Diabetes care before, during and after pregnancy

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Introduction For nurses, diabetes mellitus, whether gestational or pregestational, represents one of the most challenging medical complications encountered during pregnancy. A comprehensive and multidisciplinary approach is required to improve maternal and neonatal outcomes.

Transcript of Diabetes care before, during and after pregnancy

Diabetes care before, during and after pregnancy
Jo M. Kendrick, APN-BC, CDE Introduction For nurses, diabetes mellitus, whether gestational or pregestational, represents one of the most challenging medical complications encountered during pregnancy. A comprehensive and multidisciplinary approach is required to improve maternal and neonatal outcomes. Incidence and significance: United States
29.1 million people (21 million diagnosed and 8.1 million undiagnosed) have diabetes (CDC, 2014). Women older than 20 account for 13.4 million individuals with diabetes; this represents 10.8 percent of all women in America (CDC, 2014). An estimated 79 million adults 20 years or older have prediabetes (NIDDK, 2011). Factors contributing to the prevalence of diabetes are obesity, an aging population, urbanization, physical inactivity and stress (Veeraswamy, Vijayam, Gupta & Kapur, 2012). Maternal diabetes impacts the lifelong prevalence of obesity, diabetes, and cardiovascular disease in the offspring. Pregnancies complicated by diabetes are at increased risk of perinatal morbidity and mortality. Definition and classification
Diabetes mellitus is a metabolic disorder caused by defects in insulin secretion or action, which lead to abnormalities in the metabolism of carbohydrates, lipids and protein (ADA, 2014a). Chronic hyperglycemia associated with diabetes causes tissue damage in all organ systems. Type 1 diabetes An immune-mediated disorder characterized by destruction of the beta cells of the pancreas, which leads to an absolute insulin deficiency. Accounts for 5 to 10 percent of all diabetes cases and 1 percent of diabetes cases in pregnancy (ADA, 2014a). Definition and classification (continued)
Type 2 diabetes Accounts for 90 to 95 percent of diabetes cases (CDC, 2012) A disease of insulin resistance and relative insulin deficiency. Can be controlled initially with lifestyle modification and oral medications Gestational diabetes mellitus (GDM) Prevalence ranges from 1 to 14 percent of pregnant women, depending on the population (ADA, 2014a) Accounts for 90 percent of all pregnancies complicated by diabetes Metabolic alterations of pregnancy
During the first trimester, insulin requirements significantly decrease. By the end of the first trimester, insulin sensitivity decreases with a responding increase in insulin production. Increased insulin production occurs in response to rising insulin antagonistic hormones in the latter half of pregnancy, causing the diabetogenic state of pregnancy. Exogenous insulin requirements increase dramatically in the second and third trimesters in women with preexisting diabetes who are on insulin. The risk of ketoacidosis is increased in women with pregestational diabetes. Perinatal implications of diabetes
In pregnancies complicated by preexisting diabetes, congenitalmalformations and spontaneous abortion account for most perinatalmortality (Mathiesen & Damm 2010). Fetal growth alterations most frequently seen in women withpregestational or gestational diabetes are macrosomia andintrauterine growth restriction (IUGR) (Landon et al., 2012). Poorly controlled diabetes, whether pregestational or gestational,increases the risk of respiratory distress syndrome (RDS) in theinfant (Landon et al., 2012). The risk of neonatal hypoglycemia, hyperbilirubinemia,hypocalcemia, hypomagnesemia and polycythermia is increased ininfants born to women with diabetes who have suboptimal glycemiccontrol during the third trimester (Hawdon, 2010). Screening and diagnosis of GDM
When pancreatic beta cells fail to produce enough insulin to maintain euglycemia, hyperglycemia results, and the diagnosis of GDM can be made. ACOG (2013a) recommends universal screening for GDM. Guidelines for screening and diagnosing GDM are controversial and conflicting. ADA (2014c) recommends both one-step and two-step approaches for identifying GDM but ACOG recommends the two-step approach. ACOG (2014c) and ADA (2014c) recommend testing for overt diabetes 6 to 12 weeks postpartum in women with GDM using standard diagnostic criteria. Antepartum care Providers ideally assess women with pregestational diabetes before conception so that glycemic control can be attained before pregnancy. Evaluation includes: A complete health, obstetric, gynecologic and diabetes history A physical examination focused on detecting vascular complications and other diabetes-related abnormalities Laboratory tests Self-management The burden of diabetes management falls on the woman.
Self-monitoring of blood glucose, urine ketone testing and recordkeeping are the basis for evaluation and adjustment of therapy. Patient education topics Effect of pregnancy on diabetes control Potential outcomes of uncontrolled blood glucose Medical nutrition therapy and exercise Insulin administration and management Sick day management Significance of GDM on future pregnancies Use of glucose meter Recording blood glucose results Urine ketone testing Self-monitoring of blood glucose (SMBG)
SMBG, urine ketone testing and recordkeeping provide the basis for evaluation and adjustment of therapy. Professional organizations do not agree on glycemic thresholds, timing or frequency for SMBG testing. To determine effectiveness of diet in controlling blood glucose, women with GDM or diet-controlled type 2 diabetes that is managed by MNT initially test when fasting and 1 or 2 hours postprandially (ACOG 2013a; ADA, 2011). For women on insulin, frequent SMBG is critical to obtain glycemic goals without significant hypoglycemia. Continuous glucose monitoring (CGM)
A temporary sensor implanted subcutaneously makes it possible to measure glucose in the interstitial fluid every 5 minutes. This device provides more information on the diurnal variation in blood glucose than SMBG alone because providers can see variations in minute-to-minute changes. Further study is needed on the effectiveness and cost-effectiveness of CGM in pregnancy before wide implementation into clinical practice (Voormolen, DeVries, Evers, Mol & Franx, 2013). Urine ketone testing Pregnant women with type 1 or 2 diabetes need to test urine ketones during nausea and vomiting, illness, weight loss and reduction in calorie intake (Reader & Thomas, 2011). Testing urine ketones when blood glucose values are 180 mg/dl is necessary because diabetic ketoacidosis can develop at lower levels in pregnancy. Recordkeeping Accurate records of blood glucose values, urine ketone testing, dietary intake, activity level and timing and dosage of insulin allow for appropriate adjustment of the diabetes regimen. A womans health care provider reviews her records at each office visit and identifies areas requiring adjustment. Medical nutrition therapy (MNT)
MNT by a registered dietitian provides the cornerstone for diabetes management in women with pregestational and gestational diabetes. Nutritional management of women with preexisting and gestational diabetes does not differ and has the same goals: adequate nutrition and weight gain with prevention of ketosis and postprandial hyperglycemia. The dietitian and the woman develop an individualized meal plan that provides adequate nutrients and energy requirements for both mother and baby. IOM recommendations for weight gain in pregnancy have changed recognizing that a significant number of women begin pregnancy overweight or obese (Rassmussen, Yaktine & IOM, 2009). IOM guidelines do not include recommendations for morbidly obese women (BMI >40). MNT (continued) The diet for pregnant women with diabetes includes (Reader & Thomas, 2011): At least 175 g of carbohydrate divided into three meals and three to four snacks 1.1 g/kg per day of protein or 25 g extra 28 g of fiber and adequate intake of calcium, iron, folate, vitamin D and magnesium Recommended weight gain for pregnant women Exercise Exercise can improve well-being and glucose control, reduce cardiovascular risk factors and contribute to weight loss in individuals with diabetes before pregnancy (ADA, 2014c). Before beginning or continuing an exercise program, the pregnant woman with diabetes needs a thorough evaluation for vascular disease and other diabetes-associated complications. Pregnant women with diabetes need to check their urine ketones before exercise if their blood glucose is >200 mg/dl. Exercise can worsen hyperglycemia and ketosis; in their presence, women shouldnt exercise. Women with preexisting diabetes on insulin are at increased risk for post-exercise hypoglycemia. Pharmacologic therapy: Pregestational diabetes
Insulin requirements during pregnancy change dramatically due to the effect of insulin antagonistic placental hormones. Intensive insulin regimens during pregnancy are most often comprised of multiple daily injections (MDI) to attempt attainment of glycemic thresholds. Basal insulins approved for use in pregnancy are neutral protamine Hagedorn (NPH) and detemir (ADA, 2013). Bolus insulins approved for use during pregnancy include regular insulin (short-acting) and aspart and lispro (rapid-acting) insulin analogues. GDM Most women can control GDM with diet and exercise.
ACOG (2013) lists metformin and glyburide as oral medications that can be used as first-line therapy for GDM, although they are not approved by the FDA for use during pregnancy. Insulin dosing and timing in women with GDM is based on the results of SMBG and calculated on the womans weight and gestational age. Physiologic administration of insulin requires three to four injections, with 50 to 60 percent of the total daily dose (TDD) as the basal insulin. Continuous subcutaneous insulin infusion (CSII)
CSII (or insulin pump) consists of a syringe or cartridge filled with rapid-acting insulin or U-500 regular insulin when large quantities of insulin are needed. The pump is programmed to dispense a continuous infusion of basal insulin, plus bolus insulin for