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9: Complications of Pregnancy
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What is pregestational diabetes mellitus (GDM) and how is it characterized It is a diagnosis of diabetes mellitus prior to pregnancy It occurs in 1% of all pregnancies and includes both Type I diabetes and Type II diabetes Type II pregestational diabetes is more common and is characterized by onset later in life, obesity, peripheral insulin resistance, some insulin deficiency, and end-organ complications (renal, vascular, nervous) Type I pregestational diabetes is less common and occurs most often early in life It is characterized by an autoimmune process that destroys the pancreatic cells It is a diagnosis of diabetes mellitus defined as glucose intolerance with onset or first recognition during pregnancy 90% of diabetes cases encountered during pregnancy are GDM and more than one half of those patients at risk will end up developing pregestational diabetes later in life Placental secretion of anti-insulin and diabetogenic hormones that contribute to the diabetic state include: Growth hormone Corticotropin-releasing hormone Human placental lactogen Prolactin Progesterone
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Section III: Topics in Obstetrics
Tumor necrosis factor- and leptin have also been implicated in creating the insulin-resistant state of pregnancy What are several risk factors for the development of GDM Age >25 Obesity (BMI >30 in the nonpregnant state) Prior history of GDM Family history of diabetes (especially in a first-degree relative) Previous stillbirth or child with a congenital malformation Birth of a prior infant with weight >9 lbs (or history of macrosomia) Polycystic ovary syndrome (contributes to the insulin resistance state) 2+ glycosuria (debatable in the literature) In addition to diabetic retinopathy, nephropathy, and neuropathy, what are several obstetric-related maternal complications associated with GDM Preeclampsia Preterm birth Macrosomia and birth trauma (especially shoulder dystocia) Intrauterine growth restriction Polyhydramnios First trimester abortions and stillbirths Asymptomatic bacteriuria Higher incidence of cesarean section, vacuum, and forceps deliveries Higher incidence of neonatal respiratory distress syndrome (delay in the fetal lung maturity) With what other endocrine disorders is Type I diabetes mellitus associated There is a 5 8% incidence of hypothyroid disease as well as ~25% risk of developing postpartum thyroid dysfunction Congenital malformations Macrosomia Intrauterine fetal demise Hypoglycemia Hypocalcemia Respiratory distress syndrome
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What are several adverse neonatal outcomes associated with hyperglycemia
9: Complications of Pregnancy
Polycythemia Organomegaly (cardiac) Hyperbilirubinemia What congenital malformations are associated with maternal pregestational diabetes mellitus Heart defects (transposition of the great vessels, ventricular septal defect [VSD], atrial septal defect [ASD]) Neural tube defects Caudal regression (pathognomonic, but very rare) Situs inversus Anal/rectal atresia Renal anomalies (duplex ureter) How does hyperglycemia cause congenital malformations Hyperglycemia is teratogenic during the period of organogenesis (first 8 weeks of pregnancy); therefore, preconceptual glucose control and monitoring is crucial for normal development
Glycosylated hemoglobin (HbA1c) levels correlate directly with the frequency of congenital anomalies What is this relationship
HbA1c Levels (%) 5 6 89 99 10 How does GDM cause fetal macrosomia
Frequency of Anomalies (%) 2 3 81 20 25 Maternal glucose crosses the placenta and creates a hyperglycemic environment for the fetus In response, the fetus produces more insulin Insulin is a potent growth hormone and leads to increased somatic growth, macrosomia, central fat deposition, and enlargement of internal organs (ie, heart) Though controversial, universal screening of all pregnant women is recommended by ACOG However, low-risk women may be exempt from screening These women should have all of the following characteristics:
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