Transcript: Hypoglycemia VS Infection related to hyperglycemia Diabetes majority who develop do so from excessive weight gain, similiar pathophysiology to diabetes type 2 Gestational Diabetes ***Macrosomia caused from gestational diabetes is from the placenta hormones not allowing the mother to use extra sugar in her blood for energy. This extra sugar goes through the placenta to the baby and since they are getting more sugar than needed they become larger. Ensure an optimally healthy mother and newborn Timing of delivery depends on maternal status and fetal well-being. Goal is to deliver infant at about 38 weeks to avoid problems of prematurity. Screening for diabetes Labor and Delivery of the Diabetic Woman QUESTIONS? 1-30 weeks gestation Evaluate fetal lung maturity- Amniocentesis- Amniotic fluid positive for phosphatidyl-glycerol indicates mature fetal lungs. L/S ratio is not a specific indicator for fetal lung maturity in diabetic women. Fluorescence polarization is increasing in use. Sierra Mason Maternity Rotation November 21, 2012 Very close monitoring during labor. Answer 4 B.jitteryness hypoglycemia in a neonate is expressed as jitteryness, lethargy, diaphoresis, and a serum glucose level below 40mg/dL. A hyper alert state in a neonate is more suggestive of meuralgic irritability and has no correlation to blood glucose levels. Positive babinski reflex doesn't correlate with hypoglycemia. A serum glucose of 60 is normal Urine test Fasting 95mg/dl glucose 1hour 180 2 hour 155 3 hour 140 Complications in the IDM can be grouped into 2 categories: Prematurity and those resulting from pregnancy complicated by diabetes Any degree of glucose intolerance during pregnancy Infant of a diabetic Mother (IDM) Prenatal visits weekly Hypertensive disorders and preeclampsia Measures glucose attached to hemoglobin Concentration is higher in diabetics Useful for estimating diabetic control during past 4-6weeks With pre-gestational diabetes abnormal values correlate to fetal congenital anomalies Some clinicians prefer to avoid placental perfusion problems as the placenta ages. Establish renal function Continuous FHR monitoring Fetal scalp pH Intravenous insulin Side lying position Blood glucose determinations hourly Urine testing Pediatrician at delivery First Trimester: insulin requirements decrease from n/v and decreased food intake as well as decreased glucose from embryo/fetus taking it across the placenta second and third: insulin requirements increase from placental maturation and increased human placental lactogen and other hormones that are insulin antagonists as well the glucose use and glycogen storage by mother and baby increase postpartum: it decreases due to the placenta removal and thus the human placental lactogen, progesterone and estrogen alkso decrease. diet and exercise regime are then reestablished *intrauterine growth restriction Answer 1 A. diet oral hypoglycemics are contraindicated in pregnancy Long acting insulin isn’t usually needed for blood glucose control for GDM ultrasound to screen fetus for abnormalities 18 weeks then at 28 weeks daily maternal evaluation of fetal activity nonstress testing * If any evidence of IUGR*, preeclampsia, or uncontrolled blood sugar-perform more frequently at 32 weeks increased to twice a week if non-reactive, contraction test can be done Respiratory distress syndrome Insulin administration Majority of those who develop the condition do so from excessive weight gain, although hormonal factors figure in as well. It is a very similar patho. to diabetes type 2 in which the body is not producing enough insulin for the digestive system to work properly Exacerbation of chronic diabetes related conditions IUGR-related to maternal vasculopathy and decreased maternal perfusion *Macrosomia-major cause of c/s delivery and high incidence of traumatic vaginal delivery. assess for birth injuries, brachial plexus injury, subdural hemorrhage, cephalohematoma, and asphysxia. Macrosomia gives a cushioniod appearance *large birth weight Effects of pregnancy on Insulin requirements You are developing a plan of care for Karen's baby. Discuss nursing diagnoses and interventions crucial to the care of this newborn. Risk for the Woman *** Diabetic Ketoacidosis *Especially whose blood glucose is poorly controlled Patient education Question 3 A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education? a.“I need to stay on the diabetic diet.” b.“I will perform glucose monitoring at home.” c.“I need to avoid exercise because of the negative effects of insulin production.” d.“I need to be aware of any infections and report signs of infection immediately to my health care provider.” *fluorescence polarization:Fetal maturity testing using fluorescent polarization measures the ratio of surfactant to albumin. High values indicate high levels of surfactant and lung maturity, while
Transcript: What Can Happen? In gestational diabetes, you can't respond to insulin, so your blood sugars stay high - your body will continue to make more insulin because of the high blood sugar levels Normally when we eat, our blood sugar levels increase and our bodies make something called insulin - insulin helps take the sugar out of the blood and into different areas of the body that can use the sugar for energy These high blood sugars that stay high and don't respond to your own body's insulin can have dangerous effects on your baby Mom's extra sugar can cause the baby to grow larger than it would normally. This can can cause problems with delivery. Large babies can have problems such as damage to shoulders during birth, low blood sugar levels, and increased risk for breathing problems. If it is high, you may have gestational diabetes You will fast overnight and drink a sugar beverage the next morning. Your blood sugar is measured 1 hour later After delivery... Knowler WC, Barrett-Connor E, Fowler SE, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002; 346(6):393-403. Gestational Diabetes These babies are also at greater risk for being very overwight as children and developing diabetes as adults Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy. Cochrane Database Syst Rev. 2003;(3):CD003395. Serlin DC, Lash RW. Diagnosis and management of gestational diabetes mellitus. Am Fam Physician. 2009 Jul 1;80(1):57-62. What are the risk factors? Gestational diabetes is when a pregnant mother's blood sugar is higher than normal It is similar to type 2 diabetes, but most often goes away after the baby is born 1-2% of pregnant women develop gestational diabetes, usually in the second trimester 50% of woman with gestational diabetes become diabetic in 10 years Regular screening for diabetes is important Exercise and proper diet can lower the risk of developing diabetes in the future What is it? A similar 3 hour test will let us know for sure if you have gestational diabetes. Family history of diabetes Advanced age Obesity Non-white How Is It Treated? Adjusting the diet is the initial approach Medications like insulin and metformin may be needed These medications are safe to take during pregnancy, and can help prevent future harm to both mom and the baby Regular check-ups are scheduled to make sure the baby is growing normally References How Do I know? Most women are screened for gestational diabetes at 24-28 weeks with a fasting blood sugar test
Transcript: What is it ? - Gestatinal Diabetes is a condition caused when your body is not able to make and use all the insulin it needs for pregnancy What effect does it have on the fetus ? - affects mother in pregnancy while the baby is still growing - does not cause birth defects that are sometimes seen in mothers who had diabetes before pregnancy - could give baby high glucose levels How is it treated ? - speacial meal plans and scheduled physical activity - daily blood glucose testing and insulin injections - losing weight ( staying healthy ) is a way of lowering the chance of getting it How big of a problem is it ? - having Gestational Diabetes once can increase the chances of a mother having it again - increases risk of leading to other diabetes - Gestational Diabetes usually goes away after pregnancy Gestational Diabetes
Transcript: A form of high blood sugar only during pregnancy If your blood sugar levels are too high, too much glucose will end up in your baby's blood. When that happens, your baby's pancreas needs to produce more insulin to process the extra glucose. All this excess blood sugar and insulin can cause your baby to put on extra weight, particularly in the upper body. Gestational Diabetes Rollover After Effects? Treatment Between 2 and 10 percent of expectant mothers develop this condition, making it one of the most common health problems of pregnancy. Causes Greater than 25yrs What is It? Causes you to lose weight :) Diabetes Medication Brief Diabetes Explanation You're obese (your body mass index is over 30) The baby may be too large to enter birth canal Or head may enter but shoulders would get stuck Delivery can sometimes result in a fractured bone or nerve damage (both heal w/o permanent damage in 99% of babies) If your blood glucose level for this screening is higher than 200 mg/dL, most practitioners will consider you diabetic and you won't be required to take the glucose tolerance test. But any score between 140 and 200 means that you'll have to take the three-hour glucose tolerance test for a definite diagnosis. Risk Factors If the blood sugar control was especially poor, the baby is at risk for polycythemia (an increase in the number of red cells in the blood) and hypocalcemia (low calcium in the blood). Also, the baby's heart function could be affected as well. This chart shows the levels that the American Diabetes Association considers abnormal at each interval of the test: Interval Abnormal reading Fasting 95 mg/dl or higher 1 hour 180 mg/dl or higher 2 hours 155 mg/dl or higher 3 hours 140 mg/dl or higher Exercise and strictly follow the diet- leave this as last resort/absolutely need to Baby Some women who develop diabetes during pregnancy still have it after delivery, so they have to take another glucose test six to eight weeks after their baby is born. Delivered baby weighing more than 9lbs (4.1kg) Can lead to injuries to the vaginal area Require a large episiotomy About 1/3 to 1/2 of women who have gestational diabetes will have it again in a later pregnancy. Up to 50 % of women with gestational diabetes will develop diabetes at some point in the future Studies show that moderate exercise also helps improve your body's ability to process glucose, keeping blood sugar levels in check. Placental Hormones Your diet must have the correct balance of protein, fats, and carbohydrates, while providing the proper vitamins, minerals, and calories. According to the American Diabetes Association, you're considered at high risk for this condition if: Mom DO NOT SKIP MEALS Avoid sugary substances (candy, cookies, cakes, soda...) Drink lots of water Mom At least 30min/day Aerobic activity(swimming, walking, dancing) How Common Is It? You've had a baby with a birth defect. or unexplained stillbirth Well-Planned Diabetic/Healthy Diet Further Complications Baby You may be recommended that you give birth by cesarean section if the baby is suspected to be too large Early(preterm) birth and respiratory distress syndrome Shortly after birth, may have hypoglycemia May develop type 2 diabetes later in life May be overweight in childhood and adulthood Jaundice Almost all pregnant women have a glucose-screening test between 24 and 28 weeks. About 15% of women need medication Most patients now start with oral meds instead of injections Gestational Diabetes In most cases, there are no noticeable signs or symptoms but women may experience fatigue or increased thirst. Complications The hormones from the placenta help the baby develop, but almost all of the placental hormones impair the action of insulin in cells, thus raising the blood sugar. As the baby grows, the placenta produces more and more insulin-blocking hormones which can affect the growth and welfare of baby, also resulting in gestational diabetes. Abnormal blood glucose level If you're not able to control your blood sugar well enough with the diet and exercise, then you may be prescribed medication as well. When you eat, your digestive system breaks most of your food down into a type of sugar called glucose. The glucose enters your bloodstream and then, with the help of insulin (a hormone made by your pancreas), your cells use the glucose as fuel. However, if your body doesn't produce enough insulin – or your cells have a problem responding to the insulin – too much glucose remains in your blood instead of moving into the cells and getting converted to energy. Physical Exercise Nonwhite Race High blood pressure and preeclampsia Future diabetes You have a strong family history of diabetes Diagnosis & Cause You need to keep diligent track of the glucose levels, using a home glucose meter or strips. These are some of the treatments: Also constitutes to weight loss and lowers stress :D When you're pregnant, hormonal changes can make your cells less responsive to insulin. For
Transcript: -ADA recommendations -Fasting glucose levels should not exceed 95 mg/dL 1 h: 140 mg/dl or less 2 h: 120 mg/dl or less -HbA1c is not useful is GDM -Nutrition counseling She was tested with a 75 g 2-hr OGTT. Her two hour glucose was 164 mg/dL. Does she have GDM? Which diagnostic test did she use? Mrs. Lee has come to you for counseling. What recommendations would you make to her? Gestational Diabetes -Most prevalent medical complication in pregnancy Preexisting diabetes Gestational diabetes mellitus (GDM) -GDM affects about 14-25% of all pregnancies Treatments MNT Complications Sources Risk Factors -Similar to risk factors associated with T2DM Race Age Weight History Case Study Diagnosis Recommendations -SMBG -CHO controlled with adequate weight gain -Small meals and snacks -HTN -Counsel on future risks -Hypertension Preeclampsia Eclampsia -Cesarean Delivery -High birth weight infants -GDM not associated with congenital malformations -Prematurity Gestational Diabetes Mrs. Lee is a 34 y/o native Hawaiian. She is hesitant to be tested for GDM because of the time it takes. What would you tell her about her risk factors? -Escott-Stump, S. (2012). Nutrition and diagnosis-related care. (Vol. 7th). Lippincott Williams & Wilkins. -Mensing, C. (2011). Diabetes self-management education desk reference. (Vol. 2nd). American Association of Diabetes Educators. -Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy and pathophysiology. (2nd ed.). Belmont, CA: Wadsworth Cenage Learning. -Lifestyle changes -Medications Metformin and glyburide -Insulin Intensive insulin therapy ADA Fasting: >=92 mg/dL 1 h: >= 180 mg/dL 2 h: >=153 mg/dL ACOG 2 step approach Fasting: >= 95 mg/dL 1 h: >= 180 mg/dL 2 h: >= 155 mg/dL 3 h: >= 140 mg/dL
Transcript: For Mommy Higher risk of C-section Preeclampsia (high blood pressure) Hyperglycemia (high blood sugar) Chances are 2 in 3 that it will return in future pregnancies Developing Type 2 Diabetes years later Breast Feed Baby Get tested for diabetes (after delivery and 6 weeks later) blood sugar checked by doctor every 1 to 3 years Complications: Post birth Gestational Diabetes Alyssa Mesick Maggie Chung Princess Peñaloza It is estimated that gestational diabetes affects 18% of pregnancies. <18.5 What is Gestational Diabetes? Overweight Obese >40 Did you know? BMI For Baby BMI = weight in lbs x 703 / (height in inches x height in inches) ex. 110x703 / 60x60 = 21.48 18.5-24.9 High glucose levels (mother-baby) Macrosomia: "fat" baby Low blood glucose levels (due to baby's excess production of insulin) healthy diet regular exercise take medications monitor and check blood glucose levels regularly possible daily blood glucose tests & insulin injections Healthy Hormones related to the placenta Having had gestational diabetes in a previous pregnancy Family history of diabetes Older than 25 years old when pregnant Overweight before pregnancy 25.0-29.9 American Diabetes Association Treatment & Management Category high amount of glucose in blood temporary type of diabetes that effects only pregnant women presents itself around middle of pregnancy 30.0-39.9 Prevention: Causes/Risk Factors: Early prenatal care See doctor regularly Get screened for gestational diabetes Healthy lifestyle Underweight Extreme, High Risk of Obesity Being of African American, Native American, Asian American, Hispanic, or Pacific Islander American ethnicity
Transcript: Gestational Diabetes Gestaional diabetes is basically when a woman is having a child and she before hand was previously diagnosed with diabetes has now affected the child in the third trimester,where there are high levels of glucose in the blood during the pregnancy. Usually there are no symptoms, or the symptoms are mild and not life threatening to the pregnant woman. The blood sugar (glucose) level usually returns to normal after delivery Women with gestational diabetes also increased risk of developing type 2 diabetes mellitus or, very rarely, latent autoimmune diabetes or Type after pregnancy, as well as having a higher incidence of pre-eclampsia (High Blood-pressure) and Caesarean section (C-section) their offspring are more vulnerable to developing childhood obesity Gestational diabetes is caused when the pregnant woman does not secrete excess insulin required during pregnancy which results to to increased blood sugar levels in the woman's body. The problem with gestational diabetes is uncertain, but when the woman is pregnant her baby goes through changes to sustain the baby. hormones such as estrogen, cortisol, lactogen, ect. are very important during the pregnancy and ensures the development of the baby. The symptoms of gestational diabetes are: Feeling thirsty often Frequent urination Fatigue Nausea Vomiting Bladder infection Vaginal infection Blurred vision Visible loss of weight Unfortunately, there are possible long term side effects as well for the child. The newborn would be obese and may have impaired or slowed development in coordination such as walking and balancing. The condition of gestational diabetes and its related side effects gmost likely fade away or resolve once the pregnancy period is over. Proper medication, following a prefect diet, and regular exercises prescribed by the doctor, helps to control gestational diabetes side effects, and the very condition too End The
Transcript: Insulin resistance stems from Placental secretion of diabetogenic hormones including GH, CRH, placental lactogen & progesterone Increased maternal adipose deposition Decreased exercise Increased caloric intake Management Complication of GDM during Pregnancy Diagnostic Evaluation Pre-existing T2DM or >1 RF for GDM should be screened @ 1st prenatal visit All women 24-28 wks gestation Two-Step Approach (ACOG): SCREEN with 50g glucose load non-fasting --> 1hr later measure Positive if >130 or >140mg/dL If positive --> 100g glu load, measure fasting, 1hr, 2hr, 3hr if 2 out of 4 values elevated, positive for GDM One-Step Approach (IADPSG, ADA and WHO): 75 g 2 hr OGT if at least 1 abnormal --> GDM 1) FPG > 92 but <126 2) 1-hr >180 or 3) 2-hr >155 ~18% of all women will be dx w/ GDM w/ this lower threshold Gestational Diabetes BMI >30 kg/m2 A family hx of DM, esp. in 1st degree relatives Age >25 years Previous delivery of a baby >9 pounds [4.1 kg] Personal hx of impaired glucose tolerance Hispanic-American, African-American, Native American, South or East Asian, Pacific Islander Maternal birthweight >9 pounds or <6 pounds Glycosuria at the first prenatal visit Polycystic ovary syndrome Current use of glucocorticoids Essential hypertension or pregnancy-related hypertension Fetal Monitoring A2 GDM - NST and modified BPP begun at 32-36 wks and continue biweekly U/S btw 34-37 wks for estimated fetal weight ACOG's classic definition "women with onset or 1st recognition of abnormal glucose tolerance during pregnancy" IADPSG 2010: Overt vs. Gestational DM Overt DM - 1) FPG > 126 or 2) A1c >6.5% or RPG >200 mg/dL subseq. confirmed by FPG or A1c Gestational DM 1) FPG > 92 but < 126 at any gestational age or 2) at 24 to 28 wks gestation: Pathogenesis Definition Sidenote Risk Factors Fetal - Neonatal hypoglycemia - Hyocalcemia - immature parathyroid gland - Polychythemia – inc EPO b/c intrauterine hypoxia - Hyperbilirubin – immature liver can't clear excessive RBC b/d - RDS – immature surfactant - Macrosomia --> Shoulder Dystocia, fetal organomegaly - Usually NOT congen. anomalies or abn. organogensis - childhood obesity, high rates of inattention and/or hyperactivity Mom - Preeclampsia, eclampsia - over DM 40% likely in the next 20 yrs White Classification of Diabetes during Pregnancy * two step screening approach has been estimated to miss 25 % of cases diagnosed with the one step approach * ACOG "one step approach and criteria would increase health care costs in the absence of evidence that use of the IADPSG approach and criteria result in improvements in maternal or newborn outcomes" The 2013 NIH Consensus Conference recommended against adoption of the one step approach and criteria because it would increase the prevalence of GDM, leading to more frequent prenatal visits, more fetal and maternal surveillance, and more interventions, including induction of labor, without clear demonstration of improvements in the most clinically important health and patient-centered outcomes ADA diet plan of 2,200 cal/day 200-220 g of carbs/day Exercise (best way to enhance postprandial blood glucose control is to walk 15 mins ~30 to 40 mins after meal Monitor blood glu lvl 4x/day (fasting, 3 postprandial) Short-acting insulin in combo with intermediate-acting insulin (breakfast & lunch) and short-acting insulin at dinner Humalog (lispro) or NovoLog and NPH "problem related to metabolism of large carb boluses vs. carb intolerance at baseline" Glyburide and metformin 3 small randomized trials Deliver at 39 wks for pts on insulin or hypoglycemic agents Poorly controlled deliver at 37-39 wks if fetal maturity confirmed C-section only if EFW >4,500g Long-acting hypoglycemic agent discontinued --> glu every hr Dextrose & insulin drips to maintain glu <120 mg/dl Forceps & vacuum are generally not used for macrosomia b/c inc risk of shoulder dystocia --> Suprapubic P, McRoberts maneuver, Woods Maneuver
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