Gestational diabetes

4/3/2016Nirsuba Gurung MN 1st year
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4/3/2016
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Nirsuba Gurung MN 1st year

PRESENTED BY
NIRSUBA GURUNG
RN,MN
WOMEN HEALTH AND DEVELOPMENT
DIABETES IN PREGNANCY
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objectives
 At the end of the teaching learning session students
will be able to
 Define diabetes
 Explain metabolic changes associated with
pregnancy
 Classify different types of diabetes in pregnancy
 Maternal and fetal risk associated with diabetes
 Diagnosis and screening of diabetes in pregnancy
4

Diabetes Mellitus In Pregnancy
 DM is a chronic metabolic disorder due to
either absolute or partial insulin deficiency or
due to peripheral tissue resistance to the
action of insulin,resulting in hyperglycemia
 Diabetes mellitus is one of the most common
endocrine disorders affecting almost 6% of
the world's population
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Introduction
About 1-14% of all pregnancies are complicated
by DM and 90% of them are gestational DM.
Nearly 50%of women with GDM will become
overt diabetes over a period of 5-20 yrs.
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Carbohydrate metabolism
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Insulin
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Action of Insulin on Carbohydrate,
Protein and Fat Metabolism
Carbohydrate
 Facilitates the transport of glucose into muscle and
adipose cells
 Facilitates the conversion of glucose to glycogen for
storage in the liver and muscle.
 Decreases the breakdown and release of glucose from
glycogen by the liver
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Protein
 Stimulates protein synthesis
 Inhibits protein breakdown; diminishes
gluconeogenesis
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Fat
 Stimulates lipogenesis- the transport of triglycerides
to adipose tissue
 Inhibits lipolysis – prevents excessive production of
ketones or ketoacidosis
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Action of Insulin on the Cell metabolism
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Metabolic changes in pregnancy
 Caloric requirement for a pregnant woman
is 300 kcal higher than the non-pregnant
woman’s basal needs
 Placental hormones affect glucose and lipid
metabolism to ensure that fetus has ample
supply of nutrients
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Metabolic changes associated with
pregnancy
 Complex alteration in maternal glucose metabolism, insulin
production and metabolic homeostasis
 Glucose the primary fuel used by fetus , is transported
across the placenta through the process of diffusion
 Although glucose crosses placenta, insulin does not.
 Around 10th week of gestation fetus begins to secret its own
insulin at level adequate to use the glucose obtained from
obtained from the mother
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Metabolic changes contd…….
During the 1st trimester
 Estrogen and progesterone level rises in blood
 Hormone stimulates the beta –cells to secrete
insulin , which promotes increased peripheral use
of glucose and increase glycogen store and decrease
hepatic production of glucose , which leads to
decrease in fasting blood glucose during 1st
trimester
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Metabolic changes contd…….
During 2nd and 3rd trimester:
Increased insulin resistance
Due to hormones secreted by the placenta
that are “diabetogenic”:
Human placental lactogen
Corticotropin releasing hormone
Growth hormone
Placental insulinase
Transient maternal hyperglycemia occurs after
meals because of increased insulin
resistance
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Classification of diabetes in pregnancy
Pregestational
diabetes
Gestational diabetes
Pregnancy in
pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Diabetes diagnosed in
pregnancy
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Type I and Type II DM
 Insulin dependent diabetes mellitus (IDDM)-
type I
Absolute insulinopenia
Caused due to genetic predisposition to autoantibodies
 Non insulin dependent dependent diabetes
mellitus (NIDDM)-Type II
Insulin resistance
Genetic predisposition and other unhealthy life style
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1.Type 1 Diabetes Mellitus
Type 1 DM is characterized by loss of the
insulin-producing beta cells of the islets of
Langerhans in the pancreas leading to insulin
deficiency.
It present more commonly in childhood
Insulin therapy is required in order to prevent
the development of diabetic ketoacidosis
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Type I Diabetes Cell
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PATHOGENESIS OF TYPE 1 DM
Environment ?
Viral infection?
Genetic
Severe Insulin deficiency
ß cell Destruction
Type 1 DM
Autoimmune Insulitis
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2. Type 2 Diabetes Mellitus
Type 2 diabetes mellitus is characterized by
insulin resistance which may be
combined with relatively reduced insulin
secretion.
The defective responsiveness of body tissues
to insulin is believed to involve the insulin
receptor. However, the specific defects are
not known.
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2. Type 2 Diabetes Mellitus contd…
At this stage hyperglycemia can be reversed
by a variety of measures and medications
that improve insulin sensitivity or reduce
glucose production by the liver .
The risk of developing this type of diabetes
increase with age, obesity and lack of
physical activity
It can be managed by oral hypoglycemic
drugs. 4/3/2016
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Type II Diabetes
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PATHOGENESIS OF TYPE 2 DM
Environment
Obesity ???
ß cell defect
Genetic
ß cell
exhaustion Type 2 DM
Insulin resistance
Relative Insulin Deficiency
IDDM
Abnormal Secretion
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Pathogenesis
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GESTATIONAL DIABETES MELLITUS(GDM)
GDM is defined as CHO intolerance of variable
severity with onset or first recognition
during the present pregnancy.
Pregnancy induced glucose intolerance
Usually seen in 2nd and third trimester of
pregnancy
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Whites Classification of Pregnant Diabetic
Women
Class Onset Fasting
Plasma
Glucose
2hr post
prandial
Treatme
nt
A GDM Any age A1:Glucose<105
A2:>105
<120mg/dl
>120mg/dl
Diet
Insulin
Class Age of
onset
Duration Vascular
disease
Treatment
B
C
D
F
H
R
T
>20yrs
10-19yrs
<10yr
Any
Any
Any
Any
<10 years
10-19yrs
>20yrs
Any
Any
Any
Any
None
None
HTN
Nephropathy
CAD
Retinopathy
Renal
transplant
Insulin
Insulin
Insulin
Insulin
Insulin
Insulin
Insulin
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OVERT DIABETES
 Patient with symptoms of DM and random
plasma glucose concentration of 200mg/dl or
more is considered overt diabetic.
 According to American Diabetic Association,
diagnosis is positive if
a)Fasting plasma exceeds 126mg/dl.
b)the two hour post glucose (75gm) value
exceeds 200mg/dl.
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MATERNAL
AND
FETAL RISKS
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Maternal complications
 Worsening retinopathy
 Worsening proteinuria. GFR decline
depends on preconception creatinine and
proteinuria
 Hypertension and Cardiovascular disease
 Infection
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Effects of Diabetes in Pregnency
 During pregnancy
1. Abortion
2. Preterm labor(20%)
3. Infection
4. Increased incidence of pre-eclampsia(25%)
5. Polyhydraminos(25-50%)
6. Maternal distress
7. Diabetic Retinopathy
8. Diabetic Nephropathy
9. Ketoacidosis
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Effects of Diabetes in Pregnency Contd…
During labor
1. Prolongation of labor
due to big baby
2. Shoulder dystocia
3. Perineal injuries
4. PPH
5. Operative interference
During Puerperium
1. Puerperial sepsis
2. Lactation failure
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Maternofetal Complications
 Macrosomia: 63 percent
 Cesarean delivery: 56 percent
 Preterm delivery: 42 percent
 Preeclampsia: 18 percent
 Respiratory distress syndrome: 17 percent
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Maternofetal Complications Contd…
 Congenital malformations: 5 percent
 Perinatal mortality: 3 percent
 Spontaneous abortion, third trimester fetal
deaths, polyhydramnios, preterm birth
 Risk for type 2 DM
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Fetal complication
Maternal hyperglycemia
|
Fetal hyperglycemia
|
Fetal pancreatic beta-cell hyperplasia
|
Fetal hyperinsulinaemia
|
Macrosomia,organomegaly, polycythaemia,
hypoglycemia, RDS
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Neonatal Complications
 Morbidity associated with
preterm birth
 Macrosomia ± birth injury
(shouldeer dystocia, brachial
plexus injury)
 Polycythemia and hyperviscosity
 Hyperbilirubinemia
 Cardiomyopathy
 Hypoglycemia and other
metabolic abnormalities
(hypocalcemia,
hypomagnesemia)
 Respiratory problems
 Congenital anomalies
Fetal macrosomia
Shoulder dystocia
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Congenital Anomalies
 Skeletal and central
nervous system
 Caudal regression
syndrome
 Neural tube defects
excluding
anencephaly
 Anencephaly with or
without herniation of
neural elements
Caudal regression
syndrome
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 Cardiac
Transposition of the great vessels with or
without ventricular
Ventricular septal defects
Coarctation of the aorta with or without
ventricular septal defects or patent ductus
arteriosus
Atrial septal defects
Cardiomegaly
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 Renal anomalies
 Hydronephrosis
 Renal agenesis
 Ureteral duplication
 Gastrointestinal
 Duodenal atresia
 Anorectal atresia
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Symptoms
 Weight loss during early weight gain or Excessive
weight gain during pregnancy 2nd and third
trimester of pregnancy
 Polyuria (frequent urination)
 Polydipsia (increased thirst)
 Polyphagia(increased hunger)
 Fatigue
 Weakness
 Tingling or numbness in hands or feet.
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Signs
 Weight loss during early weight gain or Excessive weight gain
during pregnancy 2nd and third trimester of pregnancy
 Polyhydraminous
 Fundal height more than period of gestation
 Signs of dehydration
 Vision impairment
 Kusummal breathing
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Sign and symptom
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Diagnosis of Gestational Diabetes
 History
Genetic suspects
Obstetric suspect-h/o macrosomic baby, unexplained
still birth , PPH, traumatic deliver, recurrent
spontaneous abortion
Chronic hyoertention,
Maternal age >30 years
 Clinical examination:
Obesity ,HTN, repeated UTI, polyhydraminous,
glycosuria
 Screening test
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Gestational Diabetes (GDM) Diagnosis
 Universal screening for GDM at 24-28
weeks Gestational Age (GA)
 Screen earlier if risk factors for GDM:
 Positive family history of DM
 Previous birth of an overweight baby
 Previous still birth with pancreatic islets
hyperplasia revealed on autopsy
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Diagnosis GDM Contd…………..
 Unexplained perinatal loss
 Presence of polyhydraminos or recurrent
vaginal candidiasis in present pregnancy
 Persistent glycosuria
 Age>30yrs
 Obesity
 Ethnic group(East Asian,Hispanic ,African,
native American)
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Diagnostic Criteria for GDM
PREFERRED APPROACH (2
steps)
1. 50 gram glucose challenge test
2. 75 gram oral glucose tolerance
test
ALTERNATIVE APPROACH (1 step)
1. 75 gram oral glucose tolerance test
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Diagnosis: Two Approaches

Testing for GDM
 One step – first option
2 hour glucose tolerance test
75 gram oral glucose load, draw blood
sugar 2 hours later
some modify and do Fasting : <95 mg/dl
1 hour : <180 mg/dl
2 hour : <155 mg/dl
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Testing for GDM
 One step – second option
3 hour glucose tolerance test
Fasting (for 8 – 14 hours) : <95 mg/dl
100 gram oral load of glucose
1 hour post-prandial : <180 mg/dl
2 hour post-prandial : <155 mg/dl
3 hour post-prandial : < 140 mg/dl
A diagnosis of GDM is made with 2 abnormal
values
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Testing for GDM
 Two step option
First done is 50 gram oral glucose load, without
regard to time of day or last meal
blood sugar one hour later : <140 (or <130)
 If elevated, the previously described 3 hour
glucose tolerance test, with 100 gram load,
same values, is performed
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Criteria for diagnosis of impaired glucose
tolerance and diabetes with 75gm oral glucose
(ADA )
Time Normal
tolerance
Impaired
glucose
tolerance
Diabetes
Fasting <110 ≥ 110 and <
126
≥126
2 hour post
glucose
<140 ≥ 140 and < ≥200
•Venous whole blood values are 15%less than the plasma
•m mol/L =mg% × 0.0555
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Criteria for diagnosis of GDM with 100g oral
glucose
Time Carpenter&cou
stan
NDDG
fasting 95 mg/dl 105 mg/dl
1 hour 180 mg/dl 190 mg/dl
GDM is diagnosed when any two values are met or
relevant 4/3/2016
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All pregnant women should be screened for
GDM at 24-28 weeks of gestation
If there is a high risk of GDM based on multiple
clinical factors, screening should be offered at
any stage in the pregnancy . If the initial
screening is performed before 24 weeks of
gestation and is negative, rescreen between
24-28 weeks of gestation.
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Investigation on the status of diabetes
 Urine culture
 Ophthalmologic examination
 Renal function test
 ECG
 Blood glucose level including glycolated hemoglobin
Hb A1C
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Management of
diabetes in
pregnancy
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Diabetes in Pregnancy: Consider
Phases
Pregestational diabetes Gestational diabetes
1. Preconception counseling 1. Screening
2. Glycemic control during
pregnancy
2. Glycemic control during
pregnancy
3. Management in labour 3. Management in labour
4. Postpartum considerations 4. Postpartum considerations
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Aims of management
1. Achievement of euglycemia during
periconceptional period and through out the
pregnancy
2. Careful antenatal care throughout the pregnancy
3. To find out optimum time and mode of delivery
and to avoid iatrogenic prematurity
4. Avoiding maternal complication and their timely
detection and management
5. Fetal monitoring
6. Timely detection and management of fetal and
neonatal complications
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Preconception Care
1. All women of reproductive age with type 1 or type 2
diabetes should receive advice on reliable birth control,
the importance of glycemic control prior to pregnancy,
impact of BMI on pregnancy outcomes, need for folic acid
and the need to stop potentially embyropathic drugs
prior to pregnancy
2. Women with type 2 diabetes and irregular menses/PCOS
who are started on metformin or a thiazolidinedione
should be advised that fertility may improve and be
warned about possible pregnancy
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Preconception Care Contd…
3. Before attempting to become pregnant,
women with type 1 or type 2 diabetes should:
a) Receive preconception counseling that
includes optimal diabetes management
and nutrition, preferably in consultation
with an interdisciplinary pregnancy team
to optimize maternal and neonatal
outcomes
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Preconception Care contd…
b) Strive to attain a preconception A1C of ≤7.0% (or
A1C as close to normal as can safely be achieved)
to decrease the risk of:
 Spontaneous abortion
 Congenital anomalies
 Pre-eclampsia
 Progression of retinopathy in pregnancy
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c) Supplement their diet with multivitamins
containing 5 mg of folic acid at least 3 months
pre-conception and continuing until at least
12 weeks post-conception Supplementation
should continue with a multivitamin containing
0.4-1.0 mg of folic acid from 12 weeks
postconception through to 6 weeks
postpartum or as long as breastfeeding
continues
Preconception Care (continued)
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d) Discontinue medications that are potentially
embryopathic, including any from the
following classes:
ACE inhibitors and ARBs prior to conception or
upon detection of pregnancy
Statins
Preconception Care (continued)
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4. Women with type 2 diabetes who are
planning a pregnancy should switch from
non-insulin antihyperglycemic agents to
insulin for glycemic control
Women with pregestational diabetes who
also have PCOS may continue metformin
for ovulation induction
Preconception Care
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Preconception care
5. Women should undergo an ophthalmological
evaluation by an eye care specialist
6. Women should be screened for chronic
kidney disease prior to pregnancy .Women
with microalbuminuria or overt nephropathy
are at increased risk for the development of
HTN and preeclampsia ; and should be
followed closely for these conditions
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For previously
non-diabetic
mothers
67

Gestational Diabetes (GDM) Diagnosis
 Universal screening for GDM at 24-28
weeks Gestational Age (GA)
 Screen earlier if risk factors for GDM:
 Positive family history of DM
 Previous birth of an overweight baby
 Previous still birth with pancreatic islets
hyperplasia revealed on autopsy
68

Diagnosis GDM Contd…………..
 Unexplained perinatal loss
 Presence of polyhydraminos or recurrent
vaginal candidiasis in present pregnancy
 Persistent glycosuria
 Age>30yrs
 Obesity
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Management During
pregnancy
70

During pregnancy
 Women should be seen in a combined clinic
by a team that includes a physician , an
obstetrician specialist diabetes nurse and
midwife and dietician
 Because of high risk status a women with
diabetes is monitored much more frequently
and thoroughly than low pregnant women
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 Women should preferably be seen every four
weeks upto 20 weeks, than after every two
weeks untill 30 weeks and weekly thereafter
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Insulin therapy
Indication for insulin therapy
1. All type of type 1 DM
2. Gestational diabetes not controlled by
diet alone
3. Type 2 DM patient who were on oral
hypoglycemic drug before pregnancy
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Insulin therapy
Pregnant women with type 1 or type 2 diabetes
should:
a) Receive an individualized insulin
regimen and glycemic targets typically
using intensive insulin therapy
b) Strive for target glucose values
Fasting PG below : 80-110 mg/dl
2h postprandial below < 140 mg/dl
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Insulin therapy
 A total dose of 20-30 units divided into 2/3rd
morning dose (2/3rd intermediate acting
insulin and 1/3rd short acting insulin ) while
rest 1/3rd insulin is given at night (1/2
intermediate , ½ short acting) is usually
started with regular blood glucose monitoring
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Insulin therrapy
c) Perform SMBG, both pre- and
postprandially to achieve glycemic targets
and improve pregnancy outcomes
 Glycemic Targets during pregnancy:
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Target glucose values
Fasting PG <110 mg/dl
1h postprandial PG <180mg/dl
2h postprandial PG <140mg/dl

Sliding scale
The term “sliding scale” refers to the
progressive increase in the pre-meal or
nighttime insulin dose, based on pre-
defined blood glucose ranges.
150-200-2U,
200-250-4U,
250-300-6U,
300-350-8U,
350-400U-10U
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8. Women with pregestational diabetes may use
aspart or lispro in pregnancy instead of
regular insulin to improve glycemic control and
reduce hypoglycemia
9. Detemir or glargine may be used in women
with pregestational diabetes as an alternative to
NPH.
Insulin therapy
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Type of insulin
Insulin Options Shown to Be Safe During Pregnancy1
Name Type Onset Peak Effect Duration
Recommended
Dosing Interval
Aspart
Rapid-acting
(bolus)
15 min 60 min 2 hrs Start of each meal
Lispro
Rapid-acting
(bolus)
15 min 60 min 2 hrs Start of each meal
Regular
insulin
Intermediate-
acting
60 min 2-4 hrs 6 hrs
60-90 minutes
before meal
NPH
Intermediate-
acting (basal)
2 hrs 4-6 hrs 8 hrs Every 8 hours
Detemir Long-acting (basal) 2 hrs n/a 12 hrs Every 12 hours
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Nutrition therapy
 A tool to achieve
appropriate
nutrition and
glycemic goals of
pregnancy and to
normalize fetal
growth and birth
weight
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Nutrition Therapy
for GDM
Definition:
A carbohydrate controlled meal plan with
adequate nutrition for appropriate weight
gain, normoglycemia, and the absence of
ketones
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Nutrition therapy contd……
 Receive nutrition counseling
Moderate carbohydrate restriction: 3 meals
+ 3 snacks
Targets not met within 2 weeks start
insulin
Avoid hypocaloric diet  weight loss +
ketosis
83

 Nutritional counselling is usually provided by
a registered dietician
 Energy need during pregnancy is calculated
on the basis of body weight, with an average
diet including 2200kcal to 2500 kcal(30-35
Kcal /kg )
 1200-1800 Kcal/ day is recommended for
obese women
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 Bedtime snacks at least 25gm of carbohydrate
including some protein is recommended to
prevent hypoglycemia and ketosis during
night time
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Daily calorie requirement
 Daily calorie requirement :30-35 K cal per Kg
body weight
Which should consist of
 carbohydrate:50%-60 %(200-250gm/day)
 protein : 20%(1.5gm/Kg Body wt)
 fat :25-30%
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Carbohydrate having low glycemic
index is recommended
 It will prevent large fluctuations in blood
glucose levels
 It will help mother feel fuller longer and
reduce hunger
 It will help to manage weight
 It will lead to lower insulin levels
87

Glycemic index
 The Glycemic Index (GI) is a way of
ranking foods that contain carbohydrate
according to the effect they have on blood
sugar levels. The lower the GI of the food, the
smaller the rise in the blood sugar levels.
88

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Exercise
 Women should be
encouraged to do exercise
 Exercise using upper body
are ideal for most women
because they are not
associated with uterine
exercise
 Non-weight bearing
exercise
 Exercise enhances
glucose utilization
and decreases insulin
resistance
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Pre-Pregnancy
BMI
Recommended
range of total
weight gain
(Kg)
Recommended
range of total
weight gain (lb)
BMI <18.5 12.5 – 18.0 28 – 40
BMI 18.5 - 24.9 11.5 – 16.0 25 – 35
BMI 25.0 - 29.9 7.0 – 11.5 15 – 23
BMI > or = 30 5.0 – 9.0 11 – 20
IOM Guidelines for Gestational Weight
Gain

Fetal monitoring
 USG
End of first trimester to detect anencephaly
18-20 week –anomaly scan,
After that every four week
 Measurement of maternal serum alpha
fetoprotein
(16-18 week)
To access neural tube defect
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Fetal monitoring
 Fetal echocardiography to detect cardiac
anomalies
 Doppler studies of umbilical artery to detect
placental compromise
 Non-stress test/ cardiotocography :
After 32 weeks of gestation , twice a week
For women with vascular disease testing
may begin earlier
94

Fetal monitoring
 To confirm fetal lung maturity ,amniocentesis
may be performed in pregnancies earlier than
36 week
 For pregnancies complicated by diabetes ,
fetal lung maturation is better predicted by
amniotic phosphatidyl glycerol than by
lecithin / sphinomyelin ratio
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Determination of birth date and
mode of birth
 In uncomplicated cases 34-36 weeks
 Early hospitalization:
Stabilisation of diabetes
Minimizes the incidences of pre-eclampsia ,
polyhyraminous,
Preterm labor
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4/3/2016Nirsuba Gurung MN 1st year 97
Abnormal GTT
Nutrition therapy
Blood glucose profile after a week
Normal Abnormal
Deliver at term
Controlled GDM
Diet restriction
Deliver before term
Abnormal glucose profile
Diet restriction with insulin therapy

INDICATIONS FOR INDUCTION OF
LABOUR
Diabetic women controlled on insulin
after 38 completed weeks.
Women with vascular complication after
37 wks
Multipara with good obstetric history
Presence of congenital malformation in
fetus
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INDICATIONS FOR C/S
1. Elderly primi
2. Multigravida with bad obstetric histroy.
3. Diabetes with complictation or difficult to
control.
4. Obstretic complication like preeclampsia,
polyhydraminos, malpresentation.
5. Fetal macrosomia
6. Previous C/S
7. Fetal distress prior to or during labor
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Intrapartum management
 Women should be assume side lying position
during bed rest in labor to prevent supine
hypotension because of large fetus or
polyhydraminous
 Monitor progress of labor and record in
partograph when women enter active first
stage of labor
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 Monitor fetal well being: continuous CTG , if
available , otherwise FHR should be heard
every half an hourly
 Urine ketone should be assessed every 4
hourly
 Active management of labor is encouraged
 Instrumental delivery may be required
 Be aware of shoulder dystocia
101

1. Women should be closely monitored during
labour and delivery and maternal blood
glucose levels should be kept between 80-
130 mg/dl in order to minimize the risk of
neonatal hypoglycemia
2. Women should receive adequate glucose
during labour in order to meet the high
energy requirements
Intrapartum Glucose
Management
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To control blood glucose
 Maintain blood glucose :70-130 mg/dl
 Sliding scale:
The term “sliding scale” refers to the
progressive increase in the pre-meal or
nighttime insulin dose, based on pre-
defined blood glucose ranges. Sliding scale
insulin regimens approximate daily insulin
requirements.
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Dose of insulin in labor room
Blood sugar Insulin dose ,IV fluid @125ml/hr
60-100 mg/dl D5 ,insulin not required
100-140 mg/dl 4 unit in 1 Ltr D5 @32 drops/min(1 unit/hr)
140-180mg/dl 6 unit 1 Ltr NS @32 drops/min (1.5 unit/hr)
180-220 mg/dl 8 unit in 1 Ltr NS @ 32 drops/min (2 Unit/hr)
>220 mg/dl 10 unit in 1 Ltr NS @32 drops per min (2.5
unit/hr)
104

 After delivery of placenta , the insulin
infusion rate should be halved in women who
were having pre-pregnancy diabetes. And
intravenous insulin and dextrose is continued
untill the mother eats , the pre-pregnancy
insulin regimen may be than resumed
 In gestational diabetes , insulin may be
stopped after delivery, her blood sugar should
be checked every 4 hourly for 24 hour
105

Diabetic ketoacidosis
• It is a true emergency
- Usually results from omitting insulin in type 1
DM or increase insulin requirements in other
illness (e.g. infection, trauma) in type 1 DM and
type 2 DM
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Signs and symptoms:
- Fatigue,
- Nausea, vomiting,
- Evidence of dehydration,
- Rapid deep breathing(kussumal breathing ),
- Fruity breath odor,
- Hypotension and
- Tachycardia
107

Diabetic ketoacidosis (Cont’d)
- Diagnosis
- Hyperglycemia(BG->250mg/dl)
- acidosis(pH-<7.3)
- low serum bicarbonate(<15 mEq/L)
- and positive serum ketones
- Abnormalities:
- Dehydration, acidosis, sodium and
potassium deficit
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 Management:
- Fluid administration: Rapid fluid
administration to restore the vascular
volume,
- IV infusion of insulin to restore the
metabolic abnormalities. Titrate the
dose according to the blood glucose
level.
- Potassium and phosphate can be
added to the fluid if needed.
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 Follow up:
- Metabolic improvement is manifested by
an increase in serum bicarbonate or pH.
110

Postpartum Management
In immediate postpartum insulin
requirements decrease substantially because
the major source of insulin resistance ,the
placenta have been reduced
Women with type I diabetes may require only
half or two third of the prenatal insulin dose
on the first postpartum day, provided they are
eating a full diet
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111

Postpartum Management
 Women with pregestational diabetes should be
carefully monitored postpartum as they have a
high risk of hypoglycemia
 Monitor for other complication like pre-eclampsia ,
hemorrhage and infection
 Metformin and glyburide may be used during
breast-feeding
 Antibiotic should be given prophylactically to
minimize infection
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112

Early breast feeding
113

Postpartum (GDM)
Women with GDM should be encouraged to
breastfeed immediately after delivery in order to
avoid neonatal hypoglycemia and to continue for at
least three months postpartum in order to prevent
childhood obesity and reduce risk of maternal
hyperglycemia
Women should be screened with a 75g OGTT
between 6 weeks and 6 months postpartum to
detect prediabetes and diabetes 4/3/2016
114

Care of the baby
1.Asphyxia is anticipated and be treated
effectively.
2.Detect any congenital malformations.
3.All babies should have blood glucose to be
checked within 2 hours of birth to avoid
problems of hypoglycemia.
4.All babies should receive 1 mg vit k IM.
5 .Early breastfeeding.
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115

CONTRACEPTION
1.Barrier method is ideal.
2.Low dose combined oral pills are effective and
have got minimal effect on carbohydrate
metabolism.
3.Progestin only pill may be an alternative.
4.IUCD is avoided for fear of pelvic infection.
5.Permanent sterilization is considered when
family is completed.
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116

117

Diabetes Mellitus :Nursing Care
 Assessment, planning, implementation with
client according to type and severity of
diabetes
 Prevention, assessment and treatment of
complications through client self-
management and keeping appointments for
medical care
 Client and family teaching for diabetes
management
 Health promotion includes education of
healthy life style, lowering risks for
developing diabetes for all clients
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118

Diabetes Mellitus
Common Nursing Diagnoses
and Specific Teaching
Interventions
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A. Risk for impaired skin integrity:
Proper foot care
 Daily inspection of feet
 Checking temperature of any water before
washing feet
 Need for lubricating cream after drying but
not between toes
 Patients should be followed by a podiatrist
 Early reporting of any skin /cut injury
120

B. Risk for infection
Frequent hand washing
Early recognition of signs of infection
and seeking treatment
Meticulous skin care
Regular dental examinations and
consistent oral hygiene care
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121

Diabetes Mellitus
C. Risk for injury: Prevention of accidents, falls
and burns
D. Sexual dysfunction
 1. Effects of high blood sugar on sexual
functioning,
 2. Resources for treatment of impotence,
sexual dysfunction
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E. Ineffective coping
 Assisting clients with problem-solving
strategies for specific concerns
 Providing information about diabetic
resources, community education programs,
and support groups
 Utilizing any client contact as opportunity to
review coping status and reinforce proper
diabetes management and complication
prevention
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123

124

4/3/2016
125

Insulin is synthesized in_________
A. Alfa cells of islets of Langerhans
B. Intestine
C. Beta cells of islets of Langerhans
D. Liver
126
`

Which of the following is the function of insulin?
A. Regulation of menstrual cycle
B. Regulation of carbohydrate , protein and fat
metabolism
C. Enhance catabolic reaction in cells
D. Regulates cardio vascular system
127
`

Diabetes which is diagnosed during
pregnancy is known as_____________
A. GDM
B. Type I DM
C. Type II DM
D. Secondary Diabetes
128
`

All of the following are maternal
complication of DM, except
 Abortion
 PPH
 Polyhydraminous
 Congenital anomalies
129

 All pregnant women should be screened for
GDM at ____________week of gestation
A. Soon after detection of pregnancy
B. End of first trimester
C. At 24-28 weeks
D. At the time of delivery
4/3/2016
130

Which hormone Facilitates the
conversion of glucose to glycogen for
storage in the liver and muscle?
A. Glucagon
B. Insulin
C. FSH
D. Progesterone
4/3/2016
131

 In which type of diabetes there is absolute
absence of insulin
A. Type I DM
B. Type II DM
C. GDM
D. Overt DM
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132

 All of the following are the maternal
complications of GDM, except…..
A. Abortion
B. Macrosomia
C. Jaundice
D. Polyhydraminos
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133

 All pregnant women should be screened for
GDM at ____________week of gestation
A. Soon after detection of pregnancy
B. End of first trimester
C. At 24-28 weeks
D. At the time of delivery
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134

 Which one of the following is an indication for C/S in
gestational diabetic mother ?
A. Diabetic women controlled on insulin after 38
completed weeks.
B. Women with vascular complication after 37 wks
C. Multipara with good obstetric history
D. Obstretic complication like preeclampsia,
polyhydraminos,malpresentation.
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Summary
The ultimate goal of our
management is …..
Healthy mother and healthy baby
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136

References
 Dutta, D.C. (2004).Text book of Obstetrics. Sixth
edition, New Central book agency
 Arias, F. Daftary, S.N. & Bhide, A. G.(2013). Practical
guide to high risk pregnancy and delivery. Third
edition, Elsiever
 Endocrinology of Pregnancy (Chapter 8); Maternal
Nutrition (Chapter 10); Diabetes in Pregnancy
(Chapter 46). In Creasy RK, Resnick R, Iams J. (eds).
Creasy and Resnick’s Maternal-Fetal Medicine:
Principles and Practice, 6th ed. New York, McGraw
Hill Medical, 2009.
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137

 HAPO Study Cooperative Research Group. Metzger
BE, Lowe LP, et al. Hyperglycemia and Adverse
Pregnancy Outcomes. N Engl J Med 2008; 358: 1991.
 Centers for Disease Control and Prevention.
National diabetes fact sheet; national estimates and
general information on diabetes and prediabetes in
the United States, 2011. Atlanta, GA U.S.
Department of Health and Human Services, centers
for Disease Control and Prevention 2011.
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Gestational diabetes

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