Gestational diabetes

05/01/2023Nirsuba Gurung MN 1st year

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WELCOME

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Nirsuba Gurung MN 1st year

PRESENTED BYNIRSUBA GURUNG

RN,MNWOMEN 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 05/01/2023Nirsuba Gurung MN 1st year

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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 05/01/2023

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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

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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 05/01/2023

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Type I Diabetes Cell


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. 05/01/2023

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Type II Diabetes


PATHOGENESIS OF TYPE 2 DM

EnvironmentObesity ???

ß cell defectGenetic

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

Treatment

A GDM

Any age

A1:Glucose<105A2:>105

<120mg/dl>120mg/dl

Diet Insulin

Class Age of onset

Duration Vascular disease

Treatment

BCDFHRT

>20yrs10-19yrs<10yrAny AnyAnyAny

<10 years10-19yrs>20yrsAnyAnyAnyAny

NoneNone HTNNephropathyCADRetinopathyRenal transplant

InsulinInsulinInsulinInsulinInsulinInsulinInsulin

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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.05/01/2023

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MATERNAL AND

FETAL RISKS 05/01/2023

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Maternal complications

Worsening retinopathy

Worsening proteinuria. GFR decline depends on preconception creatinine and proteinuria

Hypertension and Cardiovascular disease

Infection 05/01/2023

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Effects of Diabetes in Pregnency

During pregnancy1. Abortion2. Preterm labor(20%)3. Infection4. Increased incidence of pre-eclampsia(25%)5. Polyhydraminos(25-50%)6. Maternal distress7. Diabetic Retinopathy8. Diabetic Nephropathy9. Ketoacidosis

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Effects of Diabetes in Pregnency Contd…

During labor1. Prolongation of

labor due to big baby

2. Shoulder dystocia3. Perineal injuries4. PPH5. Operative

interference

During Puerperium

1. Puerperial sepsis2. 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 percent05/01/2023

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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 dystocia05/01/2023

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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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CardiacTransposition of the great vessels

with or without ventricularVentricular septal defectsCoarctation of the aorta with or

without ventricular septal defects or patent ductus arteriosus

Atrial septal defectsCardiomegaly

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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.05/01/2023

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SignsWeight 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 05/01/2023

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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,

glycosuriaScreening 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 DMPrevious birth of an overweight babyPrevious still birth with pancreatic

islets hyperplasia revealed on autopsy 05/01/2023Nirsuba Gurung MN 1st year

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Diagnosis GDM Contd…………..

Unexplained perinatal lossPresence of polyhydraminos or

recurrent vaginal candidiasis in present pregnancy

Persistent glycosuriaAge>30yrsObesityEthnic group(East

Asian,Hispanic ,African, native American) 05/01/2023

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Diagnostic Criteria for GDM

PREFERRED APPROACH (2 steps)1. 50 gram glucose challenge

test2. 75 gram oral glucose

tolerance testALTERNATIVE 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 glucose1 hour post-prandial : <180 mg/dl2 hour post-prandial : <155 mg/dl3 hour post-prandial : < 140 mg/dl

A diagnosis of GDM is made with 2 abnormal values 05/01/2023

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Testing for GDM

Two step optionFirst 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

toleranceImpaired 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&coustan

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 05/01/2023

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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 cultureOphthalmologic examinationRenal function testECGBlood 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 complications05/01/2023Nirsuba Gurung MN 1st year

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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

mothers05/01/2023Nirsuba Gurung MN 1st year

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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 DMPrevious birth of an overweight babyPrevious still birth with pancreatic

islets hyperplasia revealed on autopsy 05/01/2023Nirsuba Gurung MN 1st year

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Diagnosis GDM Contd…………..

Unexplained perinatal lossPresence of polyhydraminos or

recurrent vaginal candidiasis in present pregnancy

Persistent glycosuriaAge>30yrsObesity

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Management During pregnancy


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During pregnancyWomen 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 therapy1. All type of type 1 DM 2. Gestational diabetes not

controlled by diet alone3. 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


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Nutrition therapy contd……

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 05/01/2023

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Nutrition therapy contd……

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 weightIt will lead to lower insulin levels


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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.


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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 – 40BMI 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 compromiseNon-stress test/ cardiotocography :

After 32 weeks of gestation , twice a week

For women with vascular disease testing may begin earlier


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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 weeksEarly hospitalization:

Stabilisation of diabetesMinimizes the incidences of pre-

eclampsia , polyhyraminous,Preterm labor

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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 LABOURDiabetic 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 primi2. Multigravida with bad obstetric

histroy.3. Diabetes with complictation or difficult

to control.4. Obstretic complication like

preeclampsia, polyhydraminos, malpresentation.

5. Fetal macrosomia6. Previous C/S7. 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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Intrapartum managementMonitor 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 05/01/2023Nirsuba Gurung MN 1st year

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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. 05/01/2023

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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)


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Intrapartum managementAfter 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


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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


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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.


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Postpartum Management

In immediate postpartum insulin requirements decrease substantially because the major source of insulin resistance ,the placenta have been reducedWomen 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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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 infection05/01/2023

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Early breast feeding


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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

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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.05/01/2023

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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. 05/01/2023

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NURSING MANAGEMENT

OF GDM

Diabetes Mellitus :Nursing CareAssessment, 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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Diabetes Mellitus

Common Nursing

Diagnoses and Specific

Teaching Interventions05/01/2023

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A. Risk for impaired skin integrity: Proper foot care

Daily inspection of feetChecking temperature of any water

before washing feetNeed for lubricating cream after

drying but not between toesPatients should be followed by a

podiatristEarly reporting of any skin /cut injury


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B. Risk for infection

Frequent hand washingEarly recognition of signs of infection and seeking treatment

Meticulous skin careRegular dental examinations and

consistent oral hygiene care

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Diabetes Mellitus

C. Risk for injury: Prevention of accidents, falls and burns

D. Sexual dysfunction1. 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 05/01/2023

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Insulin is synthesized in_________

A. Alfa cells of islets of Langerhans

B. Intestine

C. Beta cells of islets of Langerhans

D. Liver 05/01/2023Nirsuba Gurung MN 1st year

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`

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


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`

Diabetes which is diagnosed during pregnancy is known as_____________

A. GDM

B. Type I DM

C. Type II DM

D. Secondary Diabetes


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All of the following are maternal complication of DM, except

Abortion

PPH

Polyhydraminous

Congenital anomalies


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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 delivery05/01/2023

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Which hormone Facilitates the conversion of glucose to glycogen for storage in the liver and muscle?

A. Glucagon

B. Insulin

C. FSH

D. Progesterone 05/01/2023

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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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All of the following are the maternal complications of GDM, except…..

A. Abortion

B. Macrosomia

C. Jaundice

D. Polyhydraminos

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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 delivery05/01/2023

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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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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. 05/01/2023

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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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THANK YOU

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Gestational diabetes

Health & Medicine

Transcript of Gestational diabetes