Diabetes Mellitus in Pregnancy

1. Diabetes Mellitus in Pregnancy 

2. Definition A group of metabolic disorders resulting in hyperglycemia, a consequence of either inadequate insulin production, inadequate insulin secretion, or both.

3.  TYPES OF DIABETES American Diabetes Association (ADA) classified the disease in four categories Type 1 diabetes: autoimmune destruction of the pancreatic � cells, resulting in an inability to produce and secrets insulin. Type 2 diabetes: insulin resistance, a relative insulin deficiency as well, or it may be both. Third category: gestational diabetes mellitus (GDM) is defined as the onset or first recognition of diabetes during pregnancy. Fourth category: is associated with genetic disorders, pancreatic diseases, drug and chemical use, and infections

4. How to diagnose the DM ? In pregnancy, the oral glucose tolerance test should be performed as follows: in the morning after an overnight fast of between 8 and 14 hours Ask the patient to remain seated. Don�t smoke if she dose. Administer a 75-gram oral glucose load . Measure the venous plasma glucose when the patient is fasting and 30, 60, 90, and 120 minutes after administering the glucose load.

5. cont�Diagnose abnormal glucose tolerance according to the following criteria TABLE 2. Diagnostic Criteria for 50-g Glucose Challenge Test If initial glucose tolerance test is normal but the patient is thought to be at high risk repeating the glucose tolerance test at 32 weeks of gestation

7. Maternal and Fetal Complications

9. Before women plan to pregnant need HEALTH EDUCATION 1-Comprehensive visit where possible the plans 2-Education about diabetes and pregnancy 3-Delayed conception until the FBG is in the 70-100 mg/dL range and postprandial blood glucose is less than 140 at 1 hour or less than 120 mg/dL at 2 hours

10. HEALTH EDUCATION When a woman is diagnosed with GDM , treatment should commence as soon as possible : Blood glucose self-monitoring Dietary management physical activity, Stress management , Exercise, Fetal movement records, Caring for Feet occasionally insulin therapy.

11. Blood glucose self-monitoring Teach the mother how to used because It provides immediate feedback that helps management strategies, including dietary changes, stress management, physical activity, and insulin therapy Monitor blood glucose levels four times daily 1st obtaining a �fasting� level then 3 �postprandial� levels (one hour after the start of each meal). Specific goals of management are keep FBS levels at less than 95-105 mg/dL and postprandial levels at less than 130-140 at 1 hour or less than 120 mg/d L at 2 hours

14. HEALTH EDUCATION FOR NUTRIATION Approximately 80% of women may be managed with diet alone Avoid sugar and foods high in sugar High fiber diet with correct caloric intake 30-35 kcal/day with no patient receiving less than 1800 or more than 2800 calories/day Diet composed of: 1. Carbohydrate 45% 2. Protein 25% 3. Fats 30% If euglycaemia is not achieved with diet within 1-2 weeks, use S/C insulin is recommemded. Emphasize complex carbohydrates, such as starchy vegetables (such as potatoes, corn, beans and peas), grains, fruit and other starchy foods Emphasize Milk and milk products such as yogurt. Emphasize foods high in fiber Nonstarchy vegetables like lettuce, celery, and broccoli contain water and fiber, primarily, and don�t significantly affect the postprandial glucose level. Keep diet low in fat Have bedtime snacks that include both protein and complex carbohydrate

15. CHO account for 40% to 45% of total daily calories CHO servings should be distributed throughout the day in three main meals and two to four snacks less of CHO at breakfast but can tolerate greater amounts at lunch and dinner. Morning urine ketone to determine the adequacy of caloric intake. The presence of ketones in the urine indicate insufficient calories or CHO resulting in accelerated fat breakdown If spilling ketones in morning urine, increase the size of the bedtime snack or move the snack time to later at night so that the snack lasts longer.

16. Health Education Physical activity Physical activity increases insulin receptor sensitivity by counteracting the hormonal changes that accompany pregnancy. Performing 15 to 20 minutes of armchair exercises daily during routine sedentary activities, such as watching television or reading. Can help a pregnant woman reduce hyperglycemia without increasing the risk of inducing uterine contractions.

17. Health Education of Stress Stress can significantly raise blood glucose levels It�s important to assess a woman�s feelings about her diagnosis as well as her support system Nurses can also educate women on coping techniques such as deep breathing and keeping a journal Encourage them to engage in activities that they find enjoyable.

18. Health Education of Exercise Increase blood glucose uptake in skeletal and decrease insulin needs in patients with gestational diabetes Moderate level of exercise believed to be safe in pregnancy Avoid sports or exercises might cause fall. Aerobic exercise or walking for 30 minutes are good exercises to continue during pregnancy.

19. Activity along with food intake and insulin injections. If on insulin, need to take a few precautions:  Be aware of the risk of hypoglycemia, and take a high-sugar snack. It may be necessary to eat small snacks between meals. If exercise right after a meal, have a snack after the exercise. If exercise two hours or more after a meal, eat the snack before the exercise. One serving of fruit will maintain blood sugar for most short-term activities (about 30 minutes). One serving of fruit plus a serving of starch will be enough for activities that last longer (an hour or more). Don't reduce insulin intake before exercising. Don't inject insulin into a part of the body that will be exercised; for example, if walking, avoid injecting into the leg.

20. Teach mother how to record Fetal Movement Recording fetal movement is a test done by mother to help determine the condition of the baby. Fetal activity is generally a reassuring sign of well-being Women are often asked to count fetal movements regularly during the last trimester of pregnancy. Instruct the mother to set aside specific times to lie down on back or side and count the number of times the baby moves or kicks . Three or more movements in a 2-hour period are considered normal Contact obstetrician if she feel fewer than three movements to determine if other tests are needed

21. Health Education for take care of Feet keep blood glucose in target range. Check feet every day. for red spots, cuts, swelling, and blisters. If cannot see the bottoms of feet, use a mirror or ask someone for help. physical activity program with health team. coverage for special shoes. Wash feet every day. Dry them carefully, especially between the toes. Keep skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of feet, but not between toes. toenails, trim them when needed. Trim toenails straight across and file the edges with an emery board or nail file. Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect feet. Check inside shoes before wearing them. Make sure the lining is smooth and there are no objects inside. Protect feet from hot and cold. Keeps the blood flowing to feet. Put feet up when sitting. Wiggle your toes and move ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross legs for long periods of time. Don't smoke.

23. During delivery Hypoglycemia in the newborn less than 35 mg/dL in the term infant. it is more common in infants of women with pregestational diabetes The newborn must be carefully monitored for at least the first 2 hours after birth. Early feeding and intravenous glucose are therapies commonly used, depending on blood glucose level and symptoms. Infant must monitored for hypocalcaemia, hypomagnesaemia, polycythemia and hyperbilirubinemia, polycythemia, and more common in women with pregestational diabetes, and a team approach to monitoring and caring for these infants should be in place. The most common newborn complication after birth is hypoglycemia which, if uncorrected, may result in seizures.

24. POSTPARTUM HEALTH EDUCATION The midwifery role in postpartum care is similar to that for women without diabetes. Women with pregestational diabetes should continue to be managed by a physician goal of continued glycemic control, determination of postpartum recovery status, and recommendation of family planning methods. Because of evidence that the incidence of childhood diabetes is lower among those who were breastfed, breastfeeding should be encouraged and supported Breastfeeding may also promote improved glycemic and lipid profiles in women with diabetes (20). Provision of an appropriate and effective contraceptive is the first step in preconception care for a next possible pregnancy

25. Contraception for Diabetic Women All forms of contraception carry some risk and every woman must be considered Individually Additional considerations for diabetic women include: � The importance of per conceptual control of diabetes. � The constraints imposed by the complications of diabetes

26. The Combined Oral Contraceptive Pill � Effective if taken reliably. � First generation high dose estrogen pills may increase insulin requirements and increase risk of vascular disease � Second and third generation pills have a much lower dose of estrogen and can probably be used safely in the majority of women with diabetes. � Contraindications: diabetic complications, high arterial risk, Age>35years.

27. The Progestogen-only Pill There is no evidence of this pill with vascular side effects and detrimental effects on lipids or clotting factors are minimal. � This is reliable if taken regularly but omission may be more likely to result in pregnancy than with the combined pill. � Menstrual irregularity can be problematic � If amenorrhea occurs a pregnancy test should be performed; � Injectable progestogens/implants are suitable for some patients

28. Intrauterine Contraceptive Device � An advantage is the lack metabolic effects and need for compliance. � Failure rate is high (2/100 women per year). � There is no evidence for the IUCD promoting pelvic inflammatory disease . � There is disagreement as to whether or not nulliparous women with diabetes should use this form of contraception.

29. Mechanical Contraception � This method has no metabolic consequence, � High failure rates usually result from omission or incorrect usage this method is not recommended if it is essential to avoid pregnancy. � Highly motivated couples taught to use the diaphragm and sheath correctly,.

30. Sterilization � Requested by many mothers when their family is complete. � The reduced life expectancy of those with longstanding diabetes should be borne in mind when making this decision. � Sterilization is occasionally advised if there is felt to be a serious risk to the woman�s health. � For some couples vasectomy is appropriate

31. Natural Methods Highly motivated couples taught to use these methods correctly, may find this an effective and acceptable form of contraception.

32. Emergency Contraception This is safe for diabetic women and should be prescribed if needed. The "morning after" pill is a combined oral contraceptive which contains a high dose of the female hormones, estrogen and progestin. The morning after pill actually consists of four combined oral contraceptives tablets. You take two of the tablets with water immediately and two tablets 12 hours later.