4.1 Diabetes/Obesity/Breastfeeding Challenges Flashcards
Blood glucose regulation
- Small intestine breaks down carbohydrates and absorbs it into the bloodstream
- Pancreas produces insulin in beta cells (which tells liver and muscles to store glucose as glycogen) and glucagon in alpha cells (which target liver and muscle cells to cause glycogen to convert to glucose & gluconeogenesis - new glucose made)
- Liver stores glucose and produces glucose
- Muscles of the body store glucose for later
Type 1 diabetes
- The body’s immune system destroys the beta cells in the pancreas which produce insulin
- The pancreas stops making insulin because beta cells have been destroyed by the immune system → glucose cannot enter the body’s cells for energy → - Depend on insulin replacements
Type 2 diabetes
- The body becomes resistant to the normal effects of insulin and gradually loses the capacity to produce enough insulin in the pancreas - often associated with lifestyle risk factors
- Insulin is increasingly ineffective in managing BGL → pancreas responds by overproducing insulin to achieve a degree of normal BGL → loss of insulin producing cells
Pre-gestational diabetes
- Poor blood sugar levels during conception to first 8 weeks of pregnancy (organogenesis)
- Impaired glucose control is more longstanding - maternal vascular problems, kidney damage → pregnancy can aggravate these conditions
Gestational diabetes - risk factors & complications
Risk factors:
- Increased levels of HPL, cortisol, growth hormone, and progesterone during pregnancy can increase maternal glucose during pregnancy and make the mum’s body resistant to insulin - reduces mum’s utilisation of glucose so more is available for foetus
- High BMI
Complications:
- Preterm labour
- Growth restrictions
- Stillbirth
- Miscarriage
- Preeclampsia
- Foetal macrosomia
- Foetal anomalies
- Increases risk of maternal diabetes after pregnancy
- Maternal CVD, cancer of the pancreas, liver disease, depression, peripheral vascular disease
Diabetes - Midwifery care
Pre Pregnancy care - diet and insulin to control diabetes, testing and consultation with eye specialists and podiatrists, immune system support through smoking cessation, folic supplementation, alcohol cessation
Antenatal care - immediate referral to MDT, history taking, screenings, review of medications, measuring weight/height/BMI and dietician referral, regular BGL monitoring (<5.6mmol before meals, <7.8mmol after meals)
Topics to discuss:
Maternal and foetal monitoring - 2 weekly, then weekly from 36 weeks for clinical assessment and regular CTG
Doppler flow studies recommended
Labour/birth - Corticosteroids if risk for preterm delivery, high risk for c-section, concerns for macrosomia and shoulder dystocia, IV insulin and 5% dextrose for maintaining BGL between 4-7 mmol/L
Postpartum care - insulin sensitivity increases due to rapid decline of hormonal influence, frequent BGLs, meal plan for breastfeeding mothers, endocrinologist and dietitian referrals
Gestational diabetes - diagnosis
- Routine screen for gestational diabetes at approx. 26-28 weeks through a GTT or Glucose Tolerance Test
–> Woman is given a specific level of glucose and BGl is measured fasting, 1, and 2 hours post consumption - BGL above normal = diabetic - Retest 6 weeks postpartum for Type 2 diabetes
- Screening for existing diabetic complications (retinal and renal)
- Lab tests - HbA for RBC, serum creatinine and urinary excretion of protein for hypertension in pregnancy and iUGR, US at 30 weeks for assessment of foetal growth + more if clinically indicated >80th percentile baby
Maternal obesity
- Obesity = BMI of >30 (weight in kg / height in square metres)
- SFH at every antenatal appointment - if measurements are reduced, slow, or static refer to US assessment of foetal growth
Maternal obesity - risks to mum
- Increased risk of multiple gestation
- C-section
- Chest, genital, and UTI
- Cholecystitis (inflammation of gallbladder)
- Diabetes
- Difficult surgical access
- Failed IOL
- Gestational hypertension
- Preeclampsia
- Reduced breastfeeding
Maternal obesity - risks to anasthetic
- Difficulty intubating and maintaining an adequate airway
- Difficulty with IV access
- Regional anaesthetic more difficult to site
- BP monitoring difficulty
- Increased risk of regurgitation and aspiration of stomach contents
- Increased difficulty intubating and maintaining an adequate airway
Maternal obesity - fetal and neonatal risks
- NIPT failure risks
- Risk of undetected foetal structural abnormality
- Low APGAR scores
- Admission to NICU
- Congenital malformations (neural tube defects, congenital heart disease, cleft lip and palate)
- Macrosomia
- Shoulder dystocia
- Stillbirth
Maternal obesity - midwifery care
Antenatal
- Height and weight at initial visit - repeated measurements where possible for comparison and tracking
- Detailed plan of care
- Referral to dietician
- Hypertension = low dose aspirin
- Folic acid during the first trimester
- Anaesthetic assessment at 22 weeks with obstetrics review
Intrapartum
- Discuss birth plan with woman and partner
- Discuss effective ways of foetal monitoring (CTG)
- Active management of third stage
- Active attention to pressure areas and ensure anti-embolic stockings
- FBC and bladder care
- Correct blood pressure cuff is being used
- Bed size and equipment, hoist, wheelchair are available
Postnatal
- Possibility for PPH due to macrosomia and prolonged labour
- Extra support whilst breastfeeding (due to large breasts, flattish nipples)
Breastfeeding challenges
- Risk for congenital anomalies - cleft lip makes it difficult to latch
- Foetal growth and risk for preterm delivery - mothers are separated from infant in NICU therefore establishment of breastfeeding can be difficult
- Transition to extrauterine life and initiation of lactation - maternal health conditions can disrupt endocrinology of breast development and milk synthesis, resulting in lactogenesis II delay or absent milk production
- Environment, health, and milk composition - milk micronutrients, hormones, microbiome
- Maternal medications - agents could transfer through milk
- Physiological demands of breastfeeding and maternal health
- Practical demands of breastfeeding
Breastfeeding - midwife’s role
- Minimise mother-child separation (rooming in)
- Support breast drainage every 2-3 hours to as often as the child is nursing (electric breast pumps)
- Select medications that are lactation safe
–>Contraindicated medications are chemotherapeutic agents and radioactive agents
–>Relatively contraindicated medications are lithium, citalopram, cyclosporin
–>Drugs of addiction - methadone (high maternal dosage can risk infant sedation), buprenorphine (sedative effects), and marijuana (passes into breast milk - risk of sedation, feeding difficulties, poor weight gain) - Drain breasts before and after procedures to avoid engorgement or mastitis
- Care plans should address emotional, psychologic, and medical measures to manage acute illness
