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Diabetes in pregnancy

Clinical Discipline(s)/Organ System(s)
Endocrinology, Obstetrics & Gynaecology, Reproduction & Development, Paediatrics
Progress Test Topic(s)
Women's health
Description
A 35 year old NZ European woman is 28 weeks pregnant. She has an abnormal one hour glucose challenge test (polycose) and her midwife refers her to the obstetrician for review.
Applied Science for Medicine 
   - Physiology and endocrinology of pregnancy including altered glucose tolerance and insulin resistance
   - Pathogenesis of gestational diabetes, types 1 and 2 diabetes mellitus
   - Pathophysiology of fetal effects in diabetic pregnancy
   - Glucose homeostasis in the newborn
   - Pharmacology of metformin and insulin in treatment of diabetes in pregnancy
Clinical and Communication Skills 
   - History from a pregnant woman with elevated blood glucose levels, specifically assessing for risk factors for diabetes
   - Examination of a pregnant woman with diabetes
   - Screening and diagnostic tests for diabetes undertaken during pregnancy; interpret the results
   - Define gestational diabetes, and distinguish from pre-existing diabetes mellitus (type 1 and type 2); recognise clinical features of each
   - Antenatal screening specific to diabetes; risks of fetal anomalies and fetal growth abnormalities
   - Management of diabetes in pregnancy and targets for glycaemic control (diet, exercise, optimal gestational weight gain, medications, insulin regimens)
   - Emergency management of diabetic emergencies (diabetic ketoacidosis, sepsis, hypoglycaemia)
   - Maternal and fetal consequences of diabetes for: current pregnancy, labour and delivery, neonatal period, child long-term, mother long-term, future pregnancies
   - Importance of postnatal care including breastfeeding support, contraception advice, diabetic follow-up or screening (if gestational diabetes)
   - Understand the role of the multidisciplinary team including midwives, dietitians, obstetricians, obstetric physician, ultrasonographer, neonatologist in optimizing pregnancy outcome
   - Investigation and treatment of a baby with neonatal hypoglycaemia
   - Prepregnancy counselling specific to diabetes
Personal and Professional Skills 
   - Appreciate the loss of 'normality' for a pregnant women diagnosed with gestational diabetes
   - Encouraging concordance with therapy with a disease with no overt symptoms
   - Multidisciplinary management of a high risk pregnancy
   - Understanding the risks and benefits of interventions such as induction of labour, caesarean delivery
Population Health 
   - Role of obesity in impaired glucose tolerance and subsequent gestational or type 2 diabetes
   - Rationale for routine screening for diabetes in pregnancy
   - Epidemiology of gestational diabetes
   - Lifestyle modification in obese women to reduce risks of subsequent diabetes
   - Importance of pre-pregnancy counselling and planning pregnancy in women with diabetes
Conditions to be considered relating to this scenario
Common
gestational diabetes mellitus, gestational impaired glucose tolerance, type 1 diabetes mellitus, type 2 diabetes mellitus, polycystic ovarian syndrome, metabolic syndrome, drug induced, steroid use
Less common but 'important not to miss'
maternal sepsis
Uncommon
endocrine causes of hyperglycaemia