The Pregnant Woman with Complications Gestational Diabetes Mellitus

1. Chapter 26, 25 The Pregnant Woman with ComplicationsGestational Diabetes Mellitus Hyperemesis Gravidarum

2. Preexisting diabetes mellitus • Type 1 (insulin deficient) • Type 2 (insulin resistant) • Gestational diabetes mellitus (women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. Especially during their third trimester.)

3. Gestational diabetes (GDM):is a carbohydrate intolerance of variable severity that develops or is first recognized during pregnancy.

4. Risk factors: • Overweight (BMI ≥25). And obesity (BMI ≥30) • Maternal age older than 25 years • Previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension ,infant with unexplained congenital anomalies and previous fetal death) • Gestational diabetes in previous pregnancy • History of abnormal glucose tolerance • History of diabetes in a close (first degree) relative • Member of a high- risk ethnic group (Hispanic African, ).

5. Identifying Gestational Diabetes Mellitus: Glucose challenge test (GCT):administered between 24 and 28 weeks for screening of women who has any of previous risk factors. GCT: ingest 50g of oral glucose solution ; 1 hour later a blood sample is taken. If the result of the test is 140mg/dl or more the woman is scheduled for a 3houroral glucosetolerance test (OGTT) is recommended In general any women who has Fasting glucose level >126mg/dl or a nonfasting level of >200mg/dl will be diagnosed as having GDM and no added testing is needed.

6. OGTT: ingest 100g of oral glucose solution. Plasma glucose levels are then determined at 1,2, and 3 hours. • OGTT considered positive if two or more ofthe following values are met: • Fasting greater than 95mg/dL • 1hour, greater than 180mg/dL • 2hour, greater than 155mg/dL • 3hour, greater than 140mg/dL

7. Glycemic control should be evaluated on the basis of Glycosylated Hemoglobin, HbA1c. To evaluate long-term blood glucose control. • Prolonged hyperglycemia causes some of the hemoglobin in the erythrocytes to remain saturated with glucose for the life of red blood cell • Norma range for HbA1c is (4%-5.6%) • (5.7%-6.4%) Indicate increased risk for DM • (6.5% or higher) Indicate DM

8. Maternal Fetal, and Neonatal Effects: • Maternal Complications • Preeclampsia • C/S, Labor Dystocia, uterine atony after birth due to hydramnious overdestended uterus. (fetal hyperglycemiafetaldiuresishydramnious)  premature rupture of membranes because of overdistended uterus b hydramnious or large fetus.)

9. Maternal Complications cont. • Birth injury to maternal birth canal tissue • UTI: due to increase bacterial growth in nutrient-rich urine. • Keto acidosis: due to uncontrolled hyperglycemia. If untreated can progress to fetal & maternal death.

10. Fetal and Neonatal Complications • Congenital anomalies: maternal hyperglycemia In first month during organogenesis. Associated with preexisting DM. e.g neural tube defects, caudal regression syndrome (malformation that results when the sacrum, lumbar spine, and lower extremities fail to develop). • Macrosomia: fetal hyperglycemia  increase insulin to metabolize carbohydrates. Excess nutrient transported to the fetus

11. Fetal and Neonatal Complications cont. • Neonatal hypoglycemia: due to neonatal hyperinsulinemia. But maternal glucose is no longer available. • Polycythemia: fetal hypoxemia stimulate erythrocyte production • Hyperbilirubinemia: breakdown of excessive erythrocyte production • Respiratory distress:inadequate surfactant. Slowed absorption of fetal lung fluid

12. Therapeutic management 1.Diet: Should provide the calories and nutrients needed for maternal and fetal health Result in euglycemia, avoid ketosis and promote appropriate weight gain Eliminate simple sugars from diet Calories should be divided among three meals and at least three snacks.

13. 2.Exerciserecommended by a physician who take into account each woman risks factors and risks to the fetus

14. 3.Monitoring of glucose level • Measurement of fasting glucose level and postprandial blood glucose level • If blood glucose level repeatedly exceed 95mg/dl or postprandial exceed 120mg/dl insulin is started 4.Fetal assessment • US • NST • Kick count • Biophysical profile • Fetal lung maturity

15. 4.Fetal Assessment • US • Non stress test (NST) • Kickcount • Biophysical profile (NST, fetal breathing movements, gross body movement, fetal tone flexion extension, amniotic fluid volume) • Fetal lung maturity

16. Nursing interventions: • Teaching self-care skills - Self-monitoring of blood glucose - Insulin administration (Correct dose at the correct time) • Teaching dietary management • Recognizing and correcting hypoglycemia and hyperglycemia • Explaining procedures tests and plan of care

17. Signs and symptoms of maternal Hypoglycemia: • Shakiness (tremors) • Sweating • Pallor and cold, clammy skin • Disorientation, irritability • Headache • Hunger • Blurred vision

18. Management of hypoglycemia: • Treat hypoglycemia at once to prevent brain damage • The woman should take 15 g of carbohydrate if she is able to swallow • Retest after 15 minute , if the glucose level less than 70 mg /dl , repeat CHO intake and retest every 15 minute until blood glucose level return to normal • Example of 15 g glucose food include 3-4 glucose tablets, one table spoon of sugar or honey

19. CONT • Teach family how to inject glucagon in theevent that the woman cannot swallow or retain food • Notify the physician • Intravenous glucose if she is hospitalized • If untreated hypoglycemia can progress to convulsion and death • Instruct the woman to have meals at a fixed time each day and to plan snacks at the recommended times • Suggest that she carry glucose tablets or dry crackers whenever possible.

20. Glucagon injection

21. Signs and Symptoms of MaternalHyperglycemia • Fatigue • Flushed, hot skin • Dry mouth, excessive thirst • Frequent urination • Rapid, deep respirations • Odor of acetone on the breath • Drowsiness • Headache • Depressed reflexes

22. Management of hyperglycemia: • Pregnant woman must be instructed to notify the physician whenever they have an infection of any type. • If untreated, Hyperglycemia can lead to ketoacidosis coma and maternal and fetal death • Notify the doctor at once if signs and symptoms occur so that treatment can be initiated • Hospitalization is necessary for monitoring blood glucose level and intravenous administration of insulin.

23. Hyperemesis Gravidarum • Is persistent,uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy

24. Risk Factors • Unmarried white woman • First pregnancy • Multifetal pregnancy • Possible allergy to fetal protein • Elevated levels of pregnancy related hormones( estrogen, HCG) • Maternal thyroid dysfunctions • Organism that cause peptic ulcer(Helicobater pylori) • Psycologic factors

25. Manifestation • Weight loss of 5% or more of prepregnancy weight • Dehydration • Change in vital signs • Acidosis from starvation • Alkalosis from loss of hydrochloric acid in gastric fluid. • Increased blood & urinketones, HB and HCT, and creatinine • Decreased sodium,pottasium (hypokalemia) and chloride • Coagulation disorders (loss of vitamin K) • Short term hepatic dysfunction with elevated liver enzymes • Deficiency of thiamine (vit. B1. mportant in the metabolism) cause encephalopathy (permenent or reversable brain injury)

26. Complications • Maternal death • Fetal complication: • Increased risk of CNS malformation • IUGR • Fetal anomalies • Fetal death

27. Therapeutic management • Try measure used at home to treat morning sickness • Vitamin Supplement Vitamin B6 • Ginger has shown some benefit in reducing the episode of vomiting • Ante emetics such as Phenergan • Metoclopramide ( Reglan) act on CNS • Steroid(methylprednislone) • I.V fluid, electrolyte replacement • Total parental nutrition may be needed • Internal nutrition(NG tube)

28. Nursing Consideration • Assess intake and output • Assess bowel movement • Assess signs of dehydration • Weigh woman daily • Test urine for ketones • Consultation with dietitian

29. Nursing Interventions • Reduce nausea and vomiting • Small frequent meals • present attractive food • eliminate food with strong odor • Low fat and easily digested food • Avoid fluid with meals • Sitting uprights after meal • Maintain nutrition and fluid balance • Provide emotional support