DIABETES MELLITUS

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

RISK FACTORSFamily HistoryRapid hormonal change in pregnancyTumor/ infection of the pancreasObesity StressNORMAL METABOLIC CHANGES IN PREGNANCYThe 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/HPLIF 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 PREGNANCYElevated basal metabolic rate (BMR) and decreased carbon dioxide combining powertendency to metabolic acidosisNormal lowered renal threshold for sugar, increased glomerular filtration rateGLUCOSURIAVomiting during pregnancy decreases carbohydrate intakemetabolic acidosisMuscular activity in labor depletes maternal glucose including glycogen storesrequires increased carbohydrate intakeHypoglycemia is common in puerperium as involution and lactation occur.

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

InfertilitySpontaneous AbortionPIHInfections: moniliasis, UTIUteroplacental insufficiencyPremature LaborDystociaMore difficult to control DMhypoglycemia/hyperglycemiaCesarean section often indicatedUterine atonypostpartal hemorrhage

BABY

Congenital anomaliesPolyhydramniosMacrosomia(LGA)Fetal hypoxia intrauterine fetal death(IUFD),still births;increased perinatal deathNeonatal hypoglycemiaPrematurityRDSHypocalcemia

EFFECTS OF PREGNANCY ON DMDM is more difficult to conrol: difficult to maintain blood sugarInsulin Shock and ketoacidosis are commomDiscomforts nausea and vommiting predispose to ketoacidosisINSULIN REQUIREMENTS change in pregnancy1st trimester: stable insulin; may not increased need2nd trimester: rapid increase need due to increased HPL3rd trimester: rapid increaseLabor: IV Regular insulinPostpartum: rapid decrease to pre pregnant level; may not need insulin in the 1st 24 hr after delivery

ASSESSMENT FINDINGSHistoryFamily history of diabetes; gestational diabetes in previous pregnancyPrevious large infant 4000g or morePrevious infant with congenital defects; polyhydramniosFetal wastage: spontaneous abortion, fetal deaths, stillbirthsObesity with rapid weight gainIncreased incidence of vaginal moniliasis and UTIMarked abdominal enlargement Signs of hyperglycemia: 3 PsPolyphagia - excessive appetitePolydipsia excessive thirstPolyuria excessive urineWeight lossIncreased blood and urine sugar

DIAGNOSING DMa. Screening testPerformed at 26 to 28 weeks of gestation; earlier between 24 to 28 weeks for womenAt risk of gestational diabetes (ACOG, 1986)Uses 50g oral glucose challengeFinding: A plasma glucose of 140mg/dL needs a follow up test with 3 hour glucose tolerance testb. 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/dLc. 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 DMd. 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 infectionC. 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 ImplementationD. 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 ImplementationInsulin : 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 ImplementationE. Encourage hospitalization for; Control of infection Regulation of insulinAssessment 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 periodElectronic fetal monitoringLeft 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 ImplementationProvide 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:HemorrhageInfectionsInsulin shock/ Hypoglycemic shockEncourage contraception; reinforce physicians recommendationsBarrierOral contraceptive pillsIUD MAY GO HOME