Download Diabetes in Pregnancy

Diabetes in Pregnancy
N323: Parent-Child Nursing
S. Burke, PhD, RN, CDE
Pre-Gestational
Diabetes
Mother/Baby Risks
Pre-existing
Diabetes, either
type 1 or type 2
Definition
&
Diagnosti
c Criteria
Diabetes
diagnosed during
pregnancy
Gestational
Diabetes
Mother/Baby Risks
Pre-conception
counseling
Diabetes in
Pregnancy
At Risk
Populations:
Testing:
Management:
Management:
Testing:
A Little Background
 Prevalence of diabetes
is increasing at a rapid
rate
 As of 2006

20.8 million Americans
with Diabetes
 90% Type 2
 ~ 1/3 undiagnosed
 ~ 16% children and
teens w/T2DM
http://www.med.umich.edu/intmed/endocrinology/images/t2_1_1.gif
Definitions
 Pre-gestational
diabetes


 Gestational Diabetes
(GDM)
Diabetes that is
present prior to a
pregnancy
Type 1 or Type 2

Carbohydrate
intolerance of variable
severity with the onset
or first recognition
during pregnancy
AADE Core Curriculum 4th ed., (2001), p. 34
Prevanlence of Obesity, Diabetes and other obesity
related risk factors
http://www.cdc.gov/diabetes/statistics/maps/slide95.gif
High Risk Populations
Low Risk Women Medium Risk
Women
High Risk
Women
 < age 25
 BMI > 25
BMI 19 – 25
Neither high nor
low risk
 +FHx of T2 DM
Low risk
 + glucosuria
ethnicity
Negative FH
Negative
personal history
No h/o poor OB
outcomes
 Hx/O GDM
 Hx/O baby
w/bw over 9#
 Member of
high risk ethnic
group
Maternal Risks
 Pre-existing DM

Type 1 DM



Type 2 DM



Ketoacidosis
Frequent
hypoglycemia
Obesity
Hypertension
Both

Worsening
 Kidney disease
 Eye disease

Coronary heart
disease
 GDM

Hypertensive disorders



PIH
Toxemia
Development of Type 2
diabetes following IUP
Fetal/Newborn Risks
 Pre-gestational DM

Early Risks



Birth Defects
Spontaneous AB
Later Risks






Hyperinsulinemia
Overgrowth
Stillbirth
Polycythemia
RDS
Intrauterine growth
retardation (a/w
nephropathy)
 GDM


Hyperinsulinemia
Macrosomia


(>4,000 G)
Possibility of stillbirth
 Newborn Risks



Difficult birth
 Shoulder Dystocia
Neonatal
hypoglycemia
hyperbilirubinemia
2 Step Testing (GDM)
 Step 1 = 1 hour test

50 Gram Glucose Load followed by plasma
glucose at 1 hour

if > 140 mg/dL, go to Step 2
 Step 2 = 3 hour test

100 Gram Glucose Load
Diagnostic Criteria
100 Gram Glucose
Load
Fasting
Plasma
Plasma
Glucose Levels Glucose
Levels
105 mg/dL
95 mg/dL
1 hour
190 mg/dL
180 mg/dL
2 hour
165 mg/dL
155 mg/dL
3 hour
145 mg/dL
140 mg/dL
Treatment
 Meal Planning
 All patients
 Exercise
 Physical Activity that
does not  fetal risk
 Blood Glucose
Monitoring

All patients
 Insulin
 All pre-gestational
 Some GDM
http://www.cfpc.ca/cfp/2005/May/headimage.jpg
Glycemic Goals During Pregnancy
Fasting Glucose
Less than or equal to 105 mg/dL
Pre-meal Glucose
Less than or equal to 105 mg/dL
1 hour after eating
Less than or equal to 155 mg/dL
2 hours after eating
Less than or equal to 130 mg/dL
Insulin
Preparation
Onset
Peak
Duration
Rapid
5 – 15 min.
90 min.
4 - 6 hours
Regular
30 min.
2 – 4 hrs
6 - 8 hours
Intermediate
(NPH)
~ 2 hours
4 – 10 hrs
12 – 20 hrs
Long acting
~ 4 hours
Flat peak
Up to 24 hrs
http://z.about.com/f/p/440/diabetes2/d/i/Gest_Diabetes.jpg
http://www.cumc.columbia.edu/news/frontiers/images/biof040216.gif
Meal Planning
 Diet should be
 Individualized
 Culturally appropriate
 Nutritional Goals
 Provide sufficient calories
for normal fetal growth and
development
 Avoid hyperglycemia
General Nutritional Guidelines
 Spread carbohydrates throughout the day



3 meals, 3 small snacks
Fewer carbs during periods of higher insulin
resistance, e.g., AM hours
Avoid high glycemic index foods


Sugary foods or fluids between meals
Use of sugar substitutes is OK
Exercise is important
Exercises reduces insulin
resistance
Walking is generally well
tolerated, cheap, and easy.
AM time frame is when insulin
resistance is greatest, but…
consistent exercise has a
lasting impact.
Goal: patient directed, provider
approved, consistent activity at
least every other day.
Monitoring for Ketones