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.
Important ed for women regarding onset and peak of insulins?
Technique for insulin injection in GD?
o Teach when insulin’s at peak so woman can know when apt to hypoglycemia and act accordingly
o Injection technique: pull skin taught, inject at 90 degrees → women typically pref arm + thigh to stomach; rotate sites
What to tell mom to do if discovers is hypoglycemic?
drink fluid with sustained CHO like milk, with crackers - prevents rebound phenomena
What is nurse to do if discovers GD pt to be hypoerglycemic?
assess urine for ketones; if ketones in 2 samples, see dr; most common in second + third months
Considerations for insulin pump regarding treatment?
o Continuous infusion – can self admin bolus with mealtimes,
o Should clean site daily + cover with sterile gauze; choose new site q12-24hrs to optomize absorption + prevent infection
o Take gluose QID
o Do not bathe with whole set up, can shower if removes pump only
• Tests for placental fx and fetal wellbeing:
o Looks at kidney function (shows vascular system…also implies uterine perfusion adequate)
o Stress test/nonstress test for placental fx
o Monitor fetal movement (normal = 10kicks/hour)
o Ultrasound
o Corticosteroids can hasten lung maturity…not recommended for fetus who is already at risk of poor glucose control
Considerations regarding timing of birth?
o Weeks 36-40 time of great risk: fetus drawing large stores of maternal nutrients
o Used to use cessarian at 37weeks – not done now
o Vaginal birth preferable - can induce labour + cervical ripening
o Glucose level monitored during birthing process
o Avoid IV glucose solutions as plasma expanders – use RL or NS instead
Can women with DM breastfeed?
Yes, insulin doesn’t pass into milk
Postpartum close monitoring key because?
o Need close monitoring: if hydramnios present, risk for hemorrhage
GD: regular checkups to ensure Type 2 doesn’t develop
Postpartal considerations for mom’s who have DM or GD? How might insulin needs change for these populations after childbirth?
o Yet another insulin readjustment
o DM - Insulin resistance gone - may not need insulin for few days, then returns to prepregnancy requirements
o For GD: usually normal glucose levels after 24hrs, then won’t require insulin tx
*What is GDM?
A condition of abnormal glucose metabolism that arises during pregnancy
*Prevention of GDM?
Eat healthy foods
Lose any extra weight prior to pregnancy
Exercise before and during pregnancy
Maternal vitamins and supplements – onset 3 months prior to conception
Regular check ups and screening for:
Glucose tolerance test, proteinura, HTN
Glycemic control for Diabetic mothers – Type 1 or Type 2
*Diagnosis of GDM?
anyone exhibiting signs of DM needs to be checked out as soon as possible, need to be looking for this on top of any other normal considerations – look for the three P’s
Suggested screening test for GDM:
All pregnant woman between 24 – 28 weeks gestation
GGT - Gestational Diabetes Screen – a 50-g glucose load followed by a plasma glucose test measured 1 h later. (doesn’t require fasting)
How do glucose targets differ for those with GDM?
Fasting target values?
• Glucose targets are tighter during pregnancy
Fasting and preprandial target is 3.8-5.2mmol/L
Target A1C value?
should be under 6%
Why is esp important for those with GDM to pay more attention to diet and exercise and how this affects glucose levels?
ability to regulate glucose decreases
Why are babies of mom’s with GDM large?
Why are the babies at risk of hypoglycemia postpartum?
• Fetus utilizes insulin and glucose of mother – can put on excess fat
– post delivery, has own insulin now but no longer glucose produced by the mother, so at very high risk over first day to become severely hypoglycemic
= Reactive hypoglycemia – after brith until 18hrs baby at high risk!! – important baby is fed as soon as possible, put colostrum doesn’t have a lot of calories in it, may require supplemental glucose for first couple of days; keep baby warm (babies have poor thermoregulation)
Complications for mom with GDM during preg?
o Tend to be same for mother as anyone with DM
o Diabetic mother at much greater risk of pre-eclampsia (very high BP during preg)
o Retinopathy – can occur up to a year post delivery
o Tend to be more acute, affect 2 people instead of just one
- Monitor for usual complications (renal fx, neuropathy, cardio disease, etc.)
Possible heart complication for babies of mom with GDM after birth?
Foramen ovale may not close as soon – risk of shunting blood, resulting in much lower O2 level systemically, this may affect energy levels (monitor for this)
Breast feeding good because?
can help reduce incidence of obesity in the child (and therefore risk of child developing Type 2 DM later)
How will children with Type 1 DM often present at diagnosis?
with general malaise, change in appetitde, listless, severe dehydration, lips and eyes sunken from dehydration
Is rapid hydration of child with type1 smart when discover severely dehydrated?
• If rehydrate very quickly -→ cells in brain start rehydrating quickly, can result in cerebral edema (children who are undiagnosed type 1 at high risk of this) 50% mortality rate → important to be very gentle in rehydration and getting glucose level back to normal
