DIABETES MELLITUS

A chronic, metabolic disorder characterized by a

deficiency in insulin production by the islets of
Langerhans resultingin improper metabolic interaction
of carbohydrates, fats, proteins, and insulin
INCEDENCE
may be a concurrent disease in pregnancy or may
have its first onset in pregnancy.

RISK FACTORS
a. Family History
b. Rapid hormonal change in pregnancy
c. Tumor/ infection of the pancreas
d. Obesity
e. Stress
NORMAL METABOLIC CHANGES IN
PREGNANCY
a. The increased metabolic rate in pregnancy causes
increased number of islets of Langerhans
resulting in increased insulin production but which
is renderedineffective by the insulinantagonists
primarily HCS/HPL
b. IF pancreas cannot respond by producing more
insulin, glucose crosses the placenta to the fetus
where fetal insulin metabolizes it and by
resembling the growth hormone, causes extra
large fetus: MACROSOMIA

NORMAL METABOLIC CHANGES IN
PREGNANCY
d. Elevated basal metabolic rate (BMR) and
decreased carbon dioxide combining
powertendency to metabolic acidosis
e. Normal lowered renal threshold for sugar,
increased glomerular filtration
rateGLUCOSURIA
f. Vomiting during pregnancy decreases
carbohydrate intakemetabolic acidosis
g. Muscular activity in labor depletes maternal
glucose including glycogen storesrequires
increased carbohydrate intake
h. Hypoglycemia is common in puerperium as
involution and lactation occur.


EFFECTS OF DM ON THE MOTHER AND
THE BABY
When diabetes is welled-controlled, its effect on pregnancy may be
minimal; if control is inadequate there may be maternaland fetal
newborn complications:
MOTHER

Infertility
Spontaneous Abortion
PIH
Infections: moniliasis, UTI
Uteroplacental insufficiency
Premature Labor
Dystocia
More difficult to control
DMhypoglycemia/hyperglycemia
Cesarean section often indicated
Uterine atonypostpartal
hemorrhage

BABY

Congenital anomalies
Polyhydramnios
Macrosomia(LGA)
Fetal hypoxia intrauterine fetal
death(IUFD),still births;increased
perinatal death
Neonatal hypoglycemia
Prematurity
RDS
Hypocalcemia
EFFECTS OF PREGNANCY ON DM
a. DM is more difficult to conrol: difficult to maintain blood
sugar
b. Insulin Shock and ketoacidosis are commom
c. Discomforts nausea and vommiting predispose to
ketoacidosis
d. INSULIN REQUIREMENTS change in pregnancy
1
st
trimester: stable insulin; may not increased need
2
nd
trimester: rapid increase need due to increased HPL
3
rd
trimester: rapid increase
Labor: IV Regular insulin
Postpartum: rapid decrease to pre pregnant level; may not
need insulin in the 1
st
24 hr after delivery

ASSESSMENT FINDINGS
a) History
Family history of diabetes; gestational diabetes in previous
pregnancy
Previous large infant 4000g or more
Previous infant with congenital defects; polyhydramnios
Fetal wastage: spontaneous abortion, fetal deaths, stillbirths
Obesity with rapid weight gain
Increased incidence of vaginal moniliasis and UTI
Marked abdominal enlargement
b) Signs of hyperglycemia: 3 Ps
Polyphagia - excessive appetite
Polydipsia excessive thirst
Polyuria excessive urine
c) Weight loss
d) Increased blood and urine sugar




DIAGNOSING DM
a. Screening test
Performed at 26 to 28 weeks of gestation; earlier between 24 to 28 weeks for
women
At risk of gestational diabetes (ACOG, 1986)
Uses 50g oral glucose challenge
Finding: A plasma glucose of 140mg/dL needs a follow up test with 3 hour
glucose tolerance test

b. Test (Glucose Tolerance GGT): 100 g GGT; commonly done between 28 to 34 weeks
of pregnancy. The presence of two out of these four venous samples is considered an abnormal
result:
. Fasting blood sugar: greater than 105 mg/dL
. 1hour after: serum glucose greater than 190 mg/dL
. 2 hours after: serum glucose greater than 190 mg/dL

c. 2-hr Postprandial Blood Sugar (PPBS)
Abnormal Result: greater than 120 mg/dL. The goals for glycemic control include fasting
blood glucose levels (FBS) less than 105 mg/dL and 2 hr postprandial levels or less
than120mg/dL.


DIAGNOSING DM
d. Glycosylated Hemoglobin (maternal
hemoglobin irreversibly bound to glucose):
measures Long Term (3 months) COMPLIANCE to
treatment. Normal value 4% to 8% of womans total
hemoglobin increasing during hyperglycemia
(Saunders et al., 1980).

e. Urine Glucose Monitoring INAACURATE as the
urine of pregnant mother is normally with sugar.

. NURSING IMPLEMENTATION


A. Participate in EARLY DETECTION; history, symptomatology and
pre natal screening.
B. Encourage PRE NATAL MANAGEMENT and supervision.
Frequent, regular pre natal visits
Diet; Record dietary intake; monitor blood glucose levels several
times daily.
Insulin; when FBS is not consistent at lower than 105 mg/dL or 2-hrs
PPBS is not less than 120mg (ACOG, 1994)
Hospitalizations. For poorly controlled diabetes, concomitant
hypertension and treatment of infection
C. Provide teaching
Nature of DM, effects on pregnancy on DM, and effects of DM on
pregnancy.
Signs and symptoms of hyperglycemia/hypoglycemia
Need for exercise not only to regulate glucose levels but also to
enhance feelings of well-being and to control weight.
Insulin regulation/self administration of insulin.
Prompt reporting of danger signs and signs of infection.

NURSING IMPLEMENTATION

D. Promote control of DM: Maintaining maternal glucose levels
within the normal range during the prenatal intranatal
periods is important to prevent stimulation of the fetal
pancreas resulting in fetal or neonatal HYPOGLYCEMIA.
Diet: cornerstone of DM management and control; promote
adherence to dietary regimen.
Exercise decreases the need for insulin, excessive exercise
may cause hypoglycemia. Prevention of hypoglycemia from
Exercise:
Do not exercise when blood sugar is low or when
stomach is empty.
Eat after prolonged exercise.
Do not administer insulin in the extremity that will
be immediately used in the exercise.
Do not exercise alone (e.g. have a partner while
jogging) in case hypoglycemia attacks.
Always carry diabetic ID.

NURSING IMPLEMENTATION
Insulin : Oral diabetogenic agents are contraindicated.
Increase need for insulin in the second or third
trimesters, in the third trimesters, needs may be
tripled=increase tendency to a ketoacidosis.
Regular and NPH insulin are used in pregnancy; only
regular insulin are used during labor because long-acting
Insulin are not enough to prevent ketoacidosis.
Rapid acting regular insulin intravenously along
with an IV glucose infusion is used in labor; frequent check of
blood Glucose, and adjustments; and additional boluses of
insulin as needed (Creasy et al; 2004): The only insulin that
can be given Intravenously is regular insulin.
Prevention of Infection, Stress-----hyperglycemia------
increase need for insulin.

NURSING IMPLEMENTATION
E. Encourage hospitalization for;
Control of infection
Regulation of insulin
Assessment of fetal jeopardy and/or indication for early
termination of pregnancy.
ULTRASOUND-for fetal growth; measures AOG by
measuring the biparietal diameter.
Urine/blood estriol levels-to determine fetoplacental
functioning.
Amniocentesis-to determine lung maturity. An L/S
ratio of 2:1 means mature lungs ( above 36 weeks
gestation) If the mother is not diabetic; but L/S ratio
may be falsely elevated in DM making making L/S ratio
not an accurate Measure of fetal lung maturity.
Phosphatydyl-Glycerol (PG)-more accurate way to
estimate fetal lung maturity by determining lung
surfactant if the Mother is diabetic.
Stress and Non Stress Tests.

NURSING IMPLEMENTATION
Early Labor Induction or cesarian section in the presence of fetal
distress.
Delivery timing is INDIVIDUALIZED and ideally occurs around
TERM. The final time for terminating pregnancy depends On the result
of fetal/maternal well-being surveillance.
When macrosomia complicates pregnancy potentially to cause
cephalopelvic disproportion, then induction of labor may Be done
usually around 336 to 37 weeks depending on ulrasonographic
monitoring of fetal size and evidence of pulmonary Maturity.
Continued monitoring, mother and fetus, during intrapartal period
Electronic fetal monitoring
Left lateral recumbent to prevent supine hypotensive syndrome.
Fluid and electrolyte balance;
D5W needed to maintain glucose; Regular insulin added to IV
of 5 to 10% D5W , titrated to maintain glucose between 100-150
Mg/dL (IDDM). In the client with type I diabetes (IDDM), long
acting insulin is avoided (Creasy et al, 2004) because it is not
enough To prevent ketoacidosis. In addition regular insulin can
be give per IV

NURSING IMPLEMENTATION
Provide post partum care
Monitor maternal need for POST PARTAL
INSULIN;
The increase insulin resistance occurring in
pregnancy is usually resolved in few hours after
delivery, tahat IV insulin Generally is discontinued
at the time of delivery (Insucchi, 1999)
A sharp decrease in insulin requirements during
the first 24 hours necessitates monitoring of the insulin
dose which is Titrated to measured blood glucose levels
in the immediate post partum period (Insucchi, 1999).
There is a decrease in insulin need to or 2/3
pregnant dose on first post partum day if on full diet.


NURSING IMPLEMENTATION
Encourage breastfeeding has antidiabetogenic
effect
Be alert for and prevent complications in the
postpartum:
Hemorrhage
Infections
Insulin shock/ Hypoglycemic shock
Encourage contraception; reinforce physicians
recommendations
Barrier
Oral contraceptive pills
IUD

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