Download - Diabetes care before, during and after pregnancy

Transcript

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 meals, snacks or correction, thus mimicking pancreatic secretion. Women who become pregnant while using CSII may continue to use the pump, but they need education regarding the risks of pump use in general and during pregnancy. Pregnancy alone is not an indication for CSII; providers consider CSII only for women who want to use the pump during and after pregnancy. CSII (continued) Indications for CSII: Difficult-to-control diabetes
History of recurrent hypoglycemia Lifestyle or work schedule that warrants flexible insulin therapy Desire for pump therapy Hypoglycemia Intensive metabolic management during pregnancy carries an increased risk of hypoglycemia. Hypoglycemia has not been found to adversely affect the fetus, although it can be hazardous for the mother (Kitzmiller, Jovanovic, Brown, Coustan & Reader, 2008). Hypoglycemia is classified as mild, moderate or severe based on symptomatology requiring different levels of treatment. Hypoglycemia can be the result of too much insulin, inadequate food intake, vomiting or increased activity. Frequent testing of blood glucose allows early detection and appropriate treatment. If the woman is hypoglycemia-unaware, the provider helps determine the blood glucose level at which symptomatology occurs. Acute complications: Preterm labor
The incidence of preterm birth is increased in women with GDM and significantly increased in women with preexisting diabetes (Kock, Kock, Klein, Bancher-Todesca & Helmer, 2010). Vascular disease, hypertensive disorders and obesity contribute to the increased risk of preterm birth in women with diabetes. Management may include 17P Intravenous hydration Tocolytics Antenatal glucocorticoids Acute complications: Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis is an uncommon but life-threatening complication associated with pregestational diabetesall Occurs as a result of insulin deficiency leading to hyperglycemia, hyperketonemia and acidosis Most frequently seen in women with type 1 diabetes but also in women with type 2 diabetes; is rare in women with GDM Can develop in pregnancy at glucose levels 200 mg/dl (Inturrisi, Lintner & Sorem, 2013) Managed in a critical care unit with obstetric involvement. Treatment includes (Young, 2010): Aggressive hydration and insulin therapy Correction of electrolyte imbalances Identification and treatment of an underlying cause Continuous fetal and maternal monitoring Acute complications: Diabetic retinopathy
Diabetic retinopathy is the leading cause of blindness between ages 20 and 74 and the most common vascular complication in pregnancy (ADA, 2014c). Chronic hyperglycemia contributes to development of retinopathy as well as other microvascular complications of diabetes (Meyerle & Chew, 2010). Rapid normalization of blood glucose that occurs with pregnancy increases development and progression of retinopathy (ADA, 2014c). Risk factors for progression during pregnancy include (Rahman, Rahman, Yassin, Al-Suleiman & Rahman, 2007): Retinal status at conception (presence or absence of retinal changes) Duration and early onset of diabetes Elevated first-trimester A1C, persistent poor glycemic control Rapid normalization of blood glucose Hypertension Acute complications: Nephropathy
Kidney disease develops in 25 to 30 percent of women with diabetes (Landon et al., 2012). Diagnostic criteria for overt nephropathy is albuminuria of >300 mg/24 hours or total urinary protein excretion of >500 mg/24 hours in the absence of infection. Diagnosis can be made if criteria is met before 20 weeks gestation in more than two specimens (ADA, 2014c). Interventions to slow progression of renal disease include optimization of blood glucose and blood pressure control (ADA, 2014c). Aggressive management of blood pressure improves perinatal outcome. Women with overt nephropathy have increased risks for cesarean birth, preeclampsia, preterm birth, fetal growth restriction and perinatal mortality (Sibai, 2010). Providers may consider dietary protein restriction for women with progressing nephropathy in spite of glycemic and blood pressure control. Acute complications: Neuropathy
Diabetic neuropathy is a common complication of diabetes; individuals with type 1 and type 2 diabetes are affected. Chronic distal symmetric polyneuropathy (DPN) and cardiac autonomic neuropathy (CAN) are the most common neuropathies (Myers, 2010). Pregnant women face additional risks when neuropathy is directed at the gastrointestinal and cardiovascular systems due to stress from metabolic, hematologic and vascular changes associated with pregnancy. Pregnancy does not seem to accelerate progression of neuropathy. Painful symptoms can be relieved with a combination of glycemic control and medication. Acute complications: Gastroparesis
Gastroparesis involves autonomic neuropathy of the viscera, causing decreased innervation of the stomach and intestines. Prevalence rates of 30 to 50 percent have been reported in type 1 and 2 diabetes (Myers, 2010). Maternal and fetal morbidity is high because of difficulty in maintaining adequate nutrition; hospitalization and total parenteral nutrition may be required (Myers, 2010). Diagnosis requires referral to a gastroenterologist; however, providers may suspect it in women with severe nausea and vomiting and erratic blood glucose control (Myers, 2010). Treatment may be empiric addressing only the symptoms until after pregnancy when a more thorough work-up can be done. Acute complications: Cardiovascular autonomic neuropathy (CAN)
Women with diabetes who have resting tachycardia may have CAN. Three major syndromes associated with CAN (Vinik & Vinik, 2011): Cardiac denervation syndrome Abnormal cardiovascular response to exercise Orthostatic hypotension Limited data exists on CAN in pregnancy. Wearing pressure hose, changing positions slowly, getting adequate hydration and sleeping with the head of the bed elevated may minimize symptoms of postural hypotension. Improving glycemic control usually results in an improvement in hypoglycemia unawareness. Continuous subcutaneous insulin infusion may decrease the incidence of hypoglycemia. Acute complications: Cardiovascular disease (CVD)
Coronary artery disease (CAD), CAN, cerebrovascular disease and peripheral arterial disease (PAD) make up macrovascular complications of diabetes; they carry significant risks for maternal morbidity and mortality (Lorber, 2011). Preconception evaluation and control of vascular disease can help reduce adverse outcomes. Treatment for CAD or myocardial infarction (MI) during pregnancy follows the same principles as for non-pregnancy. Acute therapy consists of rapid coronary reperfusion by angioplasty, stenting and thrombolytic therapy (Easterling & Stout, 2012). Maternal death may occur if delivery happens within 2 weeks of MI; this timing should be avoided (Easterling & Stout, 2012). Cesarean birth does not reduce cardiac risk and is reserved for obstetric indications. Providers use standard cardiac care during labor with early and carefully administered regional anesthesia with little to no maternal exertion atdelivery. Maternal surveillance: Pregestational diabetes
A comprehensive antepartum assessment includes a history, physical exam and laboratory evaluation at the first prenatal visit. In the following weeks, visit frequency is based on the level of glycemic control and the presence of vascular disease or other comorbidities. Nursing surveillance of women with pregestational or gestational diabetes: Take vital signs Check weight Test urine for protein, glucose and ketones Review the self-management log Inspect injection sites for bruising, infection or atrophy. Pregnant women with nephropathy require a 24-hour urine for protein and creatinine clearance and electrolyte assessment at least once each trimester (Mathiesen, Nielsen & Damm, 2010). Maternal surveillance: GDM
If GDM is diagnosed in the first trimester, monitoring is similar to that of women with preexisting diabetes. When women present with previously undetected profound hyperglycemia, providers obtain laboratory testing for type 2 diabetes, including A1C, fasting plasma blood glucose or random blood glucose (Landon et al., 2012). If a diagnosis of type 2 diabetes is made, providers do a vascular disease workup and educate the woman about type 2 diabetes, including emotional and social support. Women who have an A1C >7.0 percent need an ultrasound to evaluate for birth defects. Women diagnosed with GDM between 24 and 28 weeks require weekly visits or phone contact to evaluate the level of glycemic control; women who initiate insulin may need more frequent visits (Landon et al., 2012). Maternal surveillance: Emotional support
Comprehensive management of diabetes in pregnancy involves ongoing assessment of the emotional impact of diabetes on pregnancy and pregnancy on diabetes. Depression, insulin resistance and hyperglycemia have been established in individuals with type 2 diabetes but have not been documented in women with gestational diabetes (Byrn & Penckofer, 2013). A pregnant womans emotional state during pregnancy has long-term effects on the neurodevelopmental outcome of her children (Glover, 2014). Recognition of emotional problems is the first step for intervention, so exploration for anxiety, depression and/or stress happen at each office visit. Fetal surveillance Perinatal morbidity and mortality in diabetic pregnancy have declined because of improved glycemic control and development of fetal surveillance techniques that identify fetal compromise and allow for timely intervention (Landon et al., 2012). ACOG (2005) recommends initiation of fetal testing in women with pregestational diabetes between 32 and 34 weeks. Method and timing are based on gestational age, level of glycemic control, obstetric history and the presence of vascular disease and other comorbid conditions. Each perinatal center determines the combination of tests it uses. There is no agreement on a single approach (ADA, 2013). Fetal surveillance: Ultrasound
An elevated A1C in the first trimester in women with preexisting diabetes alerts the sonographer to the increased possibility of the presence of a fetal birth defect that may involve any system. Fetal echocardiography is obtained when fetal heart defects are suspected or in women with uncontrolled glucose in the first trimester. Women who present with GDM either early in the pregnancy or who have A1C results that indicate the presence of undiagnosed type 2 diabetes need a detailed ultrasonographic fetal evaluation for defects. Serial ultrasound evaluation provides growth assessment to detect macrosomia or IUGR. IUGR occurs more frequently in women with preexisting diabetes complicated by vascular disease or hypertension than in unaffected women. Fetal surveillance: Maternal serum screening
Chromosomal abnormalities are not increased in diabetic pregnancy, although the incidence of open neural tube defects is. Late in a womans first trimester (11 to 13 weeks), providers may screen for aneuploidy by measuring fetal nuchal translucency (NT) using ultrasound combined with serum screening of pregnancy-associated plasma protein A (PAPP-A) and beta human chorionic gonadotripin (hCG). Multiple marker screening of alpha-fetoprotein, unconjugated estriol, inhibin-A and beta HCG obtained at 16 weeks combined with first-trimester screening provide a single risk assessment (Simpson, Holzgreve & Driscoll, 2012). Providers can offer second-trimester maternal serum screening for chromosomal abnormalities between 15 and 20 weeks. Fetal surveillance: Fetal movement count (FMC)
FMC is a noninvasive and valuable tool to evaluate fetal well-being in high-risk pregnancies. It can begin in the late-second or early-third trimester. The woman counts fetal movements after meals for a specific period of time. A decrease in perceived fetal activity warrants further exploration by NST or BPP. Fetal surveillance: Nonstress test, biophysical profile, contraction stress test
Nonstress test (NST) Many provider use NST after 26 to 28 weeks to evaluate fetal well-being in pregnancies complicated by diabetes. NST uses an electronic fetal monitor to record fetal heart rate (FHR) and uterine activity. A nonreactive pattern or lack of acceleration may indicate fetal compromise and requires further testing by biophysical profile (BPP) or contraction stress test (CST) (Landon et al., 2012). Biophysical profile (BPP) BPP is an ultrasound that measures fetal breathing, gross body movement, fetal tone and amniotic fluid. Contraction stress test (CST) CST carries some risk of initiating labor; provider do not use CST in women for whom labor timing is inappropriate. Delivery With favorable antepartum testing and well-controlled diabetes, women with GDM and preexisting diabetes may safely continue pregnancy until full term (Landon et al., 2012). Indications for delivery in diabetic pregnancy include: (Landon et al., 2012) Poor glycemic control Vascular disease with worsening hypertension Significant growth restriction Abnormal biophysical testing If preterm birth is expected but not urgent, providers may give antenatal corticosteroids to enhance fetal lung maturity; insulin adjustments are required for at least 5 days due to steroid-induced hyperglycemia; women who are diet-controlled may require insulin (Landon et al., 2010). ACOG (2005) recommends c-section when EFW exceeds 4,500 g to reduce the risk of traumatic birth injuries. Intrapartum care The nurse takes a comprehensive and detailed diabetes history for women with pregestational or gestational diabetes being admitted for labor and birth. Providers use continuous electronic fetal monitoring for laboring women with diabetes (ADA, 2013). No pain relief methods are contraindicated in women with diabetes unless there are medical complications. Providers and women thoroughly discuss pain relief options, ideally before the onset of labor. When labor pain is poorly controlled, counter-regulatory hormones that antagonize insulin are released, leading to hyperglycemia and the need for increased doses of insulin. Admission history of pregnant women with diabetes
Diabetes type and classification Microvascular complications (retinopathy, nephropathy, autonomic neuropathy) Antenatal diabetes complications of DKA and hypoglycemia with last hospitalization for pregnancy or diabetes management Glucose level that precipitates symptoms of hypoglycemia Glucose log and self-management diary Results of most recent A1C and A1C in the first trimester Meter type and frequency of testing Insulin regimen Last food intake Ultrasound findings Obstetric history Indications for increased surveillance during labor and delivery
Abnormal (low or high) amniotic fluid Elevated A1C Frequent hospital admissions during pregnancy Growth restriction Limited or no prenatal care Macrosomia Uncontrolled blood glucose Monitoring blood glucose
During labor, blood glucose levels are maintained between 70 and 90 mg/dl to reduce the risk of maternal and fetal hyperglycemia, which can lead to neonatal hypoglycemia (ADA, 2013). Nurses obtain a blood glucose reading hourly in women with pregestational diabetes and every 1 to 2 hours in women with GDM. The nurse assesses urine ketones with each void when blood glucose is >200 mg/dl, or every 4 hours if blood glucose is in target range. Intravenous fluid therapy
The nurse establishes intravenous access soon after a womans admission to allow for hydration and insulin administration. Glucose requirements are low during the early stage of labor, so normal saline may be used initially unless the capillary glucose is low (Landon et al., 2012). Glucose is required once active labor begins and can be administered at 100 to 125 ml/hour by a controlled infusion device to prevent inadvertent administration of excessive amounts of glucose (ADA, 2013). Insulin management Women with type 2 diabetes or GDM may not require insulin in labor, even if they were insulin-dependent during pregnancy. Most have sufficient pancreatic function to supply the basal insulin required for labor. All women with type 1 diabetes require insulin in labor. Insulin is administered subcutaneously or by injection or insulin pump, or intravenously per institutional protocol or physician preference. The blood glucose result taken on admission determines the need for insulin or glucose for cesarean birth, spontaneous labor or induction. Because insulin requirements plummet after delivery, the total daily dose is decreased by 50 to 60 percent (70 percent with twins), regardless of the route of administration (ADA, 2013). CSII Continuous subcutaneous insulin infusion (CSII) is rarely used for women with GDM, but many women with pregestational diabetes use CSII during pregnancy. CSII is safe for use during hospitalization for vaginal and cesarean birth. A physician capable of managing the pump during hospitalization is necessary. A certified diabetes educator (CDE) familiar with pump management can be a valuable resource for nurses. Infusion sites for CSII are changed every 48 hours to 72 hours to prevent infection (Hood, 2012). The upper abdomen is the safest site during the intrapartum period. The site for tubeless pumps is usually the upper arm. The lower abdomen is avoided due to the risk for cesarean birth. Placement in the hip is avoided because it may expose the infusion site to blood and amniotic fluid that may contribute to infection. Neonatal considerations
Most infants of mothers with diabetes have an uncomplicated perinatal course, but the risk for adverse outcome is higher than for infants born to mothers who do not have diabetes. Risks for offspring include: (Pettitt, 2012) RDS Metabolic derangements Neonatal hypoglycemia Congenital defects Birth injury Metabolic syndrome Type 2 diabetes Obesity, abnormal glucose tolerance and cardiovascular disease Neonatal considerations (continued)
Assessment of infants of diabetic mothers Observe for birth defects. Observe for birth injury. Inspect the head for cephalohematoma or caput succedaneum. Measure and document the occipital and frontal circumferences. Examine for clavicular fracture, brachial plexus injury, known shoulder dystocia or weight >4,000 g. Breastfeeding appears to modify the risk of the baby developing type 2 diabetes and obesity later in life. Nurses play a pivotal role in educating women with diabetes about lifelong risks of diabetes and obesity in their offspring. Goals of postpartum care for women with diabetes (Gilbert, 2011)
Prevention of hypoglycemia and severe hyperglycemia Encouragement and support of breastfeeding Education Reduction of risk of type 2 diabetes for women with GDM Reduction of risk of diabetes complications for women with overt diabetes Encouragement of family planning and interconception care Postpartum and interconception care
Because many women achieve glycemic control during pregnancy to improve the health of their infant, the postpartum period is an ideal time for the nurse to stress the importance of continued control. During pregnancy, many women realize they can manage their diabetes and attain a better quality of life for long-term health benefits. Immediately after birth, insulin resistance improves for all women with diabetes. Oral medications can be resumed if they are compatible with breastfeeding. Before discharge from the hospital, women with diabetes need further education regarding lifestyle modifications and dietary interventions. Postpartum and interconception care: Women with GDM
Monitoring of blood glucose continues until normoglycemic. Postpartum testing for overt type 2 diabetes is recommended (ACOG, 2013a; ADA, 2014c), but few obtain it (Keely, 2012). Women need testing at the 6-week postpartum visit or shortly after they stop breastfeeding (Gilbert, 2011). Because recurrence risk of GDM is high, postpartum women need diabetes prevention education and interconceptional evaluation. Because the lifetime risk of developing type 2 diabetes after GDM ranges from 35 to 60 percent, annual testing for diabetes is recommended in women with a history of GDM who are prediabetic (ADA, 2014a; CDC, 2011). Previous GDM also carries a lifetime risk for metabolic syndrome and cardiovascular disease (Retnakaren, Qi, Connelly, Sermer, Zinman & Hanley, 2010). Strategies to delay/prevent type 2 diabetes in women with GDM (National Diabetes Education Program, 2014) Get tested for diabetes 6 to 12 weeks postpartum. Breastfeed. Get tested for diabetes before your next pregnancy. Try to reach your pre-pregnancy weight 6 to 12 months postpartum. If overweight, lose 5 to 7 percent of body weight slowly after attainment of pre-pregnancy weight. Get at least 30 minutes of physical activity each day 5 days a week. Eat healthy foods, including fruits, vegetables, fish, lean meats, dry beans, peas, lentils, whole-grain bread and pasta, and low-fat or skim milk and cheese. Eat smaller portions. Drink water. Breastfeeding Breastfeeding poses an additional challenge for women with preexisting diabetes due to the increased risk of hypoglycemia. Women with diabetes need frequent snacks before or during breastfeeding that consist of carbohydrate and protein or fat. A schedule for snacking and meals as well as adequate intake of liquids is important to support the increased caloric demands of breastfeeding. Women who breastfeed need 500 to 800 additional calories per day (Gilbert, 2011). Insulin requirements for breastfeeding women usually are lower than for non-breastfeeding women. Contraception Ideally, a woman and her provider talk about contraception before she gives birth. When the woman breastfeeds exclusively without supplementation, breastfeeding can be used as birth control, called the lactation amenorrhea method (LAM). When lactation is well established and thrombogenic risk is minimal, women with pregestational diabetes may begin progestin-only oral contraceptives at 21 days postpartum or combined oral contraceptives (COC) at the lowest estrogen dose at 6 weeks postpartum (Segall-Gutierrez & Kjos, 2010). COC use in women with diabetes is controversial because thromboembolic disease and myocardial infarction may be increased (Landon et al., 2012). Using oral contraceptives may result in increased insulin resistance because of decreased insulin receptors in women with diabetes (Landon et al., 2012). Contraception (continued)
For women with diabetes, limited data exists on the use of the progestin intrauterine device (IUD), progestin implants or injectable depot medroxyprogesterone acetate (DMPA). However, with adequate monitoring the use of these methods is acceptable in these women. Barrier methods produce no metabolic effects and have no contraindications, although failure rate without perfect use is around 10 percent (Landon et al., 2012). Summary By providing care and education that empowers women to achieve glycemic thresholds, nurses and diabetes educators can profoundly influence treatment and prevention of diabetes-related complications in pregnancy. With combined knowledge of diabetes and obstetrics, nurses can provide interventions and support that help ensure healthy outcomes for women with diabetes and their infants.