Diabetes Mellitus in Pregnancy Diabetes Mellitus in Pregnancy

Supervised by Dr. Aida KorishBY:

FATEN ABUSAMN (1427-28 )Nur 534

DefinitionDefinition

A group of metabolic disorders resulting A group of metabolic disorders resulting in hyperglycemia, a consequence of in hyperglycemia, a consequence of either inadequate insulin production, either inadequate insulin production, inadequate insulin secretion, or bothinadequate insulin secretion, or both..

TYPES OF DIABETESTYPES OF DIABETES American Diabetes Association (ADA) classified American Diabetes Association (ADA) classified

the disease in four categoriesthe disease in four categories

Type 1 diabetesType 1 diabetes:: autoimmune destruction of the autoimmune destruction of the pancreatic β cells, resulting in an inability to produce and pancreatic β cells, resulting in an inability to produce and

secrets insulinsecrets insulin..

Type 2 diabetesType 2 diabetes: insulin resistance, a relative insulin : insulin resistance, a relative insulin deficiency as well, or it may be bothdeficiency as well, or it may be both..

Third categoryThird category:: gestational diabetes mellitus (GDM) is gestational diabetes mellitus (GDM) is defined as the onset or first recognition of diabetes defined as the onset or first recognition of diabetes during pregnancyduring pregnancy..

Fourth categoryFourth category: : is associated with genetic disorders, is associated with genetic disorders, pancreatic diseases, drug and chemical use, and pancreatic diseases, drug and chemical use, and infectionsinfections

How to diagnose the DMHow to diagnose the DM? ?

In pregnancy, the oral glucose tolerance test should be In pregnancy, the oral glucose tolerance test should be performed as followsperformed as follows::

in the morningin the morning after an after an overnight fastovernight fast of of between 8 and 14 hoursbetween 8 and 14 hours

Ask the patient to remain Ask the patient to remain seatedseated. . Don’t smokeDon’t smoke if if she doseshe dose..

Administer a Administer a 75-gram oral glucose75-gram oral glucose load load. . Measure the venous plasma glucoseMeasure the venous plasma glucose when the when the

patient is patient is fasting and 30, 60, 90, and 120 fasting and 30, 60, 90, and 120 minutesminutes after administering the glucose load after administering the glucose load . .

cont…Diagnose abnormal glucose tolerance cont…Diagnose abnormal glucose tolerance

according to the following criteriaaccording to the following criteria

TABLE 2. Diagnostic Criteria for 50-g Glucose Challenge TestTABLE 2. Diagnostic Criteria for 50-g Glucose Challenge Test

If initial glucose tolerance test is normal but the If initial glucose tolerance test is normal but the patient is thought to be at high risk patient is thought to be at high risk repeating the repeating the

glucose tolerance test at 32 weeks of gestationglucose tolerance test at 32 weeks of gestation

TABLE 3. Diagnosis of Gestational Diabetes Mellitus Using a 3-Hour 100-g Oral Glucose Load Test

Maternal and Fetal ComplicationsMaternal and Fetal Complications

Before women plan to pregnant Before women plan to pregnant need HEALTH EDUCATIONneed HEALTH EDUCATION

11--Comprehensive visit where possible the plansComprehensive visit where possible the plans

22--Education about diabetes and pregnancyEducation about diabetes and pregnancy

33--Delayed conception until the FBG is in the 70-100 Delayed conception until the FBG is in the 70-100 mg/dL range and postprandial blood glucose is less mg/dL range and postprandial blood glucose is less than 140 at 1 hour or less than 120 mg/dL at 2 hoursthan 140 at 1 hour or less than 120 mg/dL at 2 hours

HEALTH EDUCATIONHEALTH EDUCATIONWhen a woman is diagnosed with GDM , When a woman is diagnosed with GDM ,

treatment should commence as soon as treatment should commence as soon as possiblepossible: :

Blood glucose self-monitoringBlood glucose self-monitoringDietary managementDietary management

physical activityphysical activity , ,Stress managementStress management, ,

ExerciseExercise , ,Fetal movement recordsFetal movement records , ,

Caring for FeetCaring for Feetoccasionally insulin therapyoccasionally insulin therapy . .

Blood glucose self-monitoringBlood glucose self-monitoring

Teach the mother how to used becauseTeach the mother how to used becauseIt provides immediate feedbackIt provides immediate feedback

that helps management strategiesthat helps management strategies,, including dietary changes, stressincluding dietary changes, stress

management, physical activitymanagement, physical activity , ,and insulin therapyand insulin therapy Monitor bloodMonitor blood glucose levels four times daily 1glucose levels four times daily 1stst obtaining a “fasting” level then 3 “postprandial” obtaining a “fasting” level then 3 “postprandial” levels (one hour after thelevels (one hour after the start of each meal)start of each meal)..Specific goals of management are keep FBS Specific goals of management are keep FBS levels at less than 95-105 mg/dL and levels at less than 95-105 mg/dL and postprandial levels at less than 130-140 at 1 postprandial levels at less than 130-140 at 1 hour or less than 120 mg/d L at 2 hourshour or less than 120 mg/d L at 2 hours

SINGS AND SYMPTOMS OF GDMHypoglycemia (Low Blood Sugar)

CAUSESCAUSES::Too little food, too much insulin or diabetes medicine, or extra Too little food, too much insulin or diabetes medicine, or extra

exerciseexercise..

ONSETONSET:: Sudden, may progress to insulin shockSudden, may progress to insulin shock..

BLOOD SUGARBLOOD SUGAR:: Below 70 mg/dL. Normal range: 70-115 mg/dLBelow 70 mg/dL. Normal range: 70-115 mg/dL

WHAT TO DOWHAT TO DO??

Drink a cup of orange juice or milk or eat several hard candiesDrink a cup of orange juice or milk or eat several hard candiesTest Blood sugarTest Blood sugar

Within 30 minutes after symptoms go away, eat a snack e.g. Within 30 minutes after symptoms go away, eat a snack e.g. sandwich, and a glass of milksandwich, and a glass of milk

Contact doctor if symptoms don’t stopContact doctor if symptoms don’t stop

Hyperglycemia (High Blood Sugar)

CAUSESCAUSES:: Too much food, too little insulin, illness or stressToo much food, too little insulin, illness or stress..

ONSETONSET:: Gradual, may progress to diabetic comaGradual, may progress to diabetic coma..

BLOOD SUGARBLOOD SUGAR::Above 200 mg/dL.Above 200 mg/dL.

Normal range: 70-115 mg/dLNormal range: 70-115 mg/dL

WHAT TO DOWHAT TO DO??Test blood sugarTest blood sugar

If over 250mg/dL for several tests, CALL YOUR DOCTORIf over 250mg/dL for several tests, CALL YOUR DOCTOR!!

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HEALTH EDUCATION FOR NUTRIATIONHEALTH EDUCATION FOR NUTRIATIONApproximately 80% of women may be managed with diet aloneApproximately 80% of women may be managed with diet alone Avoid sugar and foods high in sugarAvoid sugar and foods high in sugar

High fiber diet with correct caloric intakeHigh fiber diet with correct caloric intake30-3530-35 kcal/day with no patient receiving less than 1800 or more than 2800 kcal/day with no patient receiving less than 1800 or more than 2800

calories/daycalories/day

Diet composed ofDiet composed of:: 11 . .Carbohydrate 45%Carbohydrate 45%

22 . .Protein 25%Protein 25% 33 . .Fats 30%Fats 30%

If euglycaemia is not achieved with diet within 1-2 weeks, use S/C insulin is If euglycaemia is not achieved with diet within 1-2 weeks, use S/C insulin is recommemdedrecommemded..

Emphasize complex carbohydrates, such as starchy vegetables (such as potatoes, Emphasize complex carbohydrates, such as starchy vegetables (such as potatoes, corn, beans and peas), grains, fruit and other starchy foodscorn, beans and peas), grains, fruit and other starchy foods

Emphasize Milk and milk products such as yogurtEmphasize Milk and milk products such as yogurt..

Emphasize foods high in fiber Nonstarchy vegetables like lettuce, celery, and Emphasize foods high in fiber Nonstarchy vegetables like lettuce, celery, and broccoli contain water and fiber, primarily, and don’t significantly affect the broccoli contain water and fiber, primarily, and don’t significantly affect the

postprandial glucose levelpostprandial glucose level . .

Keep diet low in fatKeep diet low in fat

Have bedtime snacks that include both protein and complex carbohydrateHave bedtime snacks that include both protein and complex carbohydrate

CHO account for 40% to 45% of total daily caloriesCHO account for 40% to 45% of total daily calories

CHO servings should be distributed throughout the day in three CHO servings should be distributed throughout the day in three main meals and two to four snacksmain meals and two to four snacks

less of CHO at breakfast but can tolerate greater amounts at less of CHO at breakfast but can tolerate greater amounts at lunch and dinnerlunch and dinner..

Morning urine ketone to determine the adequacy of caloric Morning urine ketone to determine the adequacy of caloric intakeintake . .

The presence of ketones in the urine indicate insufficient calories The presence of ketones in the urine indicate insufficient calories or CHO resulting in accelerated fat breakdownor CHO resulting in accelerated fat breakdown

If spilling ketones in morning urine, increase the size of the If spilling ketones in morning urine, increase the size of the bedtime snack or move the snack time to later at night so that bedtime snack or move the snack time to later at night so that the snack lasts longerthe snack lasts longer..

Health Education Physical activityHealth Education Physical activity

Physical activity increases insulin receptor Physical activity increases insulin receptor sensitivity by counteracting the hormonal sensitivity by counteracting the hormonal

changes that accompany pregnancychanges that accompany pregnancy . .Performing 15 to 20 minutes of armchair Performing 15 to 20 minutes of armchair

exercises daily during routine sedentary exercises daily during routine sedentary activities, such as watching television or activities, such as watching television or readingreading..

Can help a pregnant woman reduce Can help a pregnant woman reduce hyperglycemia without increasing the risk of hyperglycemia without increasing the risk of

inducing uterine contractionsinducing uterine contractions . .

Health Education of StressHealth Education of Stress

Stress can significantly raiseStress can significantly raise blood glucose levelsblood glucose levels

It’s important to assess a woman’s feelings It’s important to assess a woman’s feelings about her diagnosis as well as her support about her diagnosis as well as her support systemsystem

Nurses can also educate women on coping Nurses can also educate women on coping techniques such as deep breathing and techniques such as deep breathing and keeping a journalkeeping a journal

Encourage them to engage in activities that Encourage them to engage in activities that they find enjoyablethey find enjoyable..

Health Education of ExerciseHealth Education of Exercise

Increase blood glucose uptake in skeletal andIncrease blood glucose uptake in skeletal and decrease insulin needs in patients with decrease insulin needs in patients with gestational diabetesgestational diabetes

Moderate level of exercise believed to be safe Moderate level of exercise believed to be safe in pregnancyin pregnancy Avoid sports or exercises might cause fallAvoid sports or exercises might cause fall . .

Aerobic exerciseAerobic exercise or walking for 30 minutes or walking for 30 minutes are good exercises to continue during are good exercises to continue during

pregnancypregnancy . .

Activity along with food intake and insulin injections. If Activity along with food intake and insulin injections. If

on insulin, need to take a few precautionson insulin, need to take a few precautions:: Be aware of the risk of hypoglycemia, and take a high-sugar snackBe aware of the risk of hypoglycemia, and take a high-sugar snack..

It may be necessary to eat small snacks between mealsIt may be necessary to eat small snacks between meals . .

If exercise If exercise right afterright after a meal, have a snack after the exercise a meal, have a snack after the exercise . .

If exercise If exercise two hours or more after a mealtwo hours or more after a meal, eat the snack before the , eat the snack before the exerciseexercise . .

One serving of fruitOne serving of fruit will will maintain blood sugarmaintain blood sugar for most for most short-term short-term activities (about 30 minutes)activities (about 30 minutes) . .

One serving of fruit plus a serving of starchOne serving of fruit plus a serving of starch will be enough for will be enough for activities that activities that last longerlast longer (an hour or more) (an hour or more) . .

Don't reduce insulin intakeDon't reduce insulin intake before exercising before exercising . .

Don't inject insulin into a part of the bodyDon't inject insulin into a part of the body that will be exercised; for that will be exercised; for example, if walking, avoid injecting into the legexample, if walking, avoid injecting into the leg . .

Teach mother how to record Fetal Teach mother how to record Fetal MovementMovement

Recording fetal movement is a test done by mother to help Recording fetal movement is a test done by mother to help determine the condition of the babydetermine the condition of the baby . .

Fetal activity is generally a reassuring sign of well-beingFetal activity is generally a reassuring sign of well-being

Women are often asked to count fetal movements regularly during Women are often asked to count fetal movements regularly during the lastthe last trimester of pregnancytrimester of pregnancy..

Instruct the mother to set aside specific times to lie down on back Instruct the mother to set aside specific times to lie down on back or side and count the number of times the baby moves or kicksor side and count the number of times the baby moves or kicks ..

Three or more movements in a 2-hour period are considered Three or more movements in a 2-hour period are considered normalnormal

Contact obstetrician if she feel fewer than three movements to Contact obstetrician if she feel fewer than three movements to determine if other tests are neededdetermine if other tests are needed

Health Education Health Education

for take care of Feetfor take care of Feet keep blood glucose in target rangekeep blood glucose in target range..

Check feet every day. for red spots, cuts, swelling, and blisters. If cannot see the Check feet every day. for red spots, cuts, swelling, and blisters. If cannot see the bottoms of feet, use a mirror or ask someone for helpbottoms of feet, use a mirror or ask someone for help..

physical activity program with health teamphysical activity program with health team..

coverage for special shoescoverage for special shoes . .

Wash feet every day. Dry them carefully, especially between the toesWash feet every day. Dry them carefully, especially between the toes..

Keep skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms Keep skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of feet, but not between toesof feet, but not between toes . .

toenails, trim them when needed. Trim toenails straight across and file the edges toenails, trim them when needed. Trim toenails straight across and file the edges with an emery board or nail filewith an emery board or nail file . .

Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect feet. Check inside shoes before wearing them. Make sure that fit well and protect feet. Check inside shoes before wearing them. Make sure the lining is smooth and there are no objects insidethe lining is smooth and there are no objects inside..Protect feet from hot and coldProtect feet from hot and cold . .

Keeps the blood flowing to feet. Put feet up when sitting. Wiggle your toes and move Keeps the blood flowing to feet. Put feet up when sitting. Wiggle your toes and move ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross legs for long periods of time. Don't smokelegs for long periods of time. Don't smoke..

During deliveryDuring delivery

HypoglycemiaHypoglycemia in the newborn in the newborn less than 35 mg/dLless than 35 mg/dL in the term infant. it is more in the term infant. it is more common in infants of women with pregestational diabetescommon in infants of women with pregestational diabetes

The newborn must be The newborn must be carefully monitored for at least the first 2 hours after carefully monitored for at least the first 2 hours after birthbirth . .

Early feeding and intravenous glucoseEarly feeding and intravenous glucose are therapies commonly used, are therapies commonly used, depending on blood glucose level and symptomsdepending on blood glucose level and symptoms..

Infant must monitored for Infant must monitored for hypocalcaemia, hypomagnesaemia, polycythemia hypocalcaemia, hypomagnesaemia, polycythemia and hyperbilirubinemia, polycythemiaand hyperbilirubinemia, polycythemia, and more common in women with , and more common in women with pregestational diabetes, and a team approach to monitoring and caring for pregestational diabetes, and a team approach to monitoring and caring for

these infants should be in placethese infants should be in place . .The most common The most common newborn complicationnewborn complication after birth is after birth is hypoglycemiahypoglycemia which, if which, if uncorrected, may uncorrected, may result in seizuresresult in seizures..

POSTPARTUM HEALTH EDUCATIONPOSTPARTUM HEALTH EDUCATION

The midwifery role in postpartum care is similar to that for The midwifery role in postpartum care is similar to that for women without diabeteswomen without diabetes..

Women with pregestational diabetes should continue to be Women with pregestational diabetes should continue to be managed by a physician goal of continued glycemic managed by a physician goal of continued glycemic controlcontrol, determination of postpartum recovery status, , determination of postpartum recovery status, and recommendation of family planning methodsand recommendation of family planning methods..

Because of evidence that the incidence of childhood Because of evidence that the incidence of childhood diabetes is lower among those who were breastfed, diabetes is lower among those who were breastfed, breastfeeding should be encouraged and supportedbreastfeeding should be encouraged and supported Breastfeeding may also Breastfeeding may also promote improved glycemic and promote improved glycemic and lipid profiles in women with diabeteslipid profiles in women with diabetes (20) (20)..

Provision of an Provision of an appropriate and effective contraceptiveappropriate and effective contraceptive is is the first step in preconception care for a next possible the first step in preconception care for a next possible pregnancypregnancy

Contraception for Diabetic Contraception for Diabetic WomenWomen

All forms of contraception carry some risk and All forms of contraception carry some risk and every woman must be consideredevery woman must be consideredIndividuallyIndividually

Additional considerations for diabetic Additional considerations for diabetic women includewomen include::

• •The importance of per conceptual control of The importance of per conceptual control of diabetesdiabetes..

• •The constraints imposed by the The constraints imposed by the complications of diabetescomplications of diabetes

The Combined Oral Contraceptive The Combined Oral Contraceptive PillPill • •Effective if taken reliablyEffective if taken reliably..

• •First generation high dose estrogen pills may First generation high dose estrogen pills may increase insulin requirements and increase increase insulin requirements and increase risk of vascular diseaserisk of vascular disease

• •Second and third generation pills have a much Second and third generation pills have a much lower dose of estrogenlower dose of estrogen and can probably be and can probably be used safelyused safely in the majority of women with in the majority of women with diabetesdiabetes..

•• ContraindicationsContraindications : : diabetic complications, high arterial risk, diabetic complications, high arterial risk,

Age>35yearsAge>35years..

The Progestogen-only PillThe Progestogen-only Pill

There is no evidence of this pill with vascular side There is no evidence of this pill with vascular side effects and detrimental effects and detrimental effects on lipids or effects on lipids or clotting factors are minimalclotting factors are minimal..

• •This is This is reliable if taken regularlyreliable if taken regularly but omission but omission may be more likely to may be more likely to result in pregnancy than result in pregnancy than with the combined pillwith the combined pill..

• •Menstrual irregularityMenstrual irregularity can be problematic can be problematic • •If amenorrheaIf amenorrhea occurs a pregnancy test should be occurs a pregnancy test should be

performedperformed ; ; • •Injectable progestogens/implants are Injectable progestogens/implants are suitable for suitable for

some patientssome patients

Intrauterine Contraceptive DeviceIntrauterine Contraceptive Device

• •An advantageAn advantage is the lack metabolic effects is the lack metabolic effects and need for complianceand need for compliance..

• •Failure rateFailure rate is high (2/100 women per year) is high (2/100 women per year)..

• •There is There is no evidenceno evidence for the IUCD for the IUCD promoting promoting pelvic inflammatory diseasepelvic inflammatory disease. .

• •There is There is disagreemendisagreement as to whether or not t as to whether or not nulliparousnulliparous women with diabetes should women with diabetes should use this form of contraceptionuse this form of contraception..

Mechanical ContraceptionMechanical Contraception

• •This method has This method has no metabolic no metabolic consequenceconsequence , ,

• •High failure ratesHigh failure rates usually result from usually result from omission or incorrect usageomission or incorrect usage

this method this method is not recommendedis not recommended if it is if it is essential to avoid pregnancyessential to avoid pregnancy..

• •Highly motivated couples Highly motivated couples taughttaught to use to use the diaphragm and sheath correctlythe diaphragm and sheath correctly.,.,

SterilizationSterilization

• •Requested by many mothers when their Requested by many mothers when their family family is completeis complete..

• •The The reduced life expectancyreduced life expectancy of those with of those with longstanding diabetes should be borne in mind longstanding diabetes should be borne in mind when making this decisionwhen making this decision..

• •Sterilization is occasionally advised if there is felt Sterilization is occasionally advised if there is felt to be a to be a serious risk to the woman’s healthserious risk to the woman’s health..

• •For some couples For some couples vasectomy is appropriatevasectomy is appropriate

Natural MethodsNatural Methods

Highly motivated couples Highly motivated couples taughttaught to use these to use these methods correctly, may find this an effective methods correctly, may find this an effective and acceptable form of contraceptionand acceptable form of contraception..

Emergency ContraceptionEmergency Contraception

This is This is safe for diabetic womensafe for diabetic women and should be and should be prescribed if neededprescribed if needed..

The The "morning after" pill"morning after" pill is a combined oral is a combined oral contraceptive which contains a high dose of the contraceptive which contains a high dose of the female hormones, estrogen and progestin. The female hormones, estrogen and progestin. The morning after pill actually consists of four morning after pill actually consists of four combined oral contraceptives tablets. You take combined oral contraceptives tablets. You take two of the tablets with water immediately and two two of the tablets with water immediately and two

tablets 12 hours latertablets 12 hours later . .