Exam Three: too slow, too fast, too long diabetes Flashcards
issues
- too slow: dysfunctional, protracted, arrested
- too fast: precipitous (Under three hours from the start of regular contractions to birth of placenta)
- too soon: preterm (<37 weeks)
- too late: postdates (>42 weeks)
too slow labor causes
- dystocia
- dysfunctional
dystocia causing too slow labor
- lack of progress in labor
- Abnormal labor pattern due to any of the “Ps”:
1. Power
2. Passenger
3. Passageway
4. Position
5. Psyche/People
dysfunctional causing too slow labor
- Most common cause is a ‘dysfunctional’ contraction pattern (uncoordinated contractions)
- # 1 reason for Cesarean Birth
dystocia related to powers: Latent Phase Disorder: “can’t get going”
- Happens before the onset of active labor
- HYPERtonic Uterine Dysfunction– frequent and painful contractions that are not sufficient to cause the cervix to begin to change
1. Uncoordinated contractions in the midsection of the uterus instead of fundus—no downward pressure of fetus on cervix
2. Uterus may not relax completely between contractions - AKA “prodromal” labor
dystocia related to powers: Active Phase Disorders: “stalls out”
- Happens once enters active labor (≥ 6 cm with regular UCs)
- HYPOtonic uterine dysfunction–uterine contractions are not effective enough to continue making the cervix change: Montevideo units <200
-Protraction—slower than normal
-Arrest– stop making progress
1. Adequate contractions (MVU
> 200) for ≥ 4 hours
or
2. Inadequate contractions
(MVU < 200) with oxytocin
administration for ≥ 6
hours
causes of Active Phase Dysfunction
- Are contractions inadequate
- Is cephalopelvic disproportion (CPD) present?
- Is there a malposition (posterior, asynclitic)?
- Is there an intraamniotic infection (fever, tachycardia, fetal tachycardia, etc.)?
- Is the bladder full?
- Is patient exhausted or in unmanageable pain?
- Are they dehydrated?
- Is there something else?
interventions for active phase dysfunction when caused by inadequate contractions
- assess with IUPC (MVUs <200)?
- Pitocin or rupture membranes (AROM)
interventions for active phase dysfunction when caused by cephalopelvic disproportion (CPD) present
Use positions to maximize space
interventions for active phase dysfunction when caused by malposition
- Use frequent position changes
- Normal cardinal movements of baby produces OA babies
interventions for active phase dysfunction when caused by intraamniotic infection
- would see: fever, tachycardia, fetal tachycardia, etc
- Treat the infection
interventions for active phase dysfunction when caused by full bladder
- void/cath Q 2 hours
interventions for active phase dysfunction when caused by patient exhaustion or unmanaged pain
Consider pain medications
interventions for active phase dysfunction when caused by dehydration
- hydrate PO or IV
causes of latent phase dysfunction
- unknown usually
risks to latent phase dysfunction
- Fatigue, stress
- Dehydration
- Increased pain -uterine muscle anoxia and decreased coping
- Infection
treatment for latent phase dysfunction
- STOP it (therapeutic rest)- ambien, morphine sleep, Benadryl
OR
-START it (IOL/augmentation- AROM, Pitocin, nipple stimulation)
*consider impact fatigue can have on labor progression
*once they enter active labor they often progress normal
Dystocia Related to “Powers”: second stage
- Protracted– descent of fetus takes longer than expected
- Arrested– fetus stops descending
- Inadequate/ineffective pushing efforts: May be related to spinal/epidural nerve blocks or exhaustion
management of Dystocia Related to “Powers”: second stage
-Coach on pushing, encourage rest between
-Positioning—maximize space, utilize gravity
-Anesthesia to reduce epidural infusion rate
Dystocia Related to “Passenger”: Compound Presentation
- “Hand Presentation”: compound hand where the hand is down around head
-Longer labor
-Increased tears
-Increased c/s
Dystocia Related to the “Passenger”: Macrosomia
- Birth weight of more than 4000 grams (8#13oz)
- Fetus greater than 5000g (on US) is offered a c/s to reduce risks of shoulder dystocia (if GDM 4500 grams)
Dystocia Related to the “Passenger”: Macrosomia risk factors
- Gestational diabetes (GDM)
- BMI>30
- excessive weight gain
- maternal or FOB larger birth weight
- previous macrosomic baby
Dystocia Related to the “Passenger”: Macrosomia increased risk for
- Slow progress
- infection
- shoulder dystocia
- lacerations
- PPH
- need for assisted birth (VAVD, FAVD, C/S)
Dystocia Related To position
-Occiput posterior
-Asynclitic: babies head tilted to one side
-Breech
-Face, brow presentation
Dystocia Related To psyche/people
- stress
Dystocia Related to the “Passenger-Passageway”: Shoulder Dystocia
- After birth of head, the anterior shoulder remains lodged under the pubic bone and is unable to deliver
implications of Dystocia Related to the “Passenger-Passageway”: Shoulder Dystocia
- Fetal head fills with blood with no means for blood return –> hypoxia–> neuro damage –> death so prompt timing is critical (within minutes)
- Obstetrical emergency - Attempts to dislodge shoulder can cause injury to fetus:
-Brachial plexus injury (~10% are permanent)
-Fractured clavicles
risk factors for Shoulder Dystocia
- macrosomia
-labor dystocia
-vacuum/forceps
-GDM
-obesity
-postdates delivery
-previous shoulder dystocia
*High percentage of cases occur with NO RISK FACTORS
dangers of shoulder dystocia
- entrapment of the cord
- inability of child’s chest to expand properly
- severe brain damage or death if child is not delivered within minutes
Interventions for Shoulder Dystocia
- Be prepared BEFORE the birth!
-Recognize risk factors
-Notify team members – MD, charge nurse, neonatal staff
-Have stool positioned within reach
-Have extra RN at delivery to help/keep track of time - McRoberts’ Maneuver
- Suprapubic pressure
- Pressure over suprapubic bone –if you know position, push shoulder toward chest
-NO FUNDAL PRESSURE!!!! - Gaskin maneuver
- careful newborn exam: tone, moving upper extremities bilaterally, crepitus over clavicles
what is mcroberts maneuver
- hyperextend the legs- knees to ears
- Changes maternal pelvis angle
what is the gaskin maneuver
- changing the pt to hands and knees
what is the wood screw maneuver
- provider inserts fingers into vagina
- left hand goes to the front of posterior shoulder right hand to the back of the anterior shoulder and they try to rotate the fetus
Interventions for Shoulder Dystocia: Provider may incorporate other interventions
- Deliver posterior arm
- Woods Screw maneuver
- Episiotomy- make more room
- Shoulder shrug maneuver/remove posterior shoulder with fingers
- Zavanelli Maneuver-Pushing the head back into the uterus and rush to C/S!
too fast: Precipitous Labor & Birth
- Entire process of labor and birth < 3 hours long
- Cause: Strong contractions and/or low resistance in soft tissues
risk factors for Precipitous Labor & Birth
- Abruption (history of drug use–cocaine, methamphetamines, stimulants; seizure/eclampsia, HTN)
-multiparity
-very small fetal size
-previous precipitous birth
Precipitous Labor & Birth Possible Complications:
- Sudden (terrifying) birth and immediate postpartum/newborn period without provider
- Abruption (cause or effect)
- PPH
- Newborn
1. Hypoxia (diminished reserve)
2. Lower APGAR scores
3. Meconium-stained fluid
4. Trauma (facial bruising, cephalohematoma, fractured clavicle)
nursing care for Precipitous Labor & Birth
- Put on gloves
- Call for help and DO NOT LEAVE THE ROOM
- if provider is not able to make it in time, catch the baby, place skin to skin on mom, call for help
TOO SOON: Preterm Labor & Delivery
- Preterm labor (PTL): Labor that occurs between 20 and 36 6/7 weeks
- Preterm delivery (PTD): preterm labor results in delivery
- Prematurity is the #1 cause of neonatal mortality (0-28 days) in United States
Measures to Improve Birth Outcomes & Reduce Morbidity/Mortality: equity
- Eliminate racial disparities
- Remove barriers to obtaining quality care in underserved and rural communities– In the U.S. 150K babies are born to individuals living in maternity care deserts (no facilities with obstetric care/providers)
Measures to Improve Birth Outcomes & Reduce Morbidity/Mortality: access
-Protect comprehensive health care coverage
-Provide affordable, quality public health programs pre-conception
-Extend Medicaid coverage to at least 12 months postpartum
-Access to midwifery/Doula care services
-Group prenatal care and telehealth reimbursement
Measures to Improve Birth Outcomes & Reduce Morbidity/Mortality: prevention
-Advance our understanding of why individuals/infants are dying during pregnancy, birth, and postpartum (up to 12 months after birth)
-Support public health programs to improve health of birthing people and their babies
-Create paid family leave systems
-Support vaccinations and boost confidence in vaccines
-Reduce primary c-section in low-risk individuals (>37 weeks, singleton, cephalic, primigravida)
Major Health Problems for Preterm Babies
- All organ systems immature, maturational deficiencies
-Respiratory distress syndrome (RDS)
-Intraventricular hemorrhage (IVH)
-Patent ductus arteriosus
-Necrotizing enterocolitis (NEC)
-Retinopathy of prematurity (ROP) - Among extremely premature babies, just under half grow up with some form of neurological or developmental disability. Severe forms of disability were present in 23% of babies born at 22-25 weeks.
The Ethics of Prematurity:Who SHOULD We Try to Save?
- Some concepts to ponder:
-Uncertain prognoses, especially with extreme prematurity
-Considerable costs
-Long term physical, mental, emotional disabilities
-Value of disabled people in our society
- Important to have shared decision-making conversations with family members
Symptoms of Preterm Labor
- mimic common complaints of a normal, healthy pregnancy
-Back pain
-Pelvic pain
-Abdominal pain (uterine or GI)
-Menstrual like cramping
-Pelvic pressure
-Diarrhea
-Increased vaginal discharge
Risk Factors for Preterm Labor
-Previous preterm labor and delivery
-Multiple gestation
-H/O incompetent cervix: Cerclage in place
-Stress
-Age (<17 or > 35)
-Substance abuse
-Non-white race
-Anemia
-Infection
-Intimate partner violence
-Poor weight gain
-Low maternal weight
-Inadequate prenatal care
Diagnosis of Preterm Labor
- ≥ 6 contractions per hour with documented cervical change or
- Cervical dilation ≥ 2 cm and 75% effaced with a history of contractions
Screening tests used to guide PTL interventions:
- Sterile cervical exams
- Cervical length via trans-vaginal US
- > 3 cm = decreased risk of preterm labor at this time
- < 2 cm = increased risk of PTL that will progress to preterm birth - Fetal fibronectin (fFN)
- Use between 22-34 weeks GA when cervical length between 2-2.9 cm because most predictive
- High negative predictive value: if NEG < 1% chance of giving birth in next 7 days
- Low positive predictive value: if POS means nothing
- Collect via vaginal swab (before cervical exam/pelvic US)
- Test is altered by blood, lubricant, sex
Prevention of Preterm Labor
- Regular prenatal visit to identify and address risk factors
-Identify and treat maternal infections
-Assess for and promote adequate nutrition and weight gain
-Promote dental care
-Smoking/drug/alcohol cessation
-Decrease stress - Avoid unnecessary IOL-iatrogenic prematurity!
- Cerclage in women with history of incompetent cervix
- History of previous preterm birth
-Progesterone supplementation– from 16-36 6/7 weeks
-Daily vaginal progesterone OR
-Weekly IM progesterone injections
Preterm Labor Management
- tocolysis
- magnesium sulfate
- maternal corticosteroids
- antibitoics
Preterm Labor Management: tocolysis
- use of medications in patients 24-33 6/7 gestation to delay birth to allow for administration of corticosteroids or transport to higher level care
- Nifedipine, indomethacin, terbutaline
Preterm Labor Management: magnesium sulfate
- for fetal neuroprotection in patients < 32 weeks who are at high-risk of preterm birth within 24 hours
- Reduces severity/risk of CP in surviving infants
- Limit treatment to no longer than 24 hours
- discontinue with birth of baby
- dosing, side effects, care are the same as when this medication is used for pre-eclampsia
Preterm Labor Management: maternal corticosteroids
- (24-33 6/7)
- Reduces risk of neonatal death, intraventricular hemorrhage, and RDS
- Greatest benefit 48 hours -7 days post treatment
Preterm Labor Management: antibiotics
- Preterm labor (<37 weeks; GBS status unknown)– to prevent early onset neonatal GBS sepsis
- Intraamniotic infection
- pPROM (24-33 6/7)–Infection is one cause of pPROM
*Helps to delay an indicated preterm delivery due to intraamniotic infection
Preterm Labor Tocolytic agents
- Nifedipine (Ca++ channel blocker)
- Indomethacin (NSAID)
- Terbutaline (beta-adrenergic)
Nifedipine
Side effects: maternal tachycardia, palpitations, flushing, headaches, dizziness, and nausea
Indomethacin (NSAID)
Side effects: maternal nausea, heartburn; fetal constriction of ductus arteriosus, oligo, NEC
Terbutaline side effects
tachycardia (both), hyperglycemia, palpitations , pulmonary edema, myocardial ischemia, and cardiac arrhythmia
Nursing Care & Interventions for preterm labor: hospital care
- Evaluate pregnant person’s status
- Evaluate fetal status
- Administer meds & evaluate for side effects
-Ex: No Terbutaline if HR > 120; FHR > 180! - Keep SVEs to minimum
- Decrease anxiety
- Anticipatory guidance for labor & birth and neonatal period following preterm birth
- Have NICU team talk to family
Nursing Care & Interventions for preterm labor: home care
- Those at risk for PTD who are currently stable may be monitored at home for:
- Infection- elevated temperature; abnormal discharge, pain, etc.
- Increased contractions
When to NOT Attempt to Stop PTL
-Fetal demise
-Lethal fetal anomaly
-Preeclampsia with severe features/eclampsia
-Hemorrhage/severe abruption
-Chorioamnionitis
-Severe IUGR
-Fetal lung maturity (how do we check this?)
-Acute non-reassuring fetal status
TOO LATE: Post-term Pregnancy
Pregnancy that extends > 42 0/7 weeks
risk factors for post term pregnancy
-Primigravidas
-Personal history of previous post-term delivery
-Family history of post-term pregnancy –? genetic predisposition
-Fetal anomalies
-Often no risk factors
-*Inaccurate dating
Implications of post date pregnancy: Pregnant Person
- Increased risk perineal damage
-Due to increased incidence macrosomia, forceps/vacuum-assisted vaginal deliveries - Increased risk of Cesarean birth (rates double)
- Anxiety, emotional fatigue!!!
Implications of post date pregnancy: Fetal-Neonatal
- have Macrosomia: fetus continues to grow
- Birth trauma R/T macrosomia
- Eventual breakdown of the placenta: “limited shelf life”
1. Uteroplacental insufficiency: Intrauterine growth restriction (IUGR – SGA infant), Late decelerations during labor
2. Oligohydramnios : Increased chance of cord compression –> Variable decelerations - Risk for Meconium Aspiration Syndrome (MAS) while in utero or with delivery: Fetus aspirates meconium into pulmonary tree
Establishing Fetal-Well Being at 41 weeks Gestation
**In order to assess whether placental functioning remains adequate:
- Biweekly Non-Stress Tests
-Desire reactive NST - 2 accelerations in 20 minute period that meet requirements
-If nonreactive– BPP or IOL - Weekly Amniotic Fluid Check:
-Maximum vertical pocket (MVP)
-Normal = 2 cm - < 8 cm (more than 2 less than 8) - PRN Biophysical Profile
-Abnormal: < 8 - Fetal Movement
-< 10 movements in 2 hours
-Or decreased fetal movement from normal
metabolism
- chemical process by which cells produce the substances and energy needed to sustain life
- catabolism
- anabolic process
catabolism
-Organic compounds are broken down to provide heat and energy
-Provides energy for anabolism; excess stored in fat or as glycogen
Catabolic hormones
- Cortisol, glucagon, adrenalin, cytokines
anabolic process
-Simpler molecules are used to build more complex compounds like proteins for growth and repair of tissues
-Source of energy comes from catabolism
anabolic hormones
Insulin, estrogen, testosterone, & growth hormones
normal physiologic metabolic changes in pregnancy
-Lower glucose tolerance
-Higher blood glucose levels
-Progressive insulin resistance
-Increased insulin production
placentas role in metabolic changes in early pregnancy
-to provide sustained supply of glucose to developing fetus
-Estrogen and progesterone stimulate insulin production & cellular responses
-Results in ANABOLIC state that increases the storage of glycogen for future maternal-fetal demands
placentas role in metabolic changes in late pregnancy
-to provide sustained supply of glucose to developing fetus
-period of progressive insulin resistance from hPL, prolactin, cortisol, and glycogen
-Glucose actively transported across the placenta to fetus and used as a fuel source; increases as fetus grows and needs more (diabetogenic effect on pregnancy)
-Maternal fat metabolized in pregnancy during periods of fasting (nighttime)
-Maternal glucose needs met by lower peripheral uptake of glucose
Classifications of Diabetes
- Pre-existing Diabetes (prior to pregnancy)
- Gestational Diabetes (GDM) (during pregnancy)
Pre-existing Diabetes (prior to pregnancy) types
- type one
- type two
Pre-existing Diabetes (prior to pregnancy) type one
“Can’t make it”: inadequate production of insulin by ß cells (Islets of Langerhans) of the pancreatic gland
Pre-existing Diabetes (prior to pregnancy) type two
- “Can’t use it”: cell membrane receptor site failure causes inability to utilize insulin
- These are further classified based on severity of disease process
Gestational Diabetes (GDM) (during pregnancy) types
-A1GDM- diet controlled
-A2GDM- requires medications to control it (insulin first line but some providers use Metformin, Glyburide)
Gestational Diabetes
- Carbohydrate intolerance of varying degrees
- Onset or 1st recognition during pregnancy
GDM Risk Factors
*Overweight/obesity
*Lack of physical activity
*Previous GDM, pre-diabetes
*Polycystic ovary syndrome
*Diabetes in 1st degree relatives (type 1 or 2 but not GDM)
*Previous delivery of a > 9 lb. baby
*Black, Hispanic, American Indian, Asian, Pacific Islander
*Older maternal age (especially >40 years)
Screening and Testing for GDM: Pre-existing Type 1 or Type 2 DM
- No glucose screening needed
- Critical to maintain tight blood sugar control, adjust meds, prn
- Monitor Hgb A1C levels: Hgb A1C of >/=6.5% associated with higher risk of congenital anomalies (5x increase in heart, skeletal, CNS congenital defects if hyperglycemia in 1st trimester)
- Care in multidisciplinary teams crucial to optimal outcomes
- Recommend healthy diet, daily exercise, stay within recommended weight parameters in pregnancy
Screening and Testing for GDM: Universal screening
- All pregnant patients who do not have pre-existing DM or have an early diagnosis
- at 24-28 weeks
- Either 1-hour GCT or 2-hour GTT
when to do early screening and testing for GDM to screen for undiagnosed type 2 DM
- at initiation of prenatal care
- patients with a BMI >25 (23 in Asian American) and 1 or more of the following:
1. Previous GDM, macrosomia (>4000), stillbirth
2. Physical inactivity
3. 1st degree relative with diabetes
4. High risk race or ethnicity (AA, Latino, Native American. Asian American, Pacific Islander)
5. HTN, h/o CVD
6. Low HDL or high triglycerides
7. PCOS, acanthosis nigricans, morbid obesity and other conditions associated with insulin resistance
8. A1C greater than 5.7% on previous testing, impaired glucose tolerance or impaired fasting glucose
what if the early screening for undiagnosed type 2 DM is negative
- If early screening/testing is negative, RETEST at 24-28 weeks (Universal screening)
what if the early screening for undiagnosed type 2 DM is positive
If early 1-hr screening is positive– confirm with 3-hr GTT
what if there is a negative 3 hour GTT with early testing
Negative 3-hr GTT- repeat 3-hr GTT at 24-28 weeks
what if there is a positive 3 hour GTT for early testing
Positive 3-hr GTT–treated as GDM; Do not repeat testing at 24-28 weeks
Screening (2-step procedure)
- 1-hour 50g oral glucose challenge test, non fasting: Positive screen: blood glucose >130-140mg/dL (institutional)= Proceed to diagnostic testing with 3-hour 100g GTT
Diagnostic (1-step procedure)
- 2-hour 75 g GTT
- results for positive test: fasting: ≥ 92, I hour: ≥ 180, 2 hour: ≥ 153
- Need 1 abnormal for GDM diagnosis
GDM Testing: if 1 hr 50 g test results are abnormal (>/= 130-140) then…
- schedule 3 hour 100 g test
GDM Testing: if 1 hr 50 g test results are >/= 200 then
patient is diagnosed with GDM (likely pre existing) and no further testing is needed
GDM Testing (2 step method): 3-hour Glucose Tolerance Test (3-hr GTT)
- Have patient eat normal unrestricted diet prior to day of testing
- No food, smoking, exercise for 8-12 hours before first blood draw
- Procedure can take up to 4 hours
- Fasting glucose drawn
- Give 100-gram glucose drink
-NPO except water, no smoking, minimal activity
-Glucose levels drawn q 1 hour for 3 hours following glucose load
GDM Testing (2 step method): 3-hour GTT levels results
- Abnormal if fasting: ≥ 95; 1 hour: >180; 2 hour: ≥ 155; 3 hour: ≥ 140
- Need 2 abnormal values for GDM diagnosis
- If fasting is ≥ 126 the patient has GDM, most likely pre-existing. The test can be stopped
What other questions should you ask to
get a more complete history when you suspect GDM
- Prior obstetric history– previous GDM,
stillbirth, pre-eclampsia, shoulder dystocia,
size of baby - Activity level
- Family history of DM in 1st degree relative
- Medical history
1. HTN or history of Cardiovascular
disease; Low HDL or high triglycerides
2. A1C greater than 5.7% on previous
testing
3. Hx of impaired glucose tolerance or
impaired fasting
Medical treatment of GDM
- Indicated if > 30% of glucose values in one week are above the target thresholds (fasting- 95 mg/dL and 1-hr postprandial 140 mg/dL)
- Insulin preferred agent
- Oral hypoglycemic agents (Metformin/Glyburide—not FDA approved in pregnancy) may be used if individual is unwilling/unable to take Insulin or provider preference
- Classified as A2 GDM with initiation of medications
what things can you recommend to help control BS levels in GDM pt
- Keep better track—apps, alarms for tracking
- Don’t skip meals
- Decrease simple sugars and saturated fat in their diet
- Increase protein in their diet
- Increase exercise to 30 min of mod exercise daily
how does not skipping meals help glucose control
The goal is to keep glucose levels from highs and lows by eating small but frequent healthy foods throughout the day
how does Decreasing simple sugars and saturated fat in their diet help control bs levels
- Reduce juice, soda, white bread, white rice, syrup, sugary cereals, and potatoes (high glycemic foods).
- Education on better choices
- Higher levels of saturated fats may worsen pregnancy related insulin resistance
how does increasing protein help control BS levels
- Adding chicken, beef, tofu, nuts, beans to meals may improve levels
- Protein with each meal/snack-helps maintain glucose levels in a steadier state
- high-protein snack at night decreases hypoglycemia at night
how does increaseing excercise help control BS levels
- improves glucose deposition into skeletal muscle, decreases insulin and medication needs
- helps with gestational weight gain
- Education on how to incorporate exercise into her daily routine
Maternal Complications of GDM: now
- Pre-eclampsia, GHTN, abruption, postpartum hemorrhage
- Hydramnios-related to high fetal glucose levels causing excessive urination
- Poor healing, infections (UTIs/yeast infections)
- Ketoacidosis- untreated lead to maternal/fetal death
- Increased risk of a c-section
- Increased risk of forceps/vacuum assisted births
- Increased risk of a shoulder dystocia
Maternal Complications of GDM - later
- Within 20 years > 70% develop overt Type 2 DM
- Increased risk of cardiovascular disease and early atherosclerosis
Fetal/Neonatal Complications of GDM : now
-Increased perinatal mortality/stillbirth
-Macrosomia (EFW > 4,000 grams)
-Pre-term birth
-Hypoglycemia
-Birth trauma
-Hyperbilirubinemia
-Polycythemia
-Respiratory distress syndrome
Fetal/Neonatal Complications of GDM : later
-Don’t know all the implications
-Obesity- born with more body fat (even when nl weight at birth)
-Evidence of female children developing GDM in their own pregnancies.
-Impaired intellectual development, Impaired glucose tolerance
Complications of Pre-existing Diabetes
- All those listed for GDM PLUS
- Thyroid dysfunction
- Increased risk of maternal mortality
- Related to poor glucose control in the first trimester
1. Increased risk of miscarriage
2. 5X greater risk of congenital malformations (BMI >30 without pre-existing DM also has increased risk of congenital malformations)
Antepartum Care: Goals of care for women with DM (either GDM or pre-existing):
-Maintain balance between glucose and insulin
-Optimize health of mom and baby and prevent complications
what additional appointments will someone diagnosed with gdm need
- Q 1-2 week prenatal
appointments- watch BPs,
weight, glucose levels
– Refer to nutritionist/diabetic
educator
– Antenatal screening initiation prn
antenatal testing for A2GDM controlled
- start at 32 wks
- Weekly NST
- Weekly assessment of
amniotic fluid volume - US at 28-32 weeks, 36
weeks
antenatal testing for A2GDM poor control
- start at 32 wks
- Twice weekly NST
- Weekly assessment of
amniotic fluid volume - US at 28-32 weeks, 36
weeks
antenatal testing for DM
- start at 32 wks
- Twice weekly NST
- Weekly assessment of
amniotic fluid volume - Fetal ECHO for early A1C > 6.5%
- US 26-28 wks then q 4
wks
antenatal testing for A1GDM
- not indicated
Antepartum Care for GDM or pre exsisting
- Team approach
- Monitor for maternal and fetal well-being:
Visits
Fetal assessments
Education
Intrapartum Care: A1 GDM
- Expectant management acceptable until 40 6/7 weeks
- Delivery no earlier than 39 weeks unless other indications
Intrapartum Care: A2 GDM with well controlled blood sugars
Consider induction of labor between 39 weeks and 39 6/7 weeks
Intrapartum Care: A2 GDM with poorly controlled Blood sugars
Consider induction of labor between 37 weeks and 38 6/7 weeks
Intrapartum Care: Pre-existing type 1 or type 2 DM without vascular disease
Consider induction at 39 weeks with well controlled blood sugars
Intrapartum Care for GDM or pre exsisting
- Consider earlier delivery if poor control, coexisting HTN, or non-reassurring fetal testing: Amniocentesis to check for fetal lung maturity if delivery prior to 38 weeks
- Offer cesarean section if EFW >4,500 gram
Intrapartum Care: labor management
-Monitor labor progress and descent
-Continuous fetal monitoring
-Prepare for shoulder dystocia
-Monitor for s/s of preeclampsia
-A1GDM random glucose on admission
Intrapartum Care: Additional care for individuals whose diabetes is managed with medications (Type 1, Type 2, or A2GDM)
-Hourly glucose levels once in labor (goal: 70-129)
-Start insulin drip if sugars > 130; Regulated by sliding scale
-IV (fluids hospital dependent): D5LR, normal saline, LR
-Sometimes NPO
-Type I with insulin pump may sometimes use their own pump in labor
what are the possible
neonatal problems this baby might
have during the first few days of life from GDM
– Hypoglycemia
– Respiratory Complications
* Increased risk of RDS due to lack of
surfactant r/t high fetal insulin
inhibiting surfactant production
– Assess for
* Birth trauma
* Hyperbilirubinemia
Postpartum Care and Follow-up
- Insulin resistance of pregnancy rapidly dissipates after delivery of the placenta
- Insulin requirements drop dramatically
Postpartum Care and Follow-up: gestational diabetes
- Resume normal diet
- A2 GDM– stop diabetes medications after delivery
- Screen at 4-12 weeks postpartum for type 2 DM : Using 2-hour 75 g GTT for screening is recommended
Postpartum Care and Follow-up: type one and type two
- Insulin will need to be adjusted; monitor closely for hypoglycemia (type 1 DM)
- Metformin preferred oral agent
- After 24-48 hours resume standard diabetes management
care postpartum for A1GDM
- At 6 week appointment: 2-hr GTT- given 75g glucola
repeated:
- If negative q 1-3 years
– Within 20 years > 70% will revert
to Type 2 DM
– Counseling on weight loss and
physical activity as needed
PP: If someone has GDM and their FPG is > 125 or 75 g 2 hour test is >199 at 4-12 weeks PP…
- diabetes mellitus
- refer for diabetes managment
PP: If someone has GDM and their FPG is 100-125 or their 2 hour glucose test is 140-199…
- impaired fasting glucose or IGT or both
- consider referral for management
- weight loss and physical activity counseling is needed
- consider metformin if combined impaired fasting glucose and IGT
- medical nutrition therapy
- yearly assessment of glycemic status
PP: if someone has GDM and their FPG < 100 or 2 hour glucose test is <140
- normal
- assess glycemic control every 1-3 years
- weight loss and physical activity counseling as needed
