Download Diabetes Mellitus in Pregnancy

Diabetes Mellitus in Pregnancy
Supervised by Dr. Aida Korish
BY:
FATEN ABUSAMN (1427-28 )
Nur 534
Definition
A group of metabolic disorders resulting
in hyperglycemia, a consequence of
either inadequate insulin production,
inadequate insulin secretion, or both.
TYPES OF DIABETES
American Diabetes Association (ADA) classified
the disease in four categories
Type 1 diabetes: autoimmune destruction of the 
pancreatic β cells, resulting in an inability to produce and
secrets insulin.
Type 2 diabetes: insulin resistance, a relative insulin 
deficiency as well, or it may be both.
Third category: gestational diabetes mellitus (GDM) is 
defined as the onset or first recognition of diabetes
during pregnancy.
Fourth category: is associated with genetic disorders, 
pancreatic diseases, drug and chemical use, and
infections
How to diagnose the DM ?
In pregnancy, the oral glucose tolerance test should be
performed as follows:
in the morning after an overnight fast of 
between 8 and 14 hours
Ask the patient to remain seated. Don’t smoke if 
she dose.
Administer a 75-gram oral glucose load . 
Measure the venous plasma glucose when the 
patient is fasting and 30, 60, 90, and 120
minutes after administering the glucose load.
cont…Diagnose abnormal glucose tolerance
according to the following criteria
TABLE 2. Diagnostic Criteria for 50-g Glucose Challenge Test
If initial glucose tolerance test is normal but the
patient is thought to be at high risk repeating the
glucose 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 Complications
Before women plan to pregnant
need HEALTH EDUCATION
1-Comprehensive visit where possible the plans
2-Education about diabetes and pregnancy
3-Delayed conception until the FBG is in the 70-100
mg/dL range and postprandial blood glucose is less
than 140 at 1 hour or less than 120 mg/dL at 2 hours
HEALTH EDUCATION
When a woman is diagnosed with GDM ,
treatment should commence as soon as
possible :
Blood glucose self-monitoring
Dietary management
physical activity,
Stress management ,
Exercise,
Fetal movement records,
Caring for Feet
occasionally insulin therapy.

Blood glucose self-monitoring
Teach the mother how to used because
It provides immediate feedback
that helps management strategies,
including dietary changes, stress
management, physical activity,
and insulin therapy
Monitor blood glucose levels four times daily
1st obtaining a “fasting” level then 3
“postprandial” levels (one hour after the
start of each meal).
Specific goals of management are keep FBS
levels at less than 95-105 mg/dL and
postprandial levels at less than 130-140 at 1
hour or less than 120 mg/d L at 2 hours
SINGS AND SYMPTOMS OF GDM
Hypoglycemia (Low Blood Sugar)
CAUSES:
ONSET:
BLOOD SUGAR:
WHAT TO DO?
Too little food, too much insulin or diabetes medicine, or extra
exercise.
Sudden, may progress to insulin shock.
Below 70 mg/dL. Normal range: 70-115 mg/dL
Drink a cup of orange juice or milk or eat several hard candies
Test Blood sugar
Within 30 minutes after symptoms go away, eat a snack e.g.
sandwich, and a glass of milk
Contact doctor if symptoms don’t stop
Hyperglycemia (High Blood Sugar)
CAUSES:
ONSET:
BLOOD SUGAR:
WHAT TO DO?
‫آ‬
Too much food, too little insulin, illness or stress.
Gradual, may progress to diabetic coma.
Above 200 mg/dL.
Normal range: 70-115 mg/dL
Test blood sugar
If over 250mg/dL for several tests, CALL YOUR DOCTOR!
HEALTH EDUCATION FOR NUTRIATION
Approximately 80% of women may be managed with diet alone
Avoid sugar and foods high in sugar
High fiber diet with correct caloric intake
30-35 kcal/day with no patient receiving less than 1800 or more than 2800
calories/day
Diet composed of:
1. Carbohydrate 45%
2. Protein 25%
3. Fats 30%
If euglycaemia is not achieved with diet within 1-2 weeks, use S/C insulin is
recommemded.
Emphasize complex carbohydrates, such as starchy vegetables (such as potatoes,
corn, beans and peas), grains, fruit and other starchy foods
Emphasize Milk and milk products such as yogurt.
Emphasize foods high in fiber Nonstarchy vegetables like lettuce, celery, and
broccoli contain water and fiber, primarily, and don’t significantly affect the
postprandial glucose level.
Keep diet low in fat
Have bedtime snacks that include both protein and complex carbohydrate
CHO account for 40% to 45% of total daily calories
CHO servings should be distributed throughout the day in three
main meals and two to four snacks
less of CHO at breakfast but can tolerate greater amounts at
lunch and dinner.
Morning urine ketone to determine the adequacy of caloric
intake.
The presence of ketones in the urine indicate insufficient calories
or CHO resulting in accelerated fat breakdown
If spilling ketones in morning urine, increase the size of the
bedtime snack or move the snack time to later at night so that
the snack lasts longer.
Health Education Physical
activity
Physical activity increases insulin receptor 
sensitivity by counteracting the hormonal
changes that accompany pregnancy.
Performing 15 to 20 minutes of armchair 
exercises daily during routine sedentary
activities, such as watching television or
reading.
Can help a pregnant woman reduce 
hyperglycemia without increasing the risk of
inducing uterine contractions.
Health Education of Stress
Stress can significantly raise
blood glucose levels
It’s important to assess a woman’s feelings
about her diagnosis as well as her support
system
Nurses can also educate women on coping
techniques such as deep breathing and
keeping a journal
Encourage them to engage in activities that
they find enjoyable.
Health Education of Exercise
Increase blood glucose uptake in skeletal and
decrease insulin needs in patients with
gestational diabetes
Moderate level of exercise believed to be safe
in pregnancy
Avoid sports or exercises might cause fall.
Aerobic exercise or walking for 30 minutes
are good exercises to continue during
pregnancy.
Activity along with food intake and insulin injections. If
on insulin, need to take a few precautions:
Be aware of the risk of hypoglycemia, and take a high-sugar snack. 
It may be necessary to eat small snacks between meals.

If exercise right after a meal, have a snack after the exercise.

If exercise two hours or more after a meal, eat the snack before
the exercise.

One serving of fruit will maintain blood sugar for most short- 
term activities (about 30 minutes).
One serving of fruit plus a serving of starch will be enough for
activities that last longer (an hour or more).
Don't reduce insulin intake before exercising.


Don't inject insulin into a part of the body that will be exercised;
for example, if walking, avoid injecting into the leg.

Teach mother how to record Fetal
Movement
Recording fetal movement is a test done by mother to help
determine the condition of the baby.
Fetal activity is generally a reassuring sign of well-being
Women are often asked to count fetal movements regularly during
the last trimester of pregnancy.
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 kicks
.
Three or more movements in a 2-hour period are considered
normal
Contact obstetrician if she feel fewer than three movements to
determine if other tests are needed
Health Education
for take care of
Feet
keep blood glucose in target range.

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 help.
physical activity program with health team.
coverage for special shoes.
Wash 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
of feet, but not between toes.
toenails, trim them when needed. Trim toenails straight across and file the edges
with an emery board or nail file.
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
the lining is smooth and there are no objects inside.
Protect feet from hot and cold.
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 legs for long periods of time. Don't smoke.
During delivery
Hypoglycemia in the newborn less than 35 mg/dL in the term infant. it is more
common in infants of women with pregestational diabetes
The newborn must be carefully monitored for at least the first 2 hours after
birth.
Early feeding and intravenous glucose are therapies commonly used,
depending on blood glucose level and symptoms.
Infant must monitored for hypocalcaemia, hypomagnesaemia, polycythemia
and hyperbilirubinemia, polycythemia, and more common in women with
pregestational diabetes, and a team approach to monitoring and caring for
these infants should be in place.
The most common newborn complication after birth is hypoglycemia which, if
uncorrected, may result in seizures.
POSTPARTUM HEALTH EDUCATION
The midwifery role in postpartum care is similar to that for
women without diabetes.
Women with pregestational diabetes should continue to be
managed by a physician goal of continued
glycemic control, determination of postpartum
recovery status, and recommendation of family
planning methods.
Because of evidence that the incidence of childhood
diabetes is lower among those who were breastfed,
breastfeeding should be encouraged and
supported
Breastfeeding may also promote improved glycemic and
lipid profiles in women with diabetes (20).
Provision of an appropriate and effective contraceptive
is the first step in preconception care for a next
possible pregnancy
Contraception for Diabetic
Women
All forms of contraception carry some risk and
every woman must be considered
Individually
Additional considerations for diabetic
women include:
• The importance of per conceptual control of
diabetes.
• The constraints imposed by the
complications of diabetes
The Combined Oral Contraceptive
Pill
• Effective if taken reliably.
• First generation high dose estrogen pills may
increase insulin requirements and increase
risk of vascular disease
• Second and third generation pills have a much
lower dose of estrogen and can probably be
used safely in the majority of women with
diabetes.
• Contraindications:
diabetic complications, high arterial risk,
Age>35years.
The Progestogen-only Pill
There is no evidence of this pill with vascular side
effects and detrimental effects on lipids or
clotting factors are minimal.
• This is reliable if taken regularly but omission
may be more likely to result in pregnancy than
with the combined pill.
• Menstrual irregularity can be problematic
• If amenorrhea occurs a pregnancy test should be
performed;
• Injectable progestogens/implants are suitable for
some patients
Intrauterine Contraceptive Device
• An advantage is the lack metabolic effects
and need for compliance.
• Failure rate is high (2/100 women per year).
• There is no evidence for the IUCD
promoting pelvic inflammatory disease .
• There is disagreement as to whether or not
nulliparous women with diabetes should
use this form of contraception.
Mechanical Contraception
• This method has no metabolic 
consequence,
• High failure rates usually result from 
omission or incorrect usage
this method is not recommended if it is 
essential to avoid pregnancy.
• Highly motivated couples taught to use the 
diaphragm and sheath correctly,.
Sterilization
• Requested by many mothers when their family 
is complete.
• The reduced life expectancy of those with 
longstanding diabetes should be borne in mind
when making this decision.
• Sterilization is occasionally advised if there is felt 
to be a serious risk to the woman’s health.
• For some couples vasectomy is appropriate 
Natural Methods
Highly motivated couples taught to use these
methods correctly, may find this an effective
and acceptable form of contraception.
Emergency Contraception
This is safe for diabetic women and should be
prescribed if needed.
The "morning after" pill is a combined oral
contraceptive which contains a high dose of the
female hormones, estrogen and progestin. The
morning after pill actually consists of four
combined oral contraceptives tablets. You take two
of the tablets with water immediately and two
tablets 12 hours later.