Diabetes and Pregnancy

Course #33402 - $75 • 15 Hours/Credits


Study Points

  1. Describe the pathophysiology, risk factors, screening, and treatment of type 1 diabetes, type 2 diabetes, gestational diabetes, and prediabetes.
  2. Explain how metabolic changes during normal gestation increase the risk for elevated blood glucose.
  3. List maternal and fetal risks of hyperglycemia during pregnancy.
  4. Identify future risks to the offspring of mothers who had diabetes during pregnancy.
  5. Describe principles of preconception counseling in women with pre-existing diabetes.
  6. Summarize the management of pregnancy in women with pre-existing type 1 or type 2 diabetes.
  7. Review studies and findings that provide rationale for the treatment of gestational diabetes.
  8. Define recommended blood glucose targets and frequency of blood glucose monitoring in gestational diabetes.
  9. Describe goals and guidelines for nutritional management of gestational diabetes.
  10. Identify the safety and efficacy of oral diabetic agents and insulin for use in gestational diabetes.
  11. Discuss interventions to prevent the development of gestational diabetes.
  12. Describe the obstetrical management of pregnancy complicated by diabetes.
  13. Describe maternal postpartum care for pregnancy complicated by diabetes.
  14. Discuss the care of the neonate born to the mother with diabetes.
  15. Identify important aspects of psychosocial care and follow-up for the woman with diabetes during pregnancy.

    1 . In normal glucose metabolism, where is unused glucose stored following the immediate postprandial period?
    A) The small intestine
    B) Muscle and liver tissue
    C) Fat tissue and pancreas
    D) Central nervous system

    DIABETES DISEASE PROCESS: A REVIEW

    Following the immediate postprandial period, unused glucose is stored in muscle and liver tissue as glycogen. The release of this stored energy is regulated by glucagon. Glucagon normally serves as the body's major defense against hypoglycemia. Its role is to maintain blood glucose levels between meals and during the fasting state. When blood glucose levels are high, such as after eating, the secretion of glucagon by the pancreas is inhibited.

    Click to Review



    2 . What is the chief action of the incretin mimetic medications?
    A) Prolongs active incretin levels
    B) Increases insulin production from the pancreas
    C) Decreases insulin production from the pancreas
    D) Interferes with an enzyme that rapidly inactivates the incretin hormones

    DIABETES DISEASE PROCESS: A REVIEW

    Many of the more recent therapies developed for the treatment of type 2 diabetes have been incretin-based. One class of medication, the incretin mimetic, mimics the action of the incretin hormones GLP-1 and GIP, leading to an increase in insulin secretion from the pancreas. An additional beneficial effect of these medications is delayed gastric emptying, which increases satiety and promotes weight loss.

    Click to Review



    3 . Which of the following is NOT one of the clinical classes of diabetes defined by the American Diabetes Association?
    A) Prediabetes
    B) Type 1 diabetes
    C) Type 2 diabetes
    D) Gestational diabetes

    DIABETES DISEASE PROCESS: A REVIEW

    Diabetes encompasses a relatively large and somewhat diverse group of metabolic diseases. The ADA has identified four different clinical classes of diabetes based upon etiology: type 1, type 2, gestational, and other types. In addition, the ADA has defined categories of increased risk for diabetes, collectively known as "prediabetes." Many of the types of diabetes identified by the ADA are not commonly encountered in nursing practice and are related to rare genetic and immune-mediated syndromes; these fall into the "other types" class. The common pathologic factors that categorize all of these diseases as diabetes relate to abnormal insulin production, impaired insulin utilization, or both [5].

    Click to Review



    4 . Which of the following is TRUE regarding patients with type 1 diabetes?
    A) They always have a lean body type.
    B) Onset age is usually older than 30 years.
    C) They require insulin from an outside, or exogenous, source.
    D) They require oral antidiabetic medications in addition to insulin.

    DIABETES DISEASE PROCESS: A REVIEW

    Formerly known as juvenile-onset diabetes, type 1 diabetes usually has its onset in people younger than 30 years of age. It is most often seen in people with a lean body type, although it can occur in people who are older and overweight. Type 1 diabetes results when a person's pancreas cannot produce any of its own insulin for use by the body. If the individual with type 1 diabetes does not receive insulin from an outside source, he or she is likely to develop a life-threatening condition known as ketoacidosis. Patients with type 1 diabetes require insulin from an exogenous source to stay alive.

    Click to Review



    5 . Gestational diabetes complicates approximately what proportion of pregnancies?
    A) 0.1% to 0.5%
    B) 2% to 10%
    C) 20% to 30%
    D) 40% to 50%

    DIABETES DISEASE PROCESS: A REVIEW

    As discussed, GDM refers to diabetes that develops during pregnancy and complicates approximately 2% to 10% of all pregnancies [144]. It occurs more frequently among American Indian, Asian American, Hispanic/Latina, and Pacific Islander populations. Other risk factors for GDM include age older than 25 years, overweight/obesity, and personal history of GDM or family history of diabetes [9,144].

    Click to Review



    6 . How does normal pregnancy affect glucose metabolism?
    A) Placental hormones increase the mother's insulin sensitivity.
    B) Placental hormones decrease the mother's insulin production.
    C) Normal pregnancy does not affect the mother's glucose metabolism.
    D) Hormonal fluctuations alter the mother's metabolism of carbohydrate, fats, and protein.

    GLUCOSE METABOLISM DURING PREGNANCY

    Pregnancy is a time of hormonal fluctuation, altering a woman's metabolism of carbohydrates, fats, and protein. Placental hormones that help the fetus develop naturally cause some insulin resistance in the mother. Normally, these changes of pregnancy result in a mild increase in maternal glucose levels, which provides the fetus with a continuous, increased supply of glucose for its growth. Most of the time, the mother's body can overcome excessive glycemia by increasing insulin production. In a healthy pregnancy, the mother's insulin secretion doubles by the third trimester [4,10,11,12].

    Click to Review



    7 . Which of the following metabolic changes is characteristic of the third trimester of pregnancy?
    A) Maternal hypoglycemia is common.
    B) Maternal basal insulin levels are high.
    C) The diabetogenic stress of pregnancy begins.
    D) There is a dramatic increase in maternal insulin sensitivity.

    GLUCOSE METABOLISM DURING PREGNANCY

    In late pregnancy, anabolic hormones responsible for fetal growth and development increase dramatically. Insulin-opposing hormones, such as human placental lactogen, prolactin, estrogen, and progesterone, cause an even greater degree of resistance. As a result, maternal basal insulin levels are high and eating produces two to three times more insulin output than in the prepregnancy state. However, insulin sensitivity decreases by as much as 50% of that seen in the first trimester. Most cases of GDM occur early in the third trimester because of these metabolic changes.

    Click to Review



    8 . All of the following conditions, associated with diabetes, increase the risk for preterm labor and delivery, EXCEPT:
    A) Neuropathy
    B) Hypertension
    C) Vascular symptoms
    D) Urinary tract infection

    RISKS OF DIABETES IN PREGNANCY

    Maternal diabetes during pregnancy increases the risk for preterm labor [14]. Some of this risk may be due to increased uterine volume caused by macrosomia and/or polyhydramnios, which are associated with GDM. Maternal hypertension and urinary tract infections are also associated with GDM and increase the risk for preterm labor. Women with pre-existing diabetes who have vascular symptoms also have a higher risk for preterm labor.

    Click to Review



    9 . Which of the following statements is TRUE regarding polyhydramnios?
    A) It occurs in about 1% of women with GDM.
    B) Fetal hyperglycemia is the most likely cause of polyhydramnios in GDM.
    C) Polyhydramnios is diagnosed when the amniotic fluid volume is greater than 500 mL.
    D) There are no safe treatments to relieve the pressure of polyhydramnios and prevent premature rupture of the membranes.

    RISKS OF DIABETES IN PREGNANCY

    Polyhydramnios occurs in about 18% of patients with GDM and is diagnosed when the amniotic fluid volume is greater than 2,000 mL. The excess amniotic fluid can distend the amniotic sac and cause premature rupture of the membranes. Fetal hyperglycemia that leads to increased fetal diuresis is the most likely cause of polyhydramnios. Therapeutic amniocentesis can relieve the pressure of polyhydramnios and prevent premature rupture of the membranes, but it is associated with risks as well [15].

    Click to Review



    10 . HELLP syndrome
    A) is a mild form of pre-eclampsia.
    B) occurs in more than half of women with pre-eclampsia.
    C) may develop after giving birth in women who had pre-eclampsia
    D) It can increase the mother's risk for type 2 diabetes in later years.

    RISKS OF DIABETES IN PREGNANCY

    HELLP syndrome is a severe form of pre-eclampsia occurring in approximately in 5% to 12% of cases [17]. It can lead to liver hemorrhage, disseminated intravascular coagulation, pulmonary edema, kidney failure, and placental abruption. HELLP syndrome may develop after giving birth in women who had pre-eclampsia.

    Click to Review



    11 . Which of the following is NOT a fetal cardiac anomaly that may develop secondary to maternal diabetes?
    A) Cardiomyopathy
    B) Atrial septal defects
    C) Asymmetric septal hypertrophy
    D) Transposition of the great vessels

    RISKS OF DIABETES IN PREGNANCY

    Possible anomalies of the heart include asymmetric septal hypertrophy, transposition of the great vessels, ventricular septal defects, and/or cardiomyopathy. Approximately 30% of infants of mothers with diabetes present with one or more of these cardiac conditions [27].

    Click to Review



    12 . Shoulder dystocia
    A) is a minor obstetrical complication.
    B) always affects both of the infant's shoulders.
    C) is more common in cases of maternal obesity.
    D) is more common in small-for-gestational- age infants.

    RISKS OF DIABETES IN PREGNANCY

    Possible birth trauma injuries in cases of macrosomia include shoulder dystocia, brachial plexus trauma, facial nerve injuries, and asphyxia. Shoulder dystocia is potentially catastrophic. While it occurs in fewer than 3% of all vaginal deliveries, 22% of infants weighing greater than 4,500 grams experience shoulder dystocia [31]. Shoulder dystocia occurs during birth when the infant's head is delivered but the shoulder is unable to complete passage through the birth canal due to a discrepancy between the size of the fetal shoulders and the size of the pelvic inlet. Obstruction may affect one or both shoulders. Infants delivered after shoulder dystocia may experience brachial plexus injury, hypoxia, and even death. In addition to macrosomia, maternal obesity is also a risk factor for shoulder dystocia [31].

    Click to Review



    13 . What is the hypothesis of the fetal origins theory?
    A) GDM is caused by genetic factors in the fetus.
    B) Fetal hyperglycemia may be the cause of maternal GDM.
    C) Developmental overnutrition and metabolic programming play important roles in the early development of disease.
    D) Undernutrition during pregnancy initiates compensatory mechanisms in the fetus that lead to obesity later in life.

    RISKS OF DIABETES IN PREGNANCY

    The fetal origins theory provides an explanation of why exposure to hyperglycemia in the womb would predispose offspring to excess adiposity and metabolic disease later in life [36]. The theory hypothesizes that developmental overnutrition and metabolic programming play important roles in the early development of disease.

    Click to Review



    14 . The American Diabetes Association (ADA)recommends that women have what A1C level before attempting conception?
    A) Less than 2%
    B) Less than 6.5%
    C) Less than 10%
    D) Less than 15%

    PRECONCEPTION CARE FOR WOMEN WITH DIABETES

    The patient's recent glycemic control should be evaluated prior to pregnancy. In a 2016 position statement, the ADA recommended that women have an A1C of less than 6.5%, or as close to normal as possible, before attempting conception [40]. The recommended prepregnancy blood glucose targets are ≤90 mg/dL fasting, ≤130–140 mg/dL one hour postprandial, and ≤120 mg/dL two hours postprandial [40]. However, these strict targets pose a very real risk for severe hypoglycemia. Therefore, it is vital to educate patients and their support person(s) on the prevention, signs, symptoms, and treatment of hypoglycemia. It is also advisable to provide glucagon and education regarding how to use it.

    Click to Review



    15 . Which of the following medications is NOT contraindicated during pregnancy?
    A) Insulin
    B) Statins
    C) Angiotensin receptor blockers (ARBs)
    D) Angiotensin-converting enzyme (ACE) inhibitors

    PRECONCEPTION CARE FOR WOMEN WITH DIABETES

    Healthcare providers should carefully evaluate patients' medications prior to conception. Medications that may be contraindicated in pregnancy include statins, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and some oral antidiabetic agents [40].

    Click to Review



    16 . If a patient with diabetes has preproliferative retinopathy or macular edema prior to pregnancy, she should
    A) have laser photocoagulation before conception.
    B) consider sterilization, as the risk of pregnancy is too great.
    C) be at low risk for progression of the disease during pregnancy.
    D) rapidly lower blood glucose levels in the month prior to conception.

    PRECONCEPTION CARE FOR WOMEN WITH DIABETES

    As such, a dilated retinal exam by an ophthalmologist is an important part of preconception care. If a patient has preproliferative retinopathy or macular edema, she should have laser photocoagulation to stabilize her retinal status before pregnancy [41]. In women with proliferative or severe nonproliferative retinopathy, the ADA recommends slowly lowering the blood glucose levels to near-normal over a six-month period before pregnancy is attempted [25].

    Click to Review



    17 . The oral contraceptive of choice for women with diabetes is
    A) the progesterone-only pill.
    B) low-dose combined estrogen plus progestin.
    C) high-dose combined estrogen plus progestin.
    D) Oral contraceptives are contraindicated in women with diabetes.

    PRECONCEPTION CARE FOR WOMEN WITH DIABETES

    When used as directed, oral contraceptives are 98% effective [13]. The oral agent of choice in women with diabetes is a low-dose combined estrogen plus progestin pill. These agents have not been associated with increasing insulin resistance, as the higher dose pills have. For postpartum women who are breastfeeding, it is safe to start low-dose contraceptives six to eight weeks after delivery [13].

    Click to Review



    18 . According to the ADA, target pre-meal, bedtime, and overnight glycemic levels during pregnancy are
    A) 50–69 mg/dL.
    B) 60–99 mg/dL.
    C) 100–129 mg/dL.
    D) 130–149 mg/dL.

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    The ADA's goals for glycemic control during pregnancy are to achieve and maintain near normal glycemia while minimizing hypoglycemia throughout the pregnancy. Glycemic targets are [25,40]:

    • Pre-meal, bedtime, and overnight: 60–99 mg/dL

    • Peak postprandial: 100–129 mg/dL

    • Mean daily glucose: <110 mg/dL

    • A1C: <6%

    Click to Review



    19 . When is the best time for pregnant women to test peak glucose following a meal?
    A) One hour after finishing the meal
    B) Two hours after finishing the meal
    C) One hour after the beginning of the meal
    D) Two hours after the beginning of the meal

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Postprandial glucose levels are most strongly associated with excess birth weight and are the best guide to SMBG during pregnancy [16]. In women with diabetes, postprandial glucose peaks approximately 90 minutes after beginning a meal. However, there is considerable individual and day-to-day variability in this. The postprandial sample should be taken one hour after the beginning of the meal to best measure the peak glucose following the meal. Patients who use rapid-acting insulin before meals should also test their blood glucose before eating so they can adjust their dose appropriately.

    Click to Review



    20 . Ketoacidosis is more likely to develop rapidly in a pregnancy complicated by diabetes due to
    A) decreased fat metabolism during pregnancy.
    B) increased production of glucose by the liver during pregnancy.
    C) a more rapid depletion of insulin stores that occurs naturally in the pregnancy state.
    D) the physiologic increase in insulin sensitivity that naturally occurs in pregnant women.

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Ketoacidosis can develop rapidly in a pregnancy complicated by diabetes due to the physiologic insulin resistance, increased fat metabolism, and rapid depletion of insulin stores that occurs naturally in the pregnant state [25]. Diabetic ketoacidosis (DKA) is usually associated with type 1 diabetes but can also occur in type 2 diabetes and can develop at lower levels of hyperglycemia in pregnant women with either type of diabetes. DKA during pregnancy is associated with a high fetal mortality rate. Maternal fasting ketonemia is associated with decreased intelligence and poor development of fine motor skills in the offspring.

    Click to Review



    21 . What is the recommended first-line treatment of choice for pregnant women with type 1 or type 2 diabetes?
    A) Insulin
    B) Metformin
    C) Sulfonylureas
    D) All of the above

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Insulin is the treatment of choice for pregnant and nonpregnant patients with type 1 diabetes. It is also the recommended agent for women with type 2 diabetes during pregnancy, as oral agents do not usually provide adequate glycemic control [25]. Additionally, insulin does not cross the placenta, easing concern that the drug may cause harm to the fetus [52]. The primary goal of insulin replacement during pregnancy is to achieve plasma glucose concentrations nearly identical to those observed in nondiabetic women. However, achieving the goal of rigid glycemic control is less important than avoiding symptomatic hypoglycemia [16].

    Click to Review



    22 . Which of the following statements regarding hypoglycemia during pregnancy is TRUE?
    A) Maternal hypoglycemia can result in macrosomia.
    B) The risk for hypoglycemia increases during early pregnancy.
    C) Insulin-induced hypoglycemia is less pronounced in pregnancy.
    D) Blood glucose control that is not tight enough is associated with fetal growth restriction.

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    From a physiologic standpoint, the risk for hypoglycemia increases during early pregnancy. Additionally, insulin-induced hypoglycemia is more pronounced in pregnancy and is more dangerous to the fetus. Blood glucose control that is too tight is associated with growth restriction and can result in microsomia and other neonatal and developmental problems.

    Click to Review



    23 . Which of the following is included in the ADA guidelines for the nutritional management of pre-existing diabetes during pregnancy?
    A) Avoid fruit during pregnancy.
    B) Provide 40% to 50% of daily energy from protein (if renal function is normal).
    C) Base the daily carbohydrate allowance upon total carbohydrate intake from all sources.
    D) Provide 30% to 40% of daily caloric intake from carbohydrate and monounsaturated fat.

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    According to the ADA, the goals of medical nutritional therapy during pregnancy are to provide adequate energy and nutrients needed for optimal outcomes. General guidelines for the nutritional management of pre-existing diabetes are to [63]:

    • Include carbohydrates from whole grains, fruits, vegetables, and milk

    • Base the daily carbohydrate allowance upon total carbohydrate intake from all sources

    • Provide 60% to 70% of daily caloric intake from carbohydrate and monounsaturated fat

    • Provide 15% to 20% of daily energy intake from protein (if renal function is normal)

    • Provide less than 10% of the daily energy intake from saturated fats

    Click to Review



    24 . Impaired renal function during pregnancy, as seen in women with diabetic nephropathy, is a strong risk factor for
    A) macrosomia.
    B) delayed delivery.
    C) shoulder dystocia.
    D) fetal growth restriction.

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Although future risk to the mother's renal status is low, diabetic nephropathy during pregnancy poses other serious risks to both mother and fetus. Impaired renal function is a strong risk factor for fetal growth restriction, pre-eclampsia, and premature delivery. Even early nephropathy is associated with an increased risk for fetal growth restriction. There is usually a decline in the renal function of pregnant women with underlying diabetic nephropathy. As renal blood flow and the glomerular filtration rate increase by 30% to 50% during pregnancy, the risk for proteinuria increases.

    Click to Review



    25 . What lipid-lowering medications are approved for use in pregnancy?
    A) Statins
    B) Bile acid-binding resins
    C) Cholesterol absorption inhibitors
    D) None of the above

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Not many cholesterol-lowering medications are safe for use during pregnancy. While statin medications are used in patients with diabetes, they are not safe during pregnancy. Bile acid-binding resins, such as cholestyramine, are the only approved lipid-lowering medications for use in pregnancy. The ADA recommends using fibric acids and niacin as secondary strategies in pregnant women who have triglyceride levels greater than 1,000 mg/dL [10].

    Click to Review



    26 . What is an adverse effect of maternal hypothyroidism on the fetus?
    A) Macrosomia
    B) Anal/rectal atresia
    C) Fetal hyperthyroidism
    D) Inhibited fetal brain development

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Hashimoto disease, also known as autoimmune thyroiditis, is characterized by antibodies reacting against proteins in the thyroid gland and causing destruction of the gland itself, resulting in hypothyroidism. This can adversely affect glycemic control and lipid metabolism during pregnancy. Furthermore, maternal hypothyroidism can inhibit brain development and is associated with pregnancy loss and premature delivery [70].

    Click to Review



    27 . What is the safest treatment of hyperthyroidism during pregnancy?
    A) Radioactive iodine
    B) Levothyroxine sodium
    C) Propylthiouracil (PTU)
    D) Discontinuation of all anti-thyroid medications

    MANAGING PRE-EXISTING DIABETES DURING PREGNANCY

    Propylthiouracil (PTU) is the safest anti-thyroid medication for use in pregnant women. Healthcare providers should closely monitor the effects of PTU and adjust dosages accordingly, as this drug can affect the fetal thyroid gland. Although radioactive iodine is a very effective treatment for other patients with hyperthyroidism, it is a contraindicated treatment during pregnancy [71].

    Click to Review



    28 . Which cardiometabolic risk factor appears to be the single greatest risk factor for the development of GDM?
    A) Obesity
    B) Hypertension
    C) Mild hyperglycemia
    D) Elevated total cholesterol

    GESTATIONAL DIABETES

    One study showed that the risk for GDM increased with the number of pregravid cardiometabolic risk factors [84]. According to this study, cardiometabolic risk profile could predict the risk for GDM as early as seven years before pregnancy. Obesity appears to be the single greatest risk factor. The combination of obesity with mild hyperglycemia was associated with the greatest overall risk. The study concluded that the pregravid cardiometabolic risk profile might help clinicians to identify high-risk women for primary prevention and early management of GDM [84].

    Click to Review



    29 . The HAPO study found
    A) the effects of maternal hyperglycemia cannot be reduced by treatment.
    B) a definitive cut-off point for maternal hyperglycemia and pregnancy outcomes.
    C) adverse events occurred at maternal glucose levels below those diagnostic for diabetes.
    D) a strong correlation between maternal glycemia at 12 to 18 weeks' gestation and the risk for poor maternal, fetal, and neonatal outcomes.

    GESTATIONAL DIABETES

    The potential for agreement on diagnostic criteria for GDM came in 2008, upon publication of the findings from a landmark study on the effects of hyperglycemia and pregnancy. Known as the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, this research data generated a flurry of controversy that continues today. The major finding from the HAPO study was that even mild elevations of blood glucose in pregnant women could have detrimental effects on both mother and child [89]. This prompted a movement for enhanced diagnostic criteria to identify and treat lower levels of blood glucose in pregnant women than previously considered.

    Click to Review



    30 . According to the ADA, when should screening for GDM take place in pregnant women with no history or symptoms of diabetes?
    A) As soon as pregnancy is detected
    B) At 12 weeks' gestation
    C) At 24 to 28 weeks' gestation
    D) At 28 to 32 weeks' gestation

    GESTATIONAL DIABETES

    In pregnant women not known to have diabetes, the ADA recommends screening at 24 to 28 weeks' gestation using a 75-gram two-hour OGTT that should be performed in the morning after an overnight fast of at least eight hours. The test is diagnostic for GDM if any of the following values result [100,147]:

    • Fasting (prior to glucose load): ≥92 mg/dL

    • One hour after glucose load: ≥180 mg/dL

    • Two hours after glucose load: ≥153 mg/dL

    Click to Review



    31 . Which of the following statements regarding a low glycemic index diet is TRUE?
    A) Fruits are an example of a high-glycemic food.
    B) There tend to be few variations in glycemic response among individuals.
    C) The ADA does not endorse the glycemic index as a tool for diabetes medical nutritional therapy.
    D) Foods that are low on the glycemic index tend to increase blood glucose more than foods high on the index.

    GESTATIONAL DIABETES

    The glycemic index appraises the effect of specific foods on blood glucose. Foods that are high on the glycemic index tend to increase blood glucose more than foods low on the index. High-glycemic foods include white bread, pasta, rice, low-fiber cereals, and baked goods; low-glycemic foods include fruits, vegetables, whole grains, and legumes.

    Click to Review



    32 . According to data from the HAPO study, which adverse pregnancy outcome is associated with maternal obesity and GDM?
    A) Pre-eclampsia
    B) Low birth weight
    C) Fetal hypoinsulinemia
    D) Intrauterine growth restriction

    GESTATIONAL DIABETES

    Among women giving birth in the United States in 2014, 25.6% were overweight and 24.8% were obese [110]. A significant percentage of women who are overweight or obese will develop GDM when they become pregnant. Data from the HAPO study reveal that women with GDM who are obese have a significantly higher risk for adverse pregnancy outcomes, including macrosomia, fetal hyperinsulinemia, and pre-eclampsia. Greater weight gain during pregnancy also increases the likelihood of the need for insulin and the incidence of preterm delivery, although it reduces the risk for low birth weight. Furthermore, the combination of both GDM and obesity together has a greater impact on health outcomes than either one alone. The obesity epidemic has spurred interest in the effects of calorie restriction for obese women who are pregnant, including those with GDM. Calorie restriction during pregnancy raises concerns regarding the consequences of limited maternal weight gain on the growth of the fetus [111,112,113].

    Click to Review



    33 . What does current research suggest about the safety of weight loss during pregnancy for obese women?
    A) No woman should attempt weight loss during pregnancy.
    B) Even moderate caloric restriction seems to impair fetal growth in obese women.
    C) Some women may be able to lose up to 25 pounds during pregnancy without adverse outcomes.
    D) It may be safe for some pregnant women to attempt weight loss under the supervision of a qualified healthcare provider.

    GESTATIONAL DIABETES

    As discussed, the pregnancy weight gain recommendations from the IOM were revised in 2009 [64]. While these guidelines recommend less gestational weight gain for overweight and obese women, some experts feel that selected obese women should gain even less weight than the IOM suggests. Studies suggest that some obese women can gain less than 15 pounds, or even lose up to 10 pounds during pregnancy, without adverse outcomes. In these women, research indicates that moderate caloric restriction does not seem to impair fetal growth and may prevent macrosomia [114,115,116].

    Several other studies suggest that calorie restriction in obese women during pregnancy can result in positive outcomes. Obese pregnant women restricting calories by 30% to 33% appears to be safe, with no associated increase in perinatal morbidity. Calorie restriction may increase a woman's insulin sensitivity, resulting in a decreased need for injections. Even so, continued research is necessary to determine the effects of calorie restriction during pregnancy on the future health of the child [16].

    Although evidence-based guidelines for the optimal management of maternal obesity during pregnancy are lacking, the ACOG published a practice bulletin on obesity during pregnancy in 2015. The bulletin addresses clinical management questions about appropriate interventions before and during pregnancy, recommendations for weight gain, potential alterations to antepartum and intrapartum care, labor and delivery considerations, and the most effective postpartum care and strategies [117]. Additionally, experts recommend that pregnant women avoid excessive gestational weight gain, exercise moderately, and eat a healthy diet. Women should only attempt weight loss during pregnancy under the supervision of a qualified healthcare provider [16,25,113].

    Click to Review



    34 . When taken during pregnancy, metformin
    A) helps obese mothers to lose weight.
    B) may help decrease the risk for macrosomia.
    C) does not cross the placenta in significant amounts.
    D) has been proven to impact the offspring's growth in later life.

    GESTATIONAL DIABETES

    In pregnancy, metformin crosses the placenta in significant amounts. This raises the concern that it could affect fetal physiology or cause congenital anomalies. However, congenital malformations take place during the first nine weeks of pregnancy, while the diagnosis of GDM usually takes place at 24 to 28 weeks. Nevertheless, even if safe with regard to organogenesis, it will be important to study metformin's effect on the offspring during the growth years and later in life. Metformin may slightly increase the risk of prematurity [25].

    The Metformin in Gestational diabetes (MiG) trial was an important study that assessed the efficacy and safety of metformin in pregnancy. It included 751 women with GDM at 22 to 33 weeks' gestation and compared the use of insulin to metformin on measures of neonatal hypoglycemia, respiratory distress, neonatal jaundice, birth trauma, Apgar scores, and prematurity [121]. The trial results indicated that almost half of patients using metformin ended up requiring supplemental insulin to meet blood glucose targets [25]. Neonatal complications did not differ significantly between the two groups, and there were no serious adverse events associated with use of metformin. Women who used metformin reported a higher rate of satisfaction compared to insulin. While the results of MiG are promising, guidelines recommend avoiding metformin as routine therapy for GDM pending further clinical trials [10,25,75].

    The MiG Trial Offspring Follow-Up (MiG TOFU) continued to follow the offspring of mothers with GDM who used metformin during pregnancy [123]. The focus of the 2011 MiG TOFU was to examine the body composition of these children at 2 years of age. Results suggest that metformin exposure in utero might lead to improved insulin sensitivity in the fetus and result in a metabolically healthier pattern of growth in early childhood, including less development of visceral fat (central adiposity), a significant component of metabolic syndrome [123]. A 2018 MiG TOFU report showed no significant differences between offspring of those treated with metformin versus insulin at 7 years of age. However, at 9 years of age, metformin offspring were larger by measures of BMI, weight, and arm and waist circumferences. Levels of fasting glucose, triglyceride, insulin, insulin resistance, A1C, cholesterol, liver transaminases, leptin, and adiponectin were similar, as were body fat percentage and abdominal fat percentages [124]. The results of MiG TOFU, while promising at first, now suggest that in utero exposure to metformin may lead to negative implications for the prevention of diabetes in the offspring of women with GDM later in life.

    Other studies have shown that metformin may help decrease the risk for macrosomia in the offspring, but it does not appear to help obese mothers lose weight [122]. More follow-up studies and longitudinal research are needed to clarify these results.

    Click to Review



    35 . Which of the following has been shown to decrease the risk of developing GDM?
    A) Weight loss between pregnancies
    B) Engaging in regular physical activity prior to and in early pregnancy
    C) Reducing the amount of animal fat and cholesterol in the diet prior to pregnancy
    D) All of the above

    GESTATIONAL DIABETES

    A mother's diet before pregnancy appears to influence her metabolism during pregnancy, which may have important associations with a child's health at birth and later in life. Data from more than 13,000 women enrolled in the Nurses' Health Study II indicated that a prepregnancy diet high in animal fat and cholesterol could increase the risk of developing GDM. Those with the highest intake of animal fat had an increased risk for GDM compared to those with the lowest percentage. Women whose diets were high in other types of fats, such as plant-based oils, did not have an increased risk. This research suggests that reducing the amount of animal fat and cholesterol in the diet prior to pregnancy may help prevent GDM [134]. A systematic review of 14 randomised controlled trials were analyzed to determine whether dietary intervention in pregnant women could prevent GDM [133]. Three of the trials compared diet with standard antenatal care in 455 women (mean age 27.7 years in the diet group vs 29.0 years in the standard care group). All three studies reported a statistically significantly lower incidence of GDM with dietary intervention compared to standard care. Meta-analysis of two of the studies also showed a statistically significant lower incidence of gestational hypertension with dietary intervention [133].

    Click to Review



    36 . What measurement, provided by fetal ultrasound, helps detect macrosomia?
    A) Fetal BMI
    B) Fetal head circumference
    C) Total intrauterine volume
    D) Fetal abdominal circumference

    OBSTETRICAL AND POSTPARTUM MANAGEMENT OF PREGNANCY COMPLICATED BY DIABETES

    Fetal ultrasound can detect major anatomic abnormalities in the fetus, assess fetal growth status, and provide an estimate of fetal weight. It can also detect polyhydramnios, a common finding in pregnancies complicated by diabetes. The ADA recommends fetal ultrasound to screen for congenital anomalies when the pregnant woman has an A1C greater than 7% or a fasting plasma glucose greater than 120 mg/dL, as these values are associated with a greater risk for congenital malformations [13,16].

    Click to Review



    37 . What is the recommended rate of postpartum weight loss?
    A) Less than 0.5 pound per week
    B) 0.5 to 1 pound per week
    C) 1 to 2 pounds per week
    D) At least 2 pounds per week

    OBSTETRICAL AND POSTPARTUM MANAGEMENT OF PREGNANCY COMPLICATED BY DIABETES

    Postpartum weight loss should be a gradual loss of the weight gained during pregnancy, in some cases in addition to excess pre-pregnancy weight. The aim should be to lose 0.5 to 1 pound per week [16]. A more rapid weight loss may lead to fatigue and nutrient depletion.

    Click to Review



    38 . Hypoglycemia in the newborn is defined as blood glucose of
    A) 45 mg/dL or less.
    B) 60 mg/dL or less.
    C) 70 mg/dL or less.
    D) 80 mg/dL or less.

    OBSTETRICAL AND POSTPARTUM MANAGEMENT OF PREGNANCY COMPLICATED BY DIABETES

    Hypoglycemia in the newborn is defined as blood glucose of 45 mg/dL or less, usually without any other signs. It tends to be more severe in infants of mothers with pre-existing type 1 or type 2 diabetes and occurs in 25% to 40% of these births [138]. Elevated maternal glucose levels prior to birth stimulate overproduction of insulin by the infant's pancreas, leading to hypoglycemia in the early postpartum period. Macrosomic and preterm infants are at the greatest risk for hypoglycemia.

    Click to Review



    39 . Which of the following statements regarding breastfeeding and diabetes is TRUE?
    A) Mothers with diabetes should not breastfeed.
    B) Only mothers with good glycemic control should breastfeed.
    C) Breastfeeding offers health benefits to both mother and child.
    D) The insulin requirements for nursing mothers are about 25% higher during lactation

    OBSTETRICAL AND POSTPARTUM MANAGEMENT OF PREGNANCY COMPLICATED BY DIABETES

    Breastfeeding offers many health benefits to women, including those with diabetes. Furthermore, it offers immediate and future benefits to both mother and child. Healthcare providers who work with patients with diabetes should advocate for breastfeeding and support institutional policies that facilitate breastfeeding.

    Lactation increases the caloric needs of the mother [141]. The initial energy demands of breastfeeding exceed the prepregnancy demand by approximately 650 calories per day. This decreases by about 100 calories in the second half of the first year of breastfeeding. The ADA recommends that breastfeeding mothers with diabetes consume at least 1,800 calories per day to meet the requirements for lactation while allowing for gradual weight loss [16]. Stored fat meets some of this need, providing about 150 calories per day. Therefore, an increase of about 500 calories per day over the prepregnancy allowance may be needed [16].

    In addition, the insulin requirements for nursing mothers are about 25% lower during lactation. In GDM, breastfeeding may be associated with lower rates of postpartum diabetes and lower fasting glucose levels [13,141]. In fact, lactation results in more favorable cardiometabolic profile among postpartum women in general, including women with GDM. This may protect against metabolic syndrome later in life [141].

    Click to Review



    40 . Which of the following is the most appropriate first-line treatment for depression during pregnancy?
    A) Antidepressant medication
    B) Encouraging the patient to seek social support
    C) Assisting the patient to achieve improved glycemic control
    D) Referral to a mental health professional for psychotherapy

    OBSTETRICAL AND POSTPARTUM MANAGEMENT OF PREGNANCY COMPLICATED BY DIABETES

    As noted, the hormonal fluctuations of pregnancy can increase the risk for depression, and severe depression is associated with poor glycemic control and ultimately poor pregnancy outcomes. Psychotherapy is the first line of treatment for depression during pregnancy. Referral to a mental health professional is appropriate. The safety of antidepressant medications during pregnancy is questionable, as some have been linked to congenital anomalies and infantile withdrawal syndrome. In the most severe cases, the benefits of using antidepressant medication may outweigh the risks, as fetal exposure to untreated major depressive disorder is significant. Balancing the risks to the fetus exposed to severe maternal depression and to the medications to treat depression is necessary [10].

    Click to Review