Maternal Diabetes Flashcards
most frequently seen medical condition in pregnancy
Gestational Diabetes
• Affects 3-5% of pregnancies
Increase in incidence of gestational diabetes d/t?
rise is obesity and type 2 in adolescents
4 main challenges for women/fetus in gestational diabetes
1) How to manage both type1 and type 2 diabetes during pregnancy to achieve a healthy glucose/insulin balance during pregnancy
2) How to protect infant from adverse effects of increased glucose levels
3) How to care for infant in first 24hrs until infant’s insulin-glucose regulatory mechanism stabilizes
4) Reproductive planning – women with diabetes may not be good candidates of roral contraceptives (progesterone interferes with insulin activity)
WHat’s the danger for the fetus if the mom has poorly regulated gestational diabetes?
• Infants of women with unregulated diabetes 5X more likely to be born large for gestational age or with birth anomalies
o high incidence of congenital anomaly (such as filure of lower extremities to develop), spontaneous miscarriage, and stillbirth
o Neonates more prone to hypoglycermia, resp distess syndrome, hypocalcemia & hyperbilirubinemia
If DM mom’s glucose is well controlled before pregnancy, will it always be well controlled after?
Glucose-insulin regulatory systems affected by pregnancy – likely to experience less than optimal control even if successful regulation of either types pre pregnancy
Describe some of the changes that take place during preg re glucose control:
o GFR of glucose increases in pregnancy (threshold lowered) → causes slight glucosuria
o Inc resistance to insulin as preg progresses → is advantageous in reg preg to ensure no damage due to dangerously low glucose…but with diabetes must increase insulin dosing beginning wk 24 to prevent hyperglycemia
o Must simultaneously protect against hypoglycemia + acidosis as fetus uses glucose
o Rate of insulin secretion inc, fasting glucose level lowered
If has preexisting renal disease, risk of ______ in pregnancy rises sig
HTN
Why are babies of moms with DM fat fat fat?
Infants typically larger (>10lb) d/t inc insulin fetus must produce to counteract overload of glucose, which acts as growth stimulant
Hydramnios
may develop d/t high glucose – causes extra shift of fluid to amniotic fluid
When is glucose control especially important during preg for mom’s with DM?
esp important during first trimester
When does gestational diabetes typically appear in preg?
Does it last beyond preg?
Most commonly dev at pregnancy midpoint
Symptoms fade postpartum, but much higher risk of developing Type 2
What is the cause and risk factors for GD? What is it?
D/t unknown, but is either inadequate insulin response to CHO, excessive insulin resistance, or both
o Obesity
o Age >25yrs
o Hx of large babies (>10lbs)
o Hx of unexplained fetal or perinatal loss
o Hx of genital anomalies in previous pregnancies
o Hx of polycystic ovary syndrome
o Fam hx of DM (one close or two distant)
o High risk populations: first nations, Hispanic, Asian
Symptoms to look for in pregnancy woman with DM
- Dizziness (if hypoglycemic),
- Confusion (if hyperglycemic)
- Thirst
- Congenital anomalies
- Macrosomia
- Inc risk of pregnancy induced HTN
- Hydramnios,
- Possibility of inc monilial infection
- Hyperglycemia
- Poor fetal heart tone variability and rate from poor tissue perfusion
- Glycosuria, polyuria
Important screening and monitoring for gestational diabetes?
- Screen all women for DM during preg
- Threshold for diagnosis: usually done with 75-g oral glucose challenge test (glucose taken 1,2,3hrs after 75g glucose soln post fasting)
• Must see dr prior to pregnancy to ensure proper management in early times
• Best to determine if pregnancy asap
• Measure A1C
(upper normal HbA1C= 6% of total Hb)
• Urine culture done each trimester
• Ophthalmic exam once during preg for GDM and each trimester for DM (see retinal changes)
Why is a urine test done each trimester?
inc glucose = inc risk for infection
Consideration for morning sickness?
• Nausea + vomiting early on and heartburn later in preg big challenge to preventing hypoglycemia→ may need IV fluid + glucose
Imp nutritional info for DM mom’s.
- Must track CHO intake → admin # of insulin units based on insulin-to-CHO ratio
- Divide calories by 3 meals + 3 snacks, divide up CHOs so glucose level remains constant
- Ideal: 20% calories protein, 40%-50% CHO, 30% from fat
- Reduce saturated fats + cholesterol
- Inc fibre
- Extremely vulnerable to hypoglycemia at night as fetus continues to use glucose → make last snack combo of complex carb and protein for slow digestion
- Later in preg: must be extreme nutrition conscious to maintain glucose level, and keep weight gain to suitable amount (25-30lb) in hopes of making vaginal birth possible
- Should not reduce intake below 1800 calories →may lead to fat breakdown + acidosis
WHy is increased fibre important for DM diet?
decreases postprandial hyperglycemia, thus lowering insulin requirements
Important things about exercise for DM moms?
- Lowers serum glucose levels, and therefore insulin needs
- Best to start exercise before preg begins to monitor initial fluctuations in glucose
- Muscles continue to take in glucose for 12hrs post exercise
- Insulin injected in arm that is then exercised will cause rapid absorption w possible hypoglycemia – to avoid this, should eat snack of protein or complex carb before exercise + should maintain consistent exercise program
- Better to do 30mins walking/day than aerobic exercise one and nothing the next
- If poorly managed, extreme exercise will cause hyperglycemia + ketoacidosis as liver releases glucose + fats broken down (but body cannot use b/c lack of insulin)
How do insulin needs change over pregnancy?
o Will need less at first (because fetus uses glucose for rapid growth), will need inc as preg progresses (as metabolic rate increases)
With those with GD always be put on insulin?
will be started on insulin if diet alone not adequate
Will women with well managed diabetes be able to maintain same regimen during pregnancy/.
Ensure knows change in regimen necessary for changing metabolism – can be unnerving if has good management prior
How is insulin usually divided during the day?
2/3 given in AM, 1/3 given evening → 30 mins prior to breakfast (2:1 ratio of intermediate to regular) and just before dinner (1:1 ratio)
Can women with GD use oral antihypoglycemis?
No, are teratogens.
