Diabetes Mellitus

Prepared by:
Yvette M. Batar, RN, MAN, DM
 Diabetes Mellitus
DESCRIPTION SIGNS & SYMPTOMS Effects of Pregnancy on
Glucose Control
❑ A hereditary 1. Hyperglycemia • Pregnancy has profound
endocrine disorder effects on carbohydrate
2. Glycosuria metabolism as evidenced
characterized by
inadequate or lack
3. Polyuria by high incidence of
4. Polydipsia gestational diabetes.
of insulin
production that • In fact, pregnancy has
5. Weight loss been known to be a
results in impaired
6. Ketoacidosis diabetogenic state due to
glucose absorption the effects of placental
& metabolism 7. Long-term effects DM:
hormones, especially
resulting in - vascular narrowing that leads to HPL, which increases
hyperglycemia. kidney, heart, and retinal resistance to insulin and
dysfunction causing hyperglycemia.
 COMPLICATIONS OF DIABETES
Mother
A. Increased tendency to
preeclampsia & eclampsia,
urinary tract infection and
candidiasis.
B. Higher incidence of
dystocia because of large
infant.
C. Large infant
D. Maternal mortality
E. Diabetic retinopathy
F. Diabetic nephropathy
Fetus/Infant
A. IUGR J. Birth defects: Major BD
B. 1st trim: spontaneous abortion – Heart and connecting blood
or fetal anomalies vessels
C. 3rd trim: intrauterine fetal – Brain and spine
demise w/ greatest risks being abnormalities
after 36 weeks – Urinary and kidney
D. Hydramnios – Digestive tract
E. Prematurity – Caudal regression
F. Hyperbilirubinemia and syndrome (failure of the
hypocalcemia (at birth) lower extremities to
G. Predisposition to obesity & develop)
DM later in life K. Birth injury
H. Macrosomia L. Hypoglycemia
I. Stillbirth M. Respiratory Distress
 TYPES OF DIABETES MELLITUS (DM)
Type 1 Formerly known as insulin-dependent DM; characterized by
destruction of beta cells in pancreas that leads to insulin deficiency.
a. Immune-mediated - from autoimmune destruction of beta cells.
b. Idiopathic - no known cause.
Type 2 Formerly known as non-insulin dependent DM; arises because of insulin
resistance combined w/ relative deficiency in insulin production.
Gestational Abnormal glucose metabolism that arises during pregnancy.
Diabetes Possible signal of an increased risk for type 2 diabetes later in life.
Impaired A state b/n “normal” & “diabetes” in w/c the body is no longer using
Glucose &/or secreting insulin properly.
Homeostasis a. Impaired Fasting Glucose (IFG) - fasting plasma glucose of at least
110 but under 126mg/dL.
b. Impaired Glucose Tolerance (IGT) - oral glucose tolerance test of at
least 140 but under 200mg/dL in 2-hr sample.
Other Specific Caused by known etiologies or as result of or complication of other
Types diseases or conditions.
 RISK ASSESSMENT OF GESTATIONAL DIABETES

Risk Factors • 4 Fs (Familial hx; Fat; Forty; Female); Glycosuria; age over 25y.o
are: • Unexplained fetal loss; Hx of gestational diabetes in previous
pregnancy & hx of anomalies; polycystic ovary
• Hx large babies (10 lbs or more); Previous impaired fasting
glucose of126 mg/dL & above or a nonfasting plasma glucose
of 200 mg/dl
• Previous impaired glucose tolerance with oral glucose
tolerance test 2-hour glucose value 140 to 199 mg/dL

Women who Need to be screened on the first prenatal clinic visit or ASAP.
are at risk: Women w/no risk factor may be screened at 24-28 weeks.

OGTT Universal screening for gestational diabetes mellitus for all

pregnant women
 DIAGNOSIS OF GESTATIONAL DIABETES
1. Fasting Blood • Done on empty stomach (NPO x 8h except
Sugar (FBS) water)
• > to 126 mg/dL result - meets threshold for dx, no
confirmation needed.
2. Oral Glucose Test Results: Diagnosis of gestational diabetes is
Tolerance Test confirmed if 2 results from 100-g OGTT indicate
(OGTT) elevation. Normal values are:
– Fasting Plasma Glucose 95 mg/dL
– 1-h plasma glucose 180 mg/dL
– 2-h plasma glucose 155 mg/dL
– 3-h plasma glucose 140 mg/dL (ADA, 2003e)
Note: Rate is abnormal if two values are
exceeded.
 DIABETES MELLITUS: MANAGEMENT
1. Pregnancy • Achieve a stable state before conception
Planning: - Normal fasting blood glucose levels
- Normal glycosylated hemoglobin levels
- Glycosylated hemoglobin reflects the average measurement of
the glucose levels over the past 100 to 120 days.
2. Prenatal Visit • Clinic visits every 2 weeks up to 36 weeks then weekly.

3. Goal of DM • To maintain maternal glycemic control to reduce the risks associated

Mgnt w/ the disease & promote optimum fetal development.

4. Diabetic a. Caloric intake should be enough to meet needs of pregnancy, fetus

Diet and mother (1,800 to 2,400 cal/day) but not too much to promote
excessive weight gain. Calories should be supplied as:
✓ 20% - 25% of caloric intake should come from protein foods
✓ 40% - 50% from carbohydrates
✓ 30% - 40% from polyunsaturated fats
 DIABETES MELLITUS: MANAGEMENT
4. Diabetic b. Weight gain should be about 24 lbs. excessive wt gain can
Diet (cont’d) lead to macrosomic infants & CPD
c. Teach and instruct to:
• Reduce saturated fat; Reduce cholesterol
• Increase dietary fibers; Reduce concentrated sugars
• Avoid fasting and feasting
d. Have the woman become familiar with food exchange list &
caloric values of foods she usually eats
e. Jovanovic and Peterson (1993) found the following diet to
result in euglycemia:
– 30 kcal/kg/24h for normal weight women
– 24 kcal/kg/24 h for overweight women
– 12 to 15 kcal/kg/24h for morbidly obese women
– 40 kcal/kg/24h for underweight women
 DIABETES MELLITUS: MANAGEMENT
5. Exercise •A liberal cardiovascular-conditioning exercise and diet
therapy is the usual management for Class A or
Gestational Diabetes Mellitus primarily because
exercise lowers blood glucose levels and decreases
the need for insulin.
•Exercise regimen should be individualized, performed
regularly and under supervision.
•Nonweight-bearing exercise, such as swimming,
promotes greater carbohydrates use and is preferred.
•Exercise increases the rate of glucose utilization by the
body. Advise woman to eat complex carbohydrates
before exercising to prevent hypoglycemia.
 DIABETES MELLITUS: MANAGEMENT
6. Insulin a. Diabetics who are on oral hypoglycemic medication
Therapy before pregnancy must be switched to insulin during
pregnancy
b. Insulin therapy is often required in diabetes that has poor
glycemic control during pregnancy.
– All type 1 patients require insulin in their need for it
increases during pregnancy.
– Insulin requirements increase during pregnancy, as a
result, type 1 diabetic women who do not need insulin
therapy before pregnancy may have to be placed on
insulin during pregnancy to maintain glucose control.
– Gestational diabetes usually responds well with diet
therapy and exercise.
 DIABETES MELLITUS: MANAGEMENT
6. Insulin c. Factors affecting insulin dosage:
Therapy – Insulin requirements may drop slightly during the first trimester
before increasing significantly in the second and third trimesters.
(cont’d) – Insulin requirement is highest during the third trimester.
– Changes in diet and activity levels also contribute to changes in
insulin requirements throughout pregnancy.
d. Humulin is the insulin of choice during pregnancy because it is the
least allergenic as it is human derived.
e. Schedule of insulin administration:
– Split-dose therapy: most common regimen prescribed BID
– Often, short acting (regular) & intermediate acting insulin is
combined.
– 2/3 of the daily dose is administered in the morning before
breakfast; remaining 1/3 is administered at night 30 minutes
before dinner.
 DIABETES MELLITUS: MANAGEMENT
6. Insulin e. Schedule of insulin administration:
Therapy –  Multiple daily injections:
• Insulin may be injected several times a day or
(cont’d)
• W/ the use of an insulin pump that delivers a continuous
subcutaneous insulin infusion
• Pump therapy requires frequent blood glucose measurements
• Minimally, blood glucose levels should be monitored before
each meal and at bedtime.
f. Hypoglycemia could occur in persons undergoing insulin therapy
during the peak action hour of insulin:
– Short acting or regular insulin: Onset occurs within 1 hour, with
peak action in 2-4 hours. Has a clear appearance.
– Intermediate or Lente insulin: Onset occurs in 2-4 hours, with peak
action in 8-12 hours. Has a cloudy appearance.
– Long-acting or ultralente: Onset occurs in 4-8 hours, with peak
action in 16-18 hours. Has a cloudy appearance.
 DIABETES MELLITUS: MANAGEMENT
6. Insulin g. Instruct on signs of hypoglycemia, which is caused by excessive
insulin, excessive exercise, or insufficient dietary intake.
Therapy
– Pallor; Weakness, Numbness; Headache; Confusion or
(cont’d) irritability; Blurred vision; Perspiration; Hunger; Convulsions;
Coma
h. Instruct on what effective carbohydrate foods to eat to
correct hypoglycemia which includes: glass of milk, crackers, etc
7. Self a. The ADA recommends that patients with type 1 diabetes and
Monitoring pregnant women taking insulin check their blood glucose at least 3
times a day. The desired values are:
of Blood
• Before meal: 95 mg/dL
Glucose
(SMBG) • One hour after meal: <140 mg/dL
• Two hours after meal: <120 mg/dL
b. After obtaining a good understanding diet & glucose values in
the desired range, frequency of testing may be decreased to
3 days per week.
 DIABETES MELLITUS: MANAGEMENT
Serial UTZ q 4 wks during pregnancy to monitor fetal growth rate &
congenital anomalies.
• may be taken at week 28 & then again at week 36 to 38 to
determine fetal growth, amniotic fluid volume, placental location, &
biparietal diameter.
– Nonstress testing starting around 34 weeks (last tri) but can
8. Fetal Well be started when compromised fetal wellbeing is suspected.
Being (done weekly for placental functioning)
Monitoring – Instruct mother to perform daily kick counts and report
abnormal findings starting 28 weeks.
- L/S ratio by amniocentesis for surfactant levels by 36 wks of
pregnancy to assess fetal maturity or starting 32-34 weeks (in
other books)
- AFP level obtained at 15 to 17 weeks to assess for a neural
tube defect & an UTZ exam performed at18 to 20 weeks to
detect gross abnormalities
- A creatinine clearance test may be ordered each trimester.
 DIABETES MELLITUS: MANAGEMENT
9. Continuing a.Candidiasis - diabetic pregnant women are
evaluation of prone to yeast infection.
diabetic b.Retinopathy - ophthalmic exam
complications - Once during pregnancy for women w/
gestational diabetes
- Once per trimester for women w/ preexisting
diabetes
c. Hypertension - diabetic women are at risk for
gestational hypertension therefore monitor
BP during pregnancy.
 Diabetes Mellitus
Care During Labor & Delivery
1.Plan for delivery is made b/n 36-40 wks (vaginal birth is
preferred).
2.Fetal size seen on UTZ cannot be used to determine
fetal maturity.
3.Regular amniocentesis is performed for L/S ratio
testings to monitor fetal lung maturity.
4.Hospitalization & labor induction w/ prostaglandins &
pitocin is initiated to effect vaginal delivery after fetal
lung maturation has been assured.
 Diabetes Mellitus
Care During Labor & Delivery
4. Regular insulin is given on the day of the delivery not
long acting insulin because insulin requirement drop
immediately after delivery.
5. Maternal hyperglycemia during labor should be
avoided because it can stimulate large secretions of
insulin from fetal pancreas w/c can potentiate the risk of
neonatal hypoglycemia & increase the risk of fetal
hypoxia.
6. If cervix is not yet ripe, baby is macrosomic & fetal
distress occurs, baby will have to be delivered by CS.
 DIABETES MELLITUS: Post Partum Care
Mother Newborn Contraception
1.Inform woman 1. Keep newborn warm coz of poor 1.IUD & combined
that gestational temperature control mechanisms. oral contraceptives
diabetes may 2. Observe respirations (stomach are
recur in aspiration may be necessary at time of contraindicated.
subsequent birth, since hydramnios inflates 2.Norplant (progestin
pregnancies. stomach pushing it up and interferes
implant system) &
2.Women who w/ diaphragm & lung expansion).
progestin only pill
developed 3. Observe for signs of hypoglycemia
gestational (shrill cry, weakness), give glucose H2O
(minipills) may be
diabetes have 4. Observe for signs of hypocalcemia used safely by
higher tendency (tetany, tremors), give calcium diabetic women.
to develop overt gluconate.
diabetes later in 5. Observe for congenital anomalies:
life. esophageal atresia, neural tube
defect.
MENTAL ILLNESS & CANCER IN
PREGNANCY
 MENTAL ILLNESS

! May precede or occur with pregnancy.

! Schizophrenia - highest incidence in adolescents &
young adults
! Depression - occurs almost four times more
commonly in women than in men & the most
common mental illness seen in pregnant women.
! Any psychotropic medication taken by a pregnant
woman should be evaluated for possible fetal
harm.
 CANCER & PREGNANCY
Most Commonly Treatment/Management Risk
Seen w/ Pregnancy
Ovarian 1st trimester - chemo or Risk of thrombus
Uterine radiation may cause fetal formation
anomalies. postoperatively
Cervical
Breast 2nd & 3rd tri - chemo has no Cervical
adverse fetal effects. conization for
Thyroid
cervical CA - has
Leukemia Radiation - puts fetus at risk
a high fetal risk
Melanoma - throughout pregnancy if the
capable of spreading fetus is directly exposed. Px for Cervical
to the fetus. CA - HPV
Surgery to remove tumor - can vaccine
Hodgkin be completed during
Lymphomas pregnancy but fetus is at risk for
anoxia during anesthesia.
Thank you for listening!