

•Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose | If A1C>6.5%, diagnosis of pregestational diabetes is met and GCT/GTT not needed

•Cardiovascular disease

•Family history of diabetes – 1st degree relative (parent or sibling)

•Ethnicity of African American, American Indian, Asian American, Hispanic, Latina, or Pacific Islander

DOUBLE JEOPARDY:

Do you need to be fasting for the 1 hr GTT?

400

If diet/exercise alone do not improve patient's glycemic control, what is the preferred med?

Insulin

ie- refer to OB

• If a patient cannot take insulin or declines, metformin can be used
  • Counsel about metformin risks including placental cross over and no long term studies in offspring available
    • May be associated with preterm birth
  • Starting dose: 500 mg nightly for 1 week, increase to 500 twice daily
    • Check baseline creatinine
  • Adverse events include abdominal pain and diarrhea – recommend with meals
  • Maximal dose is 2,500-3,000 mg per day, in two or three divided doses
• Glyburide should not be used in place of insulin as studies show worse outcome, including macrosomia and birth injury
  • Starting does is 2.5-20 mg per day in divided doses
  • Up to 30 mg may be necessary to obtain glycemic control
  • Long term outcome studies also still lacking, although no short term adverse events have been noted

500

What are options if patient vomits/doesn't tolerate GTT?

Very concentrated, hyperosmolar -> gastric irritation, delayed emptying, GI osmotic imbalance --> nausea, in some can cause vomiting. 

- Serial POC glucose monitoring- periodic fasting, 1/2 hr postprandial if high risk. ~32 weeks is peak insulin resistance

- Periodically lab check fasting + A1c

- Repeat test another day with antiemetic drug prior

- Candy/predefined meal

Neonate

100

What are consequences of uncontrolled hyperglycemia in second/third trimester for baby?

–Premature delivery

–Stillbirth

–Macrosomia

–Shoulder dystocia

–Operative delivery

–Maternal or fetal trauma

–NICU admission

–Childhood obesity and diabetes mellitus

200

When is the most sensitive time for major organ development?  

Ex most concerns for teratogens

Embryonic period

3-8 weeks GA

The pivotal time is 3-6 weeks post-conception OR 5-8 weeks from LMP.

300

When do we begin fetal monitoring for patient with A1GDM?

A1GDM means well controlled on diet

If well controlled, may not be needed.

If not well controlled -> A2 + chronic DM start at 32 weeks, thinking is that at some point they were not well controlled so there may be an early consequence for neonate and regular assessment advised

400

When to deliver baby if mom has diabetes in pregnancy?

• Controlled on diet: ≥ 39 weeks
  • Expectant management up to 40 weeks 6 days is appropriate with antepartum testing
• Well controlled on medication: Deliver at 39 weeks 0 days to 39 weeks 6 days
• Poorly controlled: Expert guidance supports earlier delivery but data lacking regarding precise timing
  • Delivery between 37 weeks 0 days and 38 weeks 6 days may be justified
  • Delivery between 34 weeks 0 days and 36 weeks 6 days reserved for (1) failure of in-hospital glycemic control or (2) abnormal fetal testing
• Estimated fetal weight ≥ 4500: Counsel regarding risks and benefits of a scheduled cesarean section

500

What is the target glucose level in labor? Why?

< 110