Mrs. Heera KC Parajuli presented on continued nursing education about diabetes mellitus and pregnancy. She discussed that 1-14% of pregnancies are complicated by diabetes, with 90% being gestational diabetes mellitus. Nearly 50% of women with gestational diabetes will develop overt diabetes within 5-20 years. She provided an overview of the types and effects of preexisting and gestational diabetes on mothers and babies, including increased risk of complications. The presentation covered screening, management through diet, exercise and possible insulin, and obstetric management of gestational diabetes mellitus.

1. CONTINUED NURSING EDUCATION
Presented By
Mrs. Heera KC Parajuli, BN
Staff Nurse
Post-natal ward, BPKIHS
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DIABETES MELLITUS AND
PREGNANCY

2. • About 1-14 % of all pregnancies are complicated by
Diabetes mellitus and 90% of them are gestational
Diabetes Mellitus.
• Nearly 50% of women with GDM will become overt
Diabetes over a period of 5 to 20 years.
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Background
Prevalence

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4. BRAINSTMORMING
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• Mrs, Sabita Devi Shah, 37 years old , G8P7AoL6Still
birth 1 IUFD 1, SVD with Episiotomy done at 37
completed weeks.
Her history reveals that at 20 weeks she had her
fasting Blood glucose 200 mg/dl and PP 233 mg/dl.
On subsequent check up also her blood sugar were
found above normal that is FBS 150mg/dl and PP
287mg/dl. Urine test shows glycosuria. She had a
positive history of Dm before pregnancy for which
she took ayurvedic medicines as well.
a) What would be her diagnosis?

5. You got a handover from OT about a case.
• Mrs Sushma Bastola age 24 years, Emergency
LSCS done at 38 weeks of gestation for
prolonged labor with Gestational Dm. She gave
a birth of a male baby weighing 4kg. Baby was
born normal with no defects. ON medicines
along with the antibiotics protocal Inj. GIK
should be started as well.RBS should be
monitored every 2 hourly and also of Babys’
RBS at 0. 2. 4, 6, 8, 12, to then 48 hours of life.
a) What do you mean by GDM?
b) Why the RBS is monitored frequently for
both the baby’s and mother?
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6. Diabetes Mellitus
• Diabetes mellitus is a chronic metabolic disorder
due to either insulin deficiency (relative or
absolute) or due to peripheral tissue resistance
(decrease sensitivity) to the action of insulin.
• The pathophysiology involved are:
 Insulin resistance and
 Inadequate secretion of insulin(B cell
dysfunction)
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Diabetes in
pregnancy
Pre-existing
diabetes
IDDM
(Type1)
NIDDM
(Type2)
Gestational
diabetes
Pre-existing
diabetes
True GDM

8. ICD 10 (Chapter I- XXII)
Chapter XV: Pregnancy, child birth and the puerperium (O00-O99)
O 24 : DM In Pregnancy
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Type Number
O24.0= preexisting DM, Insulin dependent 2
O24.1= Preexisting DM Non insulin dependent 1
O24.2= Preexisting malnutrition -related DM 1
O24.3= Preexisting DM unspecified 2
O24.4= DM arising in pregnancy (GDM) 1
O24.9= DM in pregnancy, unspecified 87
Total 94
Title: Client attending BPKIHS in the Year 2014 Source: MRC, BPKIHS

9. Types
• Type 1 (IDDM)
 Young onset(juvenile) and absolute insulinopenia.
Genetic predisposition with presence of autoantibodies.
• Type 2 (NIDDM)
Late age onset
Overweight women
Peripheral tissue insulin resistance(hyperinsulinaemia)
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12. GESTATIONAL DIABETES MELLITUS
• Gestational Diabetes Mellitus is carbohydrates
intolerance of variable severity with onset or first
recognition during the present pregnancy.
• The entity usually presents in the second or
during the third trimester.
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13. OVERT DIABETES
• A patient with symptoms of Diabetes Mellitus
(polyuria, Polydipsia, weight loss) and random
plasma glucose concentration of 200 mg/dl or
more is overt diabetes.
• It may be detected for the first time in pregnancy.
• According to ADA, FBS >126mg/dl and
PP(75gm)> 200 mg/dl.
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14. EFFECT OF PREGNANCY ON DIABETES
 During pregnancy, due to altered carbohydrate
metabolism and an impaired insulin action, it is
difficult to stabilise the blood glucose.
The insulin antagonism is due to the combined
effect of HPL, estrogen, progesterone, free cortisol
and degradation of the insulin by the placenta.
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15. • The insulin requirement during pregnancy increases
as pregnancy advances.
• During pregnancy, renal threshold is diminished,
due to the combined effect of increased glomerular
filtration and impaired tubular reabsorption of
glucose. Glucose leaks out in the urine even though
the blood sugar level is well below 180mg/100 ml .
• Hence, repeated blood glucose test becomes
mandatory.
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16. • With the accelerated starvation, there is rapid
activation of lypolysis with short period of fasting.
• Ketoacidosis can be precipitated during
hyperemesis in early pregnancy, infections and
fasting of labor.
• It can be iatrogenically induced by certain drugs
like corticosteroids used in management of pre term
labor.
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17. • Insulin requirements fall significantly in
puerperium.
• Vascular changes, especially retinopathy,
nephropathy, CAD and neuropathy may be
worsened during pregnancy.
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18. Effect of diabetes on pregnancy
To the Mother
During pregnancy:
Abortion: recurrent spontaneous abortion may be
associated with uncontrolled DM.
Preterm labor(20%)- infection or polyhydramnious
Infection- UTI and vulvo vaginitis
Increased incidence of pre-eclampsia
Polyhydramnios (25-50%)
Maternal distress
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19. • Diabetic retinopathy
• Diabetic nephropathy
• ketoacidosis
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20. During Labor
Increase incidence of:
• Prolong labor due to big baby
• Shoulder dystocia
• Perineal injuries
• Postpartum haemorrhage
• Operative interferences
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21. Puerperium
• Puerperial sepsis
• Lactation failure
• PPH
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22. Fetal and Neonatal Hazards
FETAL MACROSOMIA:(30-40%)
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Elevation of
maternal
free fatty
acids
Maternal
hyperglycemia

23. • Congenital malformation(6-10%)
• Neonatal hypoglycaemia(<37mg/dl)
• Respiratory distress syndrome
• Hyperbillirubinaemia
• Polycythemia
• Hypocalcemia(<7mg/dl)
• cardiomyopathy
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24. Longterm effects:
• Childhood obesity
• Neuropsychological effects and diabetes
• Stillbirth
Perinatal mortality(2-3 times)
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25. GDM
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26. WHO ARE THE POTENTIAL CANDIDATES ?
• Positive family history of diabetes (parents or
siblings).
• Previous birth of an overweight baby of 4 kg or
more
• Previous stillbirth with pancreatic disease..
• Unexplained perinatal loss.
• Presence of polyhydramnios or recurrent vaginal
candidiasis in present pregnancy.
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27. • Persistent glycosuria
• Age over 30 years
• Obesity
• Ethnic group (East Asian, Pacific Island
Ancestry)
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WHO ARE THE POTENTIAL CANDIDATES ?

28. Whom should you plan for screening for
GDM??
• Low risk- absence of any risk factors mentioned
above.
• Average risk- some risk factors
• High risk- blood glucose test as soon as feasible.
• (50gm oral glucose challenge test without regard to
time of day or last meal, between 24-28 weeks of
pregnancy.)
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29. Hazards of GDM
• Increased perinatal loss associated with fasting
hyperglycaemia .
• Increased incidence of macrosomia
• Polyhydramnios
• Birth trauma
• Reoccurence of GDM in subsequent pregnancy is
about 50 %.
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30. Management
Aim
Achieve maternal near normoglycemic
level to prevent adverse perinatal
outcomes

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34. Management
• Close antenatal supervision.
• Periodic FBS/PP . FBS < than 90mg/dl.
• Maintenance of mean plasma blood glucose
between 105 and 110 mg/dl.
• Diet, exercise with or without insulin.
• Human Insulin should be started if FBS exceeds
90mg/dl and 2 hours postprandial value is
greater than 120 mg/dl(repetitive) even on diet
control.
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35. • Diet- normal woman (2000-2500kcal/day) and
restriction to 1200-1800 kcal/day for over weight
woman is recommended.
• Exercise (aerobic, brisk walking) programmes
are safe in pregnancy.
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Management con….

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38. Obstetric management
Spontaneous labor for good glycaemic control.
Elective delivery for uncontrolled GDM, requiring
insulin or with complications (macrosomia) at
around 38 weeks.
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40. Thank You
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