Diabetes Mellitus in Pregnancy glucose levels in mother Gestational Diabetes ] High blood Brings extra glucose to bab x yr Causes baby to put ‘on extra weight ®ADAN. Presentation by Prativa Dhakal M.sc. Nursing Batch 2011Contents Define diabetes in pregnancy State the incidence of diabetes in pregnancy Define overt diabetes mellitus Enlist the risk factors diabetes in pregnancy List out the screening criteria of diabetes in pregnancy Explain the effects of pregnancy on diabetes List the maternal and fetal effects of diabetes during pregnancy. Explain the management diabetes in pregnancy List the nursing diagnoses of diabetes in pregnancy Research evidence ReferencesDiabetes Mellitus = Diabetes is a chronic and progressive disorder. = The term ‘diabetes mellitus’ (DM) describes a metabolic disorder that affects the normal metabolism of carbohydrates, fats and protein. m It is characterized by hyperglycemia and glycosuria resulting from defects in insulin secretion, or insulin action or both. m Diabetes is the most common medical complication of pregnancy.Etiological Classification of Diabetes Mellitus 1. [Type i: A. Immune-mediated B. Idiopathic Cell destruction, usually absolute insulin deficiency II. Type 2: Ranges from predominantly — insulin resistance to predominantly an insulin secretory defect with insulin resistance IH. Other types A. Genetic mutations of B-cell function B. Genetic defects in insulin action C. Genetic syndromes- e.g., Down, Klinefelter, Turner D. Diseases of the exocrine pancreas-e.g., pancreatitis, cystic fibrosis E. Endocrinopathies- e.g., Cushing syndrome, pheochromocytoma, others F. Drug or chemical induced- .g., glucocorticosteroids, thiazides, adrenergic agonists, others G. Infections- congenital rubella, cytomegalovirus, coxsackievirus IV. Gestational diabetes (GDM)Diagnosis of Diabetes during Pregnancy Overt Diabetes = Women with a random plasma glucose level greater than 200 mg/dL plus classic signs and symptoms such as polydipsia, polyuria, and unexplained weight loss or a fasting glucose exceeding 125 mg/dL are considered by the American Diabetes Association (2004) to have overt diabetes. = The diagnostic cutoff value for overt diabetes is a fasting plasma glucose of 126 mg/dL or higher.Diagnosis of Diabetes during Pregnancy Gestational Diabetes = This is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. = The entity usually presents late in the second or during the third trimester.= GDM affects ~ 7% of all pregnancies, resulting in > 200,000 cases per year. = Depending on the population sample and diagnostic criteria, the prevalence may range from1 to 14%. [Source: Setji TL, BrownAJ, Feinglos MN. Gestational Diabetes Mellitus. CLINICAL DIABETES 2005;23(1)]The potential candidates for GDM Strong familial history of diabetes Have given birth to large infants (4 kg or more) Demonstrate persistent glucosuria, Have unexplained fetal losses Presence of polyhydramnios or recurrent vaginal candidiasis in present pregnancy. Over the age of 30 Obesity Ethnic group (East Asian, pacific island ancestry)Screening = Plasma glucose level after a 50-g glucose test threshold is best to identify women at risk for gestational diabetes. = Performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. = Evaluation is usually done in two steps. 50-g oral GCT is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma _ glucose concentration.GDM Risk Assessment = Should be ascertained at the first prenatal visit 1. Low Risk: Blood glucose testing not routinely required if all the following are present: © Member of an ethnic group with a low prevalence of GDM ¢ No known diabetes in first-degree relatives @ Age < 25 years ¢ Weight normal before pregnancy ¢ Weight normal at birth @ No history of abnormal glucose metabolism ¢@ No history of poor obstetrical outcomeGDM sessment cont... 2. Average Risk: Perform blood glucose testing at 24 to 28 weeks using either: Two-step procedure: 50-g GCT, followed by a diagnostic 100-g OGTT One-step procedure: Diagnostic 100-g OGTTGDM Risk Assessment cont... 3. High Risk: Perform blood glucose testing as soon as feasible, if one or more of these are present: ~ Severe obesity © Strong family history of type 2 diabetes Previous history of GDM, impaired glucose metabolism, or glucosuria. If GDM is not diagnosed, blood glucose testing should be repeated at 24 to 28 weeks or at any time there are symptoms or signs suggestive of hyperglycemia.GDM Risk Assessment cont... = The test should be performed in the morning after an overnight fast of at least 8 h but not more than 14 h and after at least 3 days of unrestricted diet (2150 g carbohydrate/d) and physical activity. = The subject should remain seated and should not smoke during the test. Oral Glucose Load Time 100g Glucose Fasting 95 mg/dL 1 hour 180 mg/dL 2 hour 155 mg/dL 3 hour 140 mg/dLEffects of pregnancy on diabetes Very difficult to stabilize blood glucose level during pregnancy. The insulin antagonism is probably due to the combined effect of HPL, oestrogen, progesterone, free cortisol and degeneration of insulin by the placenta. Insulin requirement during pregnancy increases as pregnancy advances. As more glucose leaks out in urine due to renal glycosuria , control of insulin dose cannot be made by urine test and repeated blood glucose estimation becomes mandatory.Effects of pregnancy on diabetes cont... = Ketoacidosis can be precipitated during hyperemesis in early pregnancy, infection and fasting of labour. = It can be iatrogenically increased by 8 sympathomimmetic and corticosteroids used in the management of preterm labour. = Insulin requirements falls significantly in puerperium. m= Vascular changes, specially retinopathy, nephropathy, coronary artery disease and neuropathy may be worsened during pregnancy.Maternal a. During Pregnancy: Abortion Preterm labour (20%) UTI Increased incidence of preeclampsia (25%) Polyhydramnios Maternal distress Diabetic retinopathy, microaneurysms, hemorrhages and proliferative retinopathy Diabetic nephropathy KetoacidosisMaternal and Fetal Effects cont... b. During labour: Prolongation of labour due to big baby Shoulder dystocia Perineal injuries Postpartum hemorrhages Operative interferences c. Puerperium: Puerperal sepsis Lactation failureMaternal and Fetal Effects cont... Fetal hazards ) ~ = Fetal macrosomia (30-40%): Results from: ~ Maternal hyperglycemia—hypertrophy and hyperplasia of fetal islets of Langerhans—increased secretion of fetal insulin—stimulates carbohydrate utilization and accumulation of fat. Elevation of maternal free fatty acids (FFA) in diabetes leads to increase transfer to the fetus—acceleration of triglyceride synthesis—adiposity. = Congenital malformation (6-10%) due to severity of diabetes affecting organogenesis.Fetal Effects cont... Major birth defects in infants of diabetes mellitus CNS & Cardiac Renal Gastroint | Others Skeletal estinal Neural tube VSD, ASD Renal Duodenal | Single defects Coarctation of | agenesis atresia umbilical Anencephaly | aorta Hydronephro | Anorectal |artery Microcephaly | Transposition |sis atresia Sacral agenesis |of great Ureteral vessels duplication Cardiomegaly= Birth injuries (brachial plexus) = Growth restriction (less common) = Unexplained fetal death = Neonatal complications: Hypoglycemia, Respiratory distress syndrome, Hyperbilirubinemia, Polycythemia, Hypocalcemia, Hypomagnesemia, Cardiomyopathy = Perinatal mortality: Increased 2-3 times due to hypoglycemia, RDS, polycythemia and jaundice.Management = Diet ~ 30 keal/kg/d based on prepregnant body weight for non-obese women. ® Obese women with a BMI > 30 kg/m? may benefit from a 30 % caloric restriction. ® Weekly tests for ketonuria, because maternal ketonemia has been linked with impaired psychomotor development in offspring.Management cont... = Caloric allotment is based on ideal body weight. = Recommendations are 30 kcal/kg for women with a BMI of 22 to 25, 24 kcal/kg for women with a BMI of 26 to 29, and 12 to 15 kcal/kg for women with a BMI above 30. m The recommended overall dietary ratio is 33% to 40% complex carbohydrates, 35% to 40% fat, and 20% protein. = This calorie distribution will help 75% to 80% of GDM women become normoglycemic. [Source: Gilmartin AH, Ural SH, Repke JT. Gestational Diabetes Mellitus. REVIEWS IN OBSTETRICS & GYNECOLOGY 2008; 1(3)]m Exercise = Glucose Monitoring Daily self blood-glucose monitoring had fewer macrosomic infants and gained less weight after diagnosis. Glycosylated hemoglobin should be determined at the end of first trimester and three months thereafter. HBAIC level of 5-6% is desirable.Management cont... a Insulin Therapy ~ Recommended when standard dietary management does not consistently maintain fasting plasma glucose at <95 mg/dL or the 2hour postprandial plasma glucose < 120 mg/dL (ACOG, 2001). © Total dose of 20 to 30 units OD, before breakfast, is commonly used to initiate therapy which is divided into two-thirds intermediate-acting insulin and a third short-acting insulin. Alternatively, weight-based split-dose insulin is administered twice daily. During the stabilization process of insulin dose, frequent blood sugar estimation especially at night may be necessary = Oral Hypoglycemic Agents: Avoided during pregnancy.= In uncomplicated cases, the patient is admitted at 34- 36weeks. = Early hospitalization facilities: Stabilization of diabetes Minimizes incidence of preeclampsia, polyhydramnios and preterm labour. To select out the appropriate time and method of delivery.Termination of pregnancy = Should be done at 37 weeks as majority of intrauterine death occurs in last two weeks of pregnancy. = Early delivery may be considered when there is vascular complication (hypertension) or evidences of fetal compromise on antenatal monitoring.Induction of labour The indications are: = Multipara with good obstetric history = Young primigravida without any obstetric complications = Presence of congenital malformation of fetus.Management cont... Prior to the day of induction of labour, the usual bedtime dose of insulin is administered. No breakfast and no morning dose of insulin is given on the day of induction. Normal saline infusion is begun. Induction is done by low rupture of membrane. Simultaneously oxytocin drip is started, if not contracted. An intravenous drip of one liter of 5% dextrose is set up with 10 units of soluble insulin.Management cont... = An infusion rate of 100-125ml/hr, will be maintain a good glucose control to approximately 100 mg/dl. = Insulin may also be infused from syringe pump. = Blood glucose level are estimated hourly with a glucose meter and the soluble insulin dose is adjusted accordingly. = Epidural analgesia is ideal for pain relief. If the labour fails to start within 6-8 hours of if labour progresses unsatisfactorily, caesarean section should be performed.Caesarean section: indications are a Early primigravida = Multigravida with bad obstetric history = Diabetes with complications or difficult to control = Obstetric complications like preeclampsia, polyhydramnios, malpresentation = Fetal macrosomia (>4 kg)Place of awaiting spontaneous onset of labour at term: m Young primigravida or multipara with good obstetric history = Diabetes well controlled either by diet or insulin and without any obstetric complicationsFetal monitoring Constant watch to note fetal condition is mandatory, preferably continuous electronic fetal monitoring. CTG using a scalp electrode is maintained. Fetal scalp pH sampling Labour should not exceed more than 12 hours and should be augmented by low rupture of membrane and oxytocin or delivered by Caesarean section.Management cont... Examination of cord and placenta and cord Placenta is large, the cord is thick and there is increased incidence of a single umbilical artery. Features of placentosis is present.Management of Acidosis IV insulin: 0.2-0.4 units/kg (loading dose)—2.0-10.0units/h (maintenance with frequent capillary glucose measurement) Fluids: Isotonic NaCl 4-6 L in first 12 hours. 5% dextrose in normal saline when blood glucose is 200 mg/dl. Potassium: If reduced or normal—infusion 15-20 mEq/h Bicarbonate= Puerperium Antibiotics should be given prophylactically. Insulin requirement falls dramatically following delivery. Fresh blood glucose after 24 hours of delivery. Women who breastfed should have additional 500 Kcal daily in diet In lactating women insulin dose is lower. Contraceptive devices should be used.Neonatologist should attend at the time of delivery. Baby should be kept in NICU and to remain vigilant for at least 48 hours. Asphyxia is anticipated and be treated effectively. To look for any congenital malformation All babies should have blood glucose checked within 2 hours of birth. All babies should receive 1 mg vitamin K IM. Early breastfeeding and to be repeated at three to four hourly intervals.Nursing assessment Determine immediate and previous 8 week diabetic control. Evaluate ongoing client and fetal well being. Achieve and maintain normoglycemia. Provide client/couple with appropriate information.Nursing Diagnosis Risk for imbalanced nutrition related to inability to ingest sufficient quantity of nutrients/inability to utilize nutrients appropriately/lack of information about eating appropriately. Risk for fetal injury related to elevated maternal serum glucose levels. Risk for maternal injury related to tissue hypoxia/increased maternal serum glucose level/altered immune response. Deficient knowledge regarding diabetic condition, treatment, prognosis and self care related to lack of information/unfamiliarity with information resources.References Fraser DM, Cooper MA. Myles Textbook for Midwives.15th edition. Philadelphia:Churchill livingstone elsevier;2009 Dutta DC. Textbook of obstetrics. 6th edition. Calcutta:New central book agency;2004 Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family. Sixth edition. Philadelphia; Lippincott Williams & Wilkins: 2010. Integrated management of pregnancy and childbirth. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. World Health Organization, Unicef, UNFPA, The World Bank Group. 2005. Cunningham, Leveno, Bloom. William’s obstetrics. 23" edition. United states of America; Mcgraw Hill companies: 2010.