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ABABA☺ABINALES☺ALCANTARA
APAT ☺ARMECIN ☺AQUINO ☺BENDOY
DEFINITION
an endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose levels
Affects 3% to 5% of all pregnancies and is the most frequently seen medical condition in pregnancy
classification
TYPE I TYPE II
insulin-dependent diabetes mellitus
Characterized by the destruction of the beta cells in the pancreas that usually leads to absolute insulin deficiency
a. Immune-mediated DM results from autoimmune destruction of the beta cells
b. Idiopathic type 1 refers to forms that have no known cause
Non-insulin-dependent diabetes mellitus
Usually arises because of insulin resistance combined with a relative deficiency in the production of insulin
classification
GESTATIONAL
Condition of abnormal glucose metabolism that arises during pregnancy
Possible signal of an increased risk for type 2 diabetes later in life
IMPAIRED GLUCOSE HOMEOSTASIS
State between “normal” &“diabetes” in which the body is no longer using &/or secreting insulin properly
a. Impaired fasting glucose: A state when fasting plasma glucose is at least 110 but under 126 mg/dL
b. Impaired glucose tolerance: A state when results of the oral glucose tolerance test are at least 140 but under 200 mg/dL in the 2-hour sample
Clinical characteristics & implications
TYPE I– Onset any age, usually <30
years – Usually thin at diagnosis with
recent weight loss– Etiology includes genetic,
immunologic, or environmental factors (e.g., virus)
– Often have islet cell antibodies– Little or no endogenous insulin– Need insulin to preserve life– Ketosis-prone when insulin is
absent– Acute complications of
hyperglycemia: diabetic ketoacidosis
TYPE II– Onset at any age, usually >30
years – Usually obese at diagnosis– Causes include obesity,
heredity & environmental factors
– No islet cell antibodies– Decrease in endogenous
insulin, or increased with insulin resistance
– May need insulin on a short or long term basis to prevent hyperglycemia
– Ketosis rare, except in stress or infection
– Acute complication: hyperglycemic, hyperosmolar, non-ketotic syndrome
Clinical characteristics & implications
GESTATIONAL– Onset during pregnancy, usually in the second or third trimester– Due to hormones secreted by the placenta w/c inhibit the action
of insulin– Above normal risk for perinatal complications, especially
macrosomia (abnormally large babies)– Treated with diet and if need, insulin to stricly maintain normal
blood glucose levels– Occurs in about 2% to 5% of all pregnancies– Screening test (glucose challenge test) should be performed
onALL pregnant women between 24 and 28 week’s gestation– Glucose intolerance transitory but may recur:
• In subsequent pregnancies• 30% to 40% will develop overt diabetes (usually type 2) w/in 10 years
(especially if obese)
(SYMPTOMS)
TYPE I– Frequent urination
(polyuria/nocturia) – Thirst – Fatigue – Ketones(acetone on
breath) – Weight loss-can be
dramatic – Other minor
symptoms-skin infections, muscle cramps,blurred vision, puritis
– Excessive thirst – Frequent urination – Fatigue – Blurred vision – Recurrent
infections – Sometimes weight
loss – Sometimes
ketones – Some, all or none
of the above!!
Generally, gestational diabetes may not cause any symptoms, however, the woman may experience
excessive weight gain,
excessive hunger or thirst, excessive urination recurrent
vaginal infections.
TYPE II GESTATIONAL
Types 1
Type 2
Random blood glucose test
Fasting blood glucose test
Hemoglobin A1C test (A1C)
Oral glucose tolerance test
Diagnostic test(type 1&2)
RANDOM BLOOD GLUCOSE TEST
• blood can be drawn at any time throughout the day, regardless of when the person last ate
• glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose suggests a diagnosis of diabetes
FASTING BLOOD GLUCOSE
• testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight)
• A normal fasting blood glucose level is less than 100 mg/dL.
• A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes.
• The test is done by taking a small sample of blood from a vein or fingertip.
• It must be repeated on another day to confirm that it remains abnormally high
HEMOGLOBIN A1C TEST
• measures the average blood glucose level during the past two to three months
• used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes
• Normal values for A1C are 4 to 6 percent.The test is done by taking a small sample of blood from a vein or fingertip.
ORAL GLUCOSE TOLERANCE
• most sensitive test for diagnosing diabetes and pre-diabetes
• includes a fasting blood glucose test• person then drinks a 75 gram liquid glucose
solution • Two hours later, a second blood glucose level is
measured• routinely performed at 24 to 28 weeks of
pregnancy to screen for gestational diabetes• this requires drinking a 50 gram glucose solution
with a blood glucose level drawn one hour later• For women who have an abnormally elevated
blood glucose level, a 2nd OGTT is performed on another day after drinking a 100 gram glucose solution. The blood glucose level is measured before, and at one, two, and three hours after drinking the solution.
1. Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dL (11.1 mmol/L).Casual is defined as any time of day without regard to timesince last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss or
2. Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours or
3. 2-hour postload glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure is not recommended for routine clinical use.
Criteria for diagnosis of dm
• Test for the mother • Oral glucose tolerance test
• Tests for the baby • Physical exam – skin, pelvic and
digital rectal exam• Ultrasound- visualize the woman's
reproductive organs (ovaries, cervix, vagina, uterus), used to assess the fetus and the fetal heart rate; may be taken @ week 28 & then again @ week 36-38
• Fetal movement records- healthy fetus makes approx. 10 movements/hour
• Fetal monitoring- Physiologic or biochemical monitoring of the fetus
Diagnostic test(gestational)
• Non-stress test - demonstrates at least two accelerations in the fetal heart rate at least 15 beats above the baseline heart rate and lasting at least 15 seconds
• Stress test (oxytocin challenge test)- used to identify fetuses who are only marginally compromised by assessing their reserve when subjected to uterine contractions induced through an oxytocin infusion
• Amniocentesis - the presence of phosphatidylglycerol is used to indicate lung maturity
Diagnostic test(gestational)
Being overweight,Sedentary lifestyleAbnormal cholesterol & blood fats,High blood pressure Smoking
RISK FACTORS
YOU CAN CONTROL YOU CAN’T CONTROL
Race or ethnicityFamily history of diabetesAge
RISK FACTORS (gestational)
Obesity
Age over 25 years
HISTORY OF:1. Large babies(10lbs or more)
2. Unexplained fetal loss
3. Congenital anomalies in previous pregnancies
4. Polycystic ovary syndrome
Member of a population with a high risk for
diabetes
(Native American, Asian Hispanic)
LONG-TERM DAMAGE
• KIDNEYS• ARTERIES
• EYES • NERVE PAIN • FEET
ANATOMY & PHYSIOLOGY
PATHOPHYSIOLOGY(TYPE 2)
PATHOPHYSIOLOGY(GESTATIONAL)
Increase in estrogen, progestin and other pregnancy- related hormones
Insulin sensitivity decreases
Postprandial glucose levels increases
Insufficient secretion of maternal insulin
Gestational Diabetes Milletus
management
N
E
M
P
E
management
1. NUTRITIONAL MGT. Avoid simple sugars, have complex
CHO instead Don’t skip or delay meals Eat more fiber-rich foods like
vegetables Cut down on salt Avoid alcohol During pregnancy: 1800-2400 calorie
diet;20%-CHON, 40&-50%-CHO, 30%-Fats
N/V→ temporary IV supplementation2. EXERCISE It lowers blood glucose by increasing the uptake of
glucose by the body muscles and by improving insulin utilization
Improves circulation & muscle tone if the insulin-injected arm is actively exercised, the
insulin is released so quickly→hypoglycemia She should not do aerobic exercises one day & then
none the next day but rather 30 min. of walking everyday
3.MONITORING
Self-monitoring of blood glucose enables the diabetic to adjust treatment regimen to obtain optimal blood glucose control Possible detection and prevention of hypoglycemia & hyperglycemia Woman typically uses a fingerstick technique, using one of her fingertips as the site of lancet puncture, she places a drop of blood on a test strip and then inserted into a glucose meter that determines
the glucose level
If hypoglycemic → glass of milk & some crackers
If hyperglycemic → assess urine for ketones → inform health care provider
Acidosis should be prevented during pregnancy because it can lead to fetal anoxia.
management
4. PHARMACOLOGIC THERAPY Exogenous insulin must be administered on a long-term basis to type 1 diabetes because in this type, the body loses its ability to produce insulin Type 2 diabetic patients may temporarily
require insulin during illness, infection, pregnancy, surgery, or stressful events
These should not be used during pregnancy:1. Sulfonylureas- Glibenclamide, Gliclazide, Glipizide,
Glimepiride2. Biguanide- Metformin3. Alpha-glucosidase inhibitors- Acarbose4. Thiazolidinedione- Troglitazone, Rosiglitazone, Proglitazone5. Meglitinides
management
Classifications of insulin
• Sulfonylurea drugs- stimulate your pancreas to produce and release more insulin; common side effect of is low blood sugar, especially during the first 4 months of therapy
• Meglitinides- effects similar to sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and the results fade rapidly.
• Biguanides- works by inhibiting the production and release of glucose from your liver, which means you need less insulin to transport blood sugar into your cells; tends to cause less weight gain than do other diabetes medications; side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea
medication
• Alpha-glucosidase inhibitors- block the action of enzymes in your digestive tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal; inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.
• Thiazolidinediones- make your body tissues more sensitive to insulin and keep your liver from overproducing glucose; side effects include swelling, weight gain and fatigue. A far more serious potential side effect is liver damage
medication
5. EDUCATION Client should be educated on nutrition medication effects and side effects exercise disease progression prevention strategies monitoring techniques and medication adjustment as part of their self-management behavior
management
management
• Most hazardous times for a fetus are weeks 36-40 of pregnancy
• To accomplish early births, cesarean birth was routinely performed in pregnant diabetic women at 37 weeks gestation
• Labor may be induced by rupture of the membranes or an oxytocin infusion after measures to induce cervical ripening
TIMING FOR BIRTH
• Pregnant woman w/ diabetes must undergo yet another readjustment to insulin regulation
• Often she needs no insulin during immediate postpartum
• 1 or 2-hour posprandial blood glucose determinations help to regulate how much insulin she needs
• Women w/ DM may breastfeed because insulin does not pass into breast milk from the bloodstream
• Woman who had gestational diabetes is at risk for developing type 2 diabetes later in life
POSTPARTUM ADJUSTMENT
Nursing diagnosis
Risk for ineffective tissue perfusion r/t reduced vascular flow.
Imbalanced nutrition, less than body requirements, r/t inability to use glucose.
Risk for ineffective coping r/t required change in lifestyle.
Deficient fluid volume r/t polyuria accompanying disorder.
Deficient knowledge r/t complex health problem.
Health-seeking behaviors r/t voiced need to learn home glucose monitoring.
PROGNOSIS (type 1)
Type 1 DM is associated with a high morbidity and premature mortality. More than 60% of patients with type 1 DM fare reasonably well over the long term.
Many of the rest develop blindness, end-stage renal disease, and, in some cases, early death. The risk of end stage renal disease and proliferative retinopathy (PR) in men compared with women doubles when age at onset of diabetes was less than 15 years.
If a patient w/ type 1 DM survives the period 10-20 years after onset of disease w/o fulminant complications, he or she has a high probability of good health. The 2011 ADA standard of care emphasizes the importance of long-term, coordinated care management for improved outcomes and suggests structural changes to existing systems of chronic care delivery
PROGNOSIS (type 1)
complications include hypoglycemia and hyperglycemia, increased risk of infections, microvascular complications (eg, retinopathy, nephropathy), neuropathic complications, and macrovascular disease.
As a result of these complications, people with diabetes have an increased risk of developing ischemic heart disease, cerebral vascular disease, peripheral vascular disease with gangrene of lower limbs, chronic renal disease, reduced visual acuity and blindness, and autonomic and peripheral neuropathy.
After many years, diabetes can lead to serious problems with your eyes, kidneys, nerves, heart, blood vessels, or other areas in your body.
If you have diabetes, your risk of a heart attack is the same as that of someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the normal signs of a heart attack.
If you control your blood sugar and blood pressure, you can reduce your risk of death, stroke, heart failure, and other diabetes problems.
Some people with type 2 diabetes no longer need medicine if they lose weight and become more active. When they reach their ideal weight, their body's own insulin and a healthy diet can control their blood sugar levels.
PROGNOSIS (type 2)
Gestational diabetes usually goes away after pregnancy, but, once a woman has had gestational diabetes, the chances are 75% that it will return in future pregnancies.
In a few women, however, pregnancy uncovers insulin-dependent (Type I) or non-insulin dependent (Type II) diabetes. In other women, gestational diabetes increases their chances of developing Type II diabetes within eight years.
PROGNOSIS (gestational)
references
