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Complex Midwifery Care > 6.2.1 - Diabetes - exam > Flashcards

6.2.1 - Diabetes - exam Flashcards

1
Q

Pregnancy management of diabetes

A

Multidisciplinary team.
1 diet and exercise
2 metformin
3 insulin injection

Regular monitoring of glucose levels
Ultrasound 
Size of baby
Fetal anatomy
Blood flow
Heart activity
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2
Q

Management of baby post delivery

A 
RDS - may need o2
Glucose infusion
Monitor sugars
Bilirubin
Glucose 
Calcium
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3
Q

Explain the pathophysiology of gestational diabetes mellitus

A

Patho of GDM
an increase in insulin resistance and beta cell hyperplasia

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4
Q

Explain the risk factors for gestational diabetes mellitus.

A 
Advanced maternal age >35 or 40 depends on literature
Family hx of diabetes
Previous GDM
Macrosomic baby > 4500 or 90th centile
Non Caucasian race/ethnicity
Being overweight or obese BMI >30
Smoking
Polycystic ovarian syndrome
Previous elevated BGL
Previous perinatal loss
Medications (corticosteroids - antipsychotics
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5
Q

Describe the testing and define the diagnostic criteria for gestational diabetes mellitus.

A

OGTT 75g
one elevated plasma glucose level is sufficient for a diagnosis
If a fasting glucose has been preforms for other reasons and shows an elevated value, this may be accepted as a diagnostic of GDM
HbA1c - 48 - 48 mmol/mol > 6.5%) if the woman can not tolerant the drink in early pregnancy may be sufficient to diagnose pre-exciting diabetes and requires review by an endocrinologist
Type 1 diabetes can be present in pregnancy

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6
Q

Criteria for diagnosis of GDM with a Oral Glucose tolerance test (OGTT) 75g glucose drink - usually down 24-28 gestation

A

~~~
Fasting for at least 8 hours before test
Fasting range >5.1 mmol/ml
1h glucose > or equal 10.00 mmol/ml
2h glucose >8.5
values vary according to local protocols
HbA1c <6.5%

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7
Q

What 4 tests may be used in screening for GDM?
How and when are women tested for gestational diabetes, describe the diagnostic criteria in Australia.

A
  • oral glucose tolerance test (diagnostic)
  • non fasting plasma glucose
  • HbA1c (not reimbursed by medicare)
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8
Q

Describe normal glucose metabolism in pregnancy and why it is altered.

A

see ph

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9
Q

What is the procedure for a GTT?

A
  • fasting for 10-12 hours
  • baseline plasma glucose measured
  • 75g glucose drink within 5 mins
  • plasma glucose measured at 1 hour and 2h
  • no food, smoking, drinks other than water or exercise during test
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10
Q

Describe maternal glucose metabolism when the woman has diabetes and the potential effects on the fetus.

A
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11
Q

Describe insulin resistance, and the impact for obese women (elevated BMI) in pregnancy, link this to risk for gestational diabetes.

A
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12
Q

What women are at increased risk of developing gestational diabetes (aside from high BMI).

A

Advanced maternal age >35 or 40 depends on literature
Family hx of diabetes
Previous GDM
Macrosomic baby > 4500 or 90th centile
Non Caucasian race/ethnicity
Smoking
Polycystic ovarian syndrome
Previous elevated BGL
Previous perinatal loss
Medications (corticosteroids - antipsychotics

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13
Q

What is gestational diabetes?

A

any degree of glucose intolerance with onset or first recognition in pregnancy

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14
Q

When is GDM usually tested for?

A

routinely at 24-28 weeks gestation
early for high risk women at 12-16 weeks
at 6-8 weeks postpartum in women diagnosed with gestational diabetes

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15
Q

List the topics you need to cover with a newly diagnosed woman with GDM.

A
  • modification of diet refer to a dietitian
  • regular & gentle exercise 30 mins per day
  • home blood glucose monitoring at least 4 times a day
    • Less than or equal to 5.0 mmol/l fasting
    • Less than 6.7mmol/L two after a meal
  • increased frequency of antenatal visits
  • lactation consultant ie if clinically appropriate ante natal expressing
  • cease smoking
  • timing of birth
  • interdisciplinary team (midwife, obstetrician, diabetes educator, dietition, other specialists)
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16
Q

What are the associated risks of gestational diabetes?

A
  • polyhydramnios
  • preeclampsia
  • C/S
  • PPH
  • perinatal death
  • macrosomia (shoulder dystocia, perineal trauma)
  • birth trauma
  • neonatal hypoglycaemia, hypocalcaemia, magnesaemia
  • respiratory distress syndrome
  • hyperbilirubinaemia
  • neonatal polycythaemia
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17
Q

What long term risks exist for women that have had gestational diabetes?

A

50% risk of developing type 2 DM within 20 years

18
Q

What drugs may be used to treat women with gestational diabetes that isn’t controlled sufficiently with diet?

A
  • insulin
  • metformin
  • glibenclamide (caution)
19
Q

What are the postnatal recommendations for women with gestational diabetes?

A

GTT at 6-12 weeks postpartum

diabetes testing 1-2 yearly

20
Q

List 5 important considerations providing labour care for women and fetus with GDM?

A
  • timing of birth (some facilities induce, c/s at 38-39/40, particularly if macrosomic, persistant hyperglycaemic or other complications)
  • glucose levels in labour - 4/24 monitoring
  • fetal monitoring (continuous CTG in labour for GDM on insulin, blood glucose outside optimal range or ? macrosomic)
  • ? shoulder dystocia
  • active management of third stage
21
Q

List 4 means of assessing fetal wellbeing where mum has GDM?

A
  • fetal movements
  • fundal height
  • ultrasound
  • regular CTG if IUGR or macrosomia
22
Q

What are the three different types of diabetes?

A
  • type 1 insulin deficient
  • type 2 insulin resistant
  • gestational
23
Q

What other medicines interact with insulin?

A 
decrease insulin requirements
- oral hypoglycaemic agents
- monoamine oxidase inhibitors
- non selective beta adrenergic blockers
- ACE inhibitors
- salicylates
- anabolic steroids
- quinine
- sulphonamides
increase insulin requirements
- oral contraceptives
- glucocorticoids
- thyroid hormones
- sympathomimetics
- nicotinic acid
other
- betablockers
- alcohol
24
Q

Explain the Pathophysiology of Normal pregnant woman of insulin and glucose homostatis

A

Normal pregnant woman
- Beta cells produce/secretes insulin from the pancreas (Beta Cell Hyperplasia in pregnancy)
- When the woman eats >hyperglycamia>beta cells produce insulin
- binds to target cells to allow glucose from the blood
- reduces blood glucose level
- there is still enough blood glucose for the fetus
- Fetus requires adequate glucose for energy and growth
- normal fetal growth
- in pregnancy - insulin sensitivity decreases
- effect on maternal tissue is reduce
- more glucose in the blood
- factors from the fetus for maternal body to feed it

25
Q

Explain the Pathophysiology of gestation diabetes mellitus

A

GDM
- Beta cells produce/secretes insulin from the pancreas (Beta Cell Hyperplasia in pregnancy)
- When the woman eats >hyperglycamia>beta cells produce/secretes insulin into the blood stream for uptake
- Insulin resistance (chronic insulin resistance during Pregnancy) - blood glucose is not taken up as efficiently maternal tissue
- causing Hyperglycaemia
- travels to fetus circulation
- fetal pancreas begins to produce insulin
- with more fetal insulin will take up more glucose that is avail
- increases the growth of the fetus
- maternal circulation
- symptoms of diabetics (asymptomatic)
- the four “p”
- Polyuria - frequent urination
- polyphagia - increased appetite
- Paratheisa - abnormal sensation of the skin (tingling, pricking, chilling) burning or numbness (not that common)
- Polydipisa - extreme thirst
- reasons thought of GDM occurs
-due to the placenta
- growth hormones & Human Placental lactogen causing the insulin resistance

26
Q

Intrapartum management - maternal on insulin

A

In Spont labour
- cease insulin when labour in established
IOL morning
- eat breakfast
- give rapid acting insulin
- omit morning dose of long or intermediate acting insulin
IOL - Afternoon
- give usual mealtime insulin
- give usual bedtime insulin
- monitor BGL 2/24 (safer care Victoria guidelines)
- IVC
- endo input

27
Q

Intrapartum management - maternal on OHG

A
  • cease when labour is established
  • monitor BGL 2/24- (safer care Victoria guidelines)
  • IVC
  • Endo input
28
Q

Postpartum management - maternal

A
  • diet controlled - no BGL’s required - 6 week OGTT
  • Insulin/OHG - Pre meals and BGL before bed
29
Q

Antenatal care of the pre existing diabetic woman

A
30
Q

Midwifery care for pre existing diabetes

A
  • have the woman reviewed:
    • endo
    • diab educator
      -GP
  • discuss optimal blood glucose and glycosylated haem concentrations before and during pregnancy
    Pregnancy risks associated with poor control
    • Congenital malformation
    • Pregnancy complications
      • Macrosomia
      • growth restriction
      • polyhdramnios
      • preterm birth
      • Pre - eclampsia
      • Shoulder dystocia
      • intra uterine fetal death
  • Operative delivery - ie c -section
    Newborn risks
    - hypoglycaemia (therefore required BGL monitoring)
    - Jaundice
    - RDS
31
Q

Consider possible contraindications to pregnancy for pre existing diabetic woman

A
  • Ischaemic heart disease
  • Severe renal disease
  • Advanced retinopathy
    -Severe gastropathy
  • Uncontrolled hypertension
32
Q

Describe the diabetes specialist midwifery role

A
  • medical care
  • screening test
  • CoCe
  • plan of BGL management during antenatally, intrapartum and postpartum
  • regular visits
  • gestational, Type 1 & 2
  • referred by midwife or gp or specialist
  • OGTT
  • Education to other midwives and GP
  • high risk clinic
33
Q

Tutorial

A

Padlet

34
Q

Postnatal care of neonate

A
  • BGL’s
  • 3/24 feeds
  • formula top up
  • IV dextrose 10% if sugars are unmanaged
35
Q

Woman uses

A

Lipids for energy

36
Q

Hormone

A

Human placental lactegon

37
Q

Mentimeter

A

questions

38
Q

Gestational diabetes is defined as

A

Carbohydrate intolerance hyperglycaemia first recognition in pregnancy

39
Q

Diagnostic testing for gestational diabetes is in the form of

A

Oral Glucose Tolerance Test

40
Q

Risk factors for gestational diabetes include

A

Obesity
Previous GDM
Family history
Polycystic ovarian syndrome - increased insulin resistance

Complex Midwifery Care (33 decks)

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