Tutorial 11 July 2013

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Diabetes in pregnancy.

Lead-in.

The following scenarios relate to diabetes in pregnancy.

For each, select the action from the option that best fits the scenario.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

ACE:       angiotensin converting enzyme.

ARA:      angiotensin II receptor antagonist.

GDM:    gestational diabetes mellitus.

OGTT:   oral glucose tolerance test.

Option list.

A.        advise postponement of pregnancy.

B.        normal antenatal care.

C.        refer to a joint diabetic / antenatal clinic.

D.        refer to the next joint diabetic / antenatal clinic.

E.         refer for a diabetic opinion.

F.         refer to a nephrologist.

G.       refer to a clinical psychologist.

H.        arrange referral for screening for diabetic retinopathy.

I.          screen for microalbuminuria.

J.          stop ACE inhibitor / ARA drugs and arrange for safer substitutes.

K.        advise to continue statin.

L.         asvise to stop statin.

M.      prescribe folic acid 5mg. daily and advise HbA1c , 6.1%, if not associated with untoward symptoms.

N.       stop oral hypoglycaemic drug and start insulin.

O.       discuss pros and cons of oral hypoglycaemic drug, but allow her to continue to take it.

P.        arrange fasting plasma glucose level and repeat monthly.

Q.       arrange HbA1c assay and repeat monthly.

R.        arrange a 75 gram OGTT now.

S.         arrange a 75 gram OGTT at 16 weeks

T.         arrange a 75 gram OGTT at 28 weeks.

U.       arrange a 100 gram OGTT now.

V.        arrange a 100 gram OGTT at 16 weeks

W.      arrange a 100 gram OGTT at 28 weeks.

X.        Resign, buy a yacht and sail to Bali.

Y.         none of the above

Z.          

Scenario 1.

A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 10.6 %. Her health is good. She last had screening for retinopathy 8 months ago. What is the most important advice you will give?

Scenario 2.

A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 5.4 %. She last had screening for retinopathy 8 months ago. What advice will you give about retinopathy screening?

Scenario 3.

A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her serum creatinine is 125 micromol/ litre.

Scenario 4.

A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her GFR is 60 ml./minute. What advice will you give about referral to a nephrologist?

Scenario 5.

A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her blood sugar levels are well controlled with diet and metformin. What advice will you give about metformin?

Scenario 6.

A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1^st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2^nd. stage. She is keen to have the earliest possible diagnosis of recurrence.

Scenario 7

A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1^st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2^nd. stage. She is keen to have the earliest possible diagnosis of recurrence but has needle phobia and an aversion to self-monitoring.

Scenario 8

A 25-year-old primigravida books at 10 weeks. Her health is good but her BMI is 28. What screening for hyperglycaemia will you arrange.

Scenario 9

A healthy para 1 books at 10 weeks. She takes a statin because of elevated cholesterol and triglyceride levels. Her blood pressure is 130/85. Otherwise she is well.

9	EMQ. Diabetes in pregnancy.
30	A 30-year-old woman has a booking scan at 10 weeks which shows monoamniotic twins. 1. Critically evaluate the risks associated with monoamniotic twins.  4 marks 2. Justify the history you will obtain.                                                2 marks 3. Evaluate the management options during the antenatal period.      10 marks 4. Outline the key features of the management of labour.                   4 marks
31	A 41-year-old woman attends for review after a normal hysteroscopy. She now wishes treatment for her incapacitating heavy periods which have not responded to medical management. 1. Outline the history you will take.                      4 marks.    2. Outline the investigations you will consider.      4 marks. 3. Critically evaluate your advice on the available management options.    12 marks
32	A 25-year-old primigravida attends for a routine scan and echogenic bowel is noted. 1. What is the advice of the National Screening Committee in relation      to “soft markers”?                                                6 marks. 2. What conditions are linked to echogenic bowel?     6 marks. 3. Justify your management.                                      12 marks.
33	With regard to nuchal translucency. a. What is nuchal translucency, how is it measured and what are the important values?                                                                                                              6 marks b. When is it measured and why are other times not used?                     4 marks c. Critically evaluate the uses and implications of NT measurement.      10 marks.