Diabetes Flashcards
Describe normal glucose metabolism in pregnancy
In all pregnancies the placenta secretes hormones
- progesterone
- HPL
- cortisol
which result in insulin resistance
Typically the pancreas can secrete sufficient insulinn to cope with the increase in insulin resistance over pregnancy
Therefore foetus gains a normal amount of glucose, produces normal amount of insulin, has normal growth
Describe the pathophysiology of gestational diabetes
Placenta secretes
- HPL
- progesterone
- cortisol
and other hormones which create insulin resistance
the placenta is unable to secrete sufficient insulin to overcome this resistance
Maternal hyperglycaemia –> placenta –> fetal hyperglycaemia
Foetus results in secreting extra insulin which results in excessive fetal growth
Describe the physiology and impact of type 1 diabetes In pregnancy
Type 1 diabetes is an autoimmune disease targeting the beta cells of the pancreas. Here, the pancreas is unable to secrete insulin.
Impact of overt diabetes leading into pregnancy
- may not have had adequate glycemic control during organogenesis
- high risk of miscarriage
- high risk of malformation
Describe the physiology and impact of type 2 diabetes in pregnancy
Type 2 diabetes results from chronic elevate insulin which leads to the development of insulin resistance overtime. Beta cells compensate by producing more insulin but are eventually worn out and insulin is ineffective
Risk factors for developing gestational diabetes
- previously GDM
- Family history of DM
- AMA
- ethnic background
- high BMI
- PCOS
Diagnostic testing for GDM
GTT at 26-28 weeks
- 5.1 at 0 hours
- 10 at 1 hour
- 8.5 at 2 hour
Early OGTT at 14-16 weeks if they have above risk factors
Midwifery care of women with GDM in antenatal, labour and birth, and postpartum - preexisting diabetes
Midwifery care of women with GDM in antenatal, labour and birth, and postpartum - diet controlled gestational diabetes
Delivery timing 39-40
Antenatal
- collaboration with diabetes team for effective BGL control
- offer CTG monitoring after 38 weeks or if FGR or hypertensive disorder is identified
- consider 4-6 weekly 3rd tri US
- Anaesthetic review
- early LC referral
- educate on hand expressing and collecting colostrum
Intrapartum
- 4 hourly BGL testing
- manage birth normally unless other risk factors present
- Consider continuous CTG
Postpartum
- support breastfeeding
- 6 week OGTT
- monitor baby for hypoglycaemia
Midwifery care of women with GDM in antenatal, labour and birth, and postpartum - medically managed gestational diabetes
Delivery timing:
- good control 38-39
- poor control 37-38
Antenatal:
- refer to obstetric model of care
- refer to diabetes team
- US 4-6 weekly in 3rd tri
- CTG monitoring required if risk factors identified
- anaesthetic review
- early LC referral
Intrapartum:
- 2 hourly BGL testing during labour and delivery
- Insulin regime remains normal as long as still eating meals, then ceased after birth
- continuous CTG
Postpartum
- target BGL >11.1
- cease insulin following birth
- glycemic management as per doctor post part
- LC
- BGL 4x daily
- OGTT 6 weeks postpartum
Describe the changes to insulin requirements for diabetic women and the medications used to regulate blood sugars in pregnancy
Lifestyle interventions
- Referral to dietician
- high fibre, low glycemic foods
- gestational weight gain within targets
- moderate level exercise each day - insulin sensitivity increases post exercise
Oral hypoglycaemic eg. metformin
- reduces production of glucose from liver and increases the uptake of glucose in liver
- crosses placenta
- used in some cases in combination with or when woman refuses insulin
Insulin
- when lifestyle modification does not control BGL
- typical dose starts novorapid 4-6 units before meals
- protaphane 4-8 units before bed
- uptitrated throughout pregnancy, individually prescribed
Describe potential indications for IOL, complications for mother and baby, and the increased surveillance required
- poor glycemic control
- presence of other comorbidities
- fetal growth restriction
- hypertensive disorder
What are the complications of GDM
- preeclampisa
- polyhyframnios
- Induced labour and operative birth
- PPH
- infection
- jaundice
- preterm birth
- macrosomia
- hypoglycaemia
Development of type 2 diabetes for mother and foetus
Antenatal education points
- What is GDM
- risk factors
- referrals
- management plan –> lifestyle –> insulin
- monitoring CTG in 3rd tri
- at home BGL
- impact on timing of birth
- importance of expressing and breastfeeding
Signs of poor glycemic control
A woman requiring a significant amount of insulin suddenly starts developing a decreased need for insulun
Sign of hormone shift –> placenta shutting down
Increased risk of stillbirth or premature labour
OR diet controlled to insulin controlled very quickly
