resulting from inadequate production or use of Insulin.
DIABETES MELLITUS 4 Cardinal Signs of DM: 1. Polyuria (with glycosuria) 2. Polydipsia 3. Polyphagia 4. Weight loss
Early Pregnancy: Insulin release accelerates Significant hypoglycemia may occur Increase in fat stores Late Pregnancy: Placental hormones rise sharply Insulin resistance happens Insulin insufficency occurs May have episodes of hyperglycemia Switch from CHO metabolism to gluconeogenesis Effects of Pregnancy on Fuel Metabolism DM may be difficult to control because insulin requirements are changeable. 1. During the first trimester, the need for insulin frequently decreases. 2. N/V may cause dietary fluctuations 3. Insulin requirements increase 4. Increased energy needs during labor 5. Decrease in insulin requirement occurs after the passage of the placenta
Influence of Pregnancy On Diabetes The pregnancy of a woman who has diabetes carries higher risk of complications
Influence of Diabetes on Pregnancy Outcome
Type 1 or IDDM Type 2 or NIDDM Gestational Diabetes Other specific types
Classifications of Diabetes Mellitus DIABETES MELLITUS A condition of abnormal glucose metabolism that arises during pregnancy. Possible signal of an increased risk for type 2 diabetes later in life.
DIABETES MELLITUS Overweight or obesity Chronic hypertension Maternal age older than 25 years Family history of diabetes Previous birth of a large infant (> 4000g) Previous birth of an infant with unexplained congenital anomalies Previous unexplained fetal death Gestational diabetes in previous pregnancy Multifetal pregnancy Fasting serum glucose > 140 mg/dl or random serum glucose > 200 mg/dl
Hydramnios Preeclampsia-eclampsia
Congenital anomalies LGA RDS Polycythemia Hyperbilirubinemia DIABETES MELLITUS History How long has she had the disease? How does she maintain normal blood glucose? Is she familiar with ways to monitor blood glucose and administer insulin?
DIABETES MELLITUS Physical Examination Baseline ECG should be obtained Evaluation for retinopathy Weight and BP monitoring Fundal height should be measured
DIABETES MELLITUS SCREENING TESTS Glucose Challenge Test (GCT) The woman should ingest 50g of oral glucose solution. One hour later a blood sample is taken. If the blood glucose concentration is 140 mg/dl or greater, a 3-hour oral glucose tolerance test is recommended. Some practitioners use a lower cutoff of 130 or 135 mg/dl to identify more women at risk.
DIABETES MELLITUS SCREENING TESTS Oral Glucose Tolerance Test (OGTT) The woman must fast from midnight on the day of the test. The woman should ingest 100g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3 hours.
DIABETES MELLITUS
DIABETES MELLITUS Oral Glucose Tolerance Test (OGTT) Gestational diabetes is the diagnosed if the fasting blood glucose level is abnormal or if two or more of the following values occur on the OGTT: Fasting, > 95 mg/dl 1 hr, > 180 mg/dl 2 hrs, > 155 mg/dl 3 hrs, > 140 mg/dl
DIABETES MELLITUS Monitoring a Woman with Diabetes A woman should use a home test kit to determine if she is pregnant at the earliest possible time. The measurement of glycosylated hemoglobin is used to detect the degree of hyperglycemia present. HbA1c is measured. Ophthalmic examination
DIABETES MELLITUS Risk for ineffective tissue perfusion related to reduced vascular flow. Imbalanced nutrition, less than body requirements, related to inability to use glucose. Risk for ineffective coping related to required change in lifestyle. Risk for infection related to impaired healing accompanying condition.
DIABETES MELLITUS Deficient fluid volume related to polyuria accompanying disorder. Deficient knowledge related to difficult and complex health problem. Health seeking behaviors related to voiced need to learn home glucose monitoring. Deficient knowledge related to therapeutic regimen necessary during pregnancy.
DIABETES MELLITUS Demonstrate competence in home glucose monitoring and administration of insulin before home management is initiated.
Describe a plan for meeting dietary recommendations that fits family lifestyle and food preferences.
Identify signs and symptoms of hypoglycemia and hyperglycemia and the management required for each.
Verbalize knowledge of fetal surveillance procedures and keep scheduled appointments for testing.
DIABETES MELLITUS MAJOR GOALS: 1. To maintain physiologic equilibrium of insulin availability and glucose utilization during pregnancy
2. To ensure an optimally healthy mother and newborn.
MORE IN REVIEW ARTICLES
1. Dietary Regulation Simple sugars in concentrated sweets should be eliminated For obese women, a small percentage of CHO is recommended Calories should be divided among 3 meals and at least 3 snacks
2. Exercise Exercise and active lifestyle can improve cardiorespiratory fitness
5. Evaluation of Fetal Status AFP screening Ultrasound BPP NST Contraction test
DIABETES MELLITUS Timing of birth - spontaneous labor - CS birth maybe indicated Labor management - hourly monitoring of glucose levels - 5% dextrose solution, normal saline
Maternal insulin requirements fall during postpartal period. Antihyperglycemics contraindicated during breastfeeding. Postpartum adjustment
Increasing Effective Communication Providing Opportunities for Control Providing Normal Pregnancy Care
The woman and at least one support person can demonstrate competence in home glucose monitoring and administration of insulin
The woman can describe a satisfactory plan for meeting her individual dietary requirements
The woman and at least one support person can list the signs and symptoms of hypoglycemia and hyperglycemia and describe the initial management of these conditions
The woman can verbalize knowledge of the reason for fetal surveillance procedures and keeps appointments for tests.
Murray, S. & McKinney, E. (2006). Foundations of maternal-newborn nursing (4 th ed.). USA: Saunders Elsevier.
Pilitteri, A. (2010), Maternal & child health nursing: Care of the childbearing & childrearing family (6 th ed.). Philippines: Lippincott Williams & Wilkins.