Maternal Diabetes

Question 1

most frequently seen medical condition in pregnancy

Answer 1

Gestational Diabetes

• Affects 3-5% of pregnancies

Question 2

Increase in incidence of gestational diabetes d/t?

Answer 2

rise is obesity and type 2 in adolescents

Question 3

4 main challenges for women/fetus in gestational diabetes

Answer 3

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)

Question 4

WHat’s the danger for the fetus if the mom has poorly regulated gestational diabetes?

Answer 4

• 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

Question 5

If DM mom’s glucose is well controlled before pregnancy, will it always be well controlled after?

Answer 5

Glucose-insulin regulatory systems affected by pregnancy – likely to experience less than optimal control even if successful regulation of either types pre pregnancy

Question 6

Describe some of the changes that take place during preg re glucose control:

Answer 6

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

Question 7

If has preexisting renal disease, risk of ______ in pregnancy rises sig

Answer 7

HTN

Question 8

Why are babies of moms with DM fat fat fat?

Answer 8

Infants typically larger (>10lb) d/t inc insulin fetus must produce to counteract overload of glucose, which acts as growth stimulant

Question 9

Hydramnios

Answer 9

may develop d/t high glucose – causes extra shift of fluid to amniotic fluid

Question 10

When is glucose control especially important during preg for mom’s with DM?

Answer 10

esp important during first trimester

Question 11

When does gestational diabetes typically appear in preg?

Does it last beyond preg?

Answer 11

Most commonly dev at pregnancy midpoint

Symptoms fade postpartum, but much higher risk of developing Type 2

Question 12

What is the cause and risk factors for GD? What is it?

Answer 12

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

Question 13

Symptoms to look for in pregnancy woman with DM

Answer 13

• 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

Question 14

Important screening and monitoring for gestational diabetes?

Answer 14

• 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)

Question 15

Why is a urine test done each trimester?

Answer 15

inc glucose = inc risk for infection

Question 16

Consideration for morning sickness?

Answer 16

• Nausea + vomiting early on and heartburn later in preg big challenge to preventing hypoglycemia→ may need IV fluid + glucose

Question 17

Imp nutritional info for DM mom’s.

Answer 17

• 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

Question 18

WHy is increased fibre important for DM diet?

Answer 18

decreases postprandial hyperglycemia, thus lowering insulin requirements

Question 19

Important things about exercise for DM moms?

Answer 19

• 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)

Question 20

How do insulin needs change over pregnancy?

Answer 20

o Will need less at first (because fetus uses glucose for rapid growth), will need inc as preg progresses (as metabolic rate increases)

Question 21

With those with GD always be put on insulin?

Answer 21

will be started on insulin if diet alone not adequate

Question 22

Will women with well managed diabetes be able to maintain same regimen during pregnancy/.

Answer 22

Ensure knows change in regimen necessary for changing metabolism – can be unnerving if has good management prior

Question 23

How is insulin usually divided during the day?

Answer 23

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)

Question 24

Can women with GD use oral antihypoglycemis?

Answer 24

No, are teratogens.

Question 25

Important ed for women regarding onset and peak of insulins?

Technique for insulin injection in GD?

Answer 25

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

Question 26

What to tell mom to do if discovers is hypoglycemic?

Answer 26

drink fluid with sustained CHO like milk, with crackers - prevents rebound phenomena

Question 27

What is nurse to do if discovers GD pt to be hypoerglycemic?

Answer 27

assess urine for ketones; if ketones in 2 samples, see dr; most common in second + third months

Question 28

Considerations for insulin pump regarding treatment?

Answer 28

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

Question 29

• Tests for placental fx and fetal wellbeing:

Answer 29

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

Question 30

Considerations regarding timing of birth?

Answer 30

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

Question 31

Can women with DM breastfeed?

Answer 31

Yes, insulin doesn’t pass into milk

Question 32

Postpartum close monitoring key because?

Answer 32

o Need close monitoring: if hydramnios present, risk for hemorrhage

GD: regular checkups to ensure Type 2 doesn’t develop

Question 33

Postpartal considerations for mom’s who have DM or GD? How might insulin needs change for these populations after childbirth?

Answer 33

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

Question 34

*What is GDM?

Answer 34

A condition of abnormal glucose metabolism that arises during pregnancy

Question 35

*Prevention of GDM?

Answer 35

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

Question 36

*Diagnosis of GDM?

Answer 36

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)

Question 37

How do glucose targets differ for those with GDM?

Fasting target values?

Answer 37

• Glucose targets are tighter during pregnancy

Fasting and preprandial target is 3.8-5.2mmol/L

Question 38

Target A1C value?

Answer 38

should be under 6%

Question 39

Why is esp important for those with GDM to pay more attention to diet and exercise and how this affects glucose levels?

Answer 39

ability to regulate glucose decreases

Question 40

Why are babies of mom’s with GDM large?

Why are the babies at risk of hypoglycemia postpartum?

Answer 40

• 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)

Question 41

Complications for mom with GDM during preg?

Answer 41

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.)

Question 42

Possible heart complication for babies of mom with GDM after birth?

Answer 42

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)

Question 43

Breast feeding good because?

Answer 43

can help reduce incidence of obesity in the child (and therefore risk of child developing Type 2 DM later)

Question 44

How will children with Type 1 DM often present at diagnosis?

Answer 44

with general malaise, change in appetitde, listless, severe dehydration, lips and eyes sunken from dehydration

Question 45

Is rapid hydration of child with type1 smart when discover severely dehydrated?

Answer 45

• 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