GESTATIONAL DIABETES MELLITUS - DM is a hereditary endocrine disorder due to inadequate or lack of insulin

production that results in impaired glucose absorption & metabolism.

- women appear to develop an insulin resistance as pregnancy progresses (insulin does not seem normally effective
during pregnancy) a phenomenon that is probably caused by the presence of the hormone Human Placental
Lactogen (HPL)

SIGNS AND SYMPTOMS:

1. Hyperglycemia - pancreas does not produce enough insulin, thus glucose is unable to enter the cells &
accumulates in the bloodstream resulting in hyperglycemia

2. Glycosuria –when blood glucose levels go beyond the renal threshold for sugar, glucose spills on the urine.

3. Polyuria – glucose attracts water so that when it is excreted in the kidney, it brings along with it large amounts
of water resulting in the woman excreting large amounts of urine, a condition called, POLYURIA.

4. Polydipsia – the excretion of large amounts of fluid from the body leads to dehydration. Excessive thirst or
polydipsia is an important symptom of dehydration.
EFFECTS OF DIABETES:

MOTHER:

1. Increased tendency to pre-eclampsia & eclampsia, UTI, & candidiasis

2. Increased risk for postpartum hemorrhage d/t overdistention of the uterus.
3. Maternal mortality
4. Preterm delivery

INFANT:

1. Macrosomia
2. Hydramnios
3. Prematurity
4. Hypoglycemia (lowered serum glucose levels)
5. Predisposition to diabetes mellitus later in life as the disease is hereditary
6. Birth injury

COMPLICATIONS:

1. Macrosomia – Infants of women with poorly controlled diabetes tend to be large ( more than 10 lbs.) because
glucose can cross the placental barrier, it acts as a growth stimulant. The increased glucose adds subcutaneous
fat deposits. All the nutrients that the fetus receives comes directly from the mother’s blood.

2. Birth Injury – may occur due to the baby’s large size and difficulty being born. (may cause CPD which may
necessitate being born by CS)

3. HYPOGLYCEMIA – refers to low blood sugar in the baby immediately after delivery. This problem occurs if the
mother’s blood sugar levels have been consistently high, causing the fetus to have a high level of insulin in its
circulation. After delivery, the baby continues to have a high insulin level, but no longer has the high level of
 sugar from its mother, resulting in the newborn’s blood sugar level becoming very low. The baby’s blood sugar
level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously

4. Respiratory distress (difficulty breathing) – too much insulin or too much glucose in a baby’s system may delay
lung maturation and cause respiratory difficulties in babies. This is more likely if they are born before 37 weeks
of pregnancy.

PRENATAL MANAGEMENT:

1. Diagnosis; Suspect DM in a woman

a. With a family history of DM

b. With a history of unexplained repeated abortions and stillbirth
c. With glycosuria
d. Who are obese?
e. Who have history of giving birth to large infants, over 10 lbs. and infants with congenital anomaly?

2. Screening tests
 Universal screening- 50-gram oral glucose tolerance test (OGTT) between 24-28 weeks gestation regardless of
the time of the day and meals are taken for all pregnant women. If the plasma value is more than 140 mg/dl
after one hour, 100-gram three-hour oral glucose tolerance test is performed to confirm if the woman is
having hyperglycemia.
1. DIET
a. Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,800 to 2,400 cal/day) but
not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50%
from carbohydrates, 30% from fats.
b. Weight gain should be about 24-25 lbs. Too much weight gain can lead to large infants and cephalopelvic
disproportion.
c. The goal is to maintain a fasting blood sugar level of 80 mg/dl and postprandial blood sugar level of 110mg/dl
2. Exercise
a. A liberal cardiovascular-conditioning exercise and diet therapy is the management for Gestational Diabetes
Mellitus
b. Exercise lowers blood glucose levels and decreases the need for insulin.
c. The exercise regimen should be individualized, performed regularly and under supervision.
d. Advise woman to eat complex carbohydrates before exercising to prevent hypoglycemia.

Remember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin:

 Short acting or regular insulin – after 2-3 hours of injection

 Intermediate or Lente insulin – after 6-8 hours of injection

 Long-acting or ultralente – after 16 – 18 hours of injection

 The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision

 Give a hypoglycemic person a glass of orange juice.

INSULIN THERAPY

• Insulin requirements increase during pregnancy

 • Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are
teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia.
• Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of
choice during pregnancy because it is the least allergenic
• 2/3 in the morning, 1/3 at dinner administered subcutaneously ½ hour before meals.
• Insulin requirement is decreased on the first trimester due to nausea & vomiting and highest during the third
trimester.

DELIVERY
1. Delivery is affected when the fetus is mature enough after 38 weeks gestation, but not too large so as to cause
cephalopelvic disproportion. Thus, early hospitalization and labor induction is performed to deliver the baby
before it becomes too large to pass the birth canal

2. If the cervix is not yet ripe, the baby is macrocosmic and fetal distress occurs, CS is performed

3. Regular insulin is given on the day of delivery not long-acting insulin because insulin requirement drops
immediately after delivery. The woman may not require insulin during the first 24 hours postpartum and her
insulin requirements usually fluctuate during the next few days.

CONTRACEPTION

A. IUD and combined oral contraceptives are contraindicated

> Progesterone interferes with insulin activity and therefore increases blood glucose levels.

> Estrogen increases lipid & cholesterol levels & risk for increased blood coagulation

B. Norplant (subcutaneous progestin implant system) or Depo -provera may be good choices & safely used by
diabetic women

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

 Disorder of blood clotting
= Fibrinogen levels fall below effective limits
 Symptoms
= Bruising or bleeding
= massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may
result in tissue damage from multiple thrombil), which in turn stimulate fibrolytic activity, resulting in decreased
platelet and fibrinogen level and
= signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis,
hematuria, etc.)
 Monitor PT, PTT, and Hct, protect from injury; no IM injection; early anticoagulant therapy is controversial.

CLASSIFICATION OF CARDIAC DISEASE

CLASS I (Shows no signs of cardiac insufficiency) = no limitation of activity

 CLASS II (Ordinary physical activity may result in = slight limitation of activity
discomfort and signs of cardiac insufficiency)
CLASS III (Less than ordinary activity results in excessive = marked limitation of activity
feeling of fatigue, dyspnea)
CLASS IV (Signs of cardiac insufficiency may be = severe limitation; symptoms present even at rest
experienced even at rest; physical activity increases)
NOTE: Class I and II usually do well in pregnancy

NEW YORK HEART ASSOCIATION

 CLASS I
o Ordinary physical activity does not cause dyspnea, chest pain and undue fatigue
o No pulmonary congestion
o Asymptomatic
o No limitation of ADL’s
 CLASS II
o Slight limitation of ADL’s
o No symptoms at rest but symptoms with increased activity
o Basilar crackles and S3 murmur mat be detected.
 CLASS III
o Markedly limitation on ADL’s
o Comfortable at rest but symptoms present in less than ordinary activity
 CLASS IV
o Symptoms are present even at rest
NURSE ALERT:
“Remember a pregnant woman with heart disease should avoid infection, excessive weight gain, edema and anemia
because these conditions increase the workload of the heart.”

MANAGEMENT CARE:
1. Promotion of rest (class I & class II)
o 8 hours of sleep during the night and have frequent rest periods during the day.
o Light work is allowed but no heavy work, no stair climbing, no exhaustion.
2. Diet
o High in iron, protein, minerals and vitamins
3. Avoid high attitudes, smoking areas, unpressurized planes & overcrowded areas. cigarette smoking & alcoholic
beverages are strictly prohibited.
4. Prevention of infection
o Avoid person with active infections (colds, cough)
o Early treatment of infections
5. Provide instructions on danger signs of heart failure:
o Cough with crackles is usually the first sign of impending heart failure.
o Increase dyspnea, tachycardia, rales, edema

MEDICATIONS
 Iron supplementation to prevent anemia
  Digitalis to strengthen myocardial contraction and slow down heart rate
 Nitroglycerine to relieve chest pain
 Antibiotics to prevent and treat infection
 Diuretics may be prescribed in case of heart failure

INTRAPARTAL CARE:
1. Early hospitalization – woman is hospitalized before labor begins to promote rest, for closer supervision and
prevent infection
2. Woman labor’s in semi-fowler’s position or left lateral recumbent position. No lithotomy positions
3. Vital signs - vital signs are monitored continuously. tachycardia and respiratory rate more than 24 are signs of
impending cardiac decompensation. during the first stage, monitor vital signs every 15 minutes and more
frequently during the second stage
4. Epidural anesthesia- is instituted for painless and push less delivery. forceps is used to shorten the second stage.
pushing is contraindicated
5. Women with heart disease are poor candidate for cs due to increased risk for hemorrhage, *infection and
thromboembolism

POSTPARTUM CARE
1. The most dangerous period is the immediate postpartum because of the sudden increase in circulatory blood
volume.
2. monitor vital signs
3. Promote rest- restrict visitors to allow patient to rest, the woman stays in the hospital longer, until cardiac
status has stabilized.
4. early but gradual ambulation to prevent thrombophlebitis.
5. Medications
o antibiotics
o stool softeners to prevent straining at stool caused by constipation. sedatives may be ordered to promote
rest.