Pre-Gestational Diabetes – CRASH! Medical Review Series



our topic here is going to be pre gestational diabetes and this is very different from gestational diabetes both in the cause and of the outcome so you'll want to watch my lecture on gestational diabetes first because I'm going to sort of frame this in the context of gestational diabetes and compare the two so I highly recommend watching that one first if you haven't already please consider subscribing to my patreon page at WWE comport /pw BMD you can click the link below in the description of this video or on the I button on the upper right hand corner of your screen if you hover over it you should be able to see it and that will link you up if you could consider tipping in a dollar a month a little bit goes a long ways and helps offset the costs of making these videos and helps keep them free also if you subscribe you can get access to some of my premium videos I do these case reviews that can be very useful for you if you're studying for step three for those clinical case scenarios and also just very useful in general for approaching cases in a sort of logical and coherent manner I'd like to think that my way is logical so thank you in advance or for your consideration so pre gestational diabetes is diabetes that pre-exists the pregnancy that's in contrast to just a tional diabetes which is something that exists or comes on in the second half of pregnancy and then remits after the pregnancy is over and that has to do with the physiology of the placenta with pre gestational diabetes it's just a diabetic woman who becomes pregnant it's pretty simple and that comes in two flavors type 1 diabetes and type 2 diabetes and they are slightly different to some of the complications that can come out of it as well as the management so pre gestational diabetes already defined it is the existing of type of existence of type 1 or type 2 diabetes prior to the onset of pregnancy what do you think is happening with the of pre gestational diabetes it's going up why is it going up because we are a fat country and because we are a fat country with childhood obesity obesity in the teenage years obesity in adulthood everybody's getting fatter earlier and bigger and bigger and bigger look at the map of obesity in the u.s. just from 1990 to now huge the fattest country that the fattest state in 1990 is is thinner than the thinnest state now okay so that is a big deal and so because any in the past type-2 diabetes typically came on in your 40s 50s or Beyond now because people are fatter earlier it doesn't take as long or at least you're not you don't necessarily need to be as old to start developing that insulin resistance and so people are becoming insulin resistant in their 20s and 30s which is the age that women typically get pregnant and so it's very very common for diabetes to occur in a woman of reproductive age compared to in the past so this is becoming more and more common that being said gestational diabetes is still much more common than pre-decisional diabetes by about 8 to 1 ratio so 1 percent of pregnancies in the US type 2 diabetes is actually now more common than type 1 diabetes in pregnancy and that again very remarkable because it just goes to show that type 2 diabetes is happening so much younger you think of type 1 diabetes as something truly that does happen to children and it does but now type 2 diabetes is happening in children and young adults to a much greater degree than it was happening in the past so this just speaks to how fat and lazy of a country we are you know I'm a proud American but man there are some things we need to fix all right requires different management so this is just based on the fact that with gestational diabetes we diagnosed it in second half of pregnancy okay the management is different in pre gestational diabetes because we need to intervene earlier and because we need to intervene earlier it's going to be different management we need to check baseline levels when you check arena level or renal levels we need to check our eyes because the the complications are all the more severe now the adverse outcomes for baby is much more severe in pre gestational diabetes than this for gestational diabetes and the reason is because with gestational diabetes it's only affecting the second half of pregnancy with pre gestational diabetes is affecting the entire pregnancy and because it's affecting the entire pregnancy there are things that can go wrong during some of those very critical months of development and if things go wrong there you can have problems with organogenesis with neural tube defects with cardiac defects and so you just see a wider range of things that go wrong remember it's just a tional diabetes the primary adverse outcome is macrosomia and the things that come out of that traumatic delivery shoulder dystocia leading to labor arrest higher risk of c-sections we see all those things in pre gestational diabetes but with pre gestational diabetes there's a lot of other things that can go wrong congenital malformations delayed organ maturity really big problems okay so these adverse outcomes are associated with poor glycemic control big surprise that right so if you have if your diabetes under poorer control you're at a greater risk of having problems during your pregnancy and where we really see this as congenital malformation because if this is where if you have poor control early on in the pregnancy you're going to run into problems with with just the fetal development so if Pertino globin a1c is well controlled and this is why we get a hemoglobin a1c early on if it's well controlled under 7 which is good it's normal then her risk of having a baby with congenital malformation is about 3% you might think 3% that's really high and yeah I mean it is but that's about what it is in the general population so so if her hemoglobin a1c is under good control then she's in good shape once you start exceeding seven go towards the double digits the risk of congenital malformations is uh precipitously so here you're talking five ten times more likely to have a baby with congenital malformation a higher it goes okay so this is why it is so important to keep these women under good glycemic control and this is going to be why management is so critical by her taking her blood glucose level at home it's very very important so we know when we need to increase her insulin levels and we will need to do that during pregnancy because as you know that so madam'am atrophic tropen or kingdom placental oxygen that those levels go up as the placenta gets bigger and that's going to increase your insulin resistance and therefore your insulin your the amount of insulin you need your your insulin requirements are going to go up during the course of the pregnancy this one is pretty big – so all women to the unfree conceptional folate that goes for anybody diabetic or not but this takes on very very paramount importance in diabetic women and the reason is because women who are diabetics already have an increased risk of having a baby with neural tube defects and if you're not on folate your risk of having a baby with neural tube defects goes up too so it's a double whammy if you have a diabetic woman who's not on preconception of folate she's got two things working against her being a diabetic and being polite deficient so very important that all women are on 400 micrograms of folate daily very very very important so what are some of the complications well on the maternal end the big one is preeclampsia and the reason preeclampsia is you have a higher risk with preeclampsia is probably because you have micro vascular issues going on and we typically see this more commonly in the type 1 diabetic mothers there's the type to prep to type two diabetics and the reason is because with type one diabetes you have all those micro vascular issues and remember what we believe the pathogenesis is behind preeclampsia is vascular issues with the placenta and those those vessels are small vessels and so if you already have a if you already have micro vascular issues to begin with and now you have plastination you can have you'll have a greater risk of preeclampsia because of your pre-existing risk for micro vascular disease okay so we do see a higher rate of preeclampsia in diabetic mothers spontaneous abortion for some reason women who are diabetic have an increased miscarriage risk infection postpartum hemorrhage especially in the type 2 diabetic women why because type 2 diabetic women are at increased risk for macrosomia big babies and so we see this also in gestational diabetes which is essentially a type 2 diabetes process and so because you have a big beige the uterus becomes more distended uterus becomes more distended it takes longer for the uterus to contract after delivery and so you have a higher risk of postpartum hemorrhage and along the same lines you have an increased c-section risk with a bigger be diabetic emergency so this has to do with the fact that diabetes is much harder to control during pregnancy than it is outside of pregnancy during pregnancy that's the madam'am atropine level that human placental oxygen HPL is going up and so you're kind of in a flux state whereas before the pregnancy woman could be on a certain dose of insulin and for the most part it was fixed that's the insulin that she needs during the pregnancy however her insulin requirements are going to go up gradually and so if you give her too much insulin if you adjust her insulin levels she's hyperglycemic an you adjust her insulin levels and you give her too much insulin she can become hypoglycemic on the other hand if our insulin requirements go up as it does and you're not giving her enough insulin she can have DKA and diabetic coma remember she's already at increased risk for infection infection raises your risk of DKA and diabetic coma as well okay so this all has to do is the fact that it's just difficult to manage women with who are pregnant with diabetes very difficult to keep those sugar levels under control and for the same reason they're at increased risk of vascular and organ involvement because their glucose levels can be out of whack and so they can get nephropathy and neuropathy retinopathy and cardiac issues and it's again for this reason that we're going to get these baseline levels up for first visit we're going to be getting labs that wouldn't otherwise get in your average non diabetic woman who comes in for prenatal testing on the fetal end of things of course macrosomia is a big deal so if you look at these complications since all the things that can happen in gestational diabetes plus some other problems and so macrosomia like babies getting too much glucose maybe gets too much glucose it grows faster grows faster it can be harder to do a vaginal delivery if you do try a vaginal delivery and the baby figure of course you have an increase with traumatic delivery developing Erbs palsy from pulling on those shoulders of shoulder dystocia and shoulder gets lodged behind the pubic symphysis and so this just all has to do with being a big baby delayed oregon maturation so remember you may be a big baby but that doesn't mean that the organs are more developed it just means a baby is bigger and you already have an increased risk of delayed organ maturation in babies with diabetic mothers so this can affect the lungs which would manifest in respiratory distress syndrome it can affect the liver if you have an immature liver you can have neonatal hyperbilirubinemia jaundice neurologic effects like neural tube defects pituitary thyroid axis parathyroids that those are immature you're not going to be making parathyroid hormone and then you could have a hypocalcemic baby low calcium levels then congenital malformations especially if it's poor glycemic control early on in the pregnancy congenital heart defects neural tube defects caudal regression syndrome not something we commonly see in diabetic mothers but something that we do see in babies of diabetic mothers there's a 200 full increased risk in babies of diabetic mothers situs inversus don't even ask me about the pathophysiology behind that I do not know it duplex renal year and intrauterine growth retardation who do you think we see intrauterine growth retardation in type 1 diabetics or type 2 diabetics along the same lines as preeclampsia we see it in type 1 diabetics because this is a vascular disease of the placenta you have insufficient vascularization of placenta baby is not going to be getting enough blood flow through the placenta and you think you're going to get a symmetric into you during growth retardation and then along the same lines polycythemia baby's not getting enough oxygen the erythropoietin fetal refer potent is going to go up baby's going to be making more red blood cells in the marrow than babies born it's going to have a high red blood cell count and that can lead to neonatal jaundice as well so this is just kind of comparing the results of pre gestational diabetes and the adverse effects with gestational diabetes and you can see that for most things you have a much higher risk in pre gestational diabetes compared to gestational diabetes okay so at the first visit you should be getting all the routine labs along with some additional things now I put blood pressure here just because it's important very important to get a blood pressure level because you're going to get in all women but you need to get a blood pressure level particularly because these women are going is going to be at higher risk with gestational hypertension so I just wanted to highlight that you want to get an EKG because the risk of cardiac issues this one is critical you want to get a 24-hour urine protein and creatinine we do not get that routinely the only time you're going to get a 24-hour urine protein and creatinine in a non diabetic woman is that she has some kind of renal disease not related diabetes or if when we screen her with a urine dipstick protein for her for preeclampsia and it comes back positive then we get sort of a confirmatory 24-hour year in protein but we want to get this in all women who are diabetic at their first visit here's the reason what especially in your type 1 diabetic women they may have some pre-existing nephropathy and when she comes in at 20 24 28 weeks to get checked for preeclampsia let's say her blood pressure is high and we want to check her urine protein let's say is that urine protein is 450 milligrams well if it's 450 milligrams we would assume she must have preeclampsia because more than 400 milligrams but if she has nephropathy from diabetes then she that may be what she normally pees up is 450 milligrams per day of protein until she doesn't really have preeclampsia she just has the property so we want to get a baseline urine protein because if we know what her baseline here in protein is and then we check in the second trimester for her urine protein and we see that it's the same well then even if it's let's say 600 milligrams per day we know it's not preeclampsia there's no change she's at her baseline but if let's say she was at 300 milligrams per day and her first visit and now as we're in the third trimester and she's at 900 milligrams per day well then there may be a preeclamptic process going up okay so that's why we get it we gives us a baseline see if there's any kind of pre-existing renal disease hemoglobin a1c this is important because it checks the her not only her by Seema control but also kind of her her reliability to be taking her influence and her hemoglobin a1c is his six point six well then that's great she's doing a good job of keeping her collecting her sugar under control if it is she comes in at 10 not only does that tell you that she's at increased risk for having a baby with congenital malformations but it also tells you she's probably not doing a really good job of taking our insulin and measuring her blood sugar and so you can have that conversation with her you should get diary function tests and then you should get not biologic exam remember that all those end-organ issues can occur during pregnancy you can get an optimal logic exam as a baseline and then you're going to be getting this about three months after delivery to see if there's any changes our target values for glucose so this these are pretty standard fasting we want it to be 70 to 90 so she's always going to check for glucose levels when she wakes up in the morning and it should be between 70 and 90 then after each meal so breakfast lunch and dinner she should check it one hour afterwards and it should be below 140 if she checked the two hours afterwards then it should be even lower than that it should be below 120 and she should be checking her blood glucose four times a day fasting and then after each meal breakfast lunch and dinner and she should be putting this into a diary so that when she takes it in we can look at it and make sure that everything's under control because at some point we're going to need to adjust her insulin levels and that's going to happen later on in the pregnancy so we want to make sure that everything is under control because once her blood glucose level starts exceeding this and it will if you don't change her insulin levels once it starts exceeding this then we know we need to go off on our insulin for the USMLE you don't need to worry about dosages just have in your mind the general principle that she's going to become more insulin resistance as the pregnancy goes on okay so let's talk about type one diabetes in greater detail so as a review type one diabetes is an autoimmune destruction of the pancreas beta cells which results in insufficient or absent endogenous insulin secretion and so for this reason type one diabetes is also known as insulin dependent diabetes mellitus and these patients will require insulin now as her level of human placental a Pidgeon which is secreted by the placenta goes up during pregnancy because that antagonizes the insulin that she's already taking her insulin requirements are going to go up because there's competitive inhibition going on here so she's going to need to be on more insulin as the pregnancy progresses especially in the second half of pregnancy so as far as adjusting insulin dosages again don't need to worry about dosages for the USMLE but these are just some good principles to keep in mind it may sense of physiology and how we prescribe things and everything so you want to establish a fasting glucose level 70 to 90 this is really going to be what you're looking at as far as adjusting her insulin so if she's waking up in the morning and her insulin or her blood sugar level was 150 well then we need to increase her insulin levels only at just one dosage at a time so she's going to be taking her NPH in the morning she's going to be taking her Humalog after meals and that's good but based on where her if it's her postprandial levels that are high or if it's for fasting levels that are high then we'll adjust one or the other do not change any dosage by more than 20% in one day and wait 24 hours between those changes to it's less response so why do we not change by more than 20% in one day well we don't want to be we don't want to cause her to become hypoglycemic so we want to be very careful and gradual how we change her insulin and then we wait because it may take some time for her to normalize when when her Ragosa just changed remember that diet exercise stress and infection can affect glucose levels so if she's eating more sugar or sugar level is going to be higher cheese eating less it's going to be lower if she's exercising more for glucose level is going to be lower if she's exercising less it's going to be higher if she's more stressed out if she's got infection that can cause the blood glucose level to go up or down depending on whether she's stressed or not or whether she's got infection or not okay so all of these things can affect your glucose levels where the takes on primary importance is if let's say we need to hospitalize her for some reason and now she's in bed all the time well her insulin requirements are going to go down because she's not moving around as much and so if we keep her on the same insulin dosage that she was before she came in the hospital and now she's not moving around as much she's at risk of becoming hypoglycemia so you need to be very careful likewise if you adjust her insulin levels while she's in the hospital and then send her out on that level and now she's moving around then she can become hyperglycemic because she's not getting enough insulin okay type-2 diabetes so this is just insulin resistance and so because they're already insulin resistant as the pregnancy progresses the HDL level goes up they're going to be more resistant and so for this reason they're going to need more insulin but remember a lot of patients who are type 2 diabetics are not on insulin they're either managing their diabetes with diet and exercise or they may be on something like metformin most of these patients are going to need insulin okay so for the most part patients with type 2 diabetes pre gestational type 2 diabetes you're going to manage them very similarly to how you manage just a tional diabetes but most of these women will need to go on in fo now that being said it's becoming more and more common practice to put these women on oral hypoglycemics just like with gestational diabetes so things like metformin glyburide they're Class B pregnancy Class B meaning they're pretty safe so in practice we often use those but for the test insulin is the gold standard you should choose that and the reason is that the oral hypoglycemics will they're safe during pregnancy and we don't see any teratogenic effects we don't know how safe they are in the long term so as these kids are born and they grow up we don't know what the effects are very long term so for that reason insulin is still the gold standard and that's what you should choose to manage your type 2 pre gestational diabetic so as far as managing these patients during the pregnancy aside from their insulin and 15 to 20 weeks to do the triple or quadrants 18 to 20 weeks you do the fetal anatomy so know as we do in all patients now where we start to diverge is that 22 to 24 weeks they need to get a specialized ultrasound really looking at that heart because remember they have such a higher risk of of congenital heart defects so we want to take a look at that at 20 to 24 weeks so we can anticipate that if it's some kind of severe cyanotic heart defect then we want to have peds on hand neonatology on hand surgery on hand when the baby is delivered at 32 weeks we begin we clean on stress test or biophysical profiles very similar to how we manage sensational diabetes and we get this every week if there's any sign of non reassuring fetal status we're going to deliver the baby 32 to 36 weeks we'll get a sonography to assess fetal growth what we're looking for is either intrauterine growth retardation which we would expect more in the type 1 diabetics where we have for presentation for placental circulation or in type 2 diabetics and gestational diabetic sui are looking particularly for macrosomia at 37 weeks you can offer her the option of doing an amniocentesis and we look at the lesson sphingomyelin ratio which assesses fetal lung maturity and it's the fetal lungs are mature you can induce delivery some women don't want this and the reason is that you need to color this that there is a small risk with amniocentesis that the baby could die from it and so some women don't want to take that risk some will because there are benefits to delivering at 37 weeks with with a diabetic mother but some don't want to take that risk with the amniocentesis women just want to hold out for an expert' week or two and so for them you can wait to 38 39 weeks and in that case you don't need to test for feet along the church because we're 99.9% sure that the baby's lungs are fine and we don't need to do an amniocentesis so it just depends on the woman either approaches fine you need to do an immediate delivery if you've ever seen on reassuring fetal tests with those done stress tests or biophysical profiles by the way some obese will alternate non-stress test and biophysical profiles because they kind of give you different insights so that's kind of something to put in your back pocket if there's very poor glycemic control which confers a poorer outcome if there's worsening uncontrolled hypertension and that's more from mom's sake if there's worsening renal disease again for Mom's sake or if there's poor fetal growth so if you see in for uterine growth retardation that baby is going to be coming out because it's better for baby could be on its own having its own feeds then to rely on a really bad Vasanta okay now these things are pretty important so intrapartum the physical effort of labor will usually reduce insulin requirements because she's using more glucose pulling more glucose in because of the increased effort and so her insulin requirements are going to go down so you want to be careful make sure that during delivery you're getting fingerstick glucose levels to make sure that you're not giving her too much insulin at this point you could start a dextrose dextrose an insulin drip and so you're giving her sugar and insulin and just kind of titrate those to make sure that she's between 100 and 120 so if she's too high you can increase her insulin which is too low you can increase your dextrose like why is it too high you can you can reduce her dextrose such as low you can reduce our insulin and either approach you don't need to know the details of this management for the test just understand that the physical effort of labor is going to reduce the insulin requirements kind of along the same lines of we talked about the things that reduce or alter your your insulin requirements things like infection and activity and and stuff like that postpartum this is this is critical okay so once that placenta is out then the human placental a kijun that's in her circulation is going to drop like a rock and so because that drops she's going to suddenly become more insulin sensitive and so if you have her on the same insulin if you ever on the same insulin dosage after that placenta is out what do you think is going to happen she can become hypoglycemic very easily and so especially for type 2 diabetics who have some baseline insulin that they're already making I'm like type 1 diabetics you have to be very very very very careful and so that's very important all right hopefully you understand the physiology behind that so for follow-up you'll you can resume the pre pregnancy regimens but just have in the back of your mind that the oral hypoglycemics are not extremely well studied so you will want to use caution with those or chief breastfeeding at 6 weeks postpartum you'll want to get a 24 hour urine creatinine and protein in women who have significant renal disease you can probably pass on that occur renal levels we're good during the pregnancy and then at 12 to 14 weeks postpartum you'll repeat the optoma logic exam compared to baseline make sure that nothing went wrong with her eyes so just a recap pre gestational diabetes complicates one percent of pregnancies in the US and it is worsened with for pre pregnancy glycemic control and lack of preconception all full weight women to be screened for Reno and ophthalmologic disease as well as hypertension at the first prenatal visit I will also just add here that at her first prenatal visit you want to pay very close attention to her medications a lot of women who are on who have type 2 diabetes in particular may be an ace inhibitors or angiotensin receptor blockers you want to make sure you discontinue those immediately insulin requirements for type 1 diabetes will go up as pregnancy progresses and then most type 2 diabetics that they're not on insulin already will need to switch over to insulin either from diet and exercise or from oral hypoglycemic it is becoming though increasing more common practice to manage type 2 diabetics on oral hypoglycemics pregnancy before the test 2 is insulin the target is 70 to 90 fasting one hour post prandial you want below 140 if it's too high you've been adjust the insulin expect that to happen towards the second half of pregnancy major fetal complications include congenital heart defects neural tube defects respiratory distress syndrome safe Genisys intrauterine growth retardation especially the type 1 diabetics and macrosomia especially the type 2 diabetics mom is at increased risk of preeclampsia associated to the type 1 diabetics and also the usual diabetic complications because it becomes harder to manage and hurt likely my control may become more disordered definitely monitor both mom and baby closely especially later in the pregnancy you'll be getting those non stress tests every week after 32 weeks I want to make sure that baby is growing properly not too big not too small just right Goldilocks and insulin requirements will go down during immediately after pregnancy so during pregnancy because she's exerting more effort and then immediately after in pregnancy because the placenta is hoped and that is all I've got for you you have any questions write me a note below otherwise I will see you you

6 Replies to “Pre-Gestational Diabetes – CRASH! Medical Review Series”

  1. hello Dr Bolin, God bless you for the great job you are doing for students. I study in a foreign language and so I hardly understand my profs. Ever since I discovered your channel,I'm not bothered anymore if I understand or not. your lectures are brief,organized and straight to the point. I don't have a credit card yet. I will sign up for contributions immediately I get one. God bless and increase your knowledge. most of us are very grateful to you

  2. sir please make also a video on syncope. I think that one would be veryy appreciated by a lot of students. Thank you very much!!!

  3. At about 16:00, I misspoke and said that the cutoff for pre-eclampsia is 400mg/d. It is, in fact, 300mg/d.

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