diabetes in pregnancy Flashcards
complications with fetus in pregnancy (diabetic)
-fetal death (pre-gest DM)
-birth defects (pre-gest DM)
-IUGR (pre-gest DM)
-macrosomia
-birth trauma
-NN hypoglycemia
-NN polycythemia/hyperbilirubinemia
-NN resp distress
-childhood obesity
-development metabolic diseases in lifetime (obesity, HTN, CVD, T2DM)
polycythemia
too many red blood cells
complications for mom in pregnancy (diabetic)
-hypoglycemia (early pregnancy)
-DKA
-retinopathy (pre-gest DM)
-nephropathy (pre-gest DM)
-vasculopathy (pre-gest DM)
-HTN disorders
-polyhydramnios/hydramnios
-infection
-preterm labor/birth
-PPH (bc of big baby)
-trauma
type DM:
-absolute insulin deficiency
-immune
T1DM
type DM:
-defective insulin secretion and insulin resistance
-due to lifestyle
T2DM
diabetes diagnosed in 2nd or 3rd tri that was not clearly overt diabetes prior to gestation
gestational
how does early pregnancy effect insulin production
-increased insulin production
-increased tissue sensitivity to insulin
(storing up insulin for later growth)
*easier to be hypoglycemic
how does later pregnancy effect insulin production
-increase insulin antagonistic hormones
-decreased tissue sensitivity
*easier to be hyperglycemic
factors that trigger DKA in pregnancy
-fasting hyperglycemia
-infection
-stress
-emesis
-dehydration
-gastroparesis
-meds (sympathomimetics, steroids)
what are tocolytics for
what kind of med is it
break up contractions
ex: terbutaline (sympathomimetic)
how can sympathomimetics and steroids trigger DKA
increase glucose levels
how do vascular complications with diabetes affect the fetus
impaired blood flow to placenta
recommended A1C for preconception care
<6.0-6.5
screening for gestational diabetes for women with and without risk factors for T2DM
-with risk factors: at preconception or 1st prenatal visit
-without risk factors: 24-28 weeks screening
*diagram for 2 step gestational diabetes screening
step 1 of 2 step GDM screening
1 hour (50 g) oral glucose screen
-if neg (<130): routine prenatal care
-if pos (>130): 2nd step
step 2 of 2 step GDM screening
normal diet and exercise for 3 days before test
NPO for 12 hours before test
3 hour (100 g) OGTT
-neg: routine care
-pos: if 2 or more values are exceeded
(fasting: 95+, 1 hour: 180+, 2 hour: 155+, 3 hour: 140+)
blood glucose range recommended during pregnancy
60-140
what big HTN disorder does any type of diabetes increase the risk for
pre-eclampsia
1st tri care for woman with PGDM
-early sonogram (confirm due date, assess for anomalies)
-monitor for S+S complications
-lots of pt education
what kind of diabetes is shown through 1st tri
only pregestational DM
what is considered hypoglycemia during pregnancy
<70
example of 15 grams carbs
4 oz juice/soda
Tx for blood sugar of 60-70
15 g carbs
Tx for blood sugar of 40-60
30 g carbs (1/2 liquid, 1/2 solid)
2nd tri care for PGDM/GDM (screenings)
-MSAFP @16-18 weeks (looking for NTD)
-fetal ECG @18-22 weeks, 34 weeks
-ultrasound q4-6weeks (growth, anomalies, hydramnios, possible doppler blood flow)
sick day management guidelines
-continue insulin as ordered
-check urine ketones q4-6h
-check BS q1-2h
-consume liquid or soft foods
-sip 15-30 g carbs/hr during periods vomiting
-notify HCP if liquids not tolerated
-notify HCP S+S of ketoacidosis
-notify HCP if BS >200
-notify HCP if urine ketones >moderate
S+S ketoacidosis to report to HCP
-abdominal pain
-N/V
-polyuria/polydipsia
-fruity breath
-tachypnea
-altered mental status
-leg cramps
meal plan recommendations for PGDM and GDM moms
-based on prepregnancy BMI and nutritional status
-40% carbs, 20% protein, 40% fat
-3 meals + 3 snacks
-large bedtime snack to avoid hypoglycemia
why do you have to be careful for mom with PGDM/GDM with vascular disease doing exercise
shunts blood flow away from baby
exercise recommendations for PGDM/GDM moms
-best time exercise is 10-20 min after meal
-don’t exercise if pos urine ketones, BS >200
-walking/aerobic 30 mins/day
how many times do pregestational diabetic moms have to monitor capillary BS
5-8 times/day
-fasting, 1-2 hour pp, bedtime, 2-3 am
how many times do gestational diabetic moms have to monitor capillary BS
atleast 4 times/day
-fasting, 1-2 hour pp
when during pregnancy do you need:
-less insulin
-more insulin
less: 13-20 weeks EGA
more: 20 weeks-birth
risk with continuous subq insulin infusion (CSII)
pump failure resulting in DKA
preferred med for managing diabetes in pregnancy
insulin
oral antidiabetic med options during pregnancy (2)
-metformin (drug of choice)
-glyburide
3rd tri care for PGDM/GDM moms
-delivery an option if needed
-kick counts
-NST/BPP/AFI: 28-32 weeks, 1-2x/week
-ultrasound for growth (small/large)
-monitor for vascular complications (esp T1DM)
when is it ok to await spontaneous labor or induce at 40 weeks
-well controlled diabetes
-no comorbidities
-reassuring fetal testing
*no going past term
when should there be an early birth (36-38 weeks or earlier)
-vasculopathy
-nephropathy
-poor glucose control
-prior fetal loss
-prior macrosomia
-fetal compromise
when should there be a C/S
-baby estimated weight >4500 g (9-10 lbs)
-OB indications
L&D considerations for diabetic moms (IVs, BP, baby)
-mainline IV NS
-IVPB D5 (when labor begins or BS<70)
-IVPB reg insulin in NS
-check BS q1-4h
-maintain BS between 70-110
-IV bolus prn (NS only, give slowly)
-continuous EFM
-monitor for failure to descend/progress
-anticipate shoulder dystocia
-anticipate need for neonatal resuscitation
postpartum care considerations for diabetic moms
-dramatic drop for insulin needs first 24 hours
-risk hemorrhage (uterine distention from LGA, hard to palpate fundus if obese)
-risk for infection
-delayed lactogenesis
-DC IV insulin
benefits breastfeeding for diabetic moms
-better BS control
-reduces risk infant for developing DM
when should the 2 step glucose test be repeated after birth
-4-12 weeks PP (or after breastfeeding stopped)
-1 year PP
-q3-5years
-prior to another pregnancy
nursing care for DKA
-fluids
-insulin
-electrolyte replacement (esp K)
-O2
-EFM (also tells you mom’s perfusion status)
-uterine activity (dehydration can cause Cxs)
IDM
infant of diabetic mother
effects of hypo/hyperglycemia in fetus during later pregnancy
-fetal hyperinsulinemia
-excessive growth (esp shoulders and body)
-inhibited release of surfactant
-hypoxia (increased RBC production to compensate, leads to NN polycythemia)
effects of hypo/hyperglycemia in fetus during early pregnancy
-spontaneous abortion
-congenital malformations (cardiac, CNS, GU, skeletal)
cues of shoulder dystocia during labor and delivery
-slowing of progress of labor
-more than 60 secs from head to body being born
-external rotation doesn’t occur
-when head emerges, it retracts against perineum (turtle sign)
-palpation of overlapping suture lines and edema of baby’s head during vaginal exam
proactive plan for shoulder dystocia (prepare for all diabetic moms)
-big room size
-position for birth (squatting)
-anesthesia (epidural)
-episiotomy
-empty bladder
Tx for shoulder dystocia
-call for help
-mcroberts maneuver (knees to ears)
-suprapubic pressure
if those don’t work:
-woods maneuver (“screw maneuver”, hands on baby’s scapula and clavicle, rotating shoulders toward fetal chest)
if that doesn’t work:
-gaskin maneuver (all 4s)/running start position
maternal risks with shoulder dystocia
-PPH
-extended episiotomy
-rectal injuries
neonatal risks with shoulder dystocia
-asphyxia
-brachial plexus injury
-fracture of humerus/clavicle
white’s classification of diabetes:
A1
-onset
-fasting BS
-2 hr pp BS
-Tx
onset: gestational
fasting BS: <105
2 hr pp BS: <120
Tx: diet and exercise
white’s classification of diabetes:
A2
-onset
-fasting BS
-2 hr pp BS
-Tx
onset: gestational
fasting BS: >105
2 hr pp BS: >120
Tx: insulin
white’s classification of diabetes:
B
-onset
-duration
-vascular disease
-Tx
onset: 20+ yo
duration: <10 yrs
vascular disease: none
Tx: insulin
white’s classification of diabetes:
C
-onset
-duration
-vascular disease
-Tx
onset: 10-19 yo
duration: 10-19 yrs
vascular disease: none
Tx: insulin
white’s classification of diabetes:
D
-onset
-duration
-vascular disease
-Tx
onset: <10 yo
duration: >20 (?)
vascular disease: benign retinopathy
Tx: insulin
white’s classification of diabetes:
F
-onset
-duration
-vascular disease
-Tx
onset: any
duration: any
vascular disease: nephropathy
Tx: insulin
white’s classification of diabetes:
R
-onset
-duration
-vascular disease
-Tx
onset: any
duration: any
vascular disease: proliferative retinopathy
Tx: insulin
white’s classification of diabetes:
H
-onset
-duration
-vascular disease
-Tx
onset: any
duration: any
vascular disease: heart
Tx: insulin
risk factors for type 2 diabetes which would indicate the need to screen the pregnant woman at her first prenatal visit
-morbid obesity
-family history
-gestational diabetes in previous pregnancy
how should woman prepare for 3 hr OOGT
atleast 3 days unrestricted diet and normal physical activity
no smoking or caffeine for 12 hrs before
positive results for GDM from 3 hr OOGT
fasting: 95
1 hr pp: 180
2 hr pp: 155
3 hr pp: 140
target BS levels for pregnant woman with diabetes
-fasting
-before meal
-1 hr pp
-2 hr pp
-2 am -6 am
-fasting: 60-95
-before meal: 60-105
-1 hr pp: <140
-2 hr pp: <120
-2 am-6 am: >60
recommendation for follow up testing of a woman who had gestational diabetes following the birth of the baby
-4-12 wks postpartum (or after breastfeeding stops)
-1 year after birth
-every 3-5 years
-before another pregnancy
Tx for BS of 60-70 in pregnant woman
15 g carbs (4 oz juice/soda)
Tx for BS of 40-60 in pregnant woman
30 g carbs (1/2 solid, 1/2 liquid)
*adding protein reduces risk rebound hypoglycemia
