Managing Diabetes in Pregnancy

Diabetes in Pregnancy
INTRO: Diabetes has many fetal/maternal
complications: The main concern is
prevention of Intrauterine Foetal Death
(IUFD) during last month of pregnancy.
Goal: good control before conception and
during pregnancy, and a delivery when the
fetus is mature, while avoiding IUFD.

DIABETES: Definition
A metabolic disorder due to partial or total
lack of insulin or insensitivity to insulin,
characterized by hyperglycaemia.
Gestational diabetes defined as any
degree of glucose
intolerance/hyperglycaemia with first
recognition during pregnancy.
Occurrence in pregnancy: 1-14% depending
on the population.

NORMAL Carbohydrate
Metabolism: Insulin vs Glucagon
Normal fasting blood glucose <6.1 mmol
is regulated by insulin and glucagon.
Ingestion of carbohydrates stimulates
insulin secretionreduces blood glucose;
falling blood glucose stimulates glucagon
production which prevents glucose
reduction.

Carbohydrate Metabolism
in Pregnancy
Pregnancy is a state of ever-increasing fetal
demand for fuel. This demand is met
through increased caloric intake,
hyperinsulinemia, insulin resistance, and
maternal pancreatic islet hypertrophy.
Physiological changes that occur regarding
carbohydrate metabolism in Pregnancy
produce a diabetogenic effect.

in Pregnancy
Fall in fasting blood sugar
• The foetus obtains glucose from its mother
via the placenta by the process of diffusion.
• ↑ serum levels of estrogen and progesterone
increase insulin production
• The overall result is a lowering of the fasting
glucose levels, reaching a nadir by the 12th
week.

in Pregnancy
• This acts to protect the developing
embryo from elevated glucose levels.
• Indeed, birth defects are noted at a 2-
to 3-fold higher rate in women with
diabetes without preconception
glycemic control

in Pregnancy
In the second trimester, higher fasting and
postprandial glucose levels are seen.
This facilitates the placental transfer of
glucose.
This is because of the placental hormonal
effects especially HPL that offers insulin
resistance

in Pregnancy
In summary, hormones associated with
pregnancy facilitate maternal storage of
energy in the first trimester and then
assist in the diversion of energy to the
fetus in later pregnancy as demand
increases.

in Pregnancy
Ketoacidiosis
• Lipid metabolism in the 2nd trimester shows
continued storage until mid gestation; then, as fetal
demands increase, there is enhanced mobilization
(lipolysis).
• During the 3rd trimester due to increased fetal
demands for glucose, the mother begins to utilize
fat stores laid down in the 1st & 2nd trimester.
• This results in free fatty acids and glycerol in the
blood stream and the woman becomes ketotic
more easily.

Carbohydrate Metabolism in
Pregnancy
Hormonal Effect
• As placenta matures, the levels of HPL rise
steadily during the 1st & 2nd trimesters with a
plateau in the late 3rd trimester.
• The foeto-placental unit alters the mother's
carbohydrate metabolism to make glucose more
readily available.
• HPL causes resistance to insulin in the maternal
tissues.
• The blood glucose remains raised for a longer
period than in the non-pregnant state.

in Pregnancy
Hormonal Effect
• The extra demands on the pancreatic beta
cells can precipitate glucose intolerance or
overt diabetes in those whose capacity for
producing insulin was just adequate prior to
pregnancy.
• If the mother was already diabetic before
pregnancy, her insulin need will be further
increased.

in Pregnancy
Glycosuria in Pregnancy
Glycosuria in pregnancy is not
diagnostic of diabetes because there is:
An increase in glomerular filtration rate
as it passes through the proximal
convoluted tubule faster than the
reabsorption

Gestational diabetes
is the result of hormonal changes that
occur in all women during pregnancy.
Increased levels of placental hormones
interfere with the ability of insulin to
manage glucose.
This condition is called ‘’insulin
resistance.’’

Cont…Gestational diabetes
• Usually the mother’s pancrease is able to
produce more insulin (about 3X the normal
amount) to overcome the insulin resistance.
• This is compensatory ↑ in secretion of insulin.
If this does not occur, glucose levels will rise,
resulting in gestational diabetes.
Usually, BS levels return to normal after
childbirth.
Diabetes is less common in the tropics but is
more frequent now than previously, due to?.

History: Diabetes in Pregnancy
Before insulin became available:
Many diabetic girls died before puberty
Many had amenorrhoea and infertility
When pregnancy did occur, maternal
mortality was 23-30% and fetal/neonatal
loss was 50%

Diabetes Review
Pathophysiology
Hyperglycaemia results from defects in
insulin secretion, or insulin action, or both.
Relative or complete lack of insulin secretion
by beta cells of the pancreas
May be caused by damage to beta cells in
pancreas, inactivation of insulin by antibodies
(insulin resistance), and increased body
requirements as in obesity or pregnancy.

REVIEW
Without enough insulin, glucose can’t enter
cells which become energy depleted.
Blood glucose levels are high and cells
break down fat and protein for energy.
Protein breakdownnegative nitrogen
balance. Fat metabolismketosis

Diabetes Signs/Symptoms
Cardinal Signs
Polyuria— since water is not reabsorbed by renal
tubules due to glucose’s osmotic activity
Polydipsia— due to dehydration from polyuria
Polyphagia— due to tissue loss and state of
starvation since cells can’t use glucose
Weight loss— seen with marked hyperglycaemia;
from use of fat and muscle tissue for energy

DIABETES
Signs &
Symptoms
Risks

Pathophysiology of Diabetes:
REVIEW

Pathophysiology of Diabetes…

Classification of Diabetes: Myles p. 341
1. Type 1 (beta cell destruction—usually leading to
absolute insulin deficiency, IDDM: [“Primary” DM]
Other types might be referred to as “Secondary”DM
2. Type 2: insulin resistance with relative insulin
deficiency (insulin resistance); may be able to
control with diet alone [NIDDM]
3. Gestational diabetes: patient develops
abnormal glucose during pregnancy
4. Impaired glucose regulation (“potential
diabetic”: at increased tendency to develop
diabetes during pregnancy—risk factors.

Diabetes in PREGNANCY
ASSESSMENT: ASK: History
a. Risk factors: family hx of DM, maternal
obesity, previous large for gestational age
infants (4.5 kg), previous unexplained
stillbirth, advanced maternal age >35 years
(ask if all her children are living: “perinatal”
death=“stillbirth” or death occuring in first
week“early neonatal death” after delivery)
Family history of diabetes (parents,
siblings)

Cont Risk assessment
Bad obstetric history:
Spontaneous abortions
Unexplained stillbirth
Unexplained polyhydramnios
Premature birth
LBW or BW>4000 g (some texts: 4.5kg or >)
Birth of newborn with congenital
abnormalities
5 or more pregnancies
Maternal age over 35

Cont Risk assessment
Obesity
Recurrent monilial vaginitis
Glycosuria
Possibly stress related precipitators e.g.
family problems, socioeconomic status,
cultural expectations, religious beliefs,
level of education

Diagnosis of Diabetes
Diagnosis: WHO (1999) [Myles p 341]
1. Diabetes symptoms PLUS
2. random plasma concentration of ll.1 mmol/L
OR
fasting plasma concentration >7.0 mmol/L
2 hr plasma concentration >ll.1 mmol/L 2 hrs
after 75 gm anhydrous glucose in an OGTT
3. Without symptoms, dx should NOT be based
on a single glucose determination (need
confirmation on plasma taken another day)
4. OGTT should always be used to diagnose
gestational diabetes and impaired glucose
regulation

Potential Diabetes
“Potential” diabetes is indicated by
various criteria (discussed earlier), for
example, one or both parents are
diabetic, or the mother has previously
borne an unduly large baby.
Usually, there is marked chronic obesity
and glycosuria.

Chemical Diabetes
Chemical
Chemical diabetes is characterised by
abnormal Glucose Tolerance Test (GTT)
but is without symptoms.

Overt or Clinical Diabetes
Overt or Clinical
This is indicated by abnormal GTT
with symptoms and raised fasting blood
glucose level

Diabetes: Effects of Pregnancy
diabetes
• A. Normally during first trimester there is
increased insulin production due to
progressive hyperplasia of pancreatic β cells
due to high levels of oestrogen, progesteron
and prolactin and increased tissue response.
• However, the need for INSULIN is low: Low
HPL levels, fetus needs less glucose, lower
intake due to nausea/vomiting—this
increases risk for hypoglycaemia insulin
shock/coma

Effects of Pregnancy on Diabetes
B. SECOND trimester:
• insulin requirements begin to rise as
glucose use and storage by woman and
fetus increase.
• Insulin requirements may be 2x or 4x
higher by end of pregnancy due to
placental maturity, thus ↑ in HPL
production.

diabetes
C. During the last half of pregnancy,
HPL, cortisol and progesterone causes
resistance to maternal insulin and
thus increases circulating glucose for
fetal use and increases demand on the
maternal pancreas to produce more
insulin (Increased insulin
requirement).

C. cont…Effects of Pregnancy on
Diabetes
The mother easily gets ketoacidosis as the fat
is broken down.
In late pregnancy, insulin requirements are still
high as there is reduced sensitivity of the
tissues due to the HPL.
Those Type 1 diabetes may progress to
nephropathy hence kidney failure and
retinopathy leading to blindness.
Gestational diabetes occurs only in pregnancy

diabetes
D. The fetus produces his own insulin
but gets glucose from the mother via
the placenta.
• The amount of glucose available in
maternal circulation causes fetal
pancreas to produce insulin.

Summary: Effects of Pregnancy
on Diabetes (difficult control)
The Effects of Pregnancy on Diabetes
When the mother has diabetes and then
becomes pregnant, there will be further
increase in insulin demand and even a
mother who had only been on a controlled
diet, without need for medication, may now
require insulin supplements.
There is a low renal threshold to glucose and
also low glucose intake by mother due to
nausea and vomiting—makes control difficult.

The Effects of Diabetes on
Pregnancy
It is important to know what happens
to the mother and foetus in relation to
glucose and insulin “control” and the
effects.

The Effects of Diabetes on
Pregnancy
Unrecognised or a badly treated diabetes leads
to complications in both mother and baby.
Effects relate to degree of “control” of blood
glucose levels within a range of 70mg/dL to 120
mg/dL and the degree of vascular involvement.
If well controlled, then the effects to
pregnancy may be minimal. 

Effects of Diabetes on Pregnancy:
Maternal complications include:
DKA—ketones
Diabetic retinopathy
Urinary tract infection
Candidiasis of vulva and vagina
Reduced fertility, spontaneous abortion, pregnancy
induced HTN, chronic HTN
Polyhydramnios
Preeclampsia and eclampsia, HELLP syndrome
Abruptio placenta
Maternal stroke
Pre-term labour

Long Term Complications of Diabetes
MATERNAL:
Vascular disease that complicates diabetes mellitus
may progress during pregnancy:
Hypertensionvascular changes: Nephropathy
results from renal impairment and retinopathy may
develop
(Long term effects are macrovascular and
microvascular disease: coronary heart disease,
peripheral arterial disease, kidney disease, loss of
vision and nerve damage.

Effects of Diabetes on Pregnancy:
Foetal and neonatal complications
These occur when the blood sugar is not
controlled and are mainly due to glucose
being attached to the haemoglobin
(glycosylated haemoglobin).
This results in impaired oxygen carrying
capacity because glycosylated Hb releases
oxygen poorly to the fetus.

Fetal Complications of Diabetes
during Pregnancy
Foetal Hypoxia
Intrauterine hypoxia is caused by:
vascular changes on the maternal side of the
placenta, and increased oxygen consumption by the
placenta and foetus.
Placental aging
The foetal haemoglobin is glycosylated hence there
is an increase in the red blood cells count
(polycythaemia) in order to compensate for the
demand of oxygen by the foetus. The baby is red
due to polycythaemia
Maternal ketosis

DiabetesNEONATE risks
Many of problems of neonate result from high
maternal plasma glucose levels. If maternal
ketoacidosis is untreatedincrease risk of
fetal death
Congenital abnormalities: Most anomalies
involve the heart, central nervous system and
skeletal system.
Placental pathology eg accelerated aging
SGA
stillbirth

Fetal Complications of Diabetes
during Pregnancy
Macrosoma
Glucose crosses the placental barrier easily
but insulin does not.
Hyperglycaemia in the motherfoetal
hyperglycaemia in late pregnancy. The foetal
pancreas responds by producing excess
insulin, which cannot cross back into the
maternal circulation.
The insulin converts excess glucose into
glycogen: stored as fat deposits in the tissues
resulting in a BIG baby (but often “preterm”)

Cont Effects of Diabetes on
Fetus
Higher incidence of neonatal deaths
as a result of:
RDS
Neonatal hypoglycaemia
Neonatal hypocalcaemia
Injuries at birth
Congenital anomalies

Newborn complications
LGA (Large for gestational age):
growthmacrosomia and fat deposits. high risk
for shoulder dystocia, traumatic birth injuries
and may be increased risk for impaired glucose
tolerance in later childhood.
After birth when glucose source to baby stops,
the hyperactive islet cells still produce high
insulin and depletes glucose stores in 2-4
hours.
Obesity and diabetes

Effects of Diabetes on
Pregnancy (cont.)
Complications are more common with
IDDM polyhydramnios, PIH, Stillbirth after
36 wks, Neonatal macrosomia,
hypoglycaemia, hyperbilirinaemia, delayed
fetal lung maturity resulting in respiratory
distress syndrome (RDS), and increased
incidence of congenital anomalies including
neural tube defects (NTD)

DIABETES MANAGEMENT
PRE-CONCEPTION CARE
PRENATAL CARE
INTRAPARTAL CARE (L/D)
POSTNATAL CARE

Pre-conception care
Establish good glycaemic control before
conception and continue throughout
pregnancy
Tell the client that risks can be reduced but
not eliminated
Avoid unplanned pregnancy
Health education on effects of diabetes on
pregnancy and vice versa
Role of diet, body weight and exercises

Cont.. Pre-conception care
Risks of hypo or hyperglycaemia
How nausea and vomiting in pregnancy can
affect glycemic control
Increased risk of having a big baby which
may lead to trauma and C/S
The need for assessment for long-term
complications of diabetes
Importance of maternal glycemic control
during labour and birth and early feeding of
the baby

Pre-conception care
Possibility of transient neonatal morbidity
which may require admission of the baby
Risk of baby developing obesity and/or
diabetes in later life
Taking folic acid 5 mg/day from pre-
conception until 12 weeks gestation

Pre-conception care
Adjustment of medication and self-
monitoring routines
Frequent visits, and local support including
emergency telephone contacts
Monthly HbA1c (aim is < 6.1%). Those with
>10% should avoid pregnancy
Offer: Blood glucose meter, ketone testing
strips and how to use, Diabetes structured
education programme.

Antenatal Care
Should keep FBS between 3.5 and 5.9 mmol/L and
1-hour postprandiol blood glucose <7.8 mmol/L
during pregnancy
At risk of aymptomatic bacteriuria, urine culture to
be done and if positive start treatment
immediately. Repeat cultures after TX to confirm
elimination of the infection
Protein detected in clean-catch urine specimen
should be evaluated by 24-hour urine testing and
repeated PRN
Clinical/US assessment of fetal growth, congenital
anomaly and AFI should be done routinely

Antenatal Care
• A dietician should be consulted but diet with
high fibre produces a more constant blood
glucose as carbohydrate is released for
absorption more slowly.
The need for carbohydrate increases as the
foetus grows and must be reviewed.
Teach client about prescribed diabetic diet
regulation with no concentrated sweets.
Encourage regular non-strenuous exercise
such as walking for weight and blood glucose
control.

For insulin requiring DM: Weekly NST
from 32 weeks gestation and increase
to biweekly is recommended after 36
weeks
For non-insulin requiring DM: weekly
NSTs are usually began at 36 weeks
All pts should be instructed to make
daily assessments of FMs and to alert
the physician if a decrease is noted.

BPP should be done if decreased FM is
noted or if a nonreactive NST occurs
Women suspected to have ketoacidosis
should be admitted immediately for
critical care
In case there is abnormal fetal testing,
practitioner should assess gestational
age and if fetus is found to be mature,
delivery should be expedited.

If the foetus is intermediate in maturity,
amniotic fluid assessment for pulmonary
maturity may assist in the decision regarding
whether delivery should be effected.
Lung maturity should also be assessed
before elective induction if glucose control is
questionable or if the foetus is less than 38
weeks unless foetal jeopardy is suspected.

The lecithin: sphingomyelin ratio should be
2.5 or higher due to the higher incidence of
respiratory distress in the foetus.
If the foetus is immature, further testing
such as contraction stress tests or
hospitalization with continuous foetal heart
rate monitoring is advised.
Evaluate client for complications e.g. PIH

Preterm labour is increased in patients with
diabetes, and they should be treated with
mgso4 as the initial tocolytic agent because
the beta mimetics markedly influence
glucose control.
Corticosteroids increase maternal glucose
levels, and therapy should be prescribed to
keep levels in the desired range. This
therapy may consist of continuous insulin
infusion in certain cases.

Induction of labour is recommended at
38 weeks in patients with poor glucose
control and macrosomia.
Use of Prostaglandin to ripen the cervix
reduces the caesarean section rate, but is
not advised without a negative
contraction stress test if oligohydramnios
is the indication for induction.

Hypoglycaemic therapy
Consider hypoglycaemic therapy for
women with gestational diabetes:
If lifestyle changes do not maintain
blood glucose targets over a period of
1–2 weeks or
If ultrasound shows incipient foetal
macrosomia (abdominal circumference
above the 70th percentile) at diagnosis.

Hypoglycaemic therapy
If hypoglycaemic therapy is required:
Tailor hypoglycaemic therapy to the individual
woman
Reg insulin, the rapid acting insulin analogues
or the oral hypoglycaemic agents metformin
and glibenclamide may be considered.
The pt should be managed jointly by the
diabetes and antenatal clinic team. Maintain
contact with the diabetes care team every 1–2
weeks to assess glycaemic control

Management of Labour
Diabetic patients must be advised to deliver
in hospital under skilled birth attendance.
Insulin-dependent diabetics should be
induced at 40 weeks’ gestation if
spontaneous labour has not occurred.
Diabetes Mellitus alone is not an indication
for C/section. Oxytocin is given for labour
induction similarly to normal pregnancies.

Cont…Management of
Labour
Continuous FHR monitoring is required
with careful attention to decelerations
Glucose infusion (D5W, lactated Ringer’s
solution) is given to all patients in labour
unless delivery is immediate.
Glucose levels are monitored every 2-4
hours with the goal of maintaining levels
at 3-7 mmol/L till delivery.

Labour
In those requiring insulin, give half the
dose of insulin with a light meal in the
morning on the day of delivery.
Maintain with regular insulin (25 iu/250
mL normal saline, giving a dilution of
0.1 iu/mL) by continuous infusion at
levels of 0.5-2 iu/h.

Use of partograph
Vigilant observations of the general
condition of the mother, uterine
contractions, foetal heart rate, maternal
pulse half hourly, blood pressure, vaginal
examination four hourly, and urinalysis two
hourly (or more frequently) are made and
charted on the partograph accordingly every
half, two and four hours. Any deviation from
the normal should be noted and the doctor
informed

Labour
Shoulder dystocia should always be
anticipated and prepared for.
If repeat caesarean section or other
indication for elective surgery occurs,
the patient should be directed to take
the evening insulin dose prior to
surgery, but not her morning dose.

Labour
Showering with a bacterial solution the
night before delivery seems reasonable
due to the increase in wound infections
in this group.
The patient is at increased risk of
thromboembolic events due to
decreased prostacyclin production by
the platelets.

Induction of Labour in a
Diabetic Mother
To induce labour, artificial rupture of the
membranes is done and oxytocin is put in normal
saline, which is regulated depending on the
uterine contractions.
For the nutritional needs and to prevent
hypoglycaemia, a drip of 10% dextrose is set up
and regulated at 20 drops per minute.
Soluble insulin is given by syringe pump at six
units in 60ml of normal saline. This is regulated
depending on the blood sugar levels.

Regimen in
MX of
Diabetes
During
Labour

Labour (Diabetic)
Throughout labour the blood sugar is
checked hourly.
If the results are lower than 4mmol/l,
reduce the insulin dose by half.
If they are higher, double the dose
and check blood sugar every 30
minutes.

Labour: Diabetic
Remember:
Long acting insulin is NOT given
during induction of labour because
the insulin requirements fall by
about 50 percent once the placenta
is delivered.

Neonatal care
Babies of women with diabetes should be
kept with their mothers unless there is a
clinical complication or there are abnormal
clinical signs that warrant admission for
intensive or special care. However they need
to be observed carefully for complications
such as hypoglycaemia, Respiratory Distress
Syndrome (RDS) and neonatal jaundice.
Breastfeeding is not affected by diabetes and
is generally encouraged.

Postnatal care
Women who were diagnosed with
gestational diabetes should be offered
lifestyle advice (including weight
control, diet and exercise) and offered a
fasting plasma glucose measurement at
6-week postnatal check and annually
thereafter.

Postnatal care
Contraception should be offered. For
gestational diabetes, all methods are MEC
category 1.
However if the diabetes is persistent,
hormonal methods are MEC category 2, while
IUCD is MEC category 1. Female sterilisation
needs extra preparation and precaution
(category C).

Postnatal care
In case of vascular complications
including kidney, ocular or nerve
damage, hormonal contraceptives are
categories 3 /4 meaning they should
generally not be used.

Nursing diagnoses
Nutrition: altered, risk for less than body
requirements. Risk Factors May Include:
Inability to ingest/utilize nutrients
appropriately evidenced By:
NURSING DIAGNOSIS: Injury, risk for
fetal. Risk Factors May Include: Elevated
maternal serum glucose levels, changes in
circulationPossibly evidenced By:

NURSING DIAGNOSIS: Injury, risk
for maternal. Risk Factors May
Include: Changes in diabetic control,
abnormal blood profile/anemia, tissue
hypoxia, altered immune response
evidenced By:

Diabetes in AN,L/D,PP
PRIORITY NURSING diagnoses:
Risk for imbalanced nutrition (maternal and
fetal)
More than body requirements
Risk for injury (maternal and fetal)
Anxiety
Knowledge deficit

AN: Controlling blood sugar
The aim of prenatal care is the control of
blood sugar. To avoid hypoglycaemia and
hyperglycaemia adjust the insulin dose.
Remember: Maintain blood glucose level
within the normal range of 4 - 5.9mmol/l.
Ensure that post-delivery the blood sugar
does not exceed 7.0 mmols/l.Prolong the
pregnancy to ensure foetal viability.
Once diagnosed, the mother should be
followed up keenly by the two doctors
fortnightly up to 32 weeks gestation and
then weekly up to term.

Antenatal Care: Diabetes
If a mother has risk factors: should be
cared for by diabetic specialist,
obstetrician, dietician and midwife.
She should have more frequent visits**
Ideally preconception counselling is
done and the mother is stabilised. If
she has nephropathy or retinopathy,
pregnancy should be avoided.

Diabetes in Pregnancy: Mgt
B. Medication
i) Before or as soon as pregnancy is
confirmed:
(a) stop oral hypoglycaemic agents except
metformin2, and commence insulin if
required
(b) Stop ACE inhibitors and angiotensin-II
receptor antagonists and consider
alternative antihypretensives.

Diabetes in Pregnancy:
Antenatal care
A. DIET:
Teach client about prescribed diabetic
diet regulation with no concentrated
sweets.
Dietary regulation usually adequate to
control gestational diabetes; excess wt
gain should be avoided; caloric needs
will increase as pregnancy progresses

Antenatal Care
1. Monitor Fetal Lung Maturity:
Lecithin/Sphingomyelin (L/S)( ratio needs to
be 1:3 (normal is 1:2)—to determine lung
maturity.
2. Evaluate client for complications e.g.
infection, PIH, DKA
Twice weekly nonstress testing at 32 wks.
Urgent admission if diabetic ketosis occurs.

(HbA1c not available at Tenwek)
Long term glucose control=HbA1c 
blood test which measures percent of
haemoglobin with glucose bound to it.
Levels depend on amount of glucose
available during the red blood cell’s 120
day lifespan

Cont
Insulin needs to be carefully regulated
and adjusted as pregnancy progresses
(may need as much as 4x dose
increase at term)

Oral hypoglycaemics: not
used in pregnancy

Why? (oral hypoglycaemics
NEVER used in pregnancy)
1. May be teratogenic
2. Stimulate increased production of insulin
by the fetus
3. Exaggerate neonatal hypoglycaemia
(**Decrease in insulin requirements in later
weeks of pregnancy is a grave prognostic
sign for the fetus; the decreasing need
reflects decreasing PLACENTAL function.

Diabetes in Pregnancy:Mgt
* Instruct client in frequent blood glucose
and ketone testing and keeping a diary of
test results and activity levels. (keep
fasting blood glucose levels within narrow
limits (4-5.9 mmol/L)
* Encourage regular non-strenuous exercise
such as walking for weight and blood
glucose control.

URINE:
(blood test more accurate)

cont
Diabetics have triple the normal rate of
asymptomatic bacteriuria. Urine culture
needs to be done initially, and treated
appropriately if positive and culture
repeated to confirm elimination of
infection
Protein in urine should be tested

C: MONITOR
i) Monitor fetal well-being: ultrasound
for anomalies, amniotic fluid volume,
fetal size; fetal movement counts,
weekly NST from 32 weeks and
biweekly after 36 wks, bio-physical
profile
ii) Lecithin/Sphingomyeline (L/S)(
ratio needs to be 1:3 (normal is 1:2)
(to help assess lung maturity: surfactant)

• Fetal kick chart
• Admit pts with ketoacidosis
• Arrest preterm labour with mgso4,
corticosteroids like dexamethasone can
increase maternal blood glucose. Also
beta mimetics eg salbutamol (ventolin)

D. Evaluate:
Evaluate client for complications e.g.
infection, PIH, DKA
E. LABOUR: Prepare for possible
induction of labour at 38 weeks for
clients with IDDM to reduce risk for
stillbirth caused by premature
placental aging, those poor glucose
control and macrosomia

Stabilization: Diabetes
Admission may be undertaken at 12
weeks and 32 weeks for stabilisation
when hormonal changes may affect the
mother. Hospitalisation is also done in
case any complication or infection
occurs.

Stabilization
This is the care given to the admitted
mother to bring the blood sugar down
and maintain it.
A daily urinalysis should be carried out
six hourly using dextrostix, and also
when necessary.
Blood sugar should be measured twice
weekly or daily if high.

Stabilization
Short acting insulin subcutaneously given on a sliding
scale (measure) helps to avoid gross foetal
abnormality.
Scanning is done to assess the foetal maturity/growth
and an x-ray may be carried out after 30 weeks
gestation.
The foetal wellbeing is also monitored by the mother
noting the frequency of the foetal kicks.
Any infection, for example urinary tract infections, has
to be detected early and appropriate treatment given.
At term a pelvimetry is done to assess pelvic adequacy.

Weight monitoring
A dietician should be consulted but diet
with high fibre produces a more
constant blood glucose as carbohydrate
is released for absorption more slowly.
The need for carbohydrate increases as
the foetus grows and must be
reviewed.

Health teaching concerning
diabetes for a pregnant mother
Diet, self injection, use of diabetic kit
for testing, reading and accurate
recording of the blood sugar level, signs
and symptoms of hypo/hyperglycaemia
and what to do.

Follow up after stabilization
Once the mother is stabilised, she is
discharged to continue with prenatal
clinic fortnightly or weekly depending
on the gestation.
The mother is readmitted at 37 to 38
weeks for induction of labour if she has
not gone into spontaneous labour.

DIABETES:
Labour/Delivery
and Postpartum

Pregnancy/IP/PPDiabetes
Diabetics need to be advised to deliver in
the hospital
Increased energy needs during labour
may require increased insulin to
balance IV glucose.
Postpartum: Usually abrupt decrease
in insulin requirement occurs
immediately after delivery of placenta
(decrease in HPL)

Intrapartum
1. Determine fetal lung maturity
(remember that if dexamethasone—
increases insulin requirements)
2. Monitor Blood glucose levels every 2-4
hours (maintain at 3-7 mmol/L till
delivery
3. Monitor for fetal distress:
4. Pain relief: assist in regulating blood
sugar levels and preventing
development of metabolic acidosis.

Intrapartum
1. Timing of birth: allowed to go to term with
elective induction of labour or vaginal birth
planned at 38-40 wks gestation.
2. May need C/S if signs of fetal distress. Birth
BEFORE term may be indicated for diabetic
women with vascular changes and
worsening hypertension or if evidence of
IUGR exists.

Birth plan: Diabetic
The mothers who are at risk, for instance those with
a bad obstetric history, the elderly primigravidae, the
mother with pre-eclampsia and a baby that is too big,
should not deliver vaginally.
At 36 to 38 weeks the mother is admitted for elective
Caesarean section.
On the day of operation, the morning dose of
insulin is omitted. However, if the operation is
performed at a late hour then one third or half of the
intermediate acting dose of insulin should be given in
the morning before starting the drip.

Intrapartum
AVOID sedatives & analgesics: These can
depress the foetal respiratory centre
Physical care of mother is maintained—
maintain aseptic technique
Regulate drips accurately
If she has not delivered after 8 hours of
labour, she is reassessed and caesarean
section is performed.

Use Partograph (Diabetic)
Vigilant observations of the general
condition of the mother, uterine contractions,
foetal heart rate, maternal pulse half hourly,
blood pressure, vaginal examination four
hourly, and urinalysis two hourly (or more
frequently) are made and charted on the
partograph accordingly every half, two and
four hours. Any deviation from the normal
should be noted and the doctor informed.

Delivery: Diabetic
Early delivery is not necessary IF the
diabetes is well controlled.
If labour starts spontaneously
prematurely, then dexamethasone is
given to aid in lung maturity or
salbutamol (ventolin) to relax the uterus.
**These drugs are given with care as
they both increase insulin requirements.

Labour/Delivery
“INTRAPARTUM”:
Blood glucose levels can decrease greatly
during labour—stress and labour and pain.
Maternal glucose monitor hourly.
The main goal of controlling maternal glucose
levels intrapartally is to prevent neonatal
hypoglycaemia.
Often have two IV lines. (one with saline the
other D5W)

Labour/Delivery (Diabetic)
Aim at controlling blood sugar between:
3.5 to 5.9 mmol/l.
Hyperglycaemia increases foetal insulin
production, which usually causes neonatal
hypoglycaemia.
The patient may be allowed a light breakfast
or nil by mouth. In some cases SQ insulin is
given to mothers with insulin dependent
diabetes mellitus.

Diabetes in Labour
Check glucose 2-4 hourly in labour to assess
need for glucose
Glucose—IV (for extra energy in labour)
Need insulin to help utilize the glucose
During 2nd stage and immediate PP woman
may not need added insulin
STOP insulin at end of third stage and
monitor blood glucose levels closely.

Diabetes: Postpartum
*Insulin requirements drop
dramatically after delivery of placenta
and removal of hormone influence.
*PP Client may need no insulin or
very decreased dose;
*gestational diabetics generally eat
regular diet.

Postpartum--Diabetes
• POSTPARTUM CARE:
• Immediately after 3rd stage insulin
requirements fall rapidly –Monitor blood
sugar
• Breastfeeding should be encouraged in all
women with diabetes
• Operative birth, higher risk for infection and
delayed healing. May need antibiotics.
• Need family planning counselling

Postpartum (Diabetic)
The care of a diabetic mother after
delivery is very important as it
enhances the previous care. You will
note that after delivery of the placenta
the carbohydrate metabolism returns to
“normal” almost immediately. Thus, the
insulin dose has to be reduced by half
immediately to avoid hypoglycaemia.

Postpartum F/U
The intravenous infusion is maintained until
the next meal.
Meanwhile, the blood sugar has to be
constantly checked and levels controlled
within the normal range and the insulin dose
adjusted accordingly.
When she is breast feeding, the mother will
need increased intake of carbohydrate by
50gm a day.
Small amounts of insulin enter the breast milk
but these are destroyed in the baby's
stomach.

Neonate: Management
During delivery a paediatrician should be
present to take care of the baby immediately
after birth. The principles of managing the
baby after birth involve clearing the airway,
providing warmth, giving oxygen and
preventing hypoglycaemia and
hypocalcaemia. The baby is admitted in the
baby unit for management after the
resuscitative measures are carried out.

Diabetes IP/PP
LGA (Large for gestational age):
growthmacrosomia and fat deposits. High
risk for shoulder dystocia, traumatic birth
injuries and may be increased risk for
impaired glucose tolerance in later childhood.
After birth when glucose source to baby
stops, the hyperactive islet cells still produce
high insulin and depletes glucose stores in
2-4 hours.

Diabetes: Postpartum
Oral hypoglycaemics contraindicated in
breastfeeding
Usually GDM do not need insulin postpartum
if did not need during pregnancy.
Monitor blood glucose
Check at 6 week check up
GDM has 30-40% risk of DM in 1-25 years.
If baby is in nursery, keep parents updated
and give support and encouragement
Encourage breastfeeding
FP needs

Diabetespregnancy/IP/PP/NB
Infants of diabetic mothers (cont.)
IUGR (Intrauterine growth restriction
Respiratory distress syndrome:
Polycythaemia
Hyperbilirubinaemia

NEONATE
NEONATAL CARE:
macrosomia (>4500 gm)[prolonged labour
(CPD), shoulder dystocia, birth injuries],
hypoglycaemia
**need to asses neonatal blood glucose 1-2
hours after birth and then every 4-6 hours for
first 24-48 hours.
Regular feeding is encouraged to maintain a
blood glucose of at least 2 mmol/L,
polycythaemia and respiratory distress
syndrome.

Fetal/Newborn Complications
Untreated ketoacidosisover 50% mortality
Fetal anomalies
Stillbirth
Neonatal macrosomia/LGA
But may be preterm and high risk for
asphyxia
Hypoglycaemia
Hyperbilirubinaemia
Delayed fetal lung maturity
Polycythaemia

Managing Diabetes in Pregnancy

Recommended

Recommended

More Related Content

Similar to Managing Diabetes in Pregnancy

Similar to Managing Diabetes in Pregnancy (20)

Recently uploaded

Recently uploaded (20)

Managing Diabetes in Pregnancy