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DIABETES MELLITUS

An endocrine disorder of carbohydrate metabolism,


resulting from inadequate production or use of Insulin.



DIABETES MELLITUS
4 Cardinal Signs of DM:
1. Polyuria (with glycosuria)
2. Polydipsia
3. Polyphagia
4. Weight loss


Early Pregnancy:
Insulin release accelerates
Significant hypoglycemia may occur
Increase in fat stores
Late Pregnancy:
Placental hormones rise sharply
Insulin resistance happens
Insulin insufficency occurs
May have episodes of hyperglycemia
Switch from CHO metabolism to gluconeogenesis
Effects of Pregnancy on
Fuel Metabolism
DM may be difficult to control because insulin
requirements are changeable.
1. During the first trimester, the need for insulin
frequently decreases.
2. N/V may cause dietary fluctuations
3. Insulin requirements increase
4. Increased energy needs during labor
5. Decrease in insulin requirement occurs after the
passage of the placenta

Influence of Pregnancy
On Diabetes
The pregnancy of a woman who has diabetes
carries higher risk of complications

Influence of Diabetes
on Pregnancy Outcome

Type 1 or IDDM
Type 2 or NIDDM
Gestational Diabetes
Other specific types

Classifications of Diabetes Mellitus
DIABETES MELLITUS
A condition of abnormal
glucose metabolism that
arises during pregnancy.
Possible signal of an
increased risk for type 2
diabetes later in life.

DIABETES MELLITUS
Overweight or obesity
Chronic hypertension
Maternal age older than 25 years
Family history of diabetes
Previous birth of a large infant (> 4000g)
Previous birth of an infant with unexplained
congenital anomalies
Previous unexplained fetal death
Gestational diabetes in previous pregnancy
Multifetal pregnancy
Fasting serum glucose > 140 mg/dl or random
serum glucose > 200 mg/dl

Hydramnios
Preeclampsia-eclampsia

Congenital anomalies
LGA
RDS
Polycythemia
Hyperbilirubinemia
DIABETES MELLITUS
History
How long has she had the disease?
How does she maintain normal blood
glucose?
Is she familiar with ways to monitor
blood glucose and administer insulin?


DIABETES MELLITUS
Physical Examination
Baseline ECG should be obtained
Evaluation for retinopathy
Weight and BP monitoring
Fundal height should be measured

DIABETES MELLITUS
SCREENING TESTS
Glucose Challenge Test (GCT)
The woman should ingest 50g of oral glucose
solution.
One hour later a blood sample is taken.
If the blood glucose concentration is 140
mg/dl or greater, a 3-hour oral glucose
tolerance test is recommended.
Some practitioners use a lower cutoff of 130
or 135 mg/dl to identify more women at risk.



DIABETES MELLITUS
SCREENING TESTS
Oral Glucose Tolerance Test (OGTT)
The woman must fast from midnight
on the day of the test.
The woman should ingest 100g of
oral glucose solution.
Plasma glucose levels are then
determined at 1, 2, and 3 hours.


DIABETES MELLITUS

DIABETES MELLITUS
Oral Glucose Tolerance Test (OGTT)
Gestational diabetes is the diagnosed if the fasting
blood glucose level is abnormal or if two or more of
the following values occur on the OGTT:
Fasting, > 95 mg/dl
1 hr, > 180 mg/dl
2 hrs, > 155 mg/dl
3 hrs, > 140 mg/dl


DIABETES MELLITUS
Monitoring a Woman with Diabetes
A woman should use a home test kit to
determine if she is pregnant at the earliest
possible time.
The measurement of glycosylated hemoglobin
is used to detect the degree of hyperglycemia
present.
HbA1c is measured.
Ophthalmic examination

DIABETES MELLITUS
Risk for ineffective tissue perfusion related to
reduced vascular flow.
Imbalanced nutrition, less than body
requirements, related to inability to use glucose.
Risk for ineffective coping related to required
change in lifestyle.
Risk for infection related to impaired healing
accompanying condition.

DIABETES MELLITUS
Deficient fluid volume related to polyuria
accompanying disorder.
Deficient knowledge related to difficult and
complex health problem.
Health seeking behaviors related to voiced need
to learn home glucose monitoring.
Deficient knowledge related to therapeutic
regimen necessary during pregnancy.

DIABETES MELLITUS
Demonstrate competence in home glucose monitoring
and administration of insulin before home management
is initiated.

Describe a plan for meeting dietary recommendations
that fits family lifestyle and food preferences.

Identify signs and symptoms of hypoglycemia and
hyperglycemia and the management required for each.

Verbalize knowledge of fetal surveillance procedures
and keep scheduled appointments for testing.



DIABETES MELLITUS
MAJOR GOALS:
1. To maintain physiologic equilibrium of insulin
availability and glucose utilization during
pregnancy

2. To ensure an optimally healthy mother and
newborn.








MORE IN REVIEW ARTICLES

1. Dietary Regulation
Simple sugars in concentrated sweets should be
eliminated
For obese women, a small percentage of CHO is
recommended
Calories should be divided among 3 meals and at
least 3 snacks


2. Exercise
Exercise and active lifestyle can improve
cardiorespiratory fitness


3. Blood Glucose Monitoring

4. S/Sx of Maternal Hypo/Hyper glycemia

Signs / Symptoms of
Maternal Hypoglycemia:
Signs / Symptoms of
Maternal Hyperglycemia:
- Shakiness (Tremors) - Fatigue
- Sweating - Flushed, hot skin
- Pallor; cold, clammy skin - Dry mouth, polydipsia
- Disorientation; irritability - Polyuria
- Headache - Rapid, deep respirations,
acetone breath
- Hunger - Drowsiness, headache
- Blurred vision - Depressed reflexes

5. Insulin administration
DIABETES MELLITUS

5. Evaluation of Fetal Status
AFP screening
Ultrasound
BPP
NST
Contraction test




DIABETES MELLITUS
Timing of birth
- spontaneous labor
- CS birth maybe indicated
Labor management
- hourly monitoring of glucose levels
- 5% dextrose solution, normal saline

Maternal insulin requirements fall during
postpartal period.
Antihyperglycemics contraindicated during
breastfeeding.
Postpartum adjustment

Increasing Effective Communication
Providing Opportunities for Control
Providing Normal Pregnancy Care

The woman and at least one support person can
demonstrate competence in home glucose monitoring and
administration of insulin

The woman can describe a satisfactory plan for meeting
her individual dietary requirements

The woman and at least one support person can list the
signs and symptoms of hypoglycemia and hyperglycemia
and describe the initial management of these conditions

The woman can verbalize knowledge of the reason for fetal
surveillance procedures and keeps appointments for tests.

Murray, S. & McKinney, E. (2006). Foundations of
maternal-newborn nursing (4
th
ed.). USA:
Saunders Elsevier.

Pilitteri, A. (2010), Maternal & child health nursing:
Care of the childbearing & childrearing family
(6
th
ed.). Philippines: Lippincott Williams &
Wilkins.