Prevalence can be 1-14 % depending on population studied. GDM represents 90% of pregnancies complicated by Diabetes.
2009 practice guidelines has added testing for type2 diabetes should be done in babies small for gestational age birth weight added to list of conditions for association with insulin resistance. Testing should begin at age 10 or younger if puberty starts earlier. Babies with excess insulin become children who are at risk for obesity and adults at risk for type 2 diabetes. If mom has type 1 then baby risk is 1-2 % and if father has type 1 then 6% chance. Type 2 DM baby has 10-15% risk and 33% chance for glucose intolerance. (ADA Life with diabetes 2004 3 rd edition)
Especially multiple gestation pregnancies with increase hormone production that are insulin antagonist
According to ADA 2 values must exceed for positive diagnosis. Test should be done in morning 8-14 hr after a fast and after 3 days of unrestricted >150grams of CHOs and unlimited physical activity. Should remain seated and not smoke. 100 gms of glucola – need to check concentration of glucola. Various flavors have various concentrations of glucose. Sweet Success Update Spring 2009 Dr Lois Jovanovic is on Board of Directors. Based on literature search unclear why 2 values need to be elevated. No evidenced based studies. In 2007 large Italian study the women who had the 1 hr elevation was most severe condition. (OVA) This would indicate that more studies need to be done. Research indicates that even mild hyperglycemia (below diagnostic levels) should be addressed and is related to perinatal problems which can be reduced by treatment. If the cut off on 1 hr 50gm challenge the cutoff at <140 only 80% are caught but 90% are caught if <130 is used.
Address glyburide and metformin. 2003 The ADA and the American college of Obstetricians and Gynecologist are not currently recommending oral agent during pregnancy. It has been suggested that oral agent be reconsidered as a therapy in GDM. AACE does not recommend oral agents being used. They say insulin should be given to maintain BG control. According to ADA women with type 2 diabetes need to make transition from oral agents to insulin before conception. The safety of all currently available oral agents has not been established in pregnancy and may lead to prolonged hypoglycemia in the neonate and therefore not recommended. A study shows with gestational diabetes has found glyburide to be safe and clinically effective. Type 1 (defect in insulin production – thought to be autoimmune response. Need insulin to survive. Approx 5% all diabetes. Type 2 – obesity and sedentary lifestyle. Insulin resistance and deficiency. On rise in childhood now. Managed by diet and exercise and/or oral agents and or insulin – 95% diabetes. HGB A1c and fructosamine are proteins attached to glucose in blood. A1c = bld sugar control 3 months while fructosamine 2-3 wk control. Used more with preexisting diabetes and pregnancy. Better idea of control.
Insulin should be given at same time each day. Major side effects are hypoglycemia and weight gain. Optimal absorption occurs with abd site and site should be rotated.
Occasionally, NPH is given at bedtime if having a hard time with elevated FBS
Mimics the pattern of how insulin is released in a person with out diabetes. Inject once every 3 days instead of multiple daily injections. Usually only used with type 1 or type 2 patients not gestational diabetes because of cost.
Especially heart defects – often order fetal echo
Diabetes in Pregnancy Jana McElroy RN, BSN, CDE Sandy Warner RNC- OB, MSN
“ All pregnant women want a successful outcome, a healthy baby.” Gestational Diabetes Caring for Yourself and Your Baby, International Diabetes Center, 2005.
Carbohydrate Serving (15 grams) 1 Tbsp sugar 4 oz regular pop 3 graham cracker squares ½ cup corn ½ cup oatmeal 1 cup vegetable soup ½ cup ice cream ½ cup unsweetened canned fruit ½ cup potatoes 1 container light yogurt 4 oz apple 7 saltine crackers 1 cup milk ½ cup fruit juice 1 slice of bread
We often do not look at what the patient’s current treatment is: diet, oral agents and/or insulin and sliding scale insulin. (Be proactive. Is there a need to change the patient’s current diabetes medication regimen?)
The weight of the patient is not considered or how insulin resistant the patient is. (one-size-fits all)
Better blood glucose control will improve patient outcomes.
Easier labor and delivery.
Decrease in infections.
Decrease in length of stay.
References “ American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control”, Endocrine Practice. Vol. 10, No. 1, 2004. American Diabetes Association Clinical Practice Recommendations 2009. Davidson, J., et al. Gestational Diabetes Caring for Yourself and Your Baby. International Diabetes Center, 3 rd edition, 2005.
References continued Diabetes Forecast. 2007 Resource Guide. Slocum, J. and Biastre, S. Gestational Diabetes, A Core Curriculum for Diabetes Education, Diabetes in the Life Cycle and Research. American Association of Diabetes Educators, 5 th edition, 2003. The Paradigm Platform of Insulin Pumps, Medtronic 2004.