11.1b Pregestational Diabetes Flashcards
Vascular Diseases of Diabetes
- Retinopathy
- Nephropathy
Pregestational Diabetes
- Almost always insulin dependent
- First trimester - Glucose is usually lower and insulin response to glucose is enhanced
- Insulin needs steadily increase after 1st trimester
- Insulin resistance begins 14-16 weeks gestation
- Preconception counseling recommended for all women with diabetes
Risks of Pregestational Diabetes
- Risk of miscarriage is high if diabetes is present early in pregnancy or close to contraception
WITHOUT VASCULAR DISEASE
- Risk of fetal macrosomia (birthweight greater than 4000-4500g or 90%)
- Disproportionate increase in shoulder, trunk and chest size
- Increase likelihood of c-section due to failure of fetal descent
- Episiotomy, forceps and vacuum birth also more likely
MEDICAL COMPLICATIONS
- Hypertension
- Preeclampsia
- C-section
- Preterm Birth
- Maternal mortality
- RISKS INCREASE WITH DURATION AND SEVERITY
Hydramnios
- Diabetes increases risk of this in 3rd trimester
RISKS
- Placental abruption
- Uterine dysfunction
- Postpartum Hemorrhage
- Vaginal Infection
- UTI
Ketoacidosis
- Occurs most often in 2nd and 3rd trimester
- Can occur in glucose levels barely above 200
- Infection/Illness/Stress increases hepatic glucose production and decreased peripheral uptake of glucose leading to hyperglycemia
- Ketoacidosis can lead to intrauterine fetal death
Hypoglycemia
- Risks highest early in pregnancy when hepatic glucose production is low and peripheral uptake of glucose is high
Euglycemia
- Normal glucose
Hyperglycemia Risks
- Miscarriage
- Congenital malformations
- Respiratory distress syndrome
- Extreme prematurity
IUDF (Stillbirth) Causes
- Diabetes
- Placental insufficiency
- Fetal Growth Restriction
- Macrosomia
- Polyhydramnios
- Obstructed Labor (Intrapartum Stillbirth)
Hyperglycemia Anomalies
- Happen in first trimester due to organs forming during this time
- Main birth defect of birth diabetes
- Most effected systems are CVD and CNS
Fetus
- Fetal pancreas releases insulin at 10-14 weeks gestation
- Insulin acts as a growth hormone so when baby releases extra insulin (hyperinsulinism) due to increased mom blood glucose, it increases fetal size (macrosomia)
Macrosomia Risks
- Brachial Plexus Palsy
- Facial Nerve Injury
- Humerus/Clavicle Fracture
- Cephalhematoma
Care Management
- Baseline renal function (24 hour urine collection) to measure protein and creatinine
- Urinalysis and culture to assess UTI
- Thyroid function tests due to risk of coexisting thyroid issues
- A1C Levels (Less than 6.5 is perfect)
Education
- Management and potential effects
- Insulin administration
- Hypo/Hyperglycemia
- Diabetic Diet
Associated Fetal Injuries
- Disruption of oxygen transfer
- Birth trauma
Associated Mom Injuries
- Improper insulin administration
- Hypo/Hyperglycemia
- C-section
- Postpartum infection
Antepartum Care
1st and 2nd trimester
- Routine visits every 1-2 weeks
3rd trimester
- 1-2 times a week
Glucose Levels
Fasting - 60-105
1 hour after a meal - Less than 140
2 hours after a meal - Less than 120
2am - 6am - Greater than 60
Diet
- Based on blood not urine glucose levels
Exercise
- Active 30-60 minutes a day
Benefits
- Increased insulin sensitivity
- Increased utilization of glucose
- Improved glucose control
- Reduced risk of excessive weight gain
- Can be divided into 10-20 minute periods after a meal
Blood Glucose Testing
- Glucose meter is standard for at home testing
- Urine testing is not useful in pregnancy
Complications That Require Hospitalization
- Infection (can lead to hyperglycemia and DKA)
- 3rd trimester diabetics should be closely monitored for those whose diabetes are poorly controlled
- If hypertension and preeclampsia also exist with diabetes they may also need hospitalization
Fetal Surveillance
- Detect IUFD or Preterm Birth
ULTRASOUND FOR
- Fetal Growth
- Estimated Fetal Weight
- Detect Hydramnios
- Macrosomia
- Congenital Anomalies
- Maternal Serum a-fetoprotein (15-20 weeks gestation)
- Neural Tube Defects (18-20 weeks gestation)
- Fetal echocardiogram due to increased cardiac anomalies (20-22 weeks gestation)
- Most surveillance is done in 3rd trimester because risk is greatest
Education During 3rd Trimester
Beginning at 28 weeks gestation
- Educate how to make daily fetal movements counts
Determining Birth Date and Mode of Birth
- Optimal time of birth is 39-40 weeks
- Induction of labor at 39 weeks is preferred for moms who have good control of their diabetes
- Induction of labor should be earlier for those who have not controlled their diabetes well.
- Lung maturity must first be confirmed via amniocentesis
Intrapartum Care
MONITOR
- Dehydration
- Hypo/Hyperglycemia
- IV and continuous insulin via piggyback (Only Rapid and Short Acting)
- Can also be given SubQ
- Blood glucose should be measured every hour
- Glucose should be maintained between 90-110
Postpartum Care
- First 24 hours postpartum, insulin requirements decrease substantially
- This is due to expulsion of placenta which was the main source of insulin resistance
Diagnosis of Gestational Diabetes
- Diagnosis must be made on 2 occasions
