All women with diabetes should be advised that preconception care (PCC) will reduce their risk of the following pregnancy complications.

• a)
  

  Progression of retinopathy

  
  
• b)
  

  Preeclampsia.

  
  
• c)
  

  Congenital malformation.

  
  
• d)
  

  Macrosomia.

  
  
• e)
  

  Spontaneous abortion.

Women with type 1 diabetes who do not have PCC are more likely to:

• a)
  

  Be obese

  
  
• b)
  

  Have a history of retinopathy

  
  
• c)
  

  Be younger

  
  
• d)
  

  Have been discouraged from becoming pregnant by their doctor

  
  
• e)
  

  Be an ex-smoker

It is currently recommended that women with Type I diabetes having PCC should receive the following advice

• a)
  

  Sulphonylureas should be discontinued

  
  
• b)
  

  Women should continue contraception until the woman and her partner feel her blood glucose levels are under control

  
  
• c)
  

  All women should be referred to an ophthalmologist for retinal examination

  
  
• d)
  

  Metformin should only be continued if the potential benefits outweigh any possible risks

  
  
• e)
  

  Women should be advised that folic acid daily will reduce the risk of congenital defects

Diabetic women who are considering pregnancy should be advised that pregnancy is contraindicated if:

• a)
  

  They are obese, smokers and have a family history of ischaemic heart disease.

  
  
• b)
  

  They have been diagnosed with gastroparesis

  
  
• c)
  

  They are known to have diabetic eye disease and have previously had laser treatment for retinopathy

  
  
• d)
  

  They are known to have hypoglycaemic unawareness and have had severe hypoglycaemia causing seizures.

  
  
• e)
  

  They have diabetic nephropathy with microalbuminuria and serum creatinine of 100 μmol/l.

The following statement(s) is/are true for diabetic women during pregnancy:

• a)
  

  Diabetic women with symptoms of anxiety, nausea and palpitations can be reassured that these symptoms are usually caused by pregnancy

  
  
• b)
  

  Hypoglycaemia is not increased in women with tight diabetic control

  
  
• c)
  

  Diabetic Keto-Acidosis (DKA) during pregnancy is not harmful for the fetus

  
  
• d)
  

  Women with DKA who have evidence of fetal distress should be delivered as soon as possible

  
  
• e)
  

  Severe hypoglycaemia is a cause of maternal mortality

The following is/are true regarding diabetic women during pregnancy:

• a)
  

  Women with diabetes should have their eyes dilated and retinae examined at first contact. If there is no evidence of diabetic retinopathy, a second check is required at 28 weeks gestation

  
  
• b)
  

  Women with diabetic nephropathy should have their blood pressure treated using ACE inhibitors

  
  
• a)
  

  Tight blood pressure control reduces preeclampsia and preterm delivery in women with nephropathy

  
  
• b)
  

  Renal function can be assessed during pregnancy using eGFR

  
  
• c)
  

  Intrauterine growth restriction is related to the severity of diabetic nephropathy

A 35 year old lady with type 1 diabetes comes to see you for the first time because she has found out that she is 12 weeks pregnant. She uses insulin aspart and insulin glargine. The following is/are true regarding her insulin treatment:

• a)
  

  Stop the aspart as well as the glargine because both are not allowed during pregnancy

  
  
• b)
  

  Stop the glargine only since use of glargine is not proven safe during pregnancy

  
  
• c)
  

  Stop the aspart and the glargine because the pharmacodynamic profile becomes unreliable during pregnancy

  
  
• d)
  

  Insulin pump therapy with short-acting human insulin is the best alternative

  
  
• e)
  

  She should be changed to the safer insulin detemir

A 25 year old lady has gestational diabetes and is 34 weeks pregnant. She measures the blood glucose values 4 times daily and the value after breakfast is notably high, even after a normal fasting level. This can be explained by:

• a)
  

  Hypoglycaemia late during the night

  
  
• b)
  

  The dawn phenomenon

  
  
• c)
  

  High insulin resistance (and requirement) in the morning combined with carbohydrate intake

  
  
• d)
  

  Late night snacks

  
  
• e)
  

  Insulin requirements increase as the day progresses

Insulin pump therapy is a good option in order to achieve good glycaemic control. Concerning the use of insulin pump therapy in pregnancy the following statement(s) is/are true:

• a)
  

  Trials have shown that insulin pump therapy improves glycaemic control (HbA1c) compared to conventional injection therapy (MDI) without an effect on feto-neonatal outcome

  
  
• b)
  

  Trials have shown that insulin pump therapy is associated with less macrosomia compared to MDI

  
  
• c)
  

  Trials of insulin pump therapy versus MDI have been inadequately powered to demonstrate clinical benefit

  
  
• d)
  

  Insulin pump therapy is associated with a better glycaemic control compared to MDI but with also more hypoglycaemia

  
  
• e)
  

  Insulin pump therapy is associated with a reduced incidence of pre-eclampsia compared to MDI

Regarding The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS), the following is/are true:

• a)
  

  It was a clinical trial to determine if treatment of women with gestational diabetes mellitus reduces the risk of perinatal complications

  
  
• b)
  

  The results showed that GDM treatment reduced the primary outcome (composite of perinatal death, shoulder dystocia, bone fracture and nerve palsy)

  
  
• c)
  

  The rate of macrosomic babies was not significantly reduced by the intervention

  
  
• d)
  

  Pre-eclampsia rates were similar in the treatment and control groups

  
  
• e)
  

  The treated women had lower rates of post-natal depression based on the Edinburgh Postnatal Depression Scale (EPDS) at 3 months post partum

Regarding the Maternal-Fetal Medicine Units Network trial (MFMUN) of treatment of mild gestational diabetes the following is/are true:

• a)
  

  It was a trial of GDM subjects randomised to usual prenatal care or intervention with dietary advice, self-monitoring of blood glucose, and insulin therapy if necessary

  
  
• b)
  

  The primary outcome (a composite of stillbirth or perinatal death and various neonatal complications) was significantly reduced by the GDM intervention.

  
  
• c)
  

  Birth weight was not influenced by the GDM intervention.

  
  
• d)
  

  Rates of shoulder dystocia were not altered by the GDM intervention.

  
  
• e)
  

  Pre-eclampsia rates were reduced by the GDM intervention.

The Hyperglycaemia and Adverse Pregnancy Pregnancy Outcomes (HAPO) study

• a)
  

  Was a clinical trial of treatment in GDM

  
  
• b)
  

  Had the aim of clarifying the risks of adverse pregnancy outcomes associated with various degrees of maternal glucose tolerance less severe than that of overt diabetes mellitus

  
  
• c)
  

  Showed a sharp increase in rates of LGA age babies and fetal hyperinsulinism (cord C-peptide levels) for fasting plasma glucose levels greater than 5.0 mmol/l

  
  
• d)
  

  Showed no relationship between mild maternal hyperglycaemia and primary caesarean section rates

  
  
• e)
  

  Showed an association between mild maternal hyperglycaemia and risk of pre-eclampsia

Concerning the International Association of Diabetes in Pregnancy Study Groups (IADPSG) recommendations on the diagnosis and classification of hyperglycaemia in pregnancy:

• a)
  

  They include recommendations for the diagnosis of GDM as well as a new category of overt diabetes in pregnancy

  
  
• b)
  

  The IADPSG recommendations for the diagnosis of GDM are based on the WHO criteria for the diagnosis of impaired fasting glucose and impaired glucose tolerance in non-pregnant individuals

  
  
• c)
  

  The recommendations for the diagnosis of GDM are based on analysis of the HAPO OGTT data from which cut-offs were determined for the fasting, 1 h and 2 h glucose levels at which there was an adjusted relative risk of 1.75 for birth-weight >90th percentile, cord C-peptide >90th percentile and percentage body fat >90th percentile

  
  
• d)
  

  According to the recommendations, GDM is diagnosed if any two of the following 75 g OGTT plasma glucose thresholds are equalled or exceeded: Fasting ≥5.1 mmol/l, 1 h ≥ 10.0 mmol/l and 2 h ≥ 8.5 mmol/l

  
  
• e)
  

  Overt diabetes in pregnancy is diagnosed on the basis of the fasting plasma glucose ≥7.0 mmol/l only

The proportion of women giving birth that have pre-gestational diabetes or that will develop gestational diabetes mellitus (GDM) is increasing. Reasons for this include:

• a)
  

  The incidence of type 1 diabetes is increasing

  
  
• b)
  

  Type 2 diabetes is being diagnosed at younger ages, resulting in adolescents and adult women having or developing type 2 diabetes during their reproductive years

  
  
• c)
  

  The risk of unintended pregnancy is increasing among women with pre-gestational diabetes and GDM

  
  
• d)
  

  The guidelines issued by the International Association for Diabetes in Pregnancy Study group have reduced glycaemic levels to make a GDM diagnosis

  
  
• e)
  

  The guidelines issued by the International Association for Diabetes in Pregnancy Study group have reduced the number of abnormalities required to make a GDM diagnosis

Studies reviewed have suggested that women with GDM experience the following during pregnancy:

• a)
  

  Anxiety when they learn that they have GDM

  
  
• b)
  

  Fear of having blood glucose screening in any future pregnancies

  
  
• c)
  

  Sustained anxiety in the antepartum or postpartum period

  
  
• d)
  

  Different beliefs and perceptions based on their cultural background

  
  
• e)
  

  Disbelief about the diagnosis due to the absence of physical symptoms

Studies reviewed provide the following insight into women with pre-gestational (type 1 or type 2) diabetes:

• a)
  

  Some women reported that preconception counselling made their decision to become pregnant more difficult

  
  
• b)
  

  Themes including a loss of control, the perception of having an unwell body and constant worry, pressure, and self-blame about their responsibility for the health of their unborn child emerged from the interviews

  
  
• c)
  

  Some women felt they did not need additional advice from health professionals early in pregnancy since they were experienced in managing their diabetes. This was particularly common among women who had a previous successful pregnancy

  
  
• d)
  

  Women tended not to seek preconception care due to the inconvenience or to the need to disclose health information to obtain time off from work.

  
  
• e)
  

  Adolescents with diabetes are too young to benefit from information about the importance of preconception care and pregnancy planning

Women with a Pre-pregnancy Body Mass Index of 30 kg/m ² or more:

• a)
  

  Should increase their intake to “eat for two”

  
  
• b)
  

  Should increase their weight by 5–9 kg over the whole pregnancy

  
  
• c)
  

  Should increase their weight by 11.5–16 kg over the whole pregnancy

  
  
• d)
  

  Should avoid physical activity as this could increase the risk of fetal loss

  
  
• e)
  

  Should lose weight during pregnancy

Among women with a Body Mass Index of 30 kg/m ² or more:

• a)
  

  Diagnosis and Management of Gestational Diabetes Mellitus reduces adverse pregnancy outcomes substantially

  
  
• b)
  

  High dose folic acid supplementation has been shown by RCTs to reduce congenital neural tube defects

  
  
• c)
  

  High glycaemic index foods are associated with reduced risk of macrosomia

  
  
• d)
  

  Vitamin C supplementation is associated with an increased risk of Caesarean section in an RCT

  
  
• e)
  

  10 micrograms Vitamin D daily supplementation is recommended as serum Vitamin D levels are usually low in obese pregnant women

Perinatal mortality (PNM) rates in pregnancy complicated by diabetes:

• a)
  

  Are higher when diabetes is type 1 than when diabetes is type 2

  
  
• b)
  

  With improved management of diabetes in the UK, PNM of diabetics have fallen to the normal population rate

  
  
• c)
  

  Are consistent across the developed world

  
  
• d)
  

  Have intrapartum complication as an underlying cause

  
  
• e)
  

  Have congenital anomaly as a major underlying cause

For the baby born at full term after diabetes in pregnancy:

• a)
  

  There must be a neonatologist present at delivery

  
  
• b)
  

  The baby should be admitted to a neonatal unit

  
  
• c)
  

  Blood glucose monitoring should be commenced 2 hours after birth

  
  
• d)
  

  Exclusive breast feeding is contraindicated

  
  
• e)
  

  Postnatal echocardiography should be performed

Probable significant aetiologies of congenital anomalies in diabetic pregnancies include:

• a)
  

  Transplacental passage of insulin

  
  
• b)
  

  Genetic factors

  
  
• c)
  

  Hyperglycaemia

  
  
• d)
  

  Hyperketonaemia

  
  
• e)
  

  Fetal insulin

Complications of fetal hypoxia-ischaemia include:

• a)
  

  Polycythaemia

  
  
• b)
  

  Macrosomia

  
  
• c)
  

  Hypocalcaemia

  
  
• d)
  

  Encephalopathy

  
  
• e)
  

  Stillbirth

To prevent stillbirth in pre-gestational diabetic women the following factors should be considered:

• a)
  

  Avoiding antihypertensive therapy during pregnancy

  
  
• b)
  

  Obtaining and maintaining improved glycaemic control during pregnancy

  
  
• c)
  

  Frequent ultrasound examinations should be performed

  
  
• d)
  

  Reducing fetal hyperinsulinaemia as this is associated with fetal hypoxia

  
  
• e)
  

  Pre-pregnancy counselling

Which of the following drugs is / are the most common oral diabetes medications currently used in the treatment of gestational diabetes

• a)
  

  Roglitizone

  
  
• b)
  

  Tolbutamide

  
  
• c)
  

  Metformin

  
  
• d)
  

  Repaglinide

  
  
• e)
  

  Glyburide (glibenclamide)

Regarding the mechanism of action of metformin, the following is/are true:

• a)
  

  It is an insulin analogue, so it works similar to insulin

  
  
• b)
  

  It enhances insulin sensitivity in peripheral tissue

  
  
• c)
  

  It activates the beta cells of the pancreas to increase insulin production

  
  
• d)
  

  It activates insulin receptors via a metabolic product after hepatic metabolism

  
  
• e)
  

  It antagonizes glucagon action

The following is/are correct regarding glyburide (glibenclamide):

• a)
  

  The starting oral dose of glyburide is 2.5 mg twice daily

  
  
• b)
  

  The oral dose of glyburide can be increased to a maximum of 5 mg twice daily

  
  
• c)
  

  Glyburide binds to pancreatic beta cell ATP-calcium channel receptors, to increase insulin secretion and the insulin sensitivity of peripheral tissues

  
  
• d)
  

  Glyburide has been shown not to cross the placenta

  
  
• e)
  

  Glyburide is a second-generation biguanide

Regarding trial data differences in blood glucose levels in women receiving glyburide or insulin:

• a)
  

  No differences were found in fasting blood glucose (FBG) levels in women receiving glyburide or insulin

  
  
• b)
  

  No differences were found in 2-hour postprandial glucose levels in women receiving glyburide or insulin

  
  
• c)
  

  No differences were found in both FBG and 2-hour postprandial glucose between glyburide and insulin

  
  
• d)
  

  2-hour postprandial levels are higher among women receiving metformin compared to glyburide

  
  
• e)
  

  The data is based on 3 large RCTs

In reviewing current clinical trials, the following is/are true regarding infant birth weight variation with the use of glyburide, metformin and insulin:

• a)
  

  Average birth weight is slightly higher among infants born to women treated with glyburide compared to women treated with insulin

  
  
• b)
  

  Differences in birthweight among infants born to women treated with glyburide compared to women treated with insulin are considered clinically significant

  
  
• c)
  

  The data on glyburide versus insulin is based on a meta-analysis

  
  
• d)
  

  There were no differences in infant birth weight in a large scale study comparing metformin to insulin

  
  
• e)
  

  Average birth weight is higher among infants born to women treated with metformin compared to women treated with glyburide

  
  
• 29.
  

  Regarding how the proportion of congenital malformations vary with glyburide, metformin and insulin, the following is/are true:

  
  
• a)
  

  Few studies include congenital malformations as an outcome

  
  
• b)
  

  There is little or no evidence of differences in congenital malformations in pregnancies treated with metformin or glyburide compared to insulin

  
  
• c)
  

  Few studies are adequately powered to detect statistically significant differences in congenital malformations

  
  
• d)
  

  The data on glyburide versus insulin is based on one large trial

  
  
• e)
  

  The data on metformin versus insulin is based on two large trials

Regarding the current gaps in research on oral diabetes medication, the following are true:

• a)
  

  Studies are not adequately powered to detect small differences in several clinical outcomes

  
  
• b)
  

  There are inconsistencies in the definition of key outcomes across clinical trials

  
  
• c)
  

  Lack of long-term follow-up of infants limits the ability to draw conclusions on cognitive and functional development

  
  
• d)
  

  Only a few large-scale studies exist to offer important data on maternal and neonatal outcomes

  
  
• e)
  

  Heterogeneity exists in current trials making interpretation difficult