Concurrent Disorders During Pregnancy Flashcards
Diabetes Mellitus
Classifications of Diabetes Mellitus
Type I
Type II
Gestational (GDM)
- A1GDM
- A2GDM
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Are diet-controlled diabetics
May have oral medications they take to lower blood glucose
Do still produce insulin but not enough for what their body needs
In severe cases we can see a need for insulin
Type 2
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Are insulin-dependent diabetics
Are unable to produce insulin from their body; must get it from an exogenous source
Are very prone to ketosis, DKA
Type 1
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The onset of glucose intolerance is diagnosed during pregnancy
Initiates as gestational; could be type 2 but we won’t know exactly
These women will be followed postpartum as delivery of the placenta should cure the diabetes
> If this doesn’t, it’ll lead to the diagnosis of type 2 DM
Gestational (GDM)
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Insulin-controlled subtype but also with dietary management
A2GDM
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Is the diet-controlled subtype
A1GDM
Effects on Pregnancy - Late Pregnancy (20 weeks gestation - birth)
Fetal growth accelerates, hormones sharply rise
Creates a ___
Insulin resistance in mom [glucose is not going into her cells efficiently] = oversupply of glucose for baby [is why we wait until 26 weeks gestation to test for DM]
High risk of ___ (in mother and baby)
> Remember that baby can produce insulin as well
> Baby is at risk of ___ at delivery
diabetogenic effect
hyperglycemia
hypoglycemia
Effects on Pregnancy - Early Pregnancy (1-20 weeks gestation)
Maternal metabolic rates and energy needs change little
Increased insulin release in response to serum glucose levels
High risk of ___
Consider hyperemesis/fatigue that occur in early pregnancy
hypoglycemia
Pre-Existing Diabetes Mellitus - Maternal Effects
* During pregnancy, ketoacidosis can develop at lower thresholds of hyperglycemia
> Higher risk of ketoacidosis, e.g. a blood glucose of 300 or less opposed to a previous 400 will lead to ketoacidosis in the woman
* Higher risk of preeclampsia; UTI’s; polyhydramnios (polyuria due to urine going into the amniotic fluid); PROM (see an overdistention of the uterus {from a larger baby} and polyhydramnios); the increased pressure from the overdistention increases risk that membranes could rupture prematurely); shoulder dystocia (due to fetal size); cesarean birth (due to larger baby); and postpartum hemorrhage
Pre-Existing Diabetes Mellitus - Fetal Effects
* Dependent upon timing and severity of hypo- and hyperglycemia
* Increased risk of spontaneous abortion and fetal malformations (most common is neural tube [spina bifida, anencephaly] and cardiac defects)
* Fetal insulin production acts as a growth hormone which is why these babies are larger; macrosomic
* Risk of FGR/IUGR related to placental insufficiency
> Remember, diabetes can cause narrowing of the arteries and that can include the spiral arteries of the placenta
- So, the baby starts off with having those narrowed arteries which decreases the amount of O2 coming in, CO2 coming out, and amount of nutrients coming in
Neonatal Effects (of infants born to pre-existing mothers with DM)
* Cardiomegaly
> Enlargement of the heart as insulin is a growth hormone
> Grows not only the body but internal organs as well
* Hypoglycemia
* Hypocalcemia
* Hyperbilirubinemia
* Respiratory Distress Syndrome
- Fetal lung maturation can be slower here than in a nondiabetic pregnancy
- If a diabetic mother arrives in preterm labor we want to prioritize the betamethasone or corticosteroid administration
- May take longer than 36 weeks for the diabetic mother
- Greater RDS risk due to hypoglycemia which can result in hypothermia; problems with thermoregulation
Assessment
- Assess patient’s history of glycemic control, understanding, and ability to properly treat according to physician orders, including sliding scales
> Type 1 tends to have better management than type 2
> Type 2 have a higher glucose level, higher A1C and more trouble with glycemic control
- Physical examination, including obtaining baseline ECG [look at calcium], retinal assessment [complication is diabetic retinopathy], weight [consider that type 2 may be overweight or obese], and blood pressure
- Baseline laboratory tests, including midstream urine at each visit (at increased risk for UTI’s);
> a UTI early in pregnancy can lead to spontaneous abortion; S/S present differently and you see a cystitis or pyelonephritis that can lead to preterm labor)
baseline 24 hour urine (due to increased risk for preeclampsia); thyroid function test; and HbA1C
- Fetal screenings for anomalies (neural tube defects [spina bifida, anencephaly]; abdominal wall defects [omphalacele]) including ultrasound and echocardiogram (assess for cardiomegaly during pregnancy and after delivery)
- Frequent surveillance with kick counts, biophysical profiles, and NSTs (keep in mind being at risk for placental insufficiency)
Diabetic Diet During Pregnancy
Recommended caloric intake ___ kcal/kg/day
__-__% of calories from carbohydrates
__-__% calories from protein (the 2° source of energy)
Up to __% from [healthy] fats
* Distribute over 3 meals and 2 or more snacks
* Bedtime snack to contain complex carbohydrate and protein
> Bedtime snack as blood glucose levels can drop overnight; latter will help keep the carbohydrate stable and from bottoming out
30
40-45%
12-20%
40%
Self-Monitoring Blood Glucose (SMG)
* Optimal frequency is not established for during pregnancy
* Study found postprandial levels most effective at predicting fetal macrosomia
* Perform at any time symptoms of hypo- or hyperglycemia arise
* Record results onto log and bring to each doctor’s visit (machines may self-document)
* Keeping a food log with a SMBG log can give the most insight (how does the A1C look?)
Insulin
* Needs change throughout pregnancy
> First half needs are lower (fetal growth and development)
> End of 2nd half, 3rd trimester [fetus just growing] they’re increased; issues here are where we’ll see that macrosomic infant (insulin acts as a growth hormone)
* Needs typically drop in 1st trimester and increase markedly in 2nd and 3rd trimesters
* For type 1 diabetics, infusions of insulin, as well as a dextrose solution, are often needed in labor to maintain blood glucose levels between 80-110
> Consider if giving an epidural = cannot eat; normally clear liquids (ice chips, popsicles)
* Needs fall rapidly after delivery
* For type 2 diabetics more of a need to replete glucose
* Once the placenta is delivered, needs change significantly
Gestational Diabetes Mellitus
Risk Factors
* Overweight, obese, or morbidly obese
* Maternal age over 25 years
* Previous birth outcome associated with GDM
* GDM in previous pregnancy
* History of abnormal glucose tolerance (maybe woman was told she is prediabetic at some point before)
* History of diabetes in a first-degree relative (i.e. mother/father/sister/brother)
* Member of a high-risk ethnic group
Screening for Gestational Diabetes
Glucose Challenge Test (GCT) [done at ~26 weeks]
Fasting not necessary
Ingest ___ of oral glucose solution
Blood sample obtained 1 hour after completion
If glucose is ___ mg/dL or more, OGTT is recommended
Is a screening test
50g
140 mg/dL
Oral Glucose Tolerance Test (OGTT)
Gold standard for diagnosis
Fasting screen less than __ mg/dL
Ingest ___ of oral glucose solution
1 hour screen less than ___ mg/dL
2 hour screen less than ___ mg/dL
3 hour screen less than ___ mg/dL
* If any 2 of these are abnormal, there is a diagnosis of GDM made
* If only 1 is abnormal, client is not
95 mg/dL (ensure that they did fast; if >95 = fail)
100g
180 mg/dL
155 mg/dL
140 mg/dL
GDM: Management & Nursing Care
* Work with a registered dietician to create diet appropriate for woman
* Physician-guided exercise regimen
* SMBG based on regimen prescribed by physician
* Fetal surveillance in 2nd and 3rd trimesters (NST, BPP)
* Have open communication with the woman and her family
* Give a sense of control - let her be active in creating her plan of care
Safety Alert: Identifying Hypo- and Hyperglycemia
Sx’s of Maternal Hyperglycemia
* Fatigue
* Flushed, hot skin
* Dry mouth; excessive thirst
* Frequent urination
* Rapid, deep respirations; acetone breath (with acidosis)
* Drowsiness, headache
! Depressed reflexes
Sx’s of Maternal Hypoglycemia
* Tremors
* Diaphoresis
* Pallor; cold, clammy skin
* Disorientation; irritability
* Headache
* Hunger
* Blurred vision
Cardiac Disease
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* Note that this can develop from other cardiac diseases that are seen
Cough (frequent, productive, hemoptysis)
Progressive DOE
Orthopnea
Pitting edema of the legs and feet or generalized edema of the face, hands, or sacral area
Heart palpitations
Progressive fatigue or syncope with exertion
Moist rales in the lower lobes, indicating ?
Congestive Heart Failure (CHF)
pulmonary edema
Maternal Phenylketonuria (PKU)
* Inherited single-gene recessive deficit
* Unable to metabolize phenylamine
* Goal is to be on a low phenylamine diet before conception and pregnancy
* If not treated, fetus at risk for microcephaly, intellectual disabilities, heart defects, and IUGR
