CONTINUED NURSING EDUCATION

Presented ByMrs. Heera KC Parajuli, BNStaff NursePost-natal ward, BPKIHS

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DIABETES MELLITUS AND

PREGNANCY

• 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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BackgroundPrevalence

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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?

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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?

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

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

Types

• Type 1 (IDDM) Young onset(juvenile) and absolute insulinopenia.Genetic predisposition with presence of autoantibodies.

• Type 2 (NIDDM)Late age onsetOverweight womenPeripheral tissue insulin resistance(hyperinsulinaemia)

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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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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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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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• 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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• 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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• Insulin requirements fall significantly in puerperium.

• Vascular changes, especially retinopathy, nephropathy, CAD and neuropathy may be worsened during pregnancy.

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Effect of diabetes on pregnancy

To the MotherDuring pregnancy:Abortion: recurrent spontaneous abortion may be

associated with uncontrolled DM.Preterm labor(20%)- infection or polyhydramniousInfection- UTI and vulvo vaginitisIncreased incidence of pre-eclampsiaPolyhydramnios (25-50%)Maternal distress

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• Diabetic retinopathy

• Diabetic nephropathy

• ketoacidosis

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During Labor

Increase incidence of:• Prolong labor due to big baby• Shoulder dystocia• Perineal injuries• Postpartum haemorrhage• Operative interferences

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Puerperium

• Puerperial sepsis• Lactation failure• PPH

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Fetal and Neonatal Hazards

FETAL MACROSOMIA:(30-40%)

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Elevation of

maternal free fatty acids

Maternal

hyperglycemia

• Congenital malformation(6-10%)• Neonatal hypoglycaemia(<37mg/dl)• Respiratory distress syndrome• Hyperbillirubinaemia• Polycythemia• Hypocalcemia(<7mg/dl)• cardiomyopathy

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Longterm effects: • Childhood obesity

• Neuropsychological effects and diabetes

• Stillbirth

Perinatal mortality(2-3 times)

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GDM

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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• Persistent glycosuria• Age over 30 years• Obesity• Ethnic group (East Asian, Pacific Island

Ancestry)

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WHO ARE THE POTENTIAL CANDIDATES ?

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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Hazards of GDM

• Increased perinatal loss associated with fasting hyperglycaemia .

• Increased incidence of macrosomia• Polyhydramnios• Birth trauma• Reoccurence of GDM in subsequent pregnancy is

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Management

Aim

Achieve maternal near normoglycemic level to prevent adverse perinatal outcomes

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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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• 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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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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Thank You

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