Diabetes and Pregnancy Practice Exam: Diabetes Chapter 36

Pregnancy acts as a metabolic stress test, and hyperglycemia during this critical period carries significant risks for both the mother and the developing fetus. The 2018 Clinical Practice Guidelines provide rigorous standards for pre-conception counseling, screening protocols, and tight glycemic targets to ensure the best possible start for the next generation.

This practice exam tests your ability to navigate the specific diagnostic algorithms for Gestational Diabetes Mellitus (GDM), manage complex insulin regimens during changing physiology, and ensure appropriate postpartum follow-up.

Key Concepts Covered in This Exam:

Pre-conception Care: Mastering the checklist for women with pre-existing diabetes, including the recommendation for 1 mg of folic acid daily and achieving an A1C target of $\le$ 7.0% (optimally $\le$ 6.5%) prior to conception.
Screening & Diagnosis: Differentiating between the “Preferred” Two-Step Approach (50g screening followed by 75g diagnostic OGTT) and the “Alternative” One-Step Approach.
Glycemic Targets: Memorizing the strict targets during pregnancy: Fasting/preprandial <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L, and 2-hour postprandial <6.7 mmol/L.
Pharmacotherapy: Identifying insulin as the first-line therapy for GDM and understanding the specific limitations and placental transfer of oral agents like metformin and glyburide.
Postpartum Follow-up: Recognizing that women with GDM are at high risk for developing Type 2 diabetes and require screening with a 75g OGTT between 6 weeks and 6 months postpartum.

1. Case: A woman with type 1 diabetes on CSII (insulin pump) is in active labour. She and her partner are comfortable managing her pump. What is the most appropriate recommendation regarding insulin delivery during labour?

She may continue CSII during labour if she can independently manage it
She should discontinue all insulin during active labour
She should switch to subcutaneous injections every 2 hours
She must convert to intravenous insulin infusion for safety

2. Case: A pregnant woman with type 1 diabetes at 28 weeks gestation has a sudden 20% decrease in insulin requirements over 2 weeks. What is the most appropriate clinical consideration?

Decreased insulin requirements may indicate placental insufficiency
This is normal pregnancy physiology in the third trimester
The patient has likely developed hypoglycemia unawareness
Insulin antibodies are interfering with insulin action

3. Case: A woman with type 1 diabetes at 8 weeks gestation has experienced two severe hypoglycemic episodes. Which factors are predictive of severe hypoglycemia during pregnancy?

Multiparity and advanced maternal age
High A1C and obesity
History of severe hypoglycemia in the year prior to pregnancy
Use of rapid-acting insulin analogues

4. At what gestational age should ASA 81 mg daily be started in women with pre-existing diabetes to reduce the risk of preeclampsia?

28-32 weeks’ gestation
12-16 weeks’ gestation
20-24 weeks’ gestation
As soon as pregnancy is confirmed

5. Case: A woman with pre-existing diabetes at 34 weeks gestation requires betamethasone for fetal lung maturation. According to the recommended protocol, how should insulin doses be adjusted on Days 2 and 3 after the first dose?

Increase all insulin doses by 100%
Increase all insulin doses by 40%
Keep insulin doses unchanged
Decrease all insulin doses by 20%

6. Case: A 28-year-old woman with a BMI of 23 kg/m² is diagnosed with diabetes at 26 weeks gestation. She has no risk factors for GDM, negative autoantibodies, and her mother and maternal grandmother were both diagnosed with diabetes before age 30. What is the most appropriate clinical reasoning?

Diagnose as type 2 diabetes in pregnancy
Consider genetic testing for monogenic diabetes
Repeat autoantibody testing to rule out type 1 diabetes
Treat as typical gestational diabetes with insulin

7. Case: A 38-year-old woman with a BMI of 34 kg/m², prior GDM, and a mother with type 2 diabetes is at 10 weeks gestation. What early screening approach is recommended?

No screening until 24-28 weeks
Random plasma glucose only
Immediate 75g OGTT
A1C test to identify potentially overt diabetes

8. A woman at 25 weeks gestation has a 50g glucose challenge test result of 8.5 mmol/L. What is the next appropriate step?

Proceed with a 75g oral glucose tolerance test
Repeat the 50g GCT in 2 weeks
No further testing needed; this is a normal result
Diagnose gestational diabetes and begin treatment

9. According to the preferred screening approach for gestational diabetes, what glucose challenge test (GCT) value is diagnostic for GDM without requiring further testing?

≥9.0 mmol/L
≥10.6 mmol/L
≥11.1 mmol/L
≥7.8 mmol/L

10. At what gestational age should all pregnant women without known pre-existing diabetes be screened for gestational diabetes?

30-34 weeks
24-28 weeks
18-22 weeks
12-16 weeks

11. What is the most common form of monogenic diabetes identified during pregnancy in Canada?

MODY 2 (GCK mutation) or MODY 3 (HNF1 alpha mutation)
MODY 1 (HNF4 alpha mutation)
MODY 5 (HNF1 beta mutation)
Neonatal diabetes

12. Case: A woman with GDM at 36 weeks gestation asks about timing of delivery. Her blood glucose is well-controlled on diet alone with no comorbidities. What is the recommended timing of delivery?

Immediate delivery at 36 weeks
Cesarean delivery at 37 weeks
Induction between 38-40 weeks
Expectant management until 42 weeks

13. Case: A woman with prior GDM has a postpartum 75g OGTT showing impaired glucose tolerance. She asks about strategies to prevent progression to type 2 diabetes. Based on evidence, what interventions have demonstrated benefit in this population?

No interventions have been proven effective
Insulin therapy only
Acarbose therapy
Healthy behaviour interventions with or without metformin

14. Why is glyburide NOT recommended as first- or second-line treatment for GDM according to current guidelines?

It is associated with increased birthweight, macrosomia, and neonatal hypoglycemia
It causes maternal weight loss
It does not cross the placenta
It is associated with congenital anomalies

15. Case: A woman with type 1 diabetes asks about retinopathy monitoring during pregnancy. What ophthalmological assessment schedule is recommended?

Every trimester only
During pregnancy planning, first trimester, as needed during pregnancy, and within the first year postpartum
Only if visual symptoms develop
Once at the beginning of pregnancy

16. Using the preferred 2-step screening approach, what fasting plasma glucose value on a 75g OGTT would diagnose gestational diabetes?

≥5.1 mmol/L
≥7.0 mmol/L
≥5.3 mmol/L
≥6.1 mmol/L

17. Case: A 32-year-old woman with type 1 diabetes is planning pregnancy. Her current A1C is 8.2%. She is taking lisinopril for mild hypertension and atorvastatin for dyslipidemia. What is the most appropriate preconception recommendation?

Discontinue lisinopril and atorvastatin and optimize glycemic control
Proceed with pregnancy planning as the A1C will improve during pregnancy
Wait until A1C is <5.5% before attempting pregnancy
Continue current medications and begin folic acid 0.4 mg daily

18. Case: A woman with GDM has been on nutritional therapy for 2 weeks. Her fasting blood glucose levels remain at 5.8-6.2 mmol/L and 1-hour postprandial values are 8.5-9.0 mmol/L. What is the most appropriate next step?

Initiate pharmacological therapy
Increase physical activity intensity
Reduce carbohydrate intake to <100g/day
Continue nutritional therapy for another 4 weeks

19. According to the guidelines, what is the recurrence rate of gestational diabetes in subsequent pregnancies?

30-84%
93-100%
50-67%
10-22%

20. A clinical team is debating the preferred vs. alternative GDM screening approaches. Which statement best reflects the key difference between these approaches?

There is no difference between the approaches
The preferred approach has stronger evidence for improved outcomes
The preferred approach uses higher glucose thresholds
The alternative approach is more cost-effective

21. What is the fasting plasma glucose target for pregnant women with gestational diabetes?

<6.1 mmol/L
<7.0 mmol/L
<5.3 mmol/L
4.5 mmol/L

22. What folic acid supplementation dose is recommended for women with pre-existing diabetes planning pregnancy?

0.4 mg daily
1.0 mg daily
5.0 mg daily
4.0 mg daily

23. A healthcare team is reviewing evidence on GDM prevention. Which intervention has demonstrated a significant 60% reduction in GDM development in one randomized controlled trial?

Metformin
Physical activity alone
Vitamin D supplementation
Antenatal probiotics

24. A woman with type 1 diabetes has just delivered. How should her insulin doses be adjusted in the immediate postpartum period?

Maintain pregnancy insulin doses for the first week
Discontinue insulin temporarily
Decrease insulin doses immediately by at least 50%
Increase insulin doses by 25% to prevent rebound hyperglycemia

25. A diabetes educator is developing patient education materials about breastfeeding for women with type 1 diabetes. Which statement about breastfeeding and diabetes medication is most accurate?

All oral antihyperglycemic agents are safe during breastfeeding
Metformin and glyburide may be used during breastfeeding
Women must discontinue all diabetes medications while breastfeeding
All insulin analogues are contraindicated during breastfeeding

26. What percentage of women who conceive on metformin will ultimately require add-on insulin therapy to achieve adequate glycemic control during pregnancy?

60%
25%
10%
40%

27. What is the first-line therapy for gestational diabetes according to Diabetes Canada guidelines?

Metformin
Glyburide
Insulin
Diet and physical activity

28. What is the target A1C recommended by Diabetes Canada for women with pre-existing diabetes during pregnancy, if it can be safely achieved?

≤7.0%
≤6.5%
≤6.1%
≤5.5%

29. Case: A woman with type 1 diabetes is considering pregnancy but has an eGFR of 55 mL/min/1.73 m² and significant proteinuria. Based on current evidence, what counselling about pregnancy and renal function is most accurate?

Pregnancy is contraindicated with any degree of nephropathy
Pregnancy has no effect on long-term renal function regardless of baseline function
Nephropathy only affects fetal outcomes, not maternal outcomes
Women with serum creatinine >124 μmol/L at pregnancy onset have >40% chance of accelerated progression of nephropathy

30. What minimum duration of breastfeeding is recommended for women with gestational diabetes to help prevent childhood obesity and diabetes?

At least 12 months
At least 4 months
At least 6 months
At least 2 months

31. Case: A woman with pre-existing diabetes has severe nonproliferative retinopathy. She is planning pregnancy. What preconception intervention reduces the risk of visual impairment during pregnancy?

Intravitreal anti-VEGF injections
Strict blood pressure control only
Laser photocoagulation
Delaying pregnancy for 2 years

32. What is the incidence of hypertension complicating pregnancy in women with type 1 and type 2 diabetes?

40-45%
10-15%
20-25%
30-35%

33. A diabetes educator is counselling a woman with newly diagnosed GDM about evidence-based dietary approaches. Based on current meta-analyses, which dietary intervention has demonstrated reduced insulin use and lower newborn weight without increasing SGA?

High protein, low fat diet
Very low carbohydrate diet (<50g/day)
Total energy restriction diet
Low glycemic index diet

34. Which rapid-acting insulin analogue has been studied in a randomized trial of 322 pregnant women with type 1 diabetes and shown to reduce episodes of major hypoglycemia?

Lispro
Aspart
Glulisine
Regular insulin

35. What is the target blood glucose range during labour and delivery in women with diabetes to minimize neonatal hypoglycemia?

6.0-10.0 mmol/L
3.0-5.0 mmol/L
5.0-8.0 mmol/L
4.0-7.0 mmol/L

36. After 16 years of follow-up, what percentage of women with prior gestational diabetes will develop type 2 diabetes?

10%
60%
40%
20%

37. What is the recommended postpartum screening test and timeframe for women who had gestational diabetes?

A1C at 2-4 weeks postpartum
Random plasma glucose at 1 year postpartum
Fasting plasma glucose at 12 weeks postpartum
75g OGTT between 6 weeks and 6 months postpartum

38. Case: A woman with type 2 diabetes becomes pregnant while taking glyburide and metformin. What is the most appropriate management of her diabetes medications?

Discontinue both medications immediately and start insulin
Discontinue glyburide but continue metformin throughout pregnancy
Continue both medications throughout pregnancy
Continue metformin and glyburide until insulin is initiated, then discontinue

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