DIABETES IN PREGNANCY Peggy Foster, RN, MSN April, 2008
Incidence of Diabetes <ul><li>18.2 million people—6.3% of Population—Up from 16 million in 1995  and Increasing in Younger...
Type I Diabetes <ul><li>Results from the body’s failure to produce insulin </li></ul><ul><li>Occurs more commonly in < 30 ...
Type II Diabetes <ul><li>Results from Insulin resistance—body fails to properly use insulin </li></ul><ul><li>Occurs more ...
PRE-DIABETES <ul><li>Condition that occurs when blood glucose levels are >normal, but not high enough for the Dx of Type I...
SYMPTOMS OF DIABETES <ul><li>Frequent urination </li></ul><ul><li>Excessive thirst </li></ul><ul><li>Extreme hunger </li><...
DIAGNOSIS OF DIABETES <ul><li>FBS </li></ul><ul><li>Normal Levels < 100 mg/dL </li></ul><ul><li>Pre-Diabetes levels 100-12...
DIAGNOSIS (cont’d) <ul><li>Hgb A1C-- Glycated (Glycosylated) hemoglobin  </li></ul><ul><li>Normal levels < 6 </li></ul><ul...
Blood Sugar affected by: <ul><li>Stress--  </li></ul><ul><li>Exercise--  </li></ul><ul><li>Infections--  </li></ul><ul>...
COMPLICATIONS OF DIABETES <ul><li>Heart Disease and Stroke </li></ul><ul><li>↑ Cholesterol </li></ul><ul><li>Kidney Diseas...
CARBOHYDRATE COUNTING <ul><li>Calories from CHO, Protein and Fat </li></ul><ul><li>CHO—biggest effect on Blood Sugar--With...
BASAL-BOLUS INSULIN THERAPY <ul><li>Basal Insulin—keeps some Insulin in body system at all times—Long Acting Insulin  (i.e...
BASAL-BOLUS INSULIN <ul><li>Long acting  given in a.m. and p.m. </li></ul><ul><li>Rapid Acting (or in combination with Mid...
MATERNAL COMPLICATIONS IF UNTREATED <ul><li>Preterm Labor </li></ul><ul><li>Preeclampsia </li></ul><ul><li>Operative Deliv...
FETAL OUTCOMES IF  Untreated <ul><li>   Abortions  </li></ul><ul><li>   Congenital Malformations </li></ul><ul><li>--  C...
PATHOPHYSIOLOGY—NORMAL PREGNANCY First Trimester <ul><li>In early Pg--   estrogen and progesterone affect Beta cell hyper...
PATHOPHYSIOLOGY 2 nd  and 3 rd  Trimester—Diabetogenic State of Normal Pregnancy <ul><li>In pregnancy there is a    cellu...
Pathophysiology cont’d <ul><li>The  ’d insulin requirement (~ 30%) over pre-pregnancy is ~ equivalent to the endogenous i...
FETAL RESPONSE <ul><li>Normal Fetal response to    blood glucose levels is to secrete    levels of Insulin </li></ul><ul...
Complications of FETAL MACROSOMIA <ul><li>Intrapartum </li></ul><ul><li> •  Protracted labor </li></ul><ul><li> •  Shoulde...
PP Complications—Fetal Macrosomia   <ul><li>Mother in PP    Hemorrhage </li></ul><ul><li>Infant—Neonatal </li></ul><ul><l...
GESTATIONAL DIABETES <ul><li>Who should be screened for GDM?? And What tests should be used ? </li></ul><ul><li>Treatment ...
GDM Screening <ul><li>Low risk—Screening not Required IF: </li></ul><ul><li>-- < 25 years </li></ul><ul><li>-- If low risk...
GDM Screening (cont’d) <ul><li>High risk—Screen ASAP and @ 24-28 weeks gestation </li></ul><ul><li>--Overweight/Obese </li...
Target Glucose Levels to Minimize Macrosomia <ul><li>Fasting ≤   95 mg/dl  </li></ul><ul><li>1 hour Post Prandial ≤   140 ...
  Total Calories in the Euglycemic Diet  40 % CHO 40% Fat and 20% Protein <ul><li>PERCENT OF IDEAL BODY WEIGHT </li></ul><...
DIABETIC MEDICATIONS <ul><li>Insulin—Acts to    glucose into cells </li></ul><ul><li>Types:  Regular, Semilente, Lispro, ...
INSULIN PUMPS <ul><li>Set to deliver Basal Rate and Boluses at designated times </li></ul><ul><li>Advantages—continuous, c...
IDEAL PREGNANCY TREATMENT <ul><li>PRE-CONCEPTION COUNSELING </li></ul><ul><li>Normal body weight </li></ul><ul><li>Normal ...
Diabetic Care in Hospital <ul><li>Goal to maintain BS 75-100 mg/dL </li></ul><ul><li>IV access </li></ul><ul><li>Mainline ...
Diabetic Keto-Acidosis in Pregnancy <ul><li>Definition--Hyperglycemia causes osmotic diuresis with  ↑  loss of water and e...
Contributing Factors to DKA <ul><li>Stress </li></ul><ul><li>Infection </li></ul><ul><li>Emesis </li></ul><ul><li>Steroid ...
Signs & Symptoms’s DKA <ul><li>N&V </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Polyuria </li></ul><ul><li>Polydypsi...
TREATMENT GOALS DKA <ul><li>Rehydrate </li></ul><ul><li>↓   Acidosis </li></ul><ul><li>Normalize Blood Glucose </li></ul><...
DKA  Rx in Pregnancy <ul><li>Baseline Vital Signs, Temp  </li></ul><ul><li>Fetal Assessment—Often Late Decels </li></ul><u...
What’s in our future--NOW ?? <ul><li>Continuous glucose monitoring with computerized dosing of Insulin from pump </li></ul...
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H:\Capp Diabetes In Pregnancy 04 08 3 With Monitoring[1]

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H:\Capp Diabetes In Pregnancy 04 08 3 With Monitoring[1]

  1. 1. DIABETES IN PREGNANCY Peggy Foster, RN, MSN April, 2008
  2. 2. Incidence of Diabetes <ul><li>18.2 million people—6.3% of Population—Up from 16 million in 1995 and Increasing in Younger people </li></ul><ul><li>Prevalence-- Higher in American Indians and Non-Hispanic Blacks </li></ul><ul><li>Diabetes in Pregnancy--CHO intolerance onset in Pg </li></ul><ul><li>Affects about 4 % of all pregnant women </li></ul><ul><li>1-14 % of pregnancies </li></ul><ul><li> risk fetal macrosomia and  risk future diabetes </li></ul><ul><li>When GDM adequately treated Perinatal mortality rate equivalent to that observed in normal pregnancies </li></ul>
  3. 3. Type I Diabetes <ul><li>Results from the body’s failure to produce insulin </li></ul><ul><li>Occurs more commonly in < 30 y/o </li></ul>
  4. 4. Type II Diabetes <ul><li>Results from Insulin resistance—body fails to properly use insulin </li></ul><ul><li>Occurs more commonly in > 30 y/o </li></ul>
  5. 5. PRE-DIABETES <ul><li>Condition that occurs when blood glucose levels are >normal, but not high enough for the Dx of Type II Diabetes </li></ul>
  6. 6. SYMPTOMS OF DIABETES <ul><li>Frequent urination </li></ul><ul><li>Excessive thirst </li></ul><ul><li>Extreme hunger </li></ul><ul><li>Unusual weight loss </li></ul><ul><li>Increased fatigue </li></ul><ul><li>Irritability </li></ul><ul><li>Blurry vision </li></ul>
  7. 7. DIAGNOSIS OF DIABETES <ul><li>FBS </li></ul><ul><li>Normal Levels < 100 mg/dL </li></ul><ul><li>Pre-Diabetes levels 100-125 mg/dL </li></ul><ul><li>Diabetes 126 mg/dL or > </li></ul><ul><li>OGTT—Oral Glucose Tolerance Test </li></ul><ul><li>Normal Levels < 140 mg/dL </li></ul><ul><li>Pre-Diabetes 140 – 200 mg/dL </li></ul><ul><li>Diabetes 200 mg/dL or > </li></ul>
  8. 8. DIAGNOSIS (cont’d) <ul><li>Hgb A1C-- Glycated (Glycosylated) hemoglobin </li></ul><ul><li>Normal levels < 6 </li></ul><ul><li>How works—Hgb (protein) binds with g lucose </li></ul><ul><li> blood glucose binds (glycates) with Hgb molecules--  glucose--  glycation—  A1C </li></ul><ul><li>Since RBC’s (Hgb) live 2-3 months—the A1C reflects glucose over the lifespan of RBC </li></ul>
  9. 9. Blood Sugar affected by: <ul><li>Stress--  </li></ul><ul><li>Exercise--  </li></ul><ul><li>Infections--  </li></ul><ul><li>Diet—Carbohydrates </li></ul><ul><li>Fat </li></ul><ul><li>Protein </li></ul>
  10. 10. COMPLICATIONS OF DIABETES <ul><li>Heart Disease and Stroke </li></ul><ul><li>↑ Cholesterol </li></ul><ul><li>Kidney Disease </li></ul><ul><li>Eye </li></ul><ul><li>Neuropathy </li></ul><ul><li>Foot Problems </li></ul><ul><li>Skin </li></ul>
  11. 11. CARBOHYDRATE COUNTING <ul><li>Calories from CHO, Protein and Fat </li></ul><ul><li>CHO—biggest effect on Blood Sugar--Within 2 hours after eating CHO, most changed to Blood Sugar—Protein and Fat much less effect </li></ul>
  12. 12. BASAL-BOLUS INSULIN THERAPY <ul><li>Basal Insulin—keeps some Insulin in body system at all times—Long Acting Insulin (i.e. NPH or Glargine) </li></ul><ul><li>Boluses given with meals and snacks to cover Blood sugar peak times—Rapid Acting Insulin (i.e. Regular, Aspart, Lispro, Glulisine) </li></ul>
  13. 13. BASAL-BOLUS INSULIN <ul><li>Long acting given in a.m. and p.m. </li></ul><ul><li>Rapid Acting (or in combination with Mid-acting) given just before meals/snacks/bedtime </li></ul><ul><li>Blood sugar checked 2 hours PP </li></ul>
  14. 14. MATERNAL COMPLICATIONS IF UNTREATED <ul><li>Preterm Labor </li></ul><ul><li>Preeclampsia </li></ul><ul><li>Operative Delivery </li></ul><ul><li>Type II Diabetes </li></ul>
  15. 15. FETAL OUTCOMES IF Untreated <ul><li> Abortions </li></ul><ul><li> Congenital Malformations </li></ul><ul><li>-- Cardiovascular (Transposition or Great vessels, ASD, VSD, Hypoplastic Left Heart) </li></ul><ul><li>-- CNS (Anencephaly, Myelomeningocele, Holoprosencephaly, Microcephaly) </li></ul><ul><li>-- Skeletal (Caudal regression syndrome, Spina bifida) </li></ul><ul><li>-- Genito-urinary (Potter’s, Polycystic kidneys, </li></ul><ul><li>Double ureter) </li></ul><ul><li>-- Gastrointestinal (TEF, Bowel atresia, Imperforate anus) </li></ul><ul><li> Stillbirths </li></ul>
  16. 16. PATHOPHYSIOLOGY—NORMAL PREGNANCY First Trimester <ul><li>In early Pg--  estrogen and progesterone affect Beta cell hyperplasia and  insulin secretion </li></ul><ul><li>Glycogen deposits  in peripheral tissues and  hepatic glucose production </li></ul><ul><li>By end of 1 st Trimester-- 10%  in maternal glucose levels </li></ul><ul><li>Insulin dependent women therefore, normally experience periods of hypoglycemia in 1 st Trimester </li></ul>
  17. 17. PATHOPHYSIOLOGY 2 nd and 3 rd Trimester—Diabetogenic State of Normal Pregnancy <ul><li>In pregnancy there is a  cellular sensitivity to insulin </li></ul><ul><li>As placenta grows/pregnancy advances is an  Human placental lactogen,  Progesterone,  Cortisol,  Prolactin– All are contra-insulin--  Blood Sugar levels  </li></ul><ul><li>Homeostasis requires  insulin release </li></ul><ul><li>During time when there is an  maternal glucose--  glucose supply to fetus and placenta </li></ul><ul><li>A woman with Insulin-dependent Diabetes cannot respond to this stress—requires  insulin therapy as pregnancy advances </li></ul>
  18. 18. Pathophysiology cont’d <ul><li>The  ’d insulin requirement (~ 30%) over pre-pregnancy is ~ equivalent to the endogenous increase in normal gestation </li></ul>
  19. 19. FETAL RESPONSE <ul><li>Normal Fetal response to  blood glucose levels is to secrete  levels of Insulin </li></ul><ul><li>If glucose levels remain high, fetus then gains  weight resulting in Macrosomia </li></ul>
  20. 20. Complications of FETAL MACROSOMIA <ul><li>Intrapartum </li></ul><ul><li> • Protracted labor </li></ul><ul><li> • Shoulder Dystocia--  Shoulder:Hip Ratio </li></ul><ul><li> • Perinatal Asphyxia </li></ul><ul><li> • Skeletal Injuries </li></ul><ul><li> •  risk of C/S </li></ul>
  21. 21. PP Complications—Fetal Macrosomia <ul><li>Mother in PP  Hemorrhage </li></ul><ul><li>Infant—Neonatal </li></ul><ul><li> • Hypoglycemia-usually about 3-4 hours of age </li></ul><ul><li>• Polycythemia </li></ul><ul><li> • Hyperbilirubinemia </li></ul><ul><li> • Thrombocytopenia </li></ul><ul><li> • Hypomagnesemia </li></ul><ul><li>Long Term </li></ul><ul><ul><li> risk for childhood cancer (i.e. acute lymphocytic leukemia, Wilms tumor) </li></ul></ul><ul><ul><li> risk of adolescent obesity </li></ul></ul><ul><ul><li> risk of developing Type II Diabetes at a young age </li></ul></ul><ul><li> </li></ul>
  22. 22. GESTATIONAL DIABETES <ul><li>Who should be screened for GDM?? And What tests should be used ? </li></ul><ul><li>Treatment goals: Entire Team Care—Woman-Family-MD-RN-RD-SW </li></ul>
  23. 23. GDM Screening <ul><li>Low risk—Screening not Required IF: </li></ul><ul><li>-- < 25 years </li></ul><ul><li>-- If low risk race or ethnic group </li></ul><ul><li>-- Normal pre-pregnancy weight and </li></ul><ul><li>weight gain during pregnancy </li></ul><ul><li>-- No history of abnormal blood glucose </li></ul><ul><li>-- No prior poor OB history </li></ul>
  24. 24. GDM Screening (cont’d) <ul><li>High risk—Screen ASAP and @ 24-28 weeks gestation </li></ul><ul><li>--Overweight/Obese </li></ul><ul><li>--Hx of Glucose Intolerance </li></ul><ul><li>-- Family Hx of Diabetes--1 ° Relative </li></ul><ul><li>-- Black, Latino, Native American, </li></ul><ul><li>Asian, Pacific Islander, or Indigenous </li></ul><ul><li>Australian </li></ul><ul><li>-- Current glycosuria </li></ul>
  25. 25. Target Glucose Levels to Minimize Macrosomia <ul><li>Fasting ≤ 95 mg/dl </li></ul><ul><li>1 hour Post Prandial ≤ 140 mg/dl </li></ul><ul><li>2 hour Post Prandial ≤ 120 mg/dl </li></ul><ul><li>Pre Prandial 60-100 mg/dl </li></ul>
  26. 26. Total Calories in the Euglycemic Diet 40 % CHO 40% Fat and 20% Protein <ul><li>PERCENT OF IDEAL BODY WEIGHT </li></ul><ul><li>80- 120 % </li></ul><ul><li>121-150 % </li></ul><ul><li>> 151 % </li></ul><ul><li>TOTAL </li></ul><ul><li>CALORIES </li></ul><ul><li>30 Calories/Kg Present Pg Weight </li></ul><ul><li>24 Calories/Kg PPW </li></ul><ul><li>12-15 Calories/Kg PPW </li></ul>
  27. 27. DIABETIC MEDICATIONS <ul><li>Insulin—Acts to  glucose into cells </li></ul><ul><li>Types: Regular, Semilente, Lispro, Aspart, NPH, Lente, Glargine, PZI, Ultralente, Detemir </li></ul><ul><li>Many new Oral Hypoglycemics—act differently in system--sometimes given in combination with each other and with Insulin </li></ul>
  28. 28. INSULIN PUMPS <ul><li>Set to deliver Basal Rate and Boluses at designated times </li></ul><ul><li>Advantages—continuous, covers meal times, snack times, prevents nocturnal hypoglycemia and “dawn” phenomenon </li></ul><ul><li>Disadvantages—not allow for exercise induced hypoglycemia, varied meal times or varied calorie meals and varied metabolism in relation to CHO, Fat, Protein intake </li></ul>
  29. 29. IDEAL PREGNANCY TREATMENT <ul><li>PRE-CONCEPTION COUNSELING </li></ul><ul><li>Normal body weight </li></ul><ul><li>Normal blood sugars </li></ul><ul><li>Hb A1C -- maintained b/w 5-6 </li></ul><ul><li>End organ evaluation </li></ul><ul><li>Folic acid supplementation </li></ul>
  30. 30. Diabetic Care in Hospital <ul><li>Goal to maintain BS 75-100 mg/dL </li></ul><ul><li>IV access </li></ul><ul><li>Mainline IV Normal Saline </li></ul><ul><li>2 nd IV--Sugar Line D5/LR (30 mL/hr) as maintenance </li></ul><ul><li>IV Insulin 250 Units/250 cc and Flush tubing (Insulin binds to Plastic tubing) </li></ul><ul><li>Piggy back Insulin into D5/LR line as close to Hub as possible </li></ul><ul><li>Blood sugar finger stick every hour and adjust insulin infusion according to MD Orders </li></ul>
  31. 31. Diabetic Keto-Acidosis in Pregnancy <ul><li>Definition--Hyperglycemia causes osmotic diuresis with ↑ loss of water and electrolytes </li></ul><ul><li>Results in: </li></ul><ul><li>Hypovolemia which leads to </li></ul><ul><li>Hypoperfusion of tissues, and </li></ul><ul><li>Acidosis (lactic) </li></ul><ul><li>Diagnosis of DKA: </li></ul><ul><li>Blood Glucose > 300 </li></ul><ul><li>HCO3 > 15 </li></ul><ul><li>pH < 7.3 </li></ul>
  32. 32. Contributing Factors to DKA <ul><li>Stress </li></ul><ul><li>Infection </li></ul><ul><li>Emesis </li></ul><ul><li>Steroid Administration </li></ul><ul><li>Beta Adrenergic agonists (Brethine) </li></ul><ul><li>Non-compliance </li></ul><ul><li>Insulin Pump Failure </li></ul>
  33. 33. Signs & Symptoms’s DKA <ul><li>N&V </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Polyuria </li></ul><ul><li>Polydypsia </li></ul><ul><li>Dehydration </li></ul><ul><li>Fruity breath </li></ul><ul><li>Kussmaul Respirations </li></ul><ul><li>Leg Cramps </li></ul><ul><li>∆ Mental status </li></ul><ul><li>Labs: ↑ BUN, ↓ Creatinine Clearance, ↑ WBC’s, ↑ Bands </li></ul>
  34. 34. TREATMENT GOALS DKA <ul><li>Rehydrate </li></ul><ul><li>↓ Acidosis </li></ul><ul><li>Normalize Blood Glucose </li></ul><ul><li>Maintain Normal Electrolytes (Potassium) </li></ul>
  35. 35. DKA Rx in Pregnancy <ul><li>Baseline Vital Signs, Temp </li></ul><ul><li>Fetal Assessment—Often Late Decels </li></ul><ul><li>Verify patient weight </li></ul><ul><li>Labs: CBC, Renal panel, Arterial Blood Gas, Cath Urine for U/A, Blood Glucose Stat and q 1 h </li></ul><ul><li>Foley with Urimeter </li></ul><ul><li>Hourly I&O </li></ul><ul><li>NO Steroids </li></ul><ul><li>Not rehydrate Too fast—Cerebral Edema if ↓ Glucose too rapidly </li></ul><ul><li>Watch Potassium as Diurese </li></ul>
  36. 36. What’s in our future--NOW ?? <ul><li>Continuous glucose monitoring with computerized dosing of Insulin from pump </li></ul><ul><li>Glucose Sensor--Tiny sterile flexible electrode inserted just under the skin </li></ul><ul><li>Alternative methods to give Insulin-- Dermal Applications, Nasal Insulin, Insulin tablet and pulmonary delivery </li></ul>
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