T4 - Endocrine Metabolic Disorders (Josh) Flashcards
– – is caused by lack of insulin or lack of insulin effect.
Diabetes Mellitus
***Key to optimal pregnancy outcome is strict glucose control
— — is an absolute insulin insufficiency and requires administration of exogenous insulin.
— — is insulin resistence with varying degrees of insulin deficiency.
Type 1 DM
Type 2 DM
Risk factors for Gestational Diabetes Mellitus (GDM)
obesity
aging
sedentary lifestyle
HTN
prior GDM
Gestational DM:
Class — can be controlled via diet.
Class — requires meds.
A1
A2
Gestational DM:
Woman has two or more abnormal values with normal fasting blood sugar.
Class A1
Gestational DM:
Woman was not known to have diabetes before pregnancy, but requires medication for blood glucose control.
Class A2
Pregestational DM:
Onset of disease occurs after age 20 and duration of illness is
Class B
Pregestational DM:
Onset of disease occurs b/t 10-19 years old or duration of 10-19 years or both.
Class C
***NOTE: Class A-C generally have GOOD PREG outcomes
Pregestational DM:
Onset of disease occurs at 20 years or both.
Class D
***Note: Class D-T will have vascular complications
Pregestational DM:
Client has developed diabetic nephropathy.
Class F
Pregestational DM:
Client has developed Retinitis Proliferans
Class R
Pregestational DM:
Client has had a Renal Transplant
Class T
During the first trimester, pregnancy — insulin production.
increases
***can cause hypoglycemia
What conditions lead to hypoglycemia in pregnancy?
Fetus takes lots of mom’s glucose
N/V can drop blood glucose
Human Placental Lactogen (HPL) is secreted
**an insulin antagonist
By the 2nd and 3rd trimesters, insulin requirements —
increase
***as much as 4 x’s the usual amount
With expulsion of placenta, what happens to body’s insulin needs?
abrupt drop of hormones and return to prepregnant state –> insulin needs DECREASE
When are insulin needs greatest during pregnancy?
wks 36-40
Maternal Risks w/ DM
Worsening of pre-existing disease (vascular or renal probs)
Hypoglycema first half of preg
Hyperglycemia (Ketoacidosis) in 2nd and 3rd trimesters
Polyhydramnios
Pre-eclampsia
Dystocia
***all these probs are more common with Type 1 DM
When does fetus start producing own insulin?
baby pancreas produces own insulin by 10 WEEKS gestation
Diabetes affects on fetus
Macrosomia
LGA
IUGR r/t maternal vascular probs
Delayed Lung Maturity
Hypoglycemia after birth
Neural Tube and Skeletal Defects
Screening and Testing to Rule Out Gestational DM
50 gram Oral Glucose Tolerance Test
3 Hr Oral Glucose Tolerance Test (OGTT)
Oral Glucose Tolerance Test:
How to perform 50 Gram OGTT
No fasting
Routine for all clients at 24-28 wks
50 g of oral glucose cola drink and blood drawn one hour later
Glucose > 130-140 mg/dL is positive and will follow up with 3 Hr Test
Oral Glucose Tolerance Test:
How to perform 3 Hr OGTT
Load up on CHO
Fast after midnight
100 g glucola –> blood drawn at fasting, 1, 2, and 3 hrs
Positive if 2 OR MORE VALUES equal or exceed
What values are we looking for with 3 Hr OGTT?
BOOK
Fasting = 60-99
1 hr = 100-129
2 hr =
What values are we looking for w/ 3 Hr OGTT?
her PPT slides
Fasting =
If 1 hr (50 g) OGTT is 140?
140 = do a 3 hr exam to further evaluate GDM
What is an acceptable fasting blood sugar level?
60-90 mg/dL
3 Hr OGTT:
Two elevations greater — than indicates diabetes.
140 mg/dL
What is a good number for Blood Glucose?
Fasting = 60-90
1 hr = 130-140
2 hr =
Hgb A1C:
Levels — indicate good blood sugar control.
Levels — indicates fair control
Levels — indicate poor control.
Good = 2.5 - 5.9%
Fair = 6-8%
Poor = > 8%
What is Euglycemia?
Glucose of 65-95 before meal
Glucose of 130-140 one hr after meal
Calories:
Non-obese pregnant client needs —
Obese client needs —
35 cal/kg/day
25 cal/kg/day
Diet for DM:
How many meals per day?
3 x’s day w/ 2-3 snacks
Diet for DM:
How many carbs?
Protein?
Fat?
carbs = no more than 55%
protein = 20%
fat = 25%
Diet for DM:
What type of snack is important to prevent drop in Blood Sugar during night?
night snack high in protein
Insulin Therapy:
— of daily insulin dose is given at breakfast.
2/3
**combo of intermediate or long-acting and short-acting
Insulin Therapy:
— of daily insulin is given in evening.
1/3
** combo of long and short-acting
— are seldom used during pregnancy.
Oral DM meds
S/S of Hypoglycemia
Nervousness
HA
Shaking/Irritability
Hunger
Blurred Vision
Diaphoresis
Treatment for Hypoglycemia:
What can we do if glucose is
drink 15 mg simple carbs
- **whole milk
- **hard candy
Rest 15 mins and recheck
If > 60, eat a meal w/ protein to stabilize glucose level
What is hyperglycemia?
> 130 mg/dL
S/S of Hyperglycemia
Skin dry and flushed
Thirsty w/ frequent urination
Kussmaul respiration w/ fruity odor
Fetal Surveillance for DM:
MSAFP at 15-20 wks gestation
US for anomalies
Fetal ECG at 20-22 wks
BPP
NST 1-2 times weekly from 34 wks
Daily kick counts from 28 wks
Management of Diabetes during Labor and Birth
Regular Insulin via IV piggyback
Hourly glucose checks
***maintain
Why are glucose checks done more frequently during Second Stage of Labor?
Voluntary pushing requires more energy
Why is maintaining integrity of nipples an areola important w/ DM patients?
they are more prone to infection than a normal client
Contraceptives for DM Client
Oral contraceptives contraversal r/t effect on carb metabolism and risk of thrombus
Instead, use:
- Barrier Method
- IUD
Risk Factors for Gestational DM
Family history of DM
Native Americans
Maternal Obesity
Previous LGA baby
Previous unexplained stillbirth
S/S of Hypoglycemia in Neonate
Jittery
Tremors
Hypotonia
Unstable Temp
How much weight loss can Hyperemesis cause?
at least 5% or prepregnancy weight
When does Hyperemesis ususally begin?
at 4 wks and lasts up to 20 wks
Possible causes of Hyperemesis
Increasing Estrogen levels
Increasing Progesterone levels
Increasing hCG levels
Hyperthyroidism
Esophageal Reflux
Can psycho-social factors like ambivalence cause hyperemesis?
Yes
With hyperemesis, how do we want them to eat?
every 2-3 hrs
sometimes w/out liquids
bland to begin with
What are the Fetal Risks associated w/ Hyperemesis?
IUGR
Anomalies
Death from hypoxia or maternal ketoacidosis
What are signs of starvation that can alert us to hyperemesis?
Muscle wasting
Jaundice
Bleeding Gums (Vit. Deficiency)
Mgmt of Hyperemesis
IV Fluids
NPO until dehydration resolved and for 48hrs after vomiting has stopped
I’s and O’s (including emesis)
Daily Weights
Small, frequent meals once 48 hrs w/ no vomiting
Maternal PKU:
What levels of Phenylalanine do we want?
2-6 mg/dL
