Table of contents
.
3 Macro
- Head (DVA)
- Chest (CVS)
- PVD
3 Micro
- Retinopathy, Nephropathy, Neuropathy
- Peripheral glove/stacking symmetrical sensory
- Autonomic neuropathy
- Mononeuritis multiplex (ocular nerve - ddx multiple sclerosis)
- Diabetic amyotrophy
3 Other
- Emergencies
- Infection (Immunocompromise)
- Autonomic dysfunction
Pre-Conception Advice
(Dr. Wijeratne 2017 Jan)
- Attain a preconception HbA1c of ≤ 7.0% (if safe)
- Do not recommend pregnancy with HbA1c > 7.0 (higher risk = higher HbA1c)
- Optimize Diabetes:
- Non-Pharmacological: Weight loss, dietary management etc..
- Metformin is safe (CDA has not yet adopted this)
- Switch to insulin if on oral agents
- Folic Acid - 5mg/day (at least 3mo prior to pregnancy to 12w post conception) (just like antiepileptics, hx of NTD)
- Assess and manage any complications (pregnancy worsens retinopathy/nephropathy)
- Stop teratogenic meds
- ACE inhibitors, ARBs
- Statins
NOTE: DPP4 inhibitors (gliptins) have not been studied, glyburide seems to be safe as an alternative to insulin.
Diagnosis/Screening
- ALL pegnant women should be screened for GDM 24-28w gestation.
- (If there is high risk, screen at any stage)
- If screening @ 24w is negative --> Rescreen 24-28w.
- Risk Factors:
- Previous diagnosis of GDM
- Prediabetes
- High Risk Population (Aboriginal, Hispanic, South Asian, Asian, African)
- Age >= 35yo
- BMI >= 30 kg/m2
- PCSO, acanthosis nigricans
- Corticosteroid use
- Fetal Macrosomia or polyhydraminos (current or previous)
- After birth - repeat testing at 6w post-delivery.
- Screening:
- 50g GCT to non-fasting patient. Measure PG 1hr later.
- NOTE: In old test, 75g OGTT (need two values abnormal, but new guidelines: need two abnormal)
-
<7.8 mmol/L Normal 7.8 - 11.1 mmol/L Proceed to 75g test
>= 11.1 mmol/L Diabetes -
- < 7.8 mmol/L --> Normal
- 7.8 - 11.1 mmol/L --> FASTING 75g OGGT
- Fasting --> 5.3
- 1 hour Value --> 10.6
- 2 hour Value --> 9
- >= 11.1 mmol/L = DIAGNOSIS.
-
- Diagnosis
- 75g OGTT
- PG 1hr > 10.6
- PG 2hr > 9
- Fasting > 5.3
GDM Monitoring
- Monitor:
- Fasting Blood Glucose
- 1-hr Post-Meal sugars
-
CDA Guidelines Targets:
- FBG > 5.3 start NPG 4-6u
- 1-hour Post-meal > 7.8 --> start humalog 4u before the meal with elevation (titrate up).
Delivery Target
- Target: 4-7 (less than in-hospital targets 5-10 and 8-10 to avoid neonatal hypoglycemia)
POSITIVE OGTT
- 1: Try to control with diet first!
- Avoid diet in simple sugars
- 2: If unable to keep to targets
- FBG > 5.3 --> Start insulin 0.1-0.3 u/kg
- Insulin Glargine is preferred due to slow release
- Insulin Aspart for mealtime due to low risk of postprandial hypoglycemia
- FBG > 5.3 --> Start insulin 0.1-0.3 u/kg
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